BEST PRACTICES IN DISEASE MANAGEMENT

Deanna Bell, M.D., F.A.A.P.Medical Director, MHIPTennessee Chapter of the American Academy of Pediatrics

GOALS OF D70 GRANT“ . . . to improve medical home provision for children and youth with special healthcare needs by promoting systems and service integration for children through education of parents and providers on medial home concepts of team-based care, care coordination, and disease management.”

Who are Your CYSHCN?

MOC QI AIM #3-----------------------------------------

HIGH RISK REGISTRY FORMATION

WAYS TO ID CYSHCN

•Screeners (CSHCN Screener, QuICCC, QuICCC-R) • ICD-9 lists (NHIS, CAHMI, NDP)•Administrative with risk stratification (3M-CRG)•Physician Referral•Payer referral•Pharmacy utilization

ADMINISTRATIVE: 3M CRG•Combines Dx and consequences based approaches•Uses ICD-9 and procedural codes to classify cases•Requires:6 months of claims data

2 or more encounters with same Dx code•Takes into account: type and number of Dx, recurrences,

number of acute exacerbations, cost/type/combination/frequency of services•Strengths: identifies population and individuals; assigns

severity rating; assigns groupings:

SURVEY-BASED METHODS•QuICCC: 41 question survey sequence•QuICCC-R: 16 question survey sequence• CSHCN Screener: 5 questions survey sequence• All do not require formal Dx• All 3 part sequence: consequences/presence of

condition/duration•Qualify if positive answers to one or more sequences• All identify population cohorts and can identify individuals•QuICCC and QuICCC-R: interviewer administered only

COMPARISON OF ADMINISTRATIVE AND

SURVEY-BASED METHODSOf CSHCN identified by ICD-9 lists•Only 52-53% met CSHCN criteria by survey methods

Of CSHCN identified by Survey Methods•20-24% were not identified by ICD-9 lists

Concordance between CRG/CSHCN Screener/QuICCC-R= 85-90%

CSHCN IDENTIFIED BY SURVEY AND NOT BY ADMINISTRATIVE DATA ARE LIKELY TO:

•Have developmental or emotional disorders not coded in encounter records•Use services not reimbursed under benefit

structure•Have multiple health issues that include a range of

educational, developmental, and mental health service needs and consequences•Be in transition between health plans or PCPs

MCHB/AAP DEFINITION CYSHCN

“ . . . those who have or are at increased risk for a chronic physical,  developmental, behavioral, oremotional condition and who also  require health andrelated services of a type or amount beyond  that required by children generally.”

McPherson M, Arrange P, Fox H, et al. “A new definition of children with special health care needs”, Pediatrics, 1998; 102: 137‐140.  

CHILDREN WITH SPECIAL HEALTH CARE NEEDS (CSHCN)

SCREENER©•non-condition specific, consequences- based•identifies children across the range and diversity of childhood chronic conditions and special needs•identified on the basis of one or more current functional limitations or service use needs •Scoring in based on positive cluster (e.g. 5 and 5a= positive; or 1 , 1a, and 1b=positive)

CHILDREN WITH SPECIAL HEALTH CARE NEEDS (CSHCN) SCREENER©

1. Does your child currently need or use medicine prescribed by a doctor (other than vitamins)? ٱ Yes Go to Question 1a ٱ No Go to Question 2

1a. Is this because of ANY medical, behavioral or other health condition? ٱ Yes Go to Question 1b ٱ No Go to Question 2

1b. Is this a condition that has lasted or is expected to last for at least 12 months? ٱ Yes ٱ No

2. Does your child need or use more medical care, mental health or educational services than is usual for most children of the same age? ٱ Yes Go to Question 2a ٱ No Go to Question 3

2a. Is this because of ANY medical, behavioral or other health condition? ٱ Yes Go to Question 2b ٱ No Go to Question 3

2b. Is this a condition that has lasted or is expected to last for at least 12 months? ٱ Yes ٱ No

3. Is your child limited or prevented in any way in his or her ability to do the things most children of the same age can do? ٱ Yes Go to Question 3a ٱ No Go to Question 4

3a. Is this because of ANY medical, behavioral or other health condition? ٱ Yes Go to Question 3b ٱ No Go to Question 4

3b. Is this a condition that has lasted or is expected to last for at least 12 months? ٱ Yes ٱ No

4. Does your child need or get special therapy, such as physical, occupational or speech therapy? ٱ Yes Go to Question 4a ٱ No Go to Question 5

4a. Is this because of ANY medical, behavioral or other health condition? ٱ Yes Go to Question 4b ٱ No Go to Question 5

