Approved Care Model for Project 3gi: Integration of Palliative Care into the PCMH Model

Transcription

1 1 Approved Care Model for Project 3gi: Integration of Palliative Care into the PCMH Model OneCity Health Webinar January 13, 2016

2 Overview of presentation 2 Approach to care model development Project overview Project requirements and metrics Target population Roles of partners in implementation Development of integrated delivery system Questions/Discussion

3 What is a care model? 3 A standard set of roles, responsibilities, resources, and relationships for organizations within the PPS, designed to accomplish a specific project. Examples of more detailed implementation can be helpful in understanding how a care model will work. However, detailed implementation plans require an understanding of the local environment, and will be developed in conjunction with partners. Our discussion today will focus on the care model for this project. We recognize that implementation is the fundamental work to achieve a successful initiative, and we welcome discussion with sites as we work on phasing implementation of this project across the OneCity Health PPS.

4 Development of the Palliative Care Model 4 October-December 2014 o Palliative care workgroup was created under leadership of subject matter experts to complete the NYS DOH DSRIP application. The application included description of the intervention that responded to the NYS DOH s project requirements. January-June 2015 o Clinical expertise group with broad range of backgrounds met in February and in April 2015 to review application, submit updates required by the NYS DOH, and determine implementation steps for basic implementation planning. July-December 2015 o o OneCity Health finalized details for the State Implementation Plan (SIP). Palliative Care Model developed based on national guidelines, literature review of evidence-based standards, and input from clinical expertise group and subject experts. o Palliative Care Model was completed and presented to the OneCity Health Care Models Committee on December 3, The Care Models Committee represents a range of partner types and professional backgrounds, and members were nominated through a formal application process. The care model was recommended by the Care Models Committee and subsequently approved by the OneCity Health Executive Committee.

5 Overview of presentation 5 Approach to care model development Project overview Project requirements and metrics Target population Roles of partners in implementation Development of integrated delivery system Questions/Discussion

6 Overview of Palliative Care Project 6 The objective of this project is to increasing access to palliative care for individuals with serious illnesses to ensure medical care, psychosocial and practical needs are understood, addressed. Primary palliative care is provided by non-specialists and may include: o identification of patients who would benefit from primary palliative care o basic management of symptoms including pain o management of psychological and psychiatric sources of distress o goal setting and advance planning discussions including prognosis and treatment goals o connection to social services, home care, transportation, etc. as needed to address social and functional needs o referrals to specialty palliative care when needed (e.g. complex or recalcitrant pain management, management of conflicts within families, management of the period when death is foreseen) University of Rochester Medical Center; Duke Center for Learning in Health Care and the Duke Cancer Care Research Program; the American Academy of Hospice and Palliative Medicine; and the Institute of Medicine

7 Overview of presentation 7 Approach to care model development Project overview Project requirements and metrics Target population Roles of partners in implementation Development of integrated delivery system Questions/Discussion

8 Integration of Palliative Care into the PCMH Model (3.g.i): NYSDOH Project Requirements (Milestones) 8 1. Integrate palliative care into appropriate participating PCPs that have, or will have, achieved NCQA PCMH and/or APCM certification. 2. Develop partnerships with community and provider resources including hospice to bring the palliative care supports and services into the practice. 3. Develop and adopt clinical guidelines agreed to by all partners including services and eligibility. 4. Engage staff in trainings to increase role- appropriate competence in palliative care skills and protocols developed by the PPS. 5. Engage with Medicaid Managed Care to address coverage of services. 6. Use EHRs or other IT platforms to track all patients engaged in this project.

9 State-defined metrics for Palliative Care Project 3gi Type of metric Patient engagement commitment Palliative Care Domain 3 metrics Measurement The number of participating patients receiving palliative care procedures at participating PCMH sites, in accordance with the adopted clinical guidelines. Earliest commitment is DSRIP year 1 (491 in first quarter, i.e. by 3/31/15) Annual commitments: 7,859 (DSRIP year 2) 15,718 (DSRIP year 3) 19,648 (DSRIP year 4) All Domain 3 metrics as specified by Uniform Assessment System for New York (UAS-NY) for home- and community-based long term care (*pending clarification from state) Pain: Risk adjusted percentage of members who o remained stable or demonstrated improvement in pain o had severe or more intense daily pain o whose pain was not controlled Depression Percentage of members who o experienced some feelings related to depression Advanced Directives o Talked about appointing for health decisions (legal guardian, health care proxy or family member) Other relevant metrics Reductions in potentially avoidable ER visits, admissions, and readmissions CAHPS Primary Care metrics: component on provider communication with patients, rating of provider 9

10 Overview of presentation 10 Approach to care model development Project overview Project requirements and metrics Target population Roles of partners in implementation Development of integrated delivery system Questions/ Discussion

11 Palliative care interventions will serve a range of primary care patients 11 Project design takes into account the range of patient needs encountered in the primary care setting, which is broader than that of a palliative care referral population. The project is comprised of the phased implementation of three interventions that will provide appropriate levels of care for different patient needs: 1. Health care proxy and simple advance planning 2. Symptom management 3. Advanced illness management (including end-of-life care)

12 Primary care population has subgroups that overlap in needs 12 Chronic distressing symptoms Advanced illness management End of life General population Advance planning: health care proxy and basic directive Symptom management Advanced illness management End of life care

13 Overview of presentation 13 Approach to care model development Project overview Project requirements and metrics Target population Roles of partners in implementation Development of integrated delivery system Questions/ Discussion

