Offer Integrated, Complex Care Management

Phase II: Develop Integrated Complex Care Systems (Whole Health Homes)

DOMAIN 9: OFFER INTEGRATED, COMPLEX CARE MANAGEMENT

Develop Complex Care Management Core Curriculum Materials

July – Oct 2016

  • Complex Care Management curriculum developed to include training content, training plan, tools and references
  • Develop TRAIN THE TRAINER Motivational Interviewing (MI) program
  • HCO identifies 1-2 BHICCI team members to engage in the MI ‘train the trainers’ curriculum

Oct 2016 – Feb 2017

  • Offer ICCM curriculum through virtual and in-person training/consultation
  • Focus practice coaching/testing on ICCM core processes
  • Provide in-person training for Care Manager

Feb – July 2017

  • Offer ICCM curriculum including both refreshers and more in-depth training

Jul 2017- Feb 2018

  • Plan to SUSTAIN clinical improvement.
Educate Clients and Providers about Benefits of Integrated Complex Care Management

July – Oct 2016

  • Develop client education/ engagement tools regarding the benefit of coordinated care Scripts/visual tools to inform patients
  • Scripts to inform/engage other providers
  • Ensure that universal releases are signed by each patient to include key providers-as required within each HCO

Oct 2016 – Feb 2017

  • Test and refine scripts and educational materials related to benefits of ICCM Develop/test in key languages

Feb – July 2017

  • Spread use of client and provider informing materials across HCO when implementing Health Home Program
Screen patients for mental health, physical health and substance use conditions

July – Oct 2016

  • Provide appropriate TRAINING
    • Assist teams in testing new screening tools, procedures with TP
    • Design efficient screening and workflows

Oct 2016 – Feb 2017

  • Refine screening procedures including consideration of criteria for patients to use self-administered screens
  • Standardize core screening processes

Feb – July 2017

  • STANDARDIZE BH and vitals screening tools and procedures and test SPREAD to a portion of clinic/site patients beyond the TP

Jul 2017- Feb 2018

  • SPREAD routine use of selected BH and/or medical screen­ing process for clinic/site population
Outreach and engagement for difficult to engage patients.

July – Oct 2016

  • ID team outreach lead and member(s) that will outreach to identified TP—including phone and field-based for difficult to engage patients
  • Develop/test protocols for timely outreach (including community based outreach) to patients who are disengaged
  • As contact is made use patient centered engagement strategies including focus on basic needs

Oct 2016 – Feb 2017

  • Continue outreach to refresh TP, including patients that use hospital and ED rather than PC or BH clinic/site
  • Develop/test outreach strategies and protocols across key care transitions
  • Refine and document outreach tools and processes

Feb – July 2017

  • Standardize patient outreach and engagement strategies and protocols in collaboration with hospitals/ EDs, etc.
  • Spread outreach/engagement protocols and test across/ among key systems

Jul 2017- Feb 2018

  • Sustain and evaluate/ measure policies and protocols for cross system outreach and care transitions
Promote Health Literacy Including Supporting Medication Literacy

July – Oct 2016

  • Train/educate team members re: the importance of patient/client health literacy for treatment adherence and self-management of chronic conditions.
  • Test development/use of evidence-based strategies to address health literacy including strategies such as “teach back” from National Action Plan to Improve Health Literacy and AHRQ Health Literacy Universal Precautions Toolkit
  • Plan and test workflow processes for Care Manager/ Wellness Coach to review health indicators and shared care plan objectives with client during each visit
  • Support consumer health literacy about MEDICATIONS AND SIDE EFFECTS through health teaching and other resources

Oct 2016 – Feb 2017

  • Team refines strategies to support consumer self-management skills using evidence based approaches and
  • Offer whole health programs/ curricula
  • Develop strategies with each patient/client to engage natural supports in promoting wellness
  • Use trained peer services and community health workers to promote patient and family member health literacy
  • Develop/adapt and test picture-based or graphic based instructions re: medication use
  • Test expanded use of literacy tools for medication adherence and management of chronic conditions with target population

Feb – July 2017

  • HCO leaders develop policy to support use of health literacy strategies/tools and tests expansion to other clinics/ sites
  • Standardize/ Spread use of literacy tools such as tools including medications/ medication adherence

Jul 2017- Feb 2018

  • HCO leaders sustain use of standardized evidence based health literacy strategies/ tools through training, and monitoring system-wide implementation impact on consumer experience of care
Medication Reconciliation/ Shared Medication Lists Among Providers

July – Oct 2016

  • Test process for creating accurate list of patient’s medications including OTC, herbal supplements (medication name, dose, frequency of use, route of administration). Compare and adjust Medication List at any transition point within a hospitalization or outpatient visit.
  • Map current medication reconciliation workflows
  • Train and coach team members to test and perform routine medication reconciliation with target population patients at each visit
  • Coach patients to carry updated medication list with clear written instructions

Oct 2016 – Feb 2017

  • Refine clinic/site’s patient centered medication reconciliation processes
    • Develop of clear written medication adherence plans with patients
    • Medication checklist
    • Use of smart phone apps
  • Refine and standardize workflows which support accurate and routine medication reconciliation including sharing of reconciled medication lists across patient’s providers
  • Standardize medication reconciliation processes and integrate into the EHR

