Empowering Care: Benefits of Patient-Centered Interdisciplinary Care Coordination

Presented by Concetta L. Zak, MD, DNP, MBA, FNP-BC at Empower 2016 on May 6, 2016

Community Care Alliance of Illinois has implemented a revolutionary Model of Care including the benefits of high-touch, high-contact and face-to-face care coordination. Dr. Zak shares how the health plan developed and implemented this successful model and will reveal the powerful outcomes this patient-centered approach to care has delivered in Illinois.

Transcript

1. Dr. Connie L. Zak, DNP, MBA, FNP-BC Vice President, Healthcare Management Community Care Alliance of Illinois Hosted By
2. Empowering Care: Benefits of Patient-Centered, Interdisciplinary Care Coordination
3. The Community Care Alliance of Illinois Model of Care 3
4. Care Management Program 4 Purpose • Goal-oriented • Individualized • Ongoing assessment • Partnerships • Healthcare providers • Community resources Objectives • Early intervention for complex medical and/or psychosocial needs • Serve as a liaison to community resources • Increase enrollee satisfaction of CCAI’s care team • Facilitate communication between members, their families, healthcare providers and communities Model of Care • Person-centered • Prevention-focused • Disability-competent PCPs and NPs • Wraparound care Stineman MF, Streim JE. The Biopsycho-ecological paradigm: A foundational theory for medicine. PM&R 2010; 2(11); 1035-45.
5. Biopsychoecological Framework 5 Pa ent/PCP Nego ated Care Plan • Primary preven on of acute disease/ illness, Secondary preven on of disability complica ons, CDM, Health & wellness program. PCP + care coordinator; medical specialists including PM&R; peer health coaches medical • Maximize func onal independence: mobility, ADL’s, IADL’s, communica on, social skills, leisure & voca onal pursuits. May include PA’s, DME, PT/OT/SLP, ortho cs/ prosthe cs/ assis ve technology/ voc func onal • Safe, stable housing with appropriate accessibility both into home, and within home; reliable community transporta on and access to needed services. Social work or HCBS interven on Environmental • Assist in applying for appropriate financial en tlements; considera on of income genera on opportuni es if appropriate. Social worker interven on Financial security • Help person develop a plan for primary and backup social support incl. a proxy for advance direc ve; introduce peer support services; respite services for caregivers Social supports • Appropriate mental health specialists‐e.g., psychiatrist, individual and group counselors, substance abuse treatment; Behaviorial health classes for managing stress and strengthening coping skills Psychological/ behavioral health
6. Anchor Health Homes 6 • Co-located Care Coordination Team • Nurse Care Coordinator • Long-Term Services and Supports Care Coordinator (Social worker) • Accessibility • Community • Transportation • Disability access • Interdisciplinary team availability • Person centered • Shared trust & responsibility • Coordinated and comprehensive care • 24/7
7. Best Practice • In October 2013, the Robert Wood Johnson Foundation held a Super Utilizer Summit • In conjunction with its sponsors • The Atlantic Philanthropies • Center for Health Care Strategies, Inc. hosted a conference to discuss: • The conference focused on common themes from innovative complex care management programs 7
8. Best Practices • Complex Case Management: Common portfolio of interactions • Extensive outreach and engagement strategies • 24 hour on-call system • Frequent contact with patients, and priority placed on face-to-face contact • Investment of “boots on the ground” • Seek patients in their homes, communities, providers’ offices…etc. • Phone-based care management systems are less-than-effective in super utilizer programs Hasselman, Diana. Super-Utilizer Summit Common Themes from Innovation Complex Care Management Programs. Robert Wood Johnson Foundation, 2013. 8
9. Meet Our Members: Community Care Alliance of Illinois Members’ Stories 9
10. A Member’s Success Story 10 Member Profile S.L.: • 60 year-old African American Female • Diagnoses: Morbid Obesity(BMI of 89), COPD, Asthma, Hypertension, Type II Diabetes (Insulin Dependent), Congestive Heart Failure, and Depression. • Member home-bound due to immobility • Member’s home had four steep steps, no ramp and extremely narrow doorways. Since that time, the only room of the home S.L. had seen was her bedroom. • The inaccessibility of the home posed a significant safety risk in the event of an emergency as S.L. would be trapped in her bedroom with no escape route. • Member expressed feelings of hopelessness due to being trapped in her bedroom. • Member reported to DRS counselor that she was out of her prescription medication, and unable to get to the physician’s office for an updated prescription.
11. 11 A Member’s Success Story (cont.) Support from CCAI Care Coordinator • S.L. reached out to her LTSS Care Coordinator at CCAI • S.L.’s Care Coordinator conducted a home visit to assess S.L.’s home for possible modifications, and to complete a Health Risk Assessment. • CCAI was able to assist S.L. with establishing care with Nurse Practitioner, Sandy Nicolosi. To date, S.L. continues to see her on a regular basis. She has had no lapse in medication since establishing care with Sandy Nicolosi. • S.L.’s Care Coordinator conducted a walk-through of the home and was able to determine that the layout/structure of the home would make it very simple to widen the front and bedroom doorways and build a ramp out the front door. • S.L. was also linked with home intervention therapy through CCAI’s behavioral health partner, which helped her deal with the stress and anxiety of not being able to interact with family and friends in her own home. • The necessary home accessibility modifications were recently completed. Not only do they look visually appealing, but S.L. can now safely navigate in and out of her home. She was able to sit outside for the first time in nearly four years.
12. 12 Results of S.L.’s Care with CCAI Care Coordination • Member is now able to evacuate her home in case of emergency, and complete simple activities of daily living (Grocery shopping, medical visits, etc.) to further promote her independence. • S.L. remains committed to being healthy and becoming as independent as possible. • Since working with her nurse practitioner, she has lost nearly 100 pounds through simple portion control and proper nutrition. • She is working with a Durable Medical Equipment provider and looks forward to obtaining an electric wheelchair that will best meet her mobility needs. • Her ultimate goal is to be able to join a weight loss program and to continue on her weight loss journey. A Member’s Success Story (cont.)
13. Community Care Alliance of Illinois in the News 13
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