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3. Determine the population(s).

- For now pilot project w 3 docs

- Later, 75% of patients w HTN, DM, Hyperlipidemia

4. Define what is measured

- Objective (VS,Wt,BP, DM)

- Subjective (compliance, mobility, home health, transportation, etc. )

5. Define workflows and roles.

- In Between MD/Clinic Visits (Phone)

- During Care Coordination Appointments

  • Who is involved (solo appts or linked?)
  • MD - Drive the process
  • RN - Own the treatment plan, manage interventions
  • MA - Collect info (VS, labs, etc.)
  • SW - Assess, refer
  • Pharmacy - Med Review/Educ
  • How are Patients introduced / involved

6. Discuss targets and accountability.

- Time frames w goals & task owners

- Assess/address barriers to treatment

(lack of motivation, insurance / financial needs, adverse effects, etc)

7. How to measure / report progress.

- Periodic reviews (monthly? quarterly?)

- PCMH: at "Relevant" visits

The Use of

Care Plans:

Thank you for your attention!

Why Use Care Plans?

1. Care Plans help us to manage patient care

and help identify conditions / needs, while creating goals for patients to achieve.

2. Care Planning is an important part of meeting the 2011 Standards for Patient Centered Medical Homes (PCMH).

And one more thing...

Thank you!

John Davis, PCMH Nurse

john.davis2@osumc.edu

614-366-1061

More than half of all Americans suffer from one or more chronic diseases and seventy-five percent of health care spending is for chronic disease. Researchers report that only 56% of those with chronic disease receive clinically appropriate care, and only 27% of adults (and 12% of low-income Americans) report having full access to a well-organized source of health care.

How you can Help:

- Identifying stakeholders

- Making suggestions

- Investing in Care Coordination

- Getting ready for kick off!!

The Inpatient World...

Do We Have Care Plans?

- Not right now. The inpatient world is required to have them.

- Generally, Nurses initiate care plans and can assign other staff to accomplish tasks to meet goals.

- In the Ambulatory world within IHIS, we don't have access to inpatient care plans.

More info at http://en.wikipedia.org/wiki/Nursing_care_plan

So what should GIM do?

Agreeing on

an Approach

1. Define what "care plan" means to us.

  • PCMH Guidelines
  • Our own expertise/Evidence Based Research
  • Any OSU guidelines

2. Decide who manages them and how often

3. Determine the population(s)

4. Define what is measured / metrics

5. Define workflows and roles

  • Who is involved (RN/MA/SW/RPH/MD, etc)
  • How are Patients introduced / involved

6. Discuss targets and accountability

7. How to measure / report progress

2. Decide who manages them and how often.

1. Define what "care plan" means to us.

  • PCMH Guidelines

See handout related to PCMH Standard 3:

Plan and Manage Care

  • Our own expertise.

  • Any OSU guidelines. (CPM and plans for using it in outpatient)

"The discussion we need to have also includes "who" will initiate and manage the care plan. It has been suggested that non-RNs be able to do this; I'm not convinced this is appropriate. Recent presentation by Dartmouth-Hitchcock on this topic at OSU told us about their use of outpatient "RN care coordinators" who initiate and maintain the individualized patient plan of care in the Patient Centered Medical Home. I believe an RN working in our outpatient settings "between-visits" with a population subset could impact our readmissions, and ED visits."

- Jerry Mansfield (Director of Ambulatory Nursing)

Morehouse GIM

April 2012

* This is the path that General Internal Medicine and Family Medicine is taking.

Sample Diabetes Tracking

(DM Disease Registry)

Chronic Disease Registries

Next Steps:

- Further Develop the Smart Phrase(s)

- Develop Care Plans from Care Coord Notes

- Identify Players / Roles

- Define Workflows in IHIS (between & during visits)

- Assign Staff (Pharm, MA, SW, etc.)

- How to measure progress (Surveys Pre / Post)

- Implement the Pilot Program

  • Approximately 30 patients with 3 GIM docs
  • Tayal, Grever, Li (Morehouse)
  • Kickoff: May 14th

- Cycles of PDSA (Plan/Do/Study/Act)

- Target: Have Workflows / Roles in place for Rollout to wider GIM by June 30th

Where in IHIS?

GOALS:

Plan to Use TWO Smartphrases:

.GIMCCNASSESS

.GIMCCNCAREPLAN

One example of a plan from a different world:

- Meet 2011 NCQA PCMH Standard

3: Plan / Manage Care (At least pass!)

- Care Planning / Coordination drives PCMH Nurse activities within each clinic.

- Have PCMH Nurses located at more GIM Clinics

- Better Patient Care = Saves Lives!!

Template View:

This is where being able to use something like OSU's CPM would be helpful.

Assessment is KEY

SW Inpatient Assessment

What Dodd Does...

They have custom Care Planning within IHIS just for Rehab

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