PHMO Care Management 1
PHMO Organizational Structure DUHS Organizational Opportunity Entity PHMO Networks & Populations Northern Piedmont Community Care Medicare & Medicaid Commercial ACO Under/Uninsured Other PHMO Service Lines Ambulatory care management Dark blue outline = physician network
DukeWELL Care Management Continuum 1 2 3 3
DukeWELL Vision • Currently work with populations attributed to us by payers • Become “payer agnostic” and provide services to all Duke patients • Work with inpatient care management, primary care, specialty care and homecare to create a workflow between all of these areas to: • Improve patient satisfaction • Improve patient outcomes through coordination • Increase efficiency • Focus on reduction of ED and inpatient admission/readmission 4
What is complex care management? Definition • A collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the client's health and human service needs • Characterized by advocacy , communication and resource management and promotion of quality and cost-effective interventions and outcomes What do care managers (CMs) do? CMs provide education to patients to promote self managment. They advocate for the patient and link clients with appropriate providers and resources throughout the continuum of health and human services and care settings, while ensuring that the care provided is safe, effective, client-centered, timely, efficient, and equitable. Goal: Optimum value and desirable outcomes for all stakeholders 5
DukeWELL Specialty Rounds When appropriate, being able to meet a patient’s needs in the primary care setting through use of specialty rounds may help: • Improve the patient experience • Prevent a costly, unnecessary ED visit, admission or specialty visit • Help patients feel better, faster AVAILABLE SPECIALTIES Dr. Susan Spratt Dr. Cary Ward Endocrinology Cardiology For advice on… For advice on… • Abnormal EKG / stress test • Which medicine to add next • Statin titration • Interpreting glucose logs • Cardiovascular risk • Insulin dose titration Dr. Jonathan Fischer • Diabetes education reduction Palliative Care • Nurse-led care • Diabetes risk reduction management For advice on… • Goals of care conversations • Advanced care planning Dr. Heidi White Dr. Blake Cameron • Symptom management Geriatrics Nephrology • Psychological services • Spiritual support For advice on… For advice on… • Caregiver support • External services • Decline in ADLs • Preparation for kidney • Palliative care vs. hospice • Polypharmacy failure / dialysis • Sarcopenia, anxiety, anorexia • Dietary counseling • Frequent falls • Medication • Caregiver stress 6 management • Dementia care • Transplant evaluation
DukeWELL Palliative Care Program Can enhance your patients' outcomes and overall experience at diagnosis of a serious illness , through transitions in care and at the end of life by: • Visiting your patient at home or in rehab to assess their needs, functional status and potential barriers to care • Coaching your patient to uncover their goals, enabling you to target care accordingly • Facilitating advanced care planning • Providing coordination for PCP, specialist and outpatient palliative care clinic visits • Connecting your patient to community resources (e.g., transportation) 7
Refer High-risk Patients to DukeWELL • DukeWELL is Duke Health’s ambulatory care management program • Provides support services for high-risk MSSP patients through a number of services, including: • Complex care management • Specialty rounds • Palliative care program WHAT YOU CAN DO… Others Epic-based providers • • When appropriate, refer complex MSSP When appropriate, refer complex patients to DukeWELL using: MSSP patients to DukeWELL by • Web: phmo.dukehealth.org ambulatory referral • Phone: 919.660.9355 (WELL) • Email: duke.well@duke.edu Don’t forget to specify the reason for your referral!
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