3/12/2016 Disclosures Case Management for Socially We have nothing to disclose and Medically Complex Patients Devora Keller, MD Medical Director, Emergency Department Case Management Program Assistant Clinical Professor, UCSF Elizabeth Davis, MD Medical Director of Care Coordination, San Francisco Health Network Primary Care Assistant Clinical Professor, UCSF Objectives Case Describe interdisciplinary models of care for Mr. W is a 62 year old man with CHF, CAD, � complex patients homelessness, and cocaine use disorder with frequent ED visits and admissions for chest pain and shortness of breath in the setting of cocaine use and difficulty Review the characteristics of successful case � managing his medications. management programs He infrequently engages with care and and is difficult Review the skills necessary to partner with case � to find between hospitalizations. He does not go to managers in the care of complex patients shelters or have a functioning cell phone. 1
3/12/2016 Problem Challenges: System Poorly integrated medical, psychiatric, addiction � Five percent of patients account for 50% of health- � and social services. care costs. Insufficient self management coaching leaves � Often these pts are poor and have high rates of � patients unable to manage their chronic conditions chronic disease, mental illness, and/or addiction. Inadequate support with complicated medication � Multiple barriers to effective care: homelessness, � regimens leads to medication errors and non- low literacy, social isolation, language barriers, adherence addiction, and mental illness. support limits patients ’ ability to follow-up. Lack of caregiver support and/or transportation Barriers to health care result in high rates of ED � � visits and hospitalizations, driving high costs Challenges for providers Challenges for patients Providers are overwhelmed by the patient ’ s � Competing personal priorities (the search for food, � complex social situation housing, and safety) interfere with accessing medical care. Providers do not feel competent to address � patients ’ follow up complex care issues such as homelessness Mental illness and/or substance use interfere with � Providers lack the skills to recognize and leverage � patient strengths and resiliency factors Lack of social support makes self-management � challenging Overcoming language differences can feel � impossible Other issues –lack of trust, language, costs- are � barriers to seeking care. Real or perceived cultural biases may impede � effective alliances between patients and providers. 2
3/12/2016 A Brief History of Case Management 1970s 1970s 1980 1980 Case 1990s 1990s management Medicare for patients demonstration 2010s 2010s with severe HMO-based projects mental illness nurse case Primary care- management based complex Homelessness care focused case management management Health Homes Craig, C; Eby, D; Whittington, J. Care Coordination Model: Better Care at Lower Cost for People with Multiple Health and Social Needs. Institute for Healthcare Improvement, 2011. Berry�Millett R, Bodenheimer TS. Care management of patients with complex health care needs. Synth Proj Res Synth Rep. 2009 Dec;(19) Shared Characteristics of Effective Care Steps of Program Design Management Programs Systematic process for identifying high risk patients � Comprehensive patient assessment on enrollment � Iteratively Iteratively Choose your Choose your improve your improve your Strengthen Strengthen population population Develop and Develop and enhanced enhanced partnerships partnerships Revolutionize Revolutionize Interdisciplinary care plans � and learn and learn test out your test out your care model to care model to within and within and patient patient about its about its enhanced enhanced fit the assets fit the assets outside of outside of engagement engagement assets and assets and care design care design and needs of and needs of your your needs needs your your organization organization Tracking progress of care plan goals population population � Reduce barriers to care at the system, provider, � and patient level Learn to Operate Sustainably at Full Scale: 5 to 25 to 125 to …. Include face to face visits � Berry�Millett R, Bodenheimer TS. Care management of patients with complex health care needs. Synth Proj Res From: Institute for Healthcare Improvement, Better Health at Lower Cost Collaborative Synth Rep. 2009 Dec;(19) 12 3
3/12/2016 Variability in Program Successful Program Models: Primary care based – Ambulatory ICU Design Duration of services � Intensive primary care � Intensity of services � Efficient utilization of specialty services Focus of services � � Availability � Employer based: Boeing, Stanford, Atlantic City � Length and approach to engagement period � Casino Workers Union Location of services � � Clinic based Safety net: Hennepin County Medical Center, � � Free standing Denver Health � Outreach/home-based Bodenheimer, T. Strategies to reduce cost and improve care for high utilizing Medicaid patients: Reflections on pioneering programs. Center for Health Care Strategies, October 2013. Redesigning Primary Care For Breakthrough in Health Insurance Affordability Model I: The Ambulatory Intensive Caring Unit. August 2005, California Health Care Foundation Successful Program Models: Successful Program Models: Primary care based – Wrap around Health Plan Based Patients keep their PCP � Community Care of North Carolina � � Face to face visits in hospital, home, primary care Interdisciplinary, usually nurse-led, team provides � office supportive services � Focus on safe transitions in care, self management, medications San Francisco Health Network � � Nurse led with strong pharmacy component � Nurse-health coach dyad with MD and SW support � Hospitalizations state-wide decreased 10.5% � 50% fewer hospital days after enrollment � Readmissions state-wide decreased 10.2% Cambridge Health Alliance � � Nurse-SW dyad with MD support DuBard CA, Cockerham J, Jackson C. Collaborative accountability for care � 40% fewer hosp days; 30% lower cost transitions: the community care of North Carolina transitions program. N C Med J. 2012 Jan�Feb;73(1):34�40 4
3/12/2016 Successful Program Models: Successful Program Models: Community Based and Street Outreach Community Based and Street Outreach Emergency Department Case Case Continued Management Program MSW based intensive case management program � After extensive street outreach efforts, Mr. W Wrap around medical services � engaged with a case manager with the Emergency Linkage to housing, entitlements, primary care, � Department Case Management Program mental health, substance abuse services Engaged and learned self-management skills � Direct mental health and SUD counseling � Started taking medications � Though motivational interviewing by CM decided to � Outcomes: enroll in residential treatment program Decrease in ED usage � On graduation from residential program linked to � Decrease in hospitalizations (not statistically sig) � long-term housing Decrease in homelessness � Decrease in problem drinking. � Shumway M , Boccellari A, O’Brien K, Okin RL. Cost�effectiveness of clinical case management for ED frequent users: results of a randomized trial. Am J Emerg Med. 2008 Feb; 26 (2): 155�64 Successful Program Models: Best Practices for Collaborating with Members of the Case Management Team Homeless Focused � Chicago Post hospitalization transitional housing with • Understand the role/ scope of practice of various � linkage to long term housing members of the team – ask for clarification if needed! Housing-based MSW led case management � • Maintain active communication and collaboration Randomized controlled trial � Support each other and avoid opportunities for • Outcomes: client splitting 24% decrease in hospital days � 29% decrease in emergency department visit � • Recognize differences in language and approach Sadowski LS, Kee RA, VanderWeele TJ, Buchanan D. Effect of a between different disciplines on the team housing and case management program on emergency department visits and hospitalizations among chronically ill homeless adults: a randomized trial. JAMA. 2009 May 6;301(17):1771�8. 5
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