Care Management and the role of the Health Coach

Gettysburg Adult Medicine/Brockie Internal MedicinePamela Brant, RN Nurse Care Manager

Julie Assi, LPN Health CoachAmy Mummert, LPN Health Coach

Care Manager

RN Provides service to 3 medical group practices On site for 12 hours a week at Gettysburg Adult Med Provides follow up services to the high risk population Monitors population management Provides education/goal setting/action plan development

to diabetic patients with A1c > 9 % Provides psychosocial/economic interventions in

collaboration of community services/Hospital care managers/social workers

High Risk Criteria

ED/Hospital visits related to a fall if over the age of 65 Any patient visiting the ED/Hospital for the same

diagnosis > 1 time in 3 months Diabetic patients with A1c > 9% Frail elderly (FTT) Referrals from Transition Care Manager (CRNP) Referrals from Health Coach Provider referrals: where a home visit may be

indicated

Health Coach Guiding Principles

STEEEP: Safe, timely, efficient, effective, equitable, patient centered

Triple AIM: Better health Better care Reduce the cost curve

Chronic care model—prepared, proactive care teams, engaged, activated patient

Why do we need this?

Primary care clinicians are “struggling to fit multiple agenda items into the 15 minute visit – cannot meet every need of their patients with chronic conditions.” ( Bennett, Coleman, aafp.org/2010)

“Half of patients leave primary care visits not understanding what their doctor told them.” ( Bennett, Coleman, aafp.org/2010)

Average adherence rates for prescribed medications are about 50 percent, and for lifestyle changes they are below 10 percent.” ( Bennett, Coleman, aafp.org/2010)

“Although clinical research is still being amassed,…..Health coaching has been proven in randomized trials to make a difference…People can be helped using motivational techniques.” (Buckley, 2010)

Health Coach Model:Role Expectations

Call ED/Hosp discharge patients within 48 hours Referral to CM Follow up on self-management action plans New med follow up Address barriers to treatment plan/goals F/u of referrals from CM Population management

Health Coach Program

Mid July 2011--Selection process completed. July 25, 2011– training day August 1, 2011--HC began on a part-time

status September 1, 2011-- HC began full-time 1 HC to 3 providers Transition phone calls– population

management– patient goals Phone conferences

Health Coach Program

HC patient census= 104 patients (mostly transition of care)

3 HF 6 DM 20 Physician referrals 4 Self management Majority of time is spent on transition of care First program audit is underway

Cerner Message ED/Hospital D/C

HC Tracking Form

Discharge Transition F/U Questions

Patient Name: Date: ___________DOB/MRN:_____________________

Provider:ED or Hospital D/C date: _________ F/U appointment Date: Admitting diagnosis: __________________________ 1. Are there any barriers to communication? (Language, hearing,

comprehension, literacy)2. Name of support/contact person: ______________________ Phone Number: _______________________ Relationship to patient: ________________3. How is the patient feeling today?4. Did the patient receive written discharge Instructions when they left the

hospital/ED? No Yes Review the instructions on the form with the patient (teachback). 5. Is the patient able to identify any warning signs or symptoms for their

condition. (Hypo/hyperglycemia, CHF, A- fib, pneumonia, chest pain, etc.) No Yes N/A

6. Does the patient have any restrictions in activity? No Yes N/A Details:

7. Does the patient require assistance with ambulation? No Yes N/A Details:

8. Does the patient have diet instructions or fluid restrictions? Details. No Yes N/A

Details: 9. Complete medication reconciliation: ask patient to get pill bottles for

review, retrieve discharge summary from chart and discharge instructions from PowerChart, if available. Be specific and review with the patient how they take them, how often and what they are taking each medication for.

____Medication reconciliation completed—no changes needed ____Medication reconciliation completed—changes made to eCare medication

record. ____Discrepancy from discharge summary regarding “resume home meds”.

Medication changes since hospital admission:

10. If the patient is not following medication regime determine the eason and provide intervention.

Intervention:

11. If any gaps are identified provide education or instruct them to follow up with their PCP or make an office appointment with Health Coach or Care Manager

____Additional interventions:

_____No additional interventions needed.

12. Are there any other services ordered? (Home Health, Outpatient therapy, etc)

List name of service; _______________________________________________

HC Signature: ______________________________________ Date: ________________________

Medication Dose Frequency

Upcoming Care Management Projects

Transition Care Manager (TCM)– CRNP Pilot completed Currently recruiting for position See patient in hospital F/U at home Refer to additional services as necessary Refer to Nurse Care Manager

Hospital Social Workers to begin joint service to hospital and medical group practices Pilot running in 2 medical group practices SW will spend specific amount of hours in practice weekly

Care Management Swim Lane Diagram

WellSpan Case Management Continuum Transition

(Pat

ient

’s H

ome/

R

ehab

)

Outpatient

(PC

MH

/ Ret

ail C

linic

/ R

eady

Car

e/ S

peci

alty

C

are/

ED

)

Inpatient

(Hos

pita

l/EC

F/

Obs

erva

tion)

Transition Care Manager

(CRNP)and/or VNA

WMG Case Manager/ RN

Practice Health Coach(Embedded in Practice or Virtual)

Community Case Manager (Bell

Social Services, BHS, etc.)

Illness/ Injury Priority Chronic Diseases(Diabetes/Heart Failure/COPD/Adult

Asthma/CAD)

Wellness

Hospital Case

Manager/ RNSocial Worker/Health Plan Case Manager

Goals:Better CareBetter HealthBetter Value