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PRESENTATION = CLINICAL RESEARCH 2-2016 v3 12-24-15

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PRESENTATION = CLINICAL RESEARCH 2-2016 v3 12-24-15

  1. 1. Case Management THE MISSING LINK Cathy Kauffman-Nearhoof BSN RN CCM LNC
  2. 2. Objectives 1. Define Case Management within the context of Clinical Research 2. Explain the role of Case Management process through a case study scenario 3. Demonstrate the impact of strategic collaborative care coordination 4. Describe care coordination processes that optimize the implementation of seamless healthcare services
  3. 3. Case Management  Definition: Case Management is a  collaborative process of  assessment, planning, facilitation, care coordination, evaluation, and  advocacy for options and services  to meet an individual’s and family’s comprehensive health needs  through communication and available resources  to promote quality cost-effective outcomes.“ (Case Management Society of America)
  4. 4. Case Management Components  Facilitating the seamless delivery of health care services in a patient centric model of care designed to minimize fragmentation  Single point of contact – Case Manager  Case screening – Risk assignment  Assessment – Face to face or telephonic  Plan of Care – Patient-centric/multidisciplinary  Collaboration – Case Management is a team sport!  Implementation – Care coordination  Evaluation – How did the plan work?  Multidisciplinary Team Meetings Facilitated by the Case Manager – Herding cats  Implementation – Activation of recommended team interventions  Evaluation – Ongoing Care Plan Updates
  5. 5. Case Management Process  Deliberate organization of patient care activities  Inclusion of PCP, Specialist, Patient, Family, Clinical Research Coordinator and other clinicians on the Multidisciplinary Team  Shared healthcare information among all healthcare team participants  Shared goals to achieve safer, more appropriate, more effective care as well as accurate study outcomes  Prioritizing the patient’s needs and preferences  Committed Collaborative Multidisciplinary Team Participants - show up to play  Optimize awareness of the patient’s preferences, goals and priorities  Embed patient goals into the collaborative plan of care  Identify and prioritize strategic interventions  Communicate planned and proposed patient interventions, outcomes, and barriers
  6. 6. Case Management is a Team Sport
  7. 7. Case Management Standard Changes and Healthcare Reform  As the healthcare industry changes - Case management takes the lead  The standards for case management address important foundational knowledge and skills of the case manager within a spectrum of case management practice settings and specialties  1995 – the first standards for CM identified gaps in the health care continuum  2010 – standards updates identified the impact of fragmented health care and included the following revisions:  Minimization of health care fragmentation  Use of evidence based guidelines in practice  Navigation of transitions of care  Incorporate adherence guidelines and other standardized practice tools  Expand the interdisciplinary team in planning care for individuals  Improving patient safety
  8. 8. Lucy’s Story  Lucy is a 66 years old  Medical History  Type II Diabetes  Hypertension  Chronic Anxiety and Depression  Obesity – BMI 32.6  Arthritis  Cataracts  Dyslypidemia  Demographics  Widowed  Lives alone  Daughter lives nearby  Does not drive  Medications: Norvasc 10 mg, Paxil 30 mg, Wellbutrin 300 mg, Metformin 1000 mg BID, Atorvastatin 20 mg, Advil, Calcium, and Daily Vitamin  PCP, Endocrinologist, and Psychologist
  9. 9. Lucy’s Story  Elevated blood pressure during a follow up PCP blood pressure check appointment (182/112)  The PCP prescribes Lisinopril 20 mg  Lucy fills it at the Rite Aid near her PCP office that same day but doesn’t add to her pill box  Lucy sees her Endocrinologist 2 days later during a scheduled appointment  Again, her blood pressure is elevated (180/112) and some pedal edema  This concerns the specialist who was readying Lucy for participation in a diabetic medication clinical trial  Lucy is anxious to participate in a diabetic medication study b/c of the weight loss side effect  She cannot begin until her BP is under control  The specialist prescribes Zesturetic 10/12.5  Lucy’s friend picks up the Rx for her at the CVS pharmacy on the way home  The Endocrinologist schedules a follow up appointment in 2 weeks to assess her stabilization of her BP and readiness to participate in the clinical research
  10. 10. Lucy’s Story  She is excited to begin in this 6 month study because  she will get $400.00 AND  the study medication has been proven to contribute to weight loss  She plans to start her new medications immediately  She only has to take the medication once a week  Lucy adds her newly prescribed medications to her pill box that evening  She takes her medications as prescribed the following morning  At 11 AM after standing up from her recliner Lucy feels dizzy and falls  Lucy fractures her hip  Ah Oh! What went wrong?
  11. 11. Lucy fell into the BIG BLACK Hole of Care Fragmentation .  Healthcare Silos  Communication  Collaboration  Untoward side effects  Preventable admissions  Preventable complications  Preventable emergency department visits  Preventable readmissions  Complications  Increased care costs  Medication Errors  Patient education gaps
