Care Management Implementation

Sara Greenwood, PCMHI Program Office

Erin Ingram, Philadelphia BHL

Johanna Klaus, Philadelphia BHL

What is care management again?

Care Management

• Algorithm-based care that includes routine monitoring/assessment of patients focusing on– Psychoeducation; encourage self-management skills– Brief treatment including (but not limited to) medication– Adherence to medication, treatment plan

• In consultation with the supervising clinician, provide relevant information to the PCP to allow collaboration for appropriate care decisions

Key Components of CM • Offer telephonic contact

– Much appreciated by patients• Stepped Care Approach• Strong ties to mental health supervision • Initial decisions and prescribing in primary care • Assessment based• Tracking important• Emphasis on patient self-management support• Care manager – facilitates communication

And one other thing to mention….

It Works!!

• Decreases symptoms

• Improves patient functional status

• Greater adherence to treatment & engagement in care

• Reduces mortality (yes, mortality)

7

Mr. McDuffyComes in for his primary care appointment and screens positive on the PHQ2. After he meets with the PCP, there is a warm handoff to the PCMHI provider. In the assessment, he mentions that his biggest issues are a lack of sleep and low motivation. They set up a behavioral activation plan and go over sleep hygiene. He is appreciative but ambivalent about coming back to the VA to meet again, so she suggests that Mr. McDuffy can call if would like another appointment. She puts in a note in CPRS.

Care management?

How would this look if it was care management?

Time to ponder and discuss

• What do you see as the benefits of care management?

• What barriers do you anticipate to implementing care management?

• What patients do you think would benefit from care management?

• How could you start to add/expand care management in your program?

• How could you respond?