tech-driven solution
for older patients
CM
+
is an innovative,
evidence-based care model for older adults
with chronic illnesses. It features
a unique blend of specialized care
management and information
technology support. CM
+
can help
your practice improve outcomes,
reduce costs, increase teamwork,
and streamline workflow associated
with caring for older patients with
challenging issues.
Beyond Care Management
The care manager definitely makes
my life easier. I can see more patients.
I can see them more efficiently, and
the patients get better care.”
David Tensmeyer, MD, FAAFP
Developed by Intermountain Healthcare Medical Group and research team through funding from The John A. Hartford Foundation, CM
+
provides your practice with the tools and support it needs to implement this innovative model. These include an intensive training for designated staff,technology-based enhancements to patient tracking, and ongoing consulting. This comprehensive package is currently available at a cost from the Oregon Health and Science University. CM
+
is already helping practices around the country make measurable improvements in how they care for their older patients. Ten percent of older patients—more than three million nation-wide—live with five or more chronic illnesses such as arthritis, diabetes, and heart disease. Two-thirds of Medicare dollars, including costly hospitalizations and emergency room visits, are spent on this frail fraction.
Effective primary care can improve older adults’ health and manage these costs, but most practices are not organized to respond efficiently or effectively to the broad and time-intensive range of medical, social, and psychological issues these patients present.
CM
+
can help.A Primary Care Solution
for Challenging Patients
The CM
+
Equation
On Target IT
Hands On Care
Measurable
Benefits for Patients
and Practices
Hands On Care
At the heart of CM
+
is a care manager (usually a
nurse, social worker, or physician assistant), who teams with primary care physicians to serve high-need older patients. CM+
care managers complete a
two-day training. This is complemented by a series of online learning modules that cover the fundamentals of care management, special issues in geriatric syndromes and concepts, and chronic disease management, including diabetes, depression, asthma and COPD, heart failure, sleep disturbances, and palliative care, among others.
On Target Information Technology
CM
+
fosters an ongoing, collaborative relationship with your primary care practice to help integrate special care management technology software and solutions into your clinic’s workflow. CM+
tools include:A unique care manager tracking database; A patient summary sheet; and
Messaging systems to help your clinicians access care plans, receive reminders about best practices, and facilitate communication among the health care team. •
• •
Measurable Benefits for Patients
and Practices
In peer-reviewed studies, CM
+
has demonstrated a wide range of benefits. For example, CM+
patients, particularly those with diabetes and depression, have shown improved adherence to disease guidelines. Most dramatically, CM+
patients reduced their odds of hospital admission by 24-40 percent and their annual mortality rates by more than 20 percent compared to a control group.1[The CM+ care manager] definitely
helped. [The] reinforcement was
wonderful for me. It has helped me
totally see a new part of my life that
I didn’t think that I’d ever see again,
that I didn’t think I’d ever experience.”
Sheri Wood, Patient“
40% 30% 20% 10% 0% YEAR ONE CM+ DECREASES HOSPITAL ADMISSION ODDS CM + YEAR TWO CM + 20% 15% 10% 5% 0% YEAR ONE CM+ DECREASES MORTALITY RATE CM + YEAR TWO CM + % Admitted % Deceased1Dorr DA, Wilcox AB, Brunker CP, Burdon RE, Donnelly SM. The Effect of Technology
Supported, Multidisease Care Management on the Mortality and Hospitalization of Seniors. J Am Geriatr Soc. 2008 Dec; 56 (12): 2195-2202.
Additional research has also shown that physicians are able to create a more efficient practice through better use of documentation, a slight increase in patient visits, and a change in practice pattern. With this increase in productivity and the right clinic environment, CM
+
is not only effective in improving patient outcomes, it is also cost- effective.² Dorr DA, Wilcox AB, Brunker CP, Burdon RE, Donnelly SM. The Effect of Technology Supported, Multidisease Care Management on the Mortality and Hospitalization of Seniors. J Am Geriatr
Soc. 2008 Dec; 56 (12): 2195-2202.
3Dorr DA, Wilcox A, McConnell KJ, Burns L, Brunker CP. Productivity Enhancement for Primary
Care Providers Using Multicondition Care Management. Am J Manag Care. 2007 Jan; 13 (1): 22-8.