  12. 12. Care coordination The Missing Links  Lack of a single point of contact  Un-effective model of care  Failure to consider patient priority  Missing team collaboration and communication  No patient engagement  No patient education  Duplication of services  Team Members out of the loop
  13. 13. Single Point of Contact  Minimizes healthcare fragmentation and navigation confusion  Facilitates Multidisciplinary Team collaboration  Coordinates discharge planning  Coordinates transitions of care  Establishes safe and effective outpatient care services  Identifies home safety issues  Breaks down barriers to optimal care  Connects the communication dots  Prevents duplication of services  Ensures compliance with clinical guidelines  Engages the patient in healthcare goals and decisions  Incorporates the Member’s priorities into the health care plan design
  14. 14. Patient Centered Model of Care  Promotes active involvement of patients and their families in decision-making about individual options for treatment.  "Providing (coordinating) care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.  “(The IOM definition of Patient Centered Care - Institute of Medicine)  Enables active patient engagement at every level of care design and implementation.
  15. 15. Lucy’s Care Coordination Gaps  Case Analysis: What if Lucy had a Case Manager?  She sees her PCP and an Endocrinologist regularly – Missing Link  The PCP prescribes Lisinopril 10 mg– Missing Link  Lucy sees her Endocrinologist 2 days later during a scheduled appointment – Missing Link  The specialist prescribes Zesturetic 10/12.5 for Lucy  Her friend fills the RX at a CVS pharmacy near her home – Missing Link  She is excited to begin this 6 month study because she will get $400.00 AND the study medication has been proven to contribute to weight loss – Missing Link  Lucy adds her new medications to her pill box the evening after her specialist appointment – Missing Link  She takes all her medications as prescribed the following morning – Missing Link
  16. 16. Case Management Impact in Clinical Research  Deliberate organization of patient care activities  Inclusion of Clinical Research Coordinator on the Multidisciplinary Team  Shared healthcare information with all healthcare team participants.  Team understanding and agreement on shared goals to achieve safer, more appropriate, and more effective care  Prioritizing the patient’s needs and preferences  The healthcare team seeks to discover medication to lower A1C  How does Lucy’s weight loss goal fit into the plan of care?  Committed Collaborative Multidisciplinary Teams – Sharing the same sheet of music  Optimize awareness of the patient’s preferences, goals and priorities  Create a collaborative and focused plan of care  Identify and prioritize strategic interventions  Coordinate planned and proposed patient interventions  Agreement related to breaking down barriers
  17. 17. Collaboration  Communicates with all Team Members – Multidisciplinary Team Meetings and Individually  PCP  Specialist  Clinical Research Coordinator  Case Manager  Patient  Daughter  Others selected by the Patient  Prevents duplication so lab tests  Prevents duplication of BP medications  Prevents dizziness, falls, fracture and concussion due to medication complications  Ensures all treatment team members have the same information  Ensures that the daughter is educated regarding her mother’s conditions and treatments  Collaborates with the Clinical Research Coordinator regarding Member readiness for study; ensures Coordinator has all appropriate healthcare information  Ensures that he Endocrinologist had complete healthcare information relevant to Lucy’s status and her PCPs concerns
  18. 18. Lucy on Care Coordination  The Case Manager (Payer)  Completed Case Manager comprehensive assessment  Calculation of healthcare risk  Enrollment in disease specific programs  Validation of patient demographics  Care Plan shared with the PCP and patient  Inclusion of Lucy’s healthcare priorities (weight loss) in the plan of care  PCP and Specialist input into the plan of care  Communication of healthcare information, clinical study participation and scheduled appointments  Inclusion of Lucy’s healthcare priorities (weight loss)  Seamless circle of shared healthcare information  Considers impact of Lucy’s depression  Shared focus on closure of key gaps in care  Lucy’s A1C is high – is she testing? Does she understand her diet? What role does exercise plan? When did she last have blood tests? Were results of all testing shared among the healthcare team?
  19. 19. References  http://www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/index.html  www.pcpcc.net Colorado Systems of Care/Patient Centered Medical Home Initiative: Colorado Primary Care – Specialty Care Compact  www.pcmh.ahrq.gov  www.caaretransitions.org The Care Transitions Program. Eric Coleman, MD, MPH by The MacColl Institute for Healthcare Innovation  Affordable Care Act  Medicare-Medicaid Regulations/care coordination standards  The Clinical Trials Office of Henry Ford  www.wmsa.org  www.ncqa.org/NCQA Care Coordination Standards  Medicare-Medicaid Program Dual Eligible Regulations  https://en.wikipedia.org/wiki/Case_management_(USA_health_system)

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