BEST PRACTICES IN DISEASE MANAGEMENT Deanna Bell, M.D., F.A.A.P. Medical Director, MHIP Tennessee...
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Transcript of BEST PRACTICES IN DISEASE MANAGEMENT Deanna Bell, M.D., F.A.A.P. Medical Director, MHIP Tennessee...
BEST PRACTICES IN DISEASE MANAGEMENT
Deanna Bell, M.D., F.A.A.P.Medical Director, MHIPTennessee Chapter of the American Academy of Pediatrics
GOALS OF D70 GRANT“ . . . to improve medical home provision for children and youth with special healthcare needs by promoting systems and service integration for children through education of parents and providers on medial home concepts of team-based care, care coordination, and disease management.”
Who are Your CYSHCN?
MOC QI AIM #3-----------------------------------------
HIGH RISK REGISTRY FORMATION
WAYS TO ID CYSHCN
•Screeners (CSHCN Screener, QuICCC, QuICCC-R) • ICD-9 lists (NHIS, CAHMI, NDP)•Administrative with risk stratification (3M-CRG)•Physician Referral•Payer referral•Pharmacy utilization
ADMINISTRATIVE: 3M CRG•Combines Dx and consequences based approaches•Uses ICD-9 and procedural codes to classify cases•Requires:6 months of claims data
2 or more encounters with same Dx code•Takes into account: type and number of Dx, recurrences,
number of acute exacerbations, cost/type/combination/frequency of services•Strengths: identifies population and individuals; assigns
severity rating; assigns groupings:
SURVEY-BASED METHODS•QuICCC: 41 question survey sequence•QuICCC-R: 16 question survey sequence• CSHCN Screener: 5 questions survey sequence• All do not require formal Dx• All 3 part sequence: consequences/presence of
condition/duration•Qualify if positive answers to one or more sequences• All identify population cohorts and can identify individuals•QuICCC and QuICCC-R: interviewer administered only
COMPARISON OF ADMINISTRATIVE AND
SURVEY-BASED METHODSOf CSHCN identified by ICD-9 lists•Only 52-53% met CSHCN criteria by survey methods
Of CSHCN identified by Survey Methods•20-24% were not identified by ICD-9 lists
Concordance between CRG/CSHCN Screener/QuICCC-R= 85-90%
CSHCN IDENTIFIED BY SURVEY AND NOT BY ADMINISTRATIVE DATA ARE LIKELY TO:
•Have developmental or emotional disorders not coded in encounter records•Use services not reimbursed under benefit
structure•Have multiple health issues that include a range of
educational, developmental, and mental health service needs and consequences•Be in transition between health plans or PCPs
MCHB/AAP DEFINITION CYSHCN
“ . . . those who have or are at increased risk for a chronic physical, developmental, behavioral, oremotional condition and who also require health andrelated services of a type or amount beyond that required by children generally.”
McPherson M, Arrange P, Fox H, et al. “A new definition of children with special health care needs”, Pediatrics, 1998; 102: 137‐140.
CHILDREN WITH SPECIAL HEALTH CARE NEEDS (CSHCN)
SCREENER©•non-condition specific, consequences- based•identifies children across the range and diversity of childhood chronic conditions and special needs•identified on the basis of one or more current functional limitations or service use needs •Scoring in based on positive cluster (e.g. 5 and 5a= positive; or 1 , 1a, and 1b=positive)
CHILDREN WITH SPECIAL HEALTH CARE NEEDS (CSHCN) SCREENER©
1. Does your child currently need or use medicine prescribed by a doctor (other than vitamins)? ٱ Yes Go to Question 1a ٱ No Go to Question 2
1a. Is this because of ANY medical, behavioral or other health condition? ٱ Yes Go to Question 1b ٱ No Go to Question 2
1b. Is this a condition that has lasted or is expected to last for at least 12 months? ٱ Yes ٱ No
2. Does your child need or use more medical care, mental health or educational services than is usual for most children of the same age? ٱ Yes Go to Question 2a ٱ No Go to Question 3
2a. Is this because of ANY medical, behavioral or other health condition? ٱ Yes Go to Question 2b ٱ No Go to Question 3
2b. Is this a condition that has lasted or is expected to last for at least 12 months? ٱ Yes ٱ No
3. Is your child limited or prevented in any way in his or her ability to do the things most children of the same age can do? ٱ Yes Go to Question 3a ٱ No Go to Question 4
3a. Is this because of ANY medical, behavioral or other health condition? ٱ Yes Go to Question 3b ٱ No Go to Question 4
3b. Is this a condition that has lasted or is expected to last for at least 12 months? ٱ Yes ٱ No
4. Does your child need or get special therapy, such as physical, occupational or speech therapy? ٱ Yes Go to Question 4a ٱ No Go to Question 5
4a. Is this because of ANY medical, behavioral or other health condition? ٱ Yes Go to Question 4b ٱ No Go to Question 5
4b. Is this a condition that has lasted or is expected to last for at least 12 months? ٱ Yes ٱ No
5. Does your child have any kind of emotional, developmental or behavioral problem for which he or she needs or gets treatment or counseling? ٱ Yes Go to Question 5a ٱ No
5a. Has this problem lasted or is it expected to last for at least 12 months? ٱ Yes ٱ No
CSHCN SCREENER© GRADING•All three parts of at least one screener question (or in the
case of question 5, the two parts) must be answered “yes” in order for a child to meet CSHCN Screener© criteria for having a chronic condition or special health care need. •The CSHCN Screener© has three “definitional domains:”
1) Dependency on prescription medications. 2) Service use above that considered usual or routine. 3) Functional limitations. The definitional domains are not mutually exclusive categories.