For example, according to peer-reviewed studies, in integrated health delivery systems or other capitated systems, the reduced hospitalizations associated with CM
+
net payers $79,000/clinic —after paying for the salary, train-ing, and other expenses of the care manager.²In a fee-for-service environment, our research found that CM+ practices could generate an 8-12% increase in relative value unit generation (due to higher billing codes) by physicians. A nurse care manager conducting home visits in CM
+
can also create additional billings. In a seven-physician clinic, CM+
can generate revenue of almost $8,000 annually above the costs of the program. Add in the home visit reimbursements, and CM+
practices garner more than $18,000 in annual net revenues.3Costs/Clinic
Salary + training + admin $92,077 Benefits/Clinic Productivity (7 MDs) Hospitalizations Nurse visits $99,986 $0 $10,394 Total (benefits – cost) $18,303
CM
+
in Practice
CM
+
will work in any size practice, though with different levels of efficiency. Our initial cost studies focused on practices of six to ten physicians, but we work with smaller practices to find cost-effective applications of the model as well.To implement CM
+
successfully, your practice must be committed to adopting a new care strategy for older patients with multiple co-morbidities. All changes in care routines require time and energy, and your team should understand that the benefits of CM+
for patients, and for the practice as a whole, are worth this effort. Your clinic will also need: An effective electronic medical record (EMR) that allows multiple team members (including a care manager) to create and access notes and facilitates communi-cation among team members through e-mail, internal messaging systems, or other means.•
Optimally, the EMR should also display or output full “longitudinal” records of patients for easy review or at least “best practice” alerts about patients to support decision making; and
A designated care manager with office/treatment space located in a group practice of primary care physicians. •
Photo cr
Wondering if CM
+
could work in your clinic? The following questions can give you a quick sense of whether CM+
makes sense for you. If you answer yes to most or all, then you are a good candidate for CM+
.My job is like a detective. [I have] to find out
what is really going on, what are the issues,
what is happening to make the patient have
a difficult time managing their illness. When
I start, I’ll ask a patient, ‘What is the biggest
concern that you have?’”
Ann Larsen, RN, Care Manager
Does your practice see a lot of older patients or patients with chronic diseases? Are your physicians and other clinical staff interested in redesigning care for chronically ill, complex, or time-consuming patients? Does the clinic have a care manager who could be trained to partcipate in CM
+
?Would your physicians refer patients to a care manager to coach them in self-management of their chronic diseases?
Does your practice use an electronic medical record (EMR) or have plans to use one? Does your EMR have the ability to track patients by disease category?
Do you have one key physician or clinical leader who would champion this program in your clinic?
A current problem list? A current medication list? The ability to identify patients with a particular diagnosis? The ability to identify patients overdue for a visit, lab test, or preventive service?
The ability to produce a printed patient summary sheet with current problems and medications list, preventive services or labs due, and patient alerts?
• • • •
Is CM
+
Right For You?
•
Does your current health record system include:
“
• • • • • • •If your practice is interested in implementing CM
+
, the first step is to contact the CM+
team at the Oregon Health and Science University (see back cover). We will answer your questions and have you fill out a readiness assessment. This will provide us and you with the information needed to create an implementation plan. This blueprint will guide you as you make CM+
a reality in your practice. Key elements of this plan generally include:Getting Ready for CM
+
Hiring a CM
+
Care Manager
If you don’t currently have a care manager in your practice, you will need to hire one. CM
+
care managers are generally RNs, but practices have used MSWs and physician assistants as well. Care managers must work collaboratively with physicians and other clinical staff to support older patients with multiple chronic illnesses. Their main responsibilities are to facilitate communication among clinical personnel, conduct patient assessments and education, coordinate services, address barriers, and promote an optimal allocation of resources that balance clinical quality and costs. CM+
care managers should be positive and self-directed, have at least 3-4 years of clinical experience, and demonstrate excellent communication, interpersonal, and analytical skills. We have found that a Care Management certification is often helpful. For a full CM+
care manager job description, please see our Web site: caremanagementplus.org.Training a CM
+
Care Manager
Once you hire or identify a care manager in your practice, he or she must receive training from CM
+
. Currently avail-able at a cost (although practices must pay for lodging and travel), this intensive preparation takes place over two days. This is augmented by a series of online learning modules taught, along with assignments and discussions, over eight weeks. Hosted by OHSU, the online modules can be reviewed at the care manager’s convenience. This training covers care manager fundamentals, key issues in geriatrics, and care and management of chronic disease.In particular, CM
+
care managers learn to:Teach patients with multiple chronic diseases to organize, prioritize, and implement suggested self-management strategies;
Identify barriers to care and intervene to overcome or eliminate these when possible;
Coordinate resources to ensure that necessary services are provided at the most appropriate time and level of care; Identify patient situations at risk for destabilization and intervene to eliminate the risk when possible; and Gather, interpret, and use data to identify problems and trends and to demonstrate clinical outcomes and cost-effectiveness.
Faculty and mentors include instructors from
Intermountain Healthcare, OHSU, University of Utah Health Sciences Center, University of Iowa, and the Hartford Geriatric Nursing Initiative.