4b. Is this a condition that has lasted or is expected to last for at least 12 months? ٱ Yes ٱ No

5. Does your child have any kind of emotional, developmental or behavioral problem for which he or she needs or gets treatment or counseling? ٱ Yes Go to Question 5a ٱ No

5a. Has this problem lasted or is it expected to last for at least 12 months? ٱ Yes ٱ No

CSHCN SCREENER© GRADING•All three parts of at least one screener question (or in the

case of question 5, the two parts) must be answered “yes” in order for a child to meet CSHCN Screener© criteria for having a chronic condition or special health care need. •The CSHCN Screener© has three “definitional domains:”

1) Dependency on prescription medications. 2) Service use above that considered usual or routine. 3) Functional limitations. The definitional domains are not mutually exclusive categories.

ENTRY CRITERIA FOR REGISTRY

•Positive screen for barriers to compliance•Positive CYSHCN screen•Physician referral•Health plan referral•Diagnosis list

TRACKING REGISTRY•Once your chronic or complex illness cohort is

identified, you must decide on a tracking system.•Most EMRS have flag systems, so a flag or icon can be

added to these patients•Many practices on paper charts use stickers of a specific

color on the patient’s chart.• There needs to be communication of Registry status to

patients and staff

TNAAP

High Risk Registry Tracking Tool Patient Name/DOB

Patient Name/DOB

Patient Name/DOB

Patient Name/DOB

Patient Name/DOB

Patient Name/DOB

Patient Name/DOB

Patient Name/DOB

Patient Name/DOB

Patient Name/DOB

Patient Name/DOB

Patient Name/DOB

Patient Name/DOB

Patient Name/DOB

Patient Name/DOB

Emergency Plan Updated Last

Plan of Care Last updated:

Disease States

Follow up Interval

Last appointment

Last WCC

Influenza Immunization Given? (Y/N)

Barrier to Compliance Screen Last Given

Disease Specific Plan of Care Up-to-Date? (Y/N)

Needs:

MOC QI AIM #3 MEASUREMENTS

•Report baseline registry formation based on objective screening (20 charts, alright if 0).• Institute CSHCN screener and/or other•Enter children with positive screens into registry. •Tag record with identifier positive or negative•Monthly, select 10 charts from general population that month to audit for use of CSHCN Screener or other evidence of screening for registry entry.

Care Coordination Framework

Patient Disease management

Case Management

Team-based Communication

What is Disease Management?

Disease Management

“Disease management supports the physician or practitioner/patient relationship and plan of care, emphasizes prevention of exacerbations and complications using evidence –based practice guidelines and patient empowerment strategies, and evaluates clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall health” Disease Management Association of America. DMAA Definition of Disease Management. {Accessed: January 26,2007};available from :http://www.dmaa.org/dm_definition.asp

What are the characteristics of

successful disease management programs?

Successful Disease Management ProgramsIndividualized

Case Management

In-person contacts

Focus on hospital discharges

Encourage use of cost effective therapies

SimplePatient CenteredLarge/overarchingIdentified

measurement parameters

Incentives

Context of StudiesAdult cohorts

Large volumes of same diagnosis

Good evidence base for therapies

Costs/Morbidity center around large volume cohorts

Pediatric CohortsFew large volume

cohortsMany severe

illnesses without standardized evidence base for therapy

Cost/Morbidity located in 10% of children, small cohorts

Considerations in pediatricsDisease management strategies in pediatrics must be applicable across a variety of disease states.

Disease management in pediatrics requires both population approaches and individual case management approaches

Processes in pediatrics must be fluid enough to respond to the situational needs of highly specialized/varied patients.

Formalized disease management in primary care

Disease Manager FunctionsSupport evidence based care and individual

plans of careDisease-specific knowledge a mustProvides education for self-managementCompliance tracking and reassessment a

large roleWorks with MD and case manager to optimize

access, compliance, and education

Disease Management Team Tasks

Patient screening and registry formation

Evaluates patient/family comprehension of plan of care

Performs disease education as appropriate

Refers patient to case manager as risks for noncompliance identified

Disease Management Team TasksTracks and monitors patient

compliance with care plans by registryAugments communication by keeping

team members aware of patient status Assists with transitions to/from

hospital/adult careAuthority to schedule override

Disease Management WorkflowAssess

Evidence-based plan

Maintain Registry

ExecuteLink Community Resources

Support self Management

Monitor/Evaluate/Adjust

CommunicatePlan

Keep it Simple

Form your registrySupport the evidence base with

processEducate and involve the teamUse ToolsContinually reassessSet regular communication times