Feb – July 2017

  • Spread use of Medication Reconciliation and Medica­tion Adherence policies, proto­cols, workflows, and tools such as smart phone applications to clinic/site popu­lation

Jul 2017- Feb 2018

  • HCO leaders develop and execute a plan spread and sustain effective medication reconciliation and patient medication adherence practices to other clinics or entire HCO system
Promote “Shared Decision Making” with patients as the center of their shared care plan and care team

Oct 2016 – Feb 2017

  • Offer training and coaching re: impact of shared decision making on improved treatment adherence and health out­comes
  • Support team to test shared care plan/planning centered on patient/client treatment and self-management goals, including MH and SUD, medical conditions and social determinants such as housing, that interfere with health.
    • Adapt/use sample shared care plan
  • Refine shared care planning process and tools including development of Shared Care Plan pocket guide for patients
  • Conduct focus group or interviews with patients/clients to assess the usefulness of Shared Care Planning and Shared Care Plans

Feb – July 2017

  • Develop share care plan for all ICCM pa­tients includ­ing 1-3 patient goals
  • Standardize/ Spread patient-centered Shared Care Plan template.

Jul 2017- Feb 2018

  • HCO leaders adopt shared decision making guidelines as policy including the use of patient/client centered shared care plans
Share care plan across providers

Oct 2016 – Feb 2017

  • Test processes (secure fax, registry, population health tool) to communicate shared care plan among client/patient and providers (PC, MH and SUD–and specialty providers).
  • Refine shared care plan communication processes including use in case conferences/ consultation and structured population health review.
  • Test sample of providers’ use of shared care plan (beyond the BHICCI team).

Feb – July 2017

  • Standardize and spread use of a shared care planning processes (integrated with EHR as possible).
  • Test/implement additional strategies to ensure that substance use and addictive disorders are addressed across provider continuum.

Jul 2017- Feb 2018

  • HCO leaders develop a spread plan to sustain shared decision-making and use of patient/ client centered shared care plans for individuals with complex conditions.
Use registry to track patient engagement and adherence and treatment outcomes

July – Oct 2016

  • Train team to measure and track treatment engagement, adherence, and wellness outcomes for each individual’s medical and BH condition(s) recording medical/ BH indicators and regular screening results in a population health tool/ registry.
  • Design workflows for collecting measures at appropriate intervals and data entry into registry or EHR registry tool Schedule pre-visits
  • Determine if patients can self-administer or require staff support

Oct 2016 – Feb 2017

  • Team shares out­comes with patient as a core aspect of care management and/or treatment planning/provision
  • Refine workflows and protocols for collection of patient measures and entry into registry/population health tool/EMR

Feb – July 2017

  • Standardize/ Spread and teach use of registry and measurement based prac­tice for com­plex patients beyond those included in BHICCI target population

Jul 2017- Feb 2018

  • HCO leaders develop/ implement plan to spread and sustain use of patient registry/ population health tool
Provide Measurement- Based Care, including tracking clinical outcomes using standardized measures

July – Oct 2016

  • Train staff to refer to patient’s measures and to use patient measures (BH/ medical) in evidence-based integrated care/ treatment

Oct 2016 – Feb 2017

  • Refine procedures and protocols for use of clinical outcomes in treatment processes
  • CM as well as BH and other providers use trended outcome measures data to determine need for change in treatment

Feb – July 2017

  • Standardize/ Spread measurement-based practice processes which are integrated into the EHR and whose results are easily shared with other relevant healthcare organizations.

Jul 2017- Feb 2018

  • HCO leaders develop and implement policy including training and monitoring of measurement based care and use of standardized evidence-based measures
Conduct Systematic Caseload Reviews (SCRs) that identify and prioritize patients that need attention

July – Oct 2016

  • Introduce concepts of systematic population-based caseload reviews with BHICCI populations.
  • Train and support staff testing SCR meeting roles/tasks.
    • Develop system for prioritizing caseload for SCR
    • Implement routine SCR schedule

Oct 2016 – Feb 2017

  • Refine SCR processes and develop standardized workflows that support improved clinical outcomes.
  • Test and refine integration of SCR processes (including treatment recommendations) into the EHR or popula­tion health tool

Feb – July 2017

  • Standardize SCR process­es to create spread to other pa­tients with complex care needs within the HCO.

