IC 3 Beacon Pilot Diabetes Care Coordination Training Care

1. IC3Beacon Pilot Diabetes Care Coordination TrainingCare Sarah Woolsey, M.D. Janet Tennison, PhD HealthInsight, August 16, 2012

2. Welcome

3. Pre-work

4. Today’s Objectives • Understand Care Coordination and Self-Management • How to identify high risk patients with diabetes in your system • Assessing patients’ needs and goals • Health Literacy • Motivational Interviewing • Stages of Change • Teach Back • Planned follow-up • ProQual tool • Starting Care Coordination in your setting

5. Definition: Care Coordination “The calculated integration of patient care activities between two or more participants, to facilitate the suitable provision of health care services” Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination).Technical Reviews, No. 9.7. McDonald KM, Sundaram V, Bravata DM, et al.Rockville(MD): Agency for Healthcare Research and Quality (US); 2007 Jun.

6. Coordination--Why Do We Need It? • Determine the patients’ goals • Assist those “high-risk” patients who have been unsuccessful at managing their own care • Engage patients to improve their self-care • Improve the exchange between providers, patients, community services

7. We Sometimes Get Frustrated

8. Removing Barriers to Accomplish Goals

9. Engaging Patients in Their Own Care

10. Traditional Collaborative • Professionals are experts, patients passive • Behavior change externally motivated • Non-compliance is personal deficit • Providers experts about disease; patients experts about lives • Behavior change internally motivated • Lack of goal achievement requires modifications Bodenheimer, T., & Abramowitz, S. (2010). Helping patients help themselves: How to implement self-management support. Oakland, CA: California HealthCare Foundation.

11. Differences Traditional Patient Education Self-Management Education Skills to act on problems Problems ID‘dby patients Improving confidence Goal is increased self-efficacy to improve Health team, peers, educators • Technical skills • Problems with disease control • Disease-specific knowledge • Goal is compliance to improve outcomes • Health professional is educator Bodenheimer, T., & Abramowitz, S. (2010). Helping patients help themselves: How to implement self-management support. Oakland, CA: California HealthCare Foundation.

13. Developed by Janet Tennison, PHD, Adapted from Kirsch et. al., 2008

14. Essential CC Tasks Identify high-risk patients Assess patient Develop care plan Identify care participants, communicate needs Execute care plan Monitor and adjust care Evaluate health outcomes

15. ESSENTIAL CARE TASKS and Associated Coordination Activity IDENTIFYand ASSESS PATIENTDetermine Likely Coordination Challenges, determine patients vulnerable to disconnected care DEVELOP CARE PLAN Proactive Plan for Coordination Challenges and Follow-up IDENTIFY PARTICIPANTS IN CARE AND SPECIFY ROLES Specify Who is Primarily Responsible for Coordination (Medical Home) EXECUTE CARE PLANImplement Coordination Interventions COMMUNICATE TO PATIENTS /Family AND ALL OTHER CARE PARTICIPANTS Ensure Information Exchange Across Care Interfaces MONITOR AND ADJUST CARE Monitor For and Address Coordination Failures EVALUATE HEALTH OUTCOMES Identify Coordination Problems that Impact Outcomes Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination).Technical Reviews, No. 9.7. McDonald KM, Sundaram V, Bravata DM, et al.Rockville(MD): Agency for Healthcare Research and Quality (US); 2007 Jun.

16. Case: Mr. Thomas Mr. Thomas is a 56 -year old patient with DM II. He has private insurance through his wife’s job. He is here for a cough and cold visit, has not been in for 9 months. You note he has no-shows recorded for his last 3 visits to you, both education visits and a diabetes check-up.

17. Medical Assistant Check-In He is taking 3/5 meds listed in the EMR by report. Metformin, Lisinopriland aspirin (unsure what kind). He is not on insulin, simvastatin as recorded here. He reports no pain or allergies. He has not had any office visits elsewhere. Temp=98.0 BP 152/90, pulse 88 Weight is 224lb , BMI 29 O2 sat is 99% Hba1c = 10 (last time was 8.9) Coughing In his PJ top Appears well otherwise

18. What Are You Thinking Here? MA point of view Beacon point of view Doctor point of view Care Coordination point of view

19. More Information Old Labs: LDL=144 Microalbuminis abnormal A1c=8.9 Other He did not have a flu shot in 2011 He has never had a depression screen Non-smoker Exam : Obese Nasal congestion R toenail is ingrown (you checked) Labs today: Glucose-333

20. Is Mr. Thomas High Risk? Vulnerable to disconnected care? How do you find him in your system? Name 3 ways

21. Practice Analytics Tool“Hot Spot” Pilot Diabetes Care Severity Index Composite score of labs, diagnoses, and know risk of hospitalization Option in the CC program

