Patient Navigation and Midas+ Community Case Management · 2013 Midas+ User Symposium - 2 -...

Patient Navigation and Midas+

Community Case Management

John Playford Midas+ Implementation Consultant

Patient Navigation

Objectives for this Session:

• Arrive at a common understanding of Patient Navigation as

it relates to this presentation.

• Define and Discuss Navigation Models

• Explore the need for an information system

• Relate the Community Case Management module to the

Patient Navigation model as a communication/tracking tool.

- 2 - 2013 Midas+ User Symposium

Navigation in the real world


Navigation in the real world (continued)

Let’s Zoom in a bit, does that help?


Patient Navigation

In what way is navigating the continuum of care similar to our scenario?


If I only had a GPS!

The Goals of using a GPS or SmartPhone:

• Show me where different establishments are located.

• Streamline my movement from address to address

allowing me to accomplish my goal.

• Ensure I reached my partner in a timely manner.

• Eliminate many barriers to accomplishing my task.


Patient Navigation

Patient navigation in cancer care refers to individualized

assistance offered to patients, families, and caregivers to help

overcome health care system barriers and facilitate timely

access to quality medical and psychosocial care from pre-

diagnosis through all phases of the cancer experience.

Navigation services and programs should be provided by

culturally competent professional or non-professional persons

in a variety of medical, organizational, advocacy, or

community settings. The type of navigation services will

depend upon the particular type, severity, and/or complexity

of the identified barriers.

C-Change – Collaborating to Conquer Cancer, http://www.cancerpatientnavigation.org/resources.html


Patient Navigation (continued)

Goals

• Provide Resource Support

• Streamline Patient Care

• Ensure timely diagnosis and treatment

• Eliminate barriers to care


Navigating the Care Continuum

• Prevention

• Screening

• Diagnosis

• Treatment

• Survivorship


Patient Navigation Models

Non-Clinical

• Lay Navigator

• Volunteer Navigator

• American Cancer Society (ACS) Navigator


Patient Navigation Models (continued)

Clinical

• Social Worker

• Nurse

• Advanced Practice Nurse


Navigator Responsibilities

• Clinical Responsibilities

• Performance Improvement Responsibilities

• Research

• Promotional Responsibilities


Will this GPS work for me?

Let’s take a look at some of the major points and relate them to Community Case Management.


Waypoints in our Journey

• Identify Patients for

Program

• Assess and Enroll

• Document the team

• Past Medical History

• Ongoing Evaluation

• Issue Identification

• Issue Resolution

• Resource Referrals

• Appointment Tracking


Our Journey in Midas+ CCM

Let’s look at a

roadmap for this

journey.


Identify Patients for Program

What are some ideas for identifying patients for

your Navigation program?

• Worklists based on Diagnosis Code

• Referrals from Inpatient Case Manager

• Physician Referrals

• _____________________________

• _____________________________

• _____________________________


Assess Patients for Program

• Once identified, assess patients to make certain

they fit your program’s criteria.

• Intake assessment in Community Case Management based on

organizationally developed criteria.


Intake Assessment Example

• Basic Demographics

• Name, Address, Phone Number, Emergency Contact Person

and Number

• How was Patient Referred to the program?

• Physician, Hospital, Nurse, Social Worker, Other

• Information from Physician

• Diagnosis

• Biopsy Date/Result


Intake Assessment Example (continued)

• Health Insurance Information

(which should already be available in Midas+)

• Barriers to Care Identification

(Move to Problem List)

• Financial Concerns

• Transportation

• Physical Needs

• Communication Needs

• Treatment Issues



• Family History

• Diagnostic Tests

• Labs

• Radiology

• Pathology


CCM Assessments

Why not use a Focus Study?

• No ability to move to CCM Problem

• No link with CCM Episode


CCM Assessments (continued)


Continue Pt. Assessment in Episode

• Create an Episode

• Continue to collect data within Episode

• Identify additional problems for problem list


Creating an Episode in CCM


CCM Episode


CCM Episode (continued)


Patient Medical History


Patient Medical History (continued)


Problem Update


Problem Update - Assessment


Problem Update - Episode


Problem Update


Problem Update (continued)


Referrals and Interventions

This is an extremely powerful area that can

facilitate the following:

• Documentation of any type of referral or

intervention.

• Tie any referral or intervention back to a specific

item on problem list.

• Create worklists for future reminders of virtually any item or task.


Referrals and Interventions (continued)


Worklists


CCM Encounter Update


Revisit the Map

So when we put all

of this together:

• Where does it

lead us?

• Where can I get

metrics from my

journey?

• Next Steps


Did We Reach Our Destination?


Next Steps

• How is your navigation process structured?

• Are they using a centralized database to

document their process?

• Showcase some examples of what we have seen

today.

• Attend the Hands-on CCM class to gain ‘nuts and bolts’ set-up knowledge


Navigation in the real world


Thank you for attending.

Questions?

John Playford

Implementation Consultant

[email protected]


Patient Navigation and Midas+ Community Case Management · 2013 Midas+ User Symposium - 2 -...

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