14 Intervention #1: Health care proxy and simple advance planning 14 Target population Intervention Example of methods to identify target population All patients (unscreened population) Patients >55 years Patients with stable chronic disease (e.g. diabetes, cardiovascular disease) Health care proxy Offer health care proxy routinely at visit, with brief educational intervention Health care proxy +/- simple advance planning Encourage health care proxy Advance directive for brain-injury scenario Older patients identified at check-in Patients identified on review of schedule, at morning huddle Integrate into existing disease-specific programs and registries (diabetes, HTN) Sample workflow/ staffing model Integrate into check-in protocol, patient can ask physician questions during visit if needed Completed document collected and scanned, copy provided to patient Intervention offered at check-in by staff member to be prior to visit Intervention initiated by physician to be completed before check-out Trained staff member conducts advance planning discussion Physician/ other team members have brief training to support program (in addition to dedicated staff member) Completed documents entered in EMR or scanned, copy provided to patient

15 Intervention #2: Symptom management 15 Target population Intervention Example of methods to identify target population Patients with chronic distressing symptoms (patients may not be at the end of life: e.g., painful diabetic neuropathy) Symptom management Documentation and goalsetting for symptoms management Pain management Depression/ anxiety management Referral for complex or recalcitrant symptoms Symptom screening Creation of registry of patients with ongoing pain syndromes Sample workflow/ staffing model Increased training and decision support for physicians in pain management Support knowledge and treatment protocols for other common symptoms e.g. anxiety Leverage existing Collaborative Care model for depression Identify and strengthen referral resources

16 Intervention #3: Advanced illness management Target population Intervention Example of methods to identify target population Patients with unstable illness (fluctuating or progressive) Examples (primary care site can choose focus): CHF, ESRD, cirrhosis, cancer, dementia, Parkinson s, multiple hospitalizations, ICU stay, declining functional status Advanced illness management Goals and values discussed in relation to patient s current and anticipated disease course, treatment expectations, and prognosis Consider alternative sites of care (home physician visits, nursing home) May require planning to allow for family to attend meeting May require coordination with disease-specific specialists May require coaching of staff or physician by palliative care expert Assess and refer for social, functional, and self-care needs Assess caretaker burden and assist with resources Screening tool filled out by patient Screening tool filled out by staff or physician Review of schedule/ review of patient panel by PCMH team, with phone outreach offering service Subset of patient panel can be extracted from coding and utilization data for outreach and further screening Sample workflow/ staffing model 16 Trained dedicated staff member Physicians receive training/ support from palliative care expert and may schedule 45-minute family meeting within clinic session

17 Advanced illness management may encompass end-of-life care 17 Target population Intervention Example of methods to identify target population End-of-life care Advanced illness management + end-of-life care Consider home-based care Refer to palliative care as needed Assess for hospice referral Discuss availability of 24- hour phone guidance MOLST (requires physician signature) Referral by clinicians Review of patient panel by PCMH team ( Would you be surprised if this patient died within a year? ), with phone outreach offering service Sample workflow/ staffing model Trained dedicated staff member Physicians receive training/ support from palliative care expert and may schedule 45-minute family meeting within clinic session

18 OneCity Health will work with primary care sites for phased implementation 18 Intervention #1 (basic advance planning) is anticipated to be first phase Interventions #2 and #3 require additional training, support, and development of integrated delivery systems OneCity Health will work with primary care sites to develop approach to implementation, but will elicit commitment to address all three interventions over time

19 Example resource needs for palliative care interventions 19 Intervention Staffing needs Additional resources #1: Basic advance planning Workflow changes, but not necessarily dedicated staff time, for population-wide health care proxies Workflow changes +/- dedicated staff time for targeted basic advance planning Training Tracking mechanism (IT) #2: Symptom management #3: Advanced illness management Staff time for coaching/ case reviews May require a physician within the practice to serve as an internal expert e.g. for pain medication management Dedicated staff time from staff member with advanced training Physicians given ability to schedule 45-minute family meetings Staff time for coaching/ case reviews/ coordination Training Phone coaching from palliative care expert Case reviews with palliative care expert Pharmacist consultations Tracking mechanism (IT) Training Phone coaching Case reviews Resource network (clinical, social, functional, behavioral health, transportation) Tracking mechanism (IT)

20 Overview of presentation 20 Approach to care model development Project overview Project requirements and metrics Target population Roles of partners in implementation Development of integrated delivery system Questions/ discussion

21 Examples of Integrated Delivery System in support of palliative care in the PCMH (1) 21 Domain of care Palliative care specialist services Hospice programs Care management Functional needs Services from partners Training, coaching, case reviews Outpatient clinical care Home-based clinical care Hospital and ER based care Cultural competency support Evaluation and enrolment Coordination of care, evaluation of needs, access to services Physical therapy Occupational therapy Speech and swallow Home-based and outpatient services

22 Examples of Integrated Delivery System in support of palliative care in the PCMH (2) 22 Domain of care Self-care Legal assistance Transportation Chaplaincy Nursing homes providing palliative care Services from partners Home attendants Meal delivery Wills Custody arrangements Insurance applications Burial arrangements Transportation to appointments Resources for spiritual support from CBOs, palliative care groups, or others Nursing homes

23 Examples of Integrated Delivery System in support of palliative care in the PCMH (3) 23 Domain of care Pain management services Behavioral health services Pharmacies Family support Cultural competency Services from partners Outpatient or home-based expertise in pain management Full spectrum of BH services Counseling services Assistance with symptom management including side effects Counseling Support groups Respite Distance learning and support services via computer or phone Assistance in tailoring services to cultural context (from CBOs, palliative care resources, etc.) Linkage to community resources

24 Overview of presentation 24 Approach to care model development Project overview Project requirements and metrics Target population Roles of partners in implementation Development of integrated delivery system Questions/ discussion