ENTRY CRITERIA FOR REGISTRY
•Positive screen for barriers to compliance•Positive CYSHCN screen•Physician referral•Health plan referral•Diagnosis list
TRACKING REGISTRY•Once your chronic or complex illness cohort is
identified, you must decide on a tracking system.•Most EMRS have flag systems, so a flag or icon can be
added to these patients•Many practices on paper charts use stickers of a specific
color on the patient’s chart.• There needs to be communication of Registry status to
patients and staff
TNAAP
High Risk Registry Tracking Tool Patient Name/DOB
Patient Name/DOB
Patient Name/DOB
Patient Name/DOB
Patient Name/DOB
Patient Name/DOB
Patient Name/DOB
Patient Name/DOB
Patient Name/DOB
Patient Name/DOB
Patient Name/DOB
Patient Name/DOB
Patient Name/DOB
Patient Name/DOB
Patient Name/DOB
Emergency Plan Updated Last
Plan of Care Last updated:
Disease States
Follow up Interval
Last appointment
Last WCC
Influenza Immunization Given? (Y/N)
Barrier to Compliance Screen Last Given
Disease Specific Plan of Care Up-to-Date? (Y/N)
Needs:
MOC QI AIM #3 MEASUREMENTS
•Report baseline registry formation based on objective screening (20 charts, alright if 0).• Institute CSHCN screener and/or other•Enter children with positive screens into registry. •Tag record with identifier positive or negative•Monthly, select 10 charts from general population that month to audit for use of CSHCN Screener or other evidence of screening for registry entry.
Care Coordination Framework
Patient Disease management
Case Management
Team-based Communication
What is Disease Management?
Disease Management
“Disease management supports the physician or practitioner/patient relationship and plan of care, emphasizes prevention of exacerbations and complications using evidence –based practice guidelines and patient empowerment strategies, and evaluates clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall health” Disease Management Association of America. DMAA Definition of Disease Management. {Accessed: January 26,2007};available from :http://www.dmaa.org/dm_definition.asp
What are the characteristics of
successful disease management programs?
Successful Disease Management ProgramsIndividualized
Case Management
In-person contacts
Focus on hospital discharges
Encourage use of cost effective therapies
SimplePatient CenteredLarge/overarchingIdentified
measurement parameters
Incentives
Context of StudiesAdult cohorts
Large volumes of same diagnosis
Good evidence base for therapies
Costs/Morbidity center around large volume cohorts
Pediatric CohortsFew large volume
cohortsMany severe
illnesses without standardized evidence base for therapy
Cost/Morbidity located in 10% of children, small cohorts
Considerations in pediatricsDisease management strategies in pediatrics must be applicable across a variety of disease states.
Disease management in pediatrics requires both population approaches and individual case management approaches
Processes in pediatrics must be fluid enough to respond to the situational needs of highly specialized/varied patients.