Jul 2017- Feb 2018

  • Sustain and spread use of SCR beyond target population and clinic, including introducing policies and protocols for larger HCO
Provide caseload focused psychiatric consultation

July – Oct 2016

  • Focus psychiatric consultant recruitment on practitioner skilled in recognition and treatment of alcohol and other drugs of abuse
  • Train team to effectively use a Psychiatric Consultant including providing clinical data for informed assessment and treatment recommendations.
  • Test consultation related communication processes and protocols to increase effectiveness of consultation

Oct 2016 – Feb 2017

  • Refine consultation processes including communications, sharing of consultant recommendations and use of clinical practice guidelines related to consultant recommendations.
  • Consultant is supported to foster/ nurture relationship with clinic/site’s other providers through formal and informal methods

Feb – July 2017

  • Standardize consultant protocols including: when to use caseload consultant, access to “ad hoc” consultation, and relationship/access to clinic/sites providers.
  • Develop and test financing/reimbursement strategies to continue use of medical consultant in behavioral health settings

Jul 2017- Feb 2018

  • Develop consulting agreements with individual psychiatrist or BH HCO to SUSTAIN availability of skilled medical consultation. Include financing in plan for sustaining consultation
Provide caseload focused medical consultation

Oct 2016 – Feb 2017

  • Train team to effectively and efficiently use a Primary Care Consultant, including providing sufficient data to make a well-informed assessment. Based on assessment, the Medical Consultant makes treatment recommendations, which are shared with the psychiatric and/or primary care provider caring for that patient.
  • Test consultation related communication processes and protocols to increase effectiveness of consultation.
  • Refine consultation processes including communications, sharing of consultant recommendations and use of clinical practice guidelines related to consultant recommendations.
  • Test/refine methods for Consultant to foster/nurture relationship with clinic/ site’s other providers through formal and informal methods

Feb – July 2017

  • Standardize consultant protocols including: when to use caseload consultant, access to ad hoc consultation, and relationship/ access to clinic/sites providers.
  • Develop and test financing/reimbursement strategies to continue use of medical consultant in behavioral health settings

Jul 2017- Feb 2018

  • Develop consulting agreements with individual physician or HCO to SUSTAIN availability of skilled medical consultation. Include financing in plan for sustaining consultation
Coordination of Care: Facilitate timely and effective communication between patients’ specialty and other care providers
  • Team identifies types of external providers (specialty providers, provider organizations (hospitals, ED, etc.) and communications that are commonly problematic
  • Develop typical provider communication workflows to identify communication breakdowns and areas for improvement:
    • Sharing/using care plans
    • Information to and from ED
    • Hospital Discharge plans
  • Conduct brief interviews with sample providers/provider types to identify potential improvements from their perspective (What needs to be communicated? Best vehicle (fax, EMR, What feedback provider wants, etc.)
    • Test improvements using PDSA cycles for key areas of provider communication with 2-3 providers

Oct 2016 – Feb 2017

  • Refine provider communication protocols/processes based on prior PDSA results: for specific types of providers, include preferred communication processes, timeframes, format…)
  • Test with larger group of providers, refine protocols and processes
  • Survey providers (usually BHICCI team and external provider office staff, nurses) to verify improvements and/or additional concerns

Feb – July 2017

  • HCO leaders develop and support standard communication protocols- with­in HCO and across providers
  • Spread communication protocols within network of frequently accessed providers

Jul 2017- Feb 2018

  • HCO conducts 6 months/ annual survey to determine effectiveness of communi­cations with key providers/ organizations
Facilitate and track completion of referrals.
  • July – Oct 2016

    • Design and test referral and tracking protocols/workflows to facilitate communication between referring/receiving providers, including assignment of team member to coordinate referrals. Includes:
      • Referral protocols
      • Tracking appointments including receipt of patient information
      • Appointment completion and results/clinical note received
      • Follow up on referral recommendations
    • Test strategies to prepare patients for the referral including reasons for referral, what to expect, prepare questions for referral appointment.

    Oct 2016 – Feb 2017

    • Refine and standardize referral protocols and processes including time­frames.
    • Develop patient/client referral supports such as easy to follow descriptions of what to expect, forms for noting reasons for refer­rals. May emphasize client use of shared care plan that indicates reason for referral
    • Identify patient conditions that require “advanced access” and test advanced access agreements/protocols with other HCO’s and specialty providers

    Feb – July 2017

    • Standardize referral protocols and policies and patient informing/ support and test use by other pro­viders in the clinic/ site
    • Refine/make any further adjustments in referral protocols based on spread to clinic
    • Refine and standardize “advanced access” policies and protocols

    Jul 2017- Feb 2018

    • HCO finalizes standard Referral Agreements with other HCO’s and providers, including advanced access when clinically indicated
    • Cross HCO leaders address problems that arise in referral pro­cesses
Coordinate transitions of care to ensure patient/client’s successful transition between health care orgs and/or levels of care
  • July – Oct 2016

    • Map workflows for current transitions in care to identify gaps and/ or areas for improvement(e.g. visit to ED, hospitalization)
    • Develop and test strategies to engage patient in understanding specific planned transitions in care

    Oct 2016 – Feb 2017

    • Test/refine care transition processes and develop standardized workflows and protocols to insure patient is stabilized in next level of care, reduce relapses in condition or return to higher levels of care

    Feb – July 2017

    • Integrate standardized care transitions workflow, processes into HCO policies and procedures, including the EHR.
    • Use agreed upon care transition processes to support other patients with complex care needs within the HCO.

    Jul 2017- Feb 2018

    • Sustain effective care transitions through develop­ing and monitoring implementation of agreements (MOUs as needed) for cross agency/ cross-HCO policies
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