•Record which diseases in your practice are leading to increased service utilization or functional capacity limitation•Review the evidence base for these diseases•Form your registry (General or disease-specific)

Assess

• Support evidence base with process• Identify essential action steps that will support evidence

base• Form office procedure around information exchange

that must take place to support evidence-based intervention•Describe the responsibilities in this work-flow by job

description•Don’t forget case management plan

Evidence-based plan

•Physician•Disease Management•Case Management/Linkage with Resources•Referral coordinator/other staff•Patients•PHYSICIAN MUST HAVE WRITTEN CARE PLAN FOR

PATIENTS

CommunicatePlan

•Processes for a diagnosis cohort or individual patient executed•Patient expectations communicated to patients•Team aware of plan and monitoring compliance

Execute

•Screen for barriers to compliance•Create care plan for overcoming barriers•Monitor patient compliance with this plan•Follow-up and reassess

Link Community Resources

•Written plan of care to patients•Assessment of health literacy for self management•Disease or patient-specific patient education for self management•Referral to case management as needed.

Support Self Management

•Follow-up interval specified in patient plan of care or part of evidence-based care path•Track no shows and compliance with referrals•Maintain patient contact/Assure follow-up occurs•Reassess response to interventions•Adjust plan accordingly•Continually reassess for barriers to care

Monitor/Evaluate/Adjust

A written plan of care is essential to communicating

patient specific expectations to all team members.

Three types of plans for CYSHCN

Patient Summary: Problem list, PMH, Meds, Allergies, Specialists, Therapies, Typical Laboratory Values and Exam, Cultural and Social Considerations, Legal

Action Plan: today’s additions, changesEmergency Plan

MOC QI Aim #4----------------------------------

Written plans of care for team

MOC QI Aim #4 MeasurementsReport baseline proportion of chronic

disease registry patients with written plans of care on chart (20 patients from baseline chronic illness registry, alright if 0)

Institute team management strategiesMonthly, select 10 charts from patients

seen in the chronic/complex disease registry to audit for presence of written plan of care

Example Forms

1113 Murfreesboro Rd, Ste 319 PO Box 1346

Franklin, TN 37065-1346 Phone: (615) 790-0567

Fax: (615) 595-8030

(YOUR CLINIC NAME) Plan of Care Plan de cuidados

Personal Information/Información Personal Name/Nombre: Nickname/Apodo:

DOB/Fecha de Nacimiento: Primary Language/Lenguaje:

Phone Number/Número de Teléfono: Insurance/Aseguranza:

Date Form Completed/Fecha:

Pediatrician/Pediatra:

Allergies/Alérgias:

Diagnoses/Diagnósticos ICD-9

Resolved Diagnoses/Diagnósticos Resueltos ICD-9

Upcoming Needs/Necesidades Para El Futuro

Patient Care Plan

Name: D.O.B.: Date:

Date for Next Visit: Frequency of Visits: The new changes to your care plan are listed below. Please read the Emergency Care Plan for medication list, emergency management, and routine care. Care Concern/Dx (1) Plan: Care Concern/Dx (2) Plan: Care Concern/Dx (3) Plan: Care Concern/Dx (4) Plan: If your care plan includes a referral and you have not heard from us within one week, please call to confirm the referral has been scheduled. If you have difficulty with following the care plan or filling medications, or if you have concerns, please call the office at (XXX)XXX-XXXX.

Baseline Measurements, 20 charts•Evidence of screening for barriers to compliance•Evidence of linking patients with barriers to compliance to community resources•Evidence of screening for CSHCN registry•Evidence of written care path in the record for those in CSHCN registry

Monthly Measurements10 charts general population: •Were they screened for barriers to compliance? •Were they screened for CSHCN registry10 charts with positive barrier to compliance screen: • Is there documentation of linking patient with a resource to

overcome barrier to compliance?10 charts CSHCN Registry: • Is there evidence of the written care plan you have agreed to

use?

Overall AIM Statement• Involved practices will improve chronic disease registry formation by

50% by the end of data collection.• 25% of registry patients of involved practices will have a care plan

with therapeutic recommendations and/or goal by the end of data collection.• Involved practices will improve screening for risk factors for

noncompliance by 50% by the end of data collection.• 25% of patients with a risk factor for non-compliance will be linked

with community resources needed to promote compliance by the end of data collection.

Requirements for MOC participation

Summit ParticipationBaseline/follow-up NCQA PCMH Medical Home SurveyBaseline/monthly (4 month) data entry/analysis for QIDA parameters

Participation in 2 of 4 technical assistance webinars/conference calls

Participation in final QI Program Synopsis call/meeting