Care Management- HeartSong Health In Community - a nonprofit naturopathic medical clinic

Care Management

Care management refers to clinical and administrative activities which systematically improve the delivery of health care services. Managed care helps people and their families engage in a collaborative process with health care providers in order to improve care coordination and achieve optimal health while receiving cost-effective, non-duplicative services. In the United States today, health care providers are often directed to identify and provide managed care services to people who are at higher "risk" because they offer the greatest potential for improvement in health outcomes (www.chcs.org). However, because of our commitment to parity of care, HeartSong does not provide more services to one population than another. Everyone who comes to HeartSong benefits from care management.

Care Coordination

Care Coordination refers to the deliberate organization of your care among two or more participants (including you and/or your family) to make sure that you get the care that you need in a timely manner. It involves coordinating people and resources to carry out all required care. It is managed by the exchange of information among the people responsible for different aspects of the care. At HeartSong, your care is managed using both paper and electronic technologies, including phone, fax, email, and EMR.

You care is coordinated in several ways at HeartSong:

1. Collaboration: Reasons for the referral and recommended specialists are discussed with you prior to treatment. Often, the specialist is then contacted by phone and asked whether he or she will accept you as a referral prior to sending the referral fax. If you have a specific specialist that you would like to see, then that specialist is approached.

2. Information access: Specialists to whom HeartSong refers are given password-protected access to you EMR so that they can access your entire past history at HeartSong 24/7. In addition, a detailed fax is sent to the provider explaining the reason for the referral and providing any relevant history and documentation, e.g. blood chemistry and xray reports.

3. Care documentation: Clinicians who provide specialist care outside of HeartSong send reports to HeartSong. These are included in your paper chart. They also have the option of putting notes directly into your EMR at HeartSong.
If a report is not received within a reasonable time frame, then HeartSong contacts the specialist and requests that the report be sent.

4. Care tracking: Referrals and receipt of reports from specialists are tracked electronically and manually in a tracking tool.
Electronically, every referral is made with a fax stored and sent electronically by our EMR.
Manually, the date of the referral, and the specialist contacted, is also noted in a tracking document.
When the report of care provided comes in from the specialist, the date that the report was received is noted in the tracking tool record before the report is filed in your paper chart.

5. Specialist interface: As needed, your HeartSong physician talks personally with the specialist to discuss reasons for the referral (in advance) and any required follow-up care (after care is provided).

6. Patient follow-up: After your specialized care, your report is discussed with you as needed. The date when this occurs, and the method of communication, is documented in the Care Coordination tracking tool, as well as your medical chart as appropriate.

All of these activities ensure the following:

Your primary care provider can verify that you received the care you needed in a timely fashion.
Your physician can coordinate follow-up care with you subsequent to your treatment.
You are informed about what the specialist reported to your physician and can ask questions or express concerns.
Your medical chart at HeartSong is complete, and your care is properly documented.
Your doctor can determine whether you need any additional care after you have received care from a provider outside of HeartSong.

Here is the template for our Care Coordination tracking tool. We use it to make sure that we have all the information necessary to provide you with well-coordinated care in a timely manner.

CARE COORDINATION

Care Coordination is the deliberate organization of patient care activities among two or more participants (including the patient and/or the family) to facilitate the appropriate delivery of health care services. Organizing care involves marshaling personnel and other resources to carry out all required patient care activities, which is often managed by the exchange of information among participants responsible for different aspects of the care. *From Transitions of Care Measures, Paper by National Transitions of Care Coalition (NTOCC) Measures Work Group, 2008.

PATIENT	Date of Request	Date of Referral	SPECIALIST	REPORT RECEIVED	Follow Up w/PATIENT	COMMENTS

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Care Transition

The term Care Transition is used at HeartSong to refer to administrative activities that are performed to ensure continuity of care when you come to HeartSong from another facility, or leave HeartSong for primary care elsewhere. Care Transition services include requesting records from other facilities and giving other practices access to your records at HeartSong.

Care transition services at HeartSong are documented with a tracking tool. Dates when records are requested, where they are requested from or where they are to be sent, dates they are received and reviewed are all noted. In addition, significant findings are noted, as well as when they were discussed with you after receipt of the records. If records are not received within 30 days, the facility is contacted again.

Here is a copy of our Care Transition tracking tool. We use it to make sure that we have received all past medical information necessary to continue your medical care appropriately and without interruption.

CARE TRANSITION MANAGEMENT

Transitions of Care* refers to the movement of patients between health care locations, providers, or different levels of care within the same location as their conditions and care needs change. Specifically, they can occur:

Within settings; e.g., primary care to specialty care, or intensive care unit (ICU) to ward.
Between settings; e.g., hospital to sub-acute care, or ambulatory clinic to senior center.
Across health states; e.g., curative care to palliative care or hospice, or personal residence to assisted living.
Between providers; e.g., generalist to a specialist practitioner, or acute care provider to a palliative care specialist.