Formalized disease management in primary care
Disease Manager FunctionsSupport evidence based care and individual
plans of careDisease-specific knowledge a mustProvides education for self-managementCompliance tracking and reassessment a
large roleWorks with MD and case manager to optimize
access, compliance, and education
Disease Management Team Tasks
Patient screening and registry formation
Evaluates patient/family comprehension of plan of care
Performs disease education as appropriate
Refers patient to case manager as risks for noncompliance identified
Disease Management Team TasksTracks and monitors patient
compliance with care plans by registryAugments communication by keeping
team members aware of patient status Assists with transitions to/from
hospital/adult careAuthority to schedule override
Disease Management WorkflowAssess
Evidence-based plan
Maintain Registry
ExecuteLink Community Resources
Support self Management
Monitor/Evaluate/Adjust
CommunicatePlan
Keep it Simple
Form your registrySupport the evidence base with
processEducate and involve the teamUse ToolsContinually reassessSet regular communication times
•Record which diseases in your practice are leading to increased service utilization or functional capacity limitation•Review the evidence base for these diseases•Form your registry (General or disease-specific)
Assess
• Support evidence base with process• Identify essential action steps that will support evidence
base• Form office procedure around information exchange
that must take place to support evidence-based intervention•Describe the responsibilities in this work-flow by job
description•Don’t forget case management plan
Evidence-based plan
•Physician•Disease Management•Case Management/Linkage with Resources•Referral coordinator/other staff•Patients•PHYSICIAN MUST HAVE WRITTEN CARE PLAN FOR
PATIENTS
CommunicatePlan
•Processes for a diagnosis cohort or individual patient executed•Patient expectations communicated to patients•Team aware of plan and monitoring compliance
Execute
•Screen for barriers to compliance•Create care plan for overcoming barriers•Monitor patient compliance with this plan•Follow-up and reassess
Link Community Resources
•Written plan of care to patients•Assessment of health literacy for self management•Disease or patient-specific patient education for self management•Referral to case management as needed.
Support Self Management
•Follow-up interval specified in patient plan of care or part of evidence-based care path•Track no shows and compliance with referrals•Maintain patient contact/Assure follow-up occurs•Reassess response to interventions•Adjust plan accordingly•Continually reassess for barriers to care
Monitor/Evaluate/Adjust
A written plan of care is essential to communicating
patient specific expectations to all team members.
Three types of plans for CYSHCN
Patient Summary: Problem list, PMH, Meds, Allergies, Specialists, Therapies, Typical Laboratory Values and Exam, Cultural and Social Considerations, Legal
Action Plan: today’s additions, changesEmergency Plan
MOC QI Aim #4----------------------------------
Written plans of care for team
MOC QI Aim #4 MeasurementsReport baseline proportion of chronic
disease registry patients with written plans of care on chart (20 patients from baseline chronic illness registry, alright if 0)
Institute team management strategiesMonthly, select 10 charts from patients
seen in the chronic/complex disease registry to audit for presence of written plan of care
Example Forms
1113 Murfreesboro Rd, Ste 319 PO Box 1346
Franklin, TN 37065-1346 Phone: (615) 790-0567
Fax: (615) 595-8030
(YOUR CLINIC NAME) Plan of Care Plan de cuidados
Personal Information/Información Personal Name/Nombre: Nickname/Apodo:
DOB/Fecha de Nacimiento: Primary Language/Lenguaje:
Phone Number/Número de Teléfono: Insurance/Aseguranza:
Date Form Completed/Fecha:
Pediatrician/Pediatra:
Allergies/Alérgias:
Diagnoses/Diagnósticos ICD-9
Resolved Diagnoses/Diagnósticos Resueltos ICD-9
Upcoming Needs/Necesidades Para El Futuro
Patient Care Plan
Name: D.O.B.: Date:
Date for Next Visit: Frequency of Visits: The new changes to your care plan are listed below. Please read the Emergency Care Plan for medication list, emergency management, and routine care. Care Concern/Dx (1) Plan: Care Concern/Dx (2) Plan: Care Concern/Dx (3) Plan: Care Concern/Dx (4) Plan: If your care plan includes a referral and you have not heard from us within one week, please call to confirm the referral has been scheduled. If you have difficulty with following the care plan or filling medications, or if you have concerns, please call the office at (XXX)XXX-XXXX.
Baseline Measurements, 20 charts•Evidence of screening for barriers to compliance•Evidence of linking patients with barriers to compliance to community resources•Evidence of screening for CSHCN registry•Evidence of written care path in the record for those in CSHCN registry
Monthly Measurements10 charts general population: •Were they screened for barriers to compliance? •Were they screened for CSHCN registry10 charts with positive barrier to compliance screen: • Is there documentation of linking patient with a resource to
overcome barrier to compliance?10 charts CSHCN Registry: • Is there evidence of the written care plan you have agreed to
use?
Overall AIM Statement• Involved practices will improve chronic disease registry formation by
50% by the end of data collection.• 25% of registry patients of involved practices will have a care plan
with therapeutic recommendations and/or goal by the end of data collection.• Involved practices will improve screening for risk factors for
noncompliance by 50% by the end of data collection.• 25% of patients with a risk factor for non-compliance will be linked
with community resources needed to promote compliance by the end of data collection.
Requirements for MOC participation
Summit ParticipationBaseline/follow-up NCQA PCMH Medical Home SurveyBaseline/monthly (4 month) data entry/analysis for QIDA parameters
Participation in 2 of 4 technical assistance webinars/conference calls
Participation in final QI Program Synopsis call/meeting