For a full description of the CM
+
training curriculum or to find dates for our next training session, please visit our Web site: caremanagementplus.org.2
• • • • •Assessing Your Electronic
Medical Record
At no cost to your practice, the CM
+
team will help assess your current EMR’s functionality, implement the specialized IT tools associated with the model, and streamline workflow to facilitate communications and referrals. Your practice is responsible for ongoing maintenance of electronic hardware or tools, but will receive upgrades to CM+
technology as they are developed. You will also join a learning community of CM+
practices that will help you find solutions to pressing and practical problems, particularly those associated with more effective IT use in your practice.CM
+
has developed unique software for primary care practices adopting the model (to download a free review copy, please visit our Web site atcaremanagementplus.org). This is usually implemented in a stand-alone Access database. It is not necessary to use the software to conduct CM
+
, but most EMRs do not include all of the critical functions that this technology provides.The CM
+
software enables the care manager to: Flexibly plan chronic care tasks including lab work, referrals, and classes;Schedule visits and phone calls;
Create reminder lists based on patient criteria designed to promote adherence to the care plan; and
Manage workflow and evaluate how efficiently she or he is using practice and community resources. •
• • •
The CM
+
database also generates administrative reports that help clinic managers evaluate the program. This includes a variety of analyses that can track which clinicians are using CM+
and to what ends, practice trends in out-comes for conditions such as depression and diabetes, and measurements of care manager productivity.In addition, CM
+
promotes the use of a one- or two-page patient summary sheet, which tracks a patient’s needs and serves as an invaluable tool for busy doctors and care managers.These sheets are also helpful for patients, providing a handy take-home resource with needed reminders and alerts.Diabetes Mellitus, Type 2; Hyperlipidemia; Hypertension
ACTIVE MEDICATIONS
1. Glucophage (Metformin HCI), 500 mg, Tablet; 1 TABLET; Daily 2. Simvastatin, 10 mg, Tablet, Oral; 1 TABLET; Evening
ALLERGIES
Penicillins - A Drug Allergen Group; Reaction(s): Rash
PREVENTIVE CARE
CLINICAL LABORATORY DATA
CLINIC DATA
REMINDERS
Lab [ ] HgbA1C—All Patients with Diabetes should have a HgbA1C at least every 6 months. [ ] Urine Albumin Test—Should be done yearly for Patients with Diabetes.
Procedures [ ] Pneumovax—Suggested for all Patients age 65 and above, and all Patients over age 2 with systemic chronic disease.
HgbA1c (<=7.0) UAProtein uAlb/Cr (<30) 24 Urine Albumin (<30) 12/01/2005 6.4%
11/08/2004 8.2%
01/16/2001 Negative No Data - No Data -Lipid Profile LDL (<100) Trig (<150) HDL (>45) CHOL (<200) Serum Cr Serum K
12/01/2005 11/08/2004 88 124 120 158 - - No Data - No Data -TC/HDL Ratio HCT hsCRP Homocysteine
No Data - No Data - No Data - No Data -Pap Smear Mammogram
No Data - No Data
-Date Weight BMI (<25) Weight Class Blood Pressure (<130/80) (H = home reading) 01/16/2006 144 LBS 23 Normal 01/16/2006 122/74 mmHg Last Foot Exam Last dilated retinal exam Heart Rate
CM
+
is supported by a talented team of researchers, clinicians, and other experts in primary care, information technology, and geriatrics.Principal Investigators
David Dorr, MD, MS, Associate Professor, Oregon Health and Science University, Portland, OR
Cherie P. Brunker, MD, Chief of Geriatrics, Intermountain LDS Hospital
Associate Professor, Division of Geriatric Medicine, University of Utah Health & Sciences Center
Project Staff
Kelli Radican, Project Manager, Oregon Health and Science University, Portland, OR Medical Informaticist /Consultant
Adam B. Wilcox, PhD, Assistant Professor of Biomedical Informatics, Columbia University, New York, NY
Associate Professor, Oregon Health & Science University, Portland, OR Advisory Board
Thomas S. Bodenheimer, MD, MPH, Adjunct Professor, University of California, San Francisco, CA
Cheryl Schraeder, RN, PhD, FAAN Director of Policy & Practice Initiatives Institute for Healthcare Innovation UIC College of Nursing
Eric A. Coleman, MD, MPH, Associate Professor of Medicine, University of Colorado Health Sciences Center Steven R. Counsell, MD, Director, IU Geriatrics, Indiana University School of Medicine, Bloomington, IN
I have worked here for twelve years
and I have never seen quality care
like this. I have never seen patients
who have problems that are being
met so far beyond the treatment
of medicine...Mental health needs,
diabetes education, wellness living,
anything beyond that, the care
manager is here and she is here
every day.”
caremanagementplus.org Contact us at:
Care Management
+
Oregon Health & Science University Tel: 503.494.2567
E-mail: [email protected]
CM+has been developed with funding
from The John A. Hartford Foundation. wajskol design and communications
