Evolution of Care Management and Population Health at SCHC1992- Episodic provider-patient care, UDS reporting via chart
sampling1995- Empaneling Patients1998- BPHC Health Disparities Collaboratives- RN assigned to
registries2003- i2i- additional case managers, quality manager2005- Added Clinical Pharmacist 2011- EMR implementation, MU, UDS reporting of entire patient
population2012-17- Quality Committee optimization, organization chart changes,
PCMH, Quality Specialist, Health Coach Training
Roles of the Health Coach at SCHC
• Assigned to 3-4 provider teams• Participate in daily provider team huddles• Participate in provider team quality huddles (every 6-8 weeks)• Contact A1c>9 monthly, production expectations (monthly scorecard)• Enroll at risk patients into the Enhanced Care Coordination program
and manage them accordingly• Individual assignments- ER follow up, hospital follow up, procedure
follow up • PTAT, i2i, iTi
Health Coach Training
• Iowa Chronic Care Consortium
http://clinicalhealthcoach.com/siouxland/
Future
• Certified Diabetic Educators• Insulin pump management• Certified Diabetic Education Center- AADE• Importance of Risk stratification• Global Care Management- not just by payor• UDS National Quality Award goal• CCM of Medicare patients
Clinical Pharmacy Service Goals• Improve patient outcomes
• Improved disease state status• Identify and reduce adverse drug events• Manage pharmaceutical cost
• Decrease workload on licenses independent practitioners• Increase capacity of licenses independent practitioners
Who Receives Services?• Multiple Comorbid Conditions• Poorly Controlled Disease States• Barriers to Healthcare• Social Determinates of Health• Frequent Flyers• Quality driven initiatives• ER and Hospital Admissions
Top 15 Cause of Admissions1
Pneumonia Congestive Heart Failure
Chest Pain/ Coronary Artery Disease/Heart
Attack
Chronic Obstructive
Lung disease
Stroke Irregular Heart Complication of Procedures Mood disorders
Fluid and Electrolyte Disorders
Urinary Infections Asthma Diabetes
Skin/Systemic Infections
GI Related Disorders Hip Fractures
Medication Misuse 2
Pneumonia Congestive Heart Failure
Chest Pain/ Coronary Artery Disease/Heart
Attack
Chronic Obstructive
Lung disease
Stroke Irregular Heart Complication of Procedures Mood disorders
Fluid and Electrolyte Disorders
Urinary Infections Asthma Diabetes
Skin/Systemic Infections
GI Related Disorders Hip Fractures
Adverse Drug Related EventsDiuretics
NSAID
Anti-diabetic
Antiplatelet/Anticoagulation
Opioids
Antipsychotics/Sedatives
Misadventures in medication• Overuse and Underuse• Expected or Unexpected Side Effects• Drug Interaction• Never Prescribed• Missed laboratory monitoring• Medication Errors
Where can pharmacists help?• Diabetes• Hypertension• Anticoagulation• Asthma/COPD • Polypharmacy• Multiple comorbidities• Hepatitis C
Patient Centers Services• Education
• Medication • Disease State
• Transitions of Care• Medication management/Reconciliation• Disease state monitoring• Goal Setting
Collaborative Practice• Between pharmacist and physician
• Medication Titration• Hypertension• Diabetes• Respiratory Care• Warfarin
• Routine Lab monitoring
62.00%
64.00%
66.00%
68.00%
70.00%
72.00%
74.00%
Seen by Pharmacist Not Seen by Pharmacist
Perc
enta
ge o
f Pat
ient
s
Blood pressure at Goal
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
Historically Blood Pressurewas at goal, above goal
now
Has not achieved Bloodpressure goal
Perc
ent o
f Pat
ient
s
Hypertension Poor Control
Seen byPharmacist
Not Seen byPharmacist
Organizational Centered Services• Pharmacy and Therapeutics• Provider education• Treatment Guidelines
Funding• 340b savings• Incident to Billing– 99211• Chronic Care Management Billing• Annual Wellness Visits• Immunizations• Performance Incentive Payments
References• Elixhaser A. Owens P. Reasons for being admitted to the hospital through the emergency department 2003: Statistical brief #2. 2006 Feb. In: Healthcare Cost and Utilization project: (HUCP) Statistical Briefs Rockville (MD): Agnecy for Healthcare Research and Quality 9US) 2006 Feb-.
• Howard. RL, Avery AJ, et al. Which drugs cause Preventable admissions to hospitals? A systemic review. Br J ClinPharmacol. 2007 Feb; 63(2):136-147. Published online 2006 26.
• Cost of ESRD https://www.usrds.org/2013/view/v2_11.aspx
• Care management at PCHC is shared across the care team and involves nurses, aids, health coaches, referral and scheduling staff.
• Communication and sharing pertinent information is important to avoid missed care opportunities.
• Our formal huddle process was initiated in April 2015 as part of our PCMH accreditation.
• The process focuses on age and disease specific care measures. A separate huddle form was developed for adults and pediatrics. A huddle form is completed for each provider and reviewed with that provider at the beginning of the day.
Provider______________________ Date______________
Time_____Name_____________ RFV:
ð Wellness code date_____Due__ ð DM: A1c,LEAP,eye,microalb ð Orders/Referrals: OK / DUE
ð Pop-ups None / Ok / Delete ð 18+ SBIRT, PHQ OK/DUE ð Pap: Ages 21-64 : Last Date
ð HHB/Adv Directives: OK / DUE ð Colon cancer: Age 50-75 DUE ð Mammo: Ages 40-75 : OK /DUE
ð IZ: Flu / Tdap / Pneumovax ð BMP, TSH, LIPIDS OK/ DUE ð Reports: Referral, ER/ Hospital
Zostavax/Prevnar ð HIV/Hep C screening
Example of adult huddle sheet
June 2016 Team Huddles# of pt on
huddle# of pt
reviewed % reviewed
(Provider name) 104 52 50%
NSP Missed 2 (3.8% of reviewed)
Mammo Missed 2 (3.8% of reviewed)
Td Missed 7 (13.5% of reviewed)
Micro Missed 8 (15.4% of reviewed)
AD Missed 26 (50% of reviewed)
Pneumo Missed 1 (1.9% of reviewed)
PAP Missed 1 (1.9% of reviewed)
DM Eye Missed 2 (3.8% of reviewed)
Orders Missed 1 (1.9% of reviewed)
A1C Missed 1 (1.9% of reviewed)
Leap Missed 1 (1.9% of reviewed)
Colon Missed 1 (1.9% of reviewed)
• Labor intensive and dependent on staffing• “No one’s favorite task”• Varied levels of engagement with providers
• Purchased the iTi module for i2i.• Development process for the iTi huddle has been a group effort.• Same idea as the paper huddle sheet: looking at age and disease specific care measures. • Protocols developed for each measure. • Difficulties have included IZs with complex schedules (pneumonia, HPV), and catch up
schedule for IZs. • Goal: to decrease staff time spent in preparing huddles, increase use of huddles to
decrease gaps in care. • Needed to invest in 2 additional color printers to take advantage of the color coding on
the huddle sheets.