Transitions of care are a set of actions designed to ensure coordination and continuity. They should be based on a comprehensive care plan and the availability of well-trained practitioners who have current information about the patient's treatment goals, preferences, and health or clinical status. They include logistical arrangements and education of patient and family, as well as coordination among the health professionals involved in the transition.

*From Transitions of Care Measures, Paper by National Transitions of Care Coalition (NTOCC) Measures Work Group, 2008.

At HeartSong, Transitions of Care refers to transition into or out of HS for primary care services. All transitions related to care provided by HS or any specialist to whom a patient has been referred by HS is tracked under "Coordination of Care", not "Transitions of Care".

PATIENT	Date of Request	BY WHOM	FROM WHERE	DATE RECEIVED	DATE REVIEWED	FOLLOW UP WITH PATIENT	COMMENTS

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Collaboration

In addition to cooperating with other providers involved in your care, your physician collaborates with you and your family to ensure that: (1) you have all the information you need to make informed choices; (2) you have the self-awareness and confidence to actively participate in your care; (3) you have the support you need to complete your course of treatment, such as self-management tools, personal copies of your treatment plan, timely access to your personal health information, including medications (dosage, purpose), appointment reminders, access to appropriate community resources; and (4) you receive counseling around issues that might prevent you from achieving your personal health goals.

I. SELF-CARE MANAGEMENT TRACKING TOOL

We use this to document our performance related to self-care support and education.
See Self-Responsibility for a complete discussion of the definitions used in the self-care tracking tool.

See NCQA Patient-Centered Medical Home for the actual standards.

SELF-CARE MANAGEMENT

"Self Care in health refers to the activities individuals, families and communities undertake with the intention of (A) enhancing health, (B) preventing disease, (C) limiting illness, and (D) restoring health. These activities are derived from knowledge and skills from the pool of both professional and lay experience. They are undertaken by lay people on their own behalf, either separately or in participative collaboration with professionals." (World Health Organization: 1998)

KEY

(1) PV: Pre-visit preparation (PCMH 3C1)

(2) HE: Health education provided and documented under EMR Plan. (PCMH 4A1)

(3) Info: EMR education, noted in EMR Plan, tracked by PF (PCMH 4A2)

(4) Co-P: Treatment goals and plan collaboratively developed with clinician, patient, family, noted under EMR Plan. (PCMH 4A3)

(5) SA: Self-awareness assessed. (PCMH 4A3)

(6) SE: Self-empowerment assessed. (PCMH 4A3)

(7) SM: Self-management skills assessed (PCMH 4A4)

(8) SMT: Self-management tool(s) provided (PCMH 4A5)

(9) WP: Written plan provided (PCMH 3C3)

(10) Barr: Barriers to treatment goals assessed and addressed (PCMH 4A4)

(11) Healthy Lifestyle Counseling: SC: Self-care (A-D above) LS: Lifestyle Counseling (health promoting behaviors) IH: Integral Health (Mindbodyspirit) MM: Medication Management (natural/chemical), noted in EMR and MM table.

(12) MM: Medication Management (PCMH 3D1-6)

(13) CS: Clinical summary provided (PCMH 3C5)

(14) ID: People who need extra care management are identified (PCMH 3C6)

(15) FU: Follow-up for missed appointments (PCMH 3C7)

(16) CR: Community resource referral (PCMH 4B2)

II. MEDICATION MANAGEMENT TRACKING TOOL

We use this to document our performance related to PCMH Standard 3D. See NCQA Patient-Centered Medical Home.

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Preventive Medicine Screenings

Regular testing to screen for certain chronic illnesses which can be prevented or more successfully treated if diagnosed early, such as hypertension (high blood pressure), diabetes, cardiovascular disease, is another part of care management at HeartSong.

HeartSong regularly performs regular preventive medicine screenings at various intervals according to current evidenced-based guidelines. These are tracked and recorded so that people who need the tests done can be identified and notified in a timely manner.

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Hear what people have to say about care management:

The one-on-one care is very nice and you remember who I am when I come in and I was so happy I brought my children and husband and they are happy and you remember who they are too.

I feel that just by coming here and talking with you about our problems and health and getting the information that we need to feel better and be healthier, we're just feeling so much better, even my husband who was reluctant to come because he doesn't like doctors, seems calmer.

Keri Roberts, Brattleboro

Care Management

Manage health care

Care Management

Care Coordination

Care Transition

Collaboration

Preventive Medicine Screenings

Hear what people have to say about care management: