Population Management and Using a Registry to Drive Care Session 4 Used with permission from the University of Washington AIMS Center Used with permission from the University of Washington AIMS Center
Learning Objectives • Define measurement ‐ base care and treatment to target and give an example of using a registry as an RN care manager • Describe how a registry is a population ‐ based tool to use with a caseload of SPMI clients in a behavioral health setting • Practice with patient cases the actions you would take as a RN care manager 2 Used with permission from the University of Washington AIMS Center
Population Health Management Population Health • The health outcomes of a group of individuals, including the distribution of such outcomes within the group www.ihi.org 3 Used with permission from the University of Washington AIMS Center
Measurement ‐ Based Care “Involves the systematic use of symptom rating scales to drive clinical decision making.” https://www.thekennedyforum.org/news/measurement ‐ based ‐ care ‐ issue ‐ brief 4 Used with permission from the University of Washington AIMS Center
Measurement ‐ Based Care in Practice • Data collection integrated into clinical workflow. Standard protocol for data collection at prescriber visit. Who and where recorded? —Weight/ BMI —Blood pressure —Labs • Outside lab results called to attention of prescriber or PCP, as necessary • During course of treatment, BMI regularly tracked and 12 ‐ week labs obtained 5 Used with permission from the University of Washington AIMS Center
What is a registry and what do you do with it? 6 Used with permission from the University of Washington AIMS Center
Example Systematic Case/Data Review • When: Weekly, 60 ‐ 90 minute sessions • Who: Medical RN care manager, prescriber, case managers • How: In ‐ person or by phone – Registry & EHR must be available to both • Goal: Monitor entire caseload over time – Review all patients on caseload in one session – Only priority patients over several sessions 7 Used with permission from the University of Washington AIMS Center
Small Group Activity Collaborative Care Lab Instructions 1. In groups of five, assign care team roles A. Care Manager B. Primary Care Consultant C. Psychiatrist Consultant D. Case Manager E. “Scribe,” if not one of the above 2. Review four cases and their accompanying registry in the next 15 mins. 3. Develop a treatment plan, assigning tasks to each team member. 8 Used with permission from the University of Washington AIMS Center
Contact Information • John Kern MD jkern2@uw.edu 13 Used with permission from the University of Washington AIMS Center
Evaluations & Adjourn The project described was supported by Funding Opportunity Number CMS-1G1-14-001 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies. 14
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