Systems Support: Care Management Protocols, Disease Registries, and Other Tools Amy M. Kilbourne, PhD, MPH VA Ann Arbor Serious Mental Illness Treatment.

Systems Support: Care Management Protocols, Disease

Registries, and Other Tools

Amy M. Kilbourne, PhD, MPHVA Ann Arbor Serious Mental Illness Treatment

Research and Evaluation Center

Department of Psychiatry, University of Michigan

SMITRECMental Health Services Research Group

Chronic Care Model- chronic mental illness Quality improvement interventions to improve

medication adherence Mental health performance measures Primary Care – Mental Health Integration

Program Substance abuse in primary care Predictors of suicide Aging and preventable mortality National VA Psychosis Registry National VA Registry for Depression

Implementation

Care Management Guidelines Patient Registries Other Tools

Wagner Chronic Care ModelWagner Chronic Care Model

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

Functional and Clinical Outcomes

DeliverySystemDesign

Decision Support

ClinicalInformation

Systems

Self-Management

Support

Health SystemCommunity

Health Care OrganizationResources and Policies

CCM: Core Clinical Elements

Leadership

Practice

Design

Clinical

Information

Systems

Vision Resources

Care management Protocols- coordinated care

Clinical information tracking Feedback to clinicians

CCM: Core Clinical Elements

Decision

Support

Self-management

Support

Community

Resources

Guidelines Expert/specialist

consultation

Patient preferences Information on treatment

Information on and for consumers, groups, etc.

Access to non-provider sources of care

Care Manager Role

General Medical

(Chronic care, Prevention, Follow-up)

Care Manager Self-management Liaison: PCP, MHCrisis intervention

Behavioral Health (crisis

referral for ICM, etc.)

Care Manager: Skills

Tracks depressive symptoms and treatment response (PHQ-9)

Consults with team psychiatrist Collaborates closely with patient’s primary care

provider (PCP) Provides follow-up and recommendations to PCP

who prescribes antidepressants Facilitates referrals to specialty, community Prepares for relapse prevention

Care Manager: Skills

Familiar with commonly used antidepressant medications, doses

Patient education about antidepressants Support antidepressant medication

adherence Know when treatment is ‘not working’

CM: Self-management

Eliciting concerns/barriers Problem-solving Providing information Clarifying preferences Encouraging informed decision-making Teaching skills Monitoring progress Reinforcing self-management Community resources

CM: Self-Management Tools

Medication lists Pillboxes Appointment reminders Healthy behaviors Pleasure activities list

CM: Therapeutic Alliance

Cultural competence Role of families Role of religion/spirituality Competing needs

CM: Liaison

Relay concerns/progress Refills Symptoms and side effects Urgent, emergent protocols Medical record documentation

Cue providers if no improvement Supplement, not replace providers

CM: Liaison

Help patients and providers ID Potentially inadequate doses Ineffective treatment (e.g., persistent depression after Adequate duration of antidepressant trial) Side effects

Facilitate patient-provider (e.g., PCP) communication about antidepressant medications

Consult about medication questions

Examples of CM-Provider Contact

Medication toxicity, cross-reactivity Notifying provider of patient concerns, follow-up

Fatigue, physical symptoms CM prompted provider to call pt. after missed appt

Managing multiple medications, depression, diabetes, and HT (medication lists, pillboxes)

Alcohol use and grief management

Kilbourne AM. Bipolar disorders, in press 2008

Kilbourne AM. Psychiatric services, under review, 2008

Provider Communication Tips

Obtain preferred mode of communication Emphasize as a supplemental service Focus on providing information on changes in

treatment response, side effects, etc to inform decisions Baseline, Current PHQ Length of time on medications Problematic symptoms/side effects

Adequate contact, but don’t overdo it

CM: Crisis Intervention

Suicidal ideation- coordinate with clinic Protocols On-call numbers

Missed appointments Immediate follow-up

CM: Suicidal Ideation

If the patient articulates thoughts death/suicide: Where are you now? What is your phone number at the location? Are you alone or with someone? Do you have a plan of how you would do this? Do you have these things available (guns, pills)? Have you actually rehearsed or practiced how you would

do this? Have you attempted suicide in the past? Do you have voices telling you to harm or kill yourself?

Care Manager Registry

Registries are . . . Simple tools to track patient progress (K.I.S.S.) NOT EMRs Best if “home-grown”

Facilitate structured patient contacts Types of registries, pros and cons

Excel file Web-based

Developing RegistriesThings to Know

Know your stakeholders and get their input (purchasers, payers)

Know your population- case mix, location Know your key data sources

What is in the administrative datasets? Do they capture utilization?

Know what information technologies are available and whether they can be tailored Web-based patient health risk assessments

Developing RegistriesThings to Know (cont.)

Know your end users (e.g., care managers, clinic staff, providers), including their work flow, and ensure they can work with the registry on a day-to-day basis

Know what stakeholders want in terms of outcomes: What quality and cost measures are they interested in, and use registry to enhance performance measures

Registry: Sample FieldsGeneral information (update at each contact):

Patient contact info, including emergency contact Providers Best time to call/OK to leave message? Plan to keep then safe/calm

Contact (Encounter)-specific information: Contact or visit date Current Mood, Speech, Comorbidities Current medications/OTCs, refills needed? Medications not taking and reason Symptoms and side effects Health behaviors (sleeping, drug use, smoking ,exercise) Job/personal problems Education provided Access/barriers, provider engagement Next appt

Registry Examples

SMAHRT IMPACT

Care Manager Toolbox

Self-management materials Antidepressant medication list Registry file Provider contact sheet

Preferences Crisis intervention

Operations manual

Care Manager Initial Visit

Rapport- providers Patient initial intake

Contact preferencesCrisis and urgent care protocols

Assessment Discuss treatment options / plans Coordinate care with PCP Start initial treatment plan Arrange follow-up contact Document initial visit

Care Manager Subsequent Visit

Upcoming appointments Registry- ongoing tracking