22. What else do you want to know about Mr. Thomas?

23. Patient Point of View? Consider… WHAT IS his GOAL for his care? Today? Overall? How do you know?

24. ESSENTIAL CARE TASKS and Associated Coordination Activity IDENTIFY/ASSESSPATIENTDetermine Likely Coordination Challenges, determine patients vulnerable to disconnected care DEVELOP CARE PLAN Proactive Plan for Coordination Challenges and Follow-up IDENTIFY PARTICIPANTS IN CARE AND SPECIFY ROLES Specify Who is Primarily Responsible for Coordination (Medical Home) EXECUTE CARE PLANImplement Coordination Interventions COMMUNICATE TO PATIENTS /Family AND ALL OTHER CARE PARTICIPANTS Ensure Information Exchange Across Care Interfaces MONITOR AND ADJUST CARE Monitor For and Address Coordination Failures EVALUATE HEALTH OUTCOMES Identify Coordination Problems that Impact Outcomes Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination).Technical Reviews, No. 9.7. McDonald KM, Sundaram V, Bravata DM, et al.Rockville(MD): Agency for Healthcare Research and Quality (US); 2007 Jun.

25. Patient Assessment “Why is Mr. Thomas so non-compliant?” The patient is not yet engaged! Patient and provider both have responsibility to determine and address barriers. Three methods: • Health Literacy • Stages of Change • Motivational Interviewing (MI)

26. Health Literacy • tervisealasekirjaoskuse • अनुवाद करने के लिए यहाँ पाठ दर्ज करें • בריאות אוריינות • alfabetizasyonsante • Gesundheitskompetenz • y tế biết đọc biết viết

27. Definition Health Literacy Functional Health Literacy The ability to read and comprehend prescription bottles, appointment slips, other essential health-related materials required to successfully function as a patient. Healthy People. (2010). Cited in What is Health Literacy? Retrieved from www.chcs.org The capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.

28. Health Literacy Only 12% of adults have proficient health literacy 9/10 patients lack skills to manage their health/prevent disease Ask Me 3 Advocate for Health Literacy in your organization (n. d.). Quick Guide to Health Literacy. Retrieved from http://HHS.com

29. Determine then Support Health Literacy Verify understanding by “teach back” “Tell me in your own words what we just talked about” “Why do you take this medication?” Provide instructions like you’re speaking with a friend

30. MOST IMPORTANT! Create a shame-free environment where low-literacy patients can seek help without embarrassment or being stigmatized

31. Don’t Forget Culture Ethnic/racial/population/religious differences affect perceptions, trust, access to medical care Poverty, language and communication barriers, other demographics Personal bias, prejudices, lack of understanding

32. Mr. Thomas and Health Literacy Visit Summary Example

33. The Stages of Change

34. Inappropriate Assumptions About Behavior Change This person ought to change, and wants to change. This patient’s health is the prime motivating factor for him/her. If he or she does not decide to change, the consultation has failed. Patients are either motivated to change, or not. Now is the right time to consider change. A tough approach is always best. I’m the expert. He or she must follow my advice. A negotiation-based approach is best. Emmons, K. M. , & Rollnick, S. (2001). Motivational Interviewing in health care settings: Opportunities and limitations. American Journal of Preventive Medicine, 20(1)

35. How To Suppress Change Tell patients what to do (give advice) Misjudge sense of importance regarding behavior change Use scare tactics, argue, blame them for no willpower and self-concern Overestimate readiness to change and degree of confidence Take control away and generate resistance

36. Is Patient Ready to Change? Readiness to change: Stages of Change. (2005). Retrieved July 10, 2011, from Well-Fit Bodies Website: http://www.well-fitbodies.com/readiness_for_change

38. Patient Assessments

39. True Change Takes Time Some may remain in one phase a long time or forever Pre-contemplation—cons of quitting outweigh the pros Relapse is expected, should be integrated to normalize it Most don’t go from pre-contemplation to action Goal—try to move through stages

40. Success = Positive Relationships & Support Provider-patient relationship most important determinant of diabetes self-management Craig, C., Eby, D., & Whittington, J. (2011). Care Coordination Model: Better care at lower cost for people with multiple health and social needs. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement.

41. Where is Mr. Thomas? Contemplation Pre-contemplation Preparation Action Maintenance

42. BREAK

43. Motivational Interviewing

44. Motivational Interviewing “A collaborative, patient-centered form of guiding to elicit and strengthen motivation for change” Miller, W.R. & Rollnick, S. (2009). Ten things that Motivational Interviewing is not. Behavioural and Cognitive Psychotherapy, 37, 129-40.

45. Motivational Interviewing Non-coercive Non-judgmental Non-confrontational Non-adversarial Explore and resolve inconsistency Help patients envision a better future, and become increasingly motivated to achieve it

46. Why Do We Need MI? No matter what reasons we might offer to convince individuals of the need to change their behavior, or how much we want them to do so, lasting change is more likely to occur when they discover their own reasons and determination to change.

47. Four Principles of MI Express empathy Explore differences Roll with resistance Support of self-efficacy

48. OARS Open-ended questions Affirmations Reflections Summaries

49. Patient Assessment

50. Mr. Thomas Role play referral for insulin use, why was it unsuccessful before? What would you say and do? What is his goal?