Assessing the Client - Part 2

[Site Name] Health Home Staff Training

Service Model Developed Primary Care Development Corp

Objectives

Upon completion of the training, staff will…

• Understand the purpose of and value of case conferencing

• Improve skills related to obtaining quality and accurate information from the case conferencing process.

• Have increased understanding of the providers’ perspective

• Become familiar with best practice techniques for conducting case conferences.

Agenda

• 9:30am Feedback & Review• 9:45am Purpose of the case conference• 10:30am Review of workflows and tools• 11:00am Role Plays • 11:10am Teach Backs• 11:20am Summary & Take-A-Ways• 11:30am Close

Feedback & Review

• Feedback• Does everyone know where the tools

are?

Recall - Assessment Domains

• Domains–Medical–Mental Health– Substance Abuse–Housing– Social/Legal– Vocational/Educational

Why do we case conference with providers?

• Assessment specific• Critical medical/mental health event• Significant change in client status• To accurately and completely

document that appropriate Health Home services were provided

Why do we case conference with providers?

• Assessment (Comprehensive Care Management)– Gather information– Gain fuller understanding of client – Set goals and plan follow-up steps

• Coordinate Care (Care Coordination and Health Promotion)– Follow-up on goal progress

• Client’s, Provider’s, Care Manager’s

–Manage care transitions• i.e. Hospitalizations or ER admissions/discharges

Workflow and Tools

• In-person Case Conference Workflow• Assessment Templates– Providers

Patient Assessment In-Person Case Conferencing Workflow

In-Person Case Conferencing Workflow - Continued

In-Person Case Conferencing Workflow - Continued

Provider Templates

• Medical• Mental Health• Substance Abuse• Housing

Obtaining Medical Documentation from Brooklyn PC Site

1. Send e-mail to medical case manager indicating client(s) for whom you need documentation• No more than 3 requests at a time

2. Medical case manager will add your client(s) to her eCW calendar and e-mail you date & time for case conference.• Will occur w/in 24 hours of your request• Can be in person or via phone

3. You will confirm appoint and indicate format (in person or phone).

4. You will arrive for case conference PROMPTLY or call medical case manager to reschedule (x6032).

5. Medical case manager will provide you with documentation and requested information at this time.

Other Providers

How do you request information from providers outside of our organization?• Who do you reach out to if not the

doctor?

Practice Specific

• Every practice has a different procedure–Medical Case Manager– Reception Desk Staff–Nurse– Practice Manager– Others

• Relationship-building is key!

Role Play

• Care Manager & Primary Care Provider

• Care Manager & Mental Health Provider

• Debrief

Teach-Backs/Practice Templates

• Groups of 2• Each group practice one template• Debrief

Summary/Take-A-Ways

• Care Managers should use workflow & templates to prepare for case conferencing

• Templates & Workflows are available on shared drive

• Case Conferencing is critical in providing care coordination

• Building relationships with providers & their staff will help you get the information you need

• Think creatively and persevere!