Presentation Title

Presentation Title

Health Home Care Coordinators Basic Training January 2018 1 I diagnosed abdominal pain when the real problem was hunger, I confused social issues with medical problems in other patients, too. I mislabeled the hopelessness of long-term unemployment as depression and the poverty that causes patients to miss pills or appointments as noncompliance. In one older patient, I mistook the inability to read for dementia. My medical training had not prepared me for this ambush of social circumstance. Real-life obstacles had an enormous impact on my patients lives, but

because I had neither the skills nor the resources for treating them, I ignored the social context of disease altogether. Laura Gottlieb, MD University of California San Francisco 2 Introductions Your name? What do you do? What agency do you work for? What Lead Organization/s will you work with? Briefly state, your relevant work experience. 3

Purpose Provide the core curriculum for Health Homes in Washington State for Lead Organizations and Care Coordination Organizations (CCOs) 4 Learning Objectives and Agenda Overview The six Health Home services Outreach, engagement and retention strategies Care coordination key components and delivery mechanisms Administration of Insignias Patient Activation Measures and how to use the level of activation to develop a Health Action Plan TRAINING

5 Learning Objectives and Agenda Overview (cont.) Administration of mandatory screens and optional screens Documentation of the delivery of Health Home Services in progress notes and Health Action Plans Required elements for Care Transitions 6 Overview of the Curriculum Classroom Training Manual with important forms and documents

Location of the manual on the DSHS training Website: https://www.dshs.wa.gov/altsa/stakeholders/washington-healt h-home-program-core-training 7 The Health Care Authority (HCA) Website http:// www.hca.wa.gov/billers-providers/programs-and-services/resources-0#care-co ordinator-training Training materials may be accessed

from the HCA website 8 The DSHS Website https://www.dshs.wa.gov/altsa/washington-health-home-program Training resources and webinar PowerPoints are located on the DSHS

website 9 Fundamentals Health Homes and the Affordable Care Act Washingtons model Eligibility The Health Home services Health Home tiers and billing 10 What are Health Home Services? Clients receiving Health Home services will be assigned a Health Home Care Coordinator who will partner with client, their families, doctors and

other agencies providing services to ensure coordination across these systems of care. The primary role of the Health Home Care Coordinator is to work with their client do develop a Health Action Plan that is person-centered. In addition, the Health Home Care Coordinator will make in-person visits and be available by telephone to empower the client to take charge of their wellness. 11 Lets look at a sample Health Action Plan (HAP) 12

Sample HAP for Jordan Larson 13 The Patient Protection and Affordable Care Act Health Homes are described in: Section 2703. State option to provide health homes for clients with chronic conditions. http://www.hhs.gov/healthcare/rights/law/index.ht 14 Washington Opts In The primary goals of the Health Home Program include:

Improve the quality and coordination of care across systems of care Reduce expenditures Increase confidence and self management of health goals Provide a single point of contact to bridge systems of care 15 Washington State Model of Health Home 16 Health Home Coverage Areas 17

Who May Become a Health Home Care Coordinator? Care Coordinators may be employed by: Lead Entity or Care Coordination Organization that has contracted with a Lead Required education or licensure:

Registered nurse, licensed practical nurse, bachelor or masters prepared social worker, licensed social worker, licensed mental health counselor, chemical dependency counselor and other professionals 18 Who May Be Covered By Health Homes? 1. Dual Eligible Eligible for Medicare and Medicaid

2. Apple Health 3. Uses the Fee-For-Service (FFS) traditional Medicare/Medicaid providers Managed Care Organizations (MCO) plans Fee-for-Service: traditional Medicaid coverage for those not dually eligible 19

Eligibility for Health Home Services Must have one chronic condition and Must have a PRISM score of 1.5 or higher Indicates a risk for a second chronic condition Note: includes all ages 20 The Health Home Services Health Home services are designed to:

Conduct screenings to identify health risks and referral needs Set person-centered goals that will improve clients health and service access Improve management of health conditions through health action planning, education and coaching 21 The Health Home Services (cont.) Support changes to improve clients ability to function in their home and community and increase self-management of their chronic disease/s Slow the progression of disease and disability Access the right care, at the right time, the right place

and the right provider 22 The Health Home Services (cont.) Successfully transition from hospital to other care settings and get necessary follow-up care Reduce avoidable health care costs Make health care decisions during evenings or weekends when the Health Home Care Coordinator is not available 23

Lets Pause to Check for Understanding Do you have any experience with the program that you wish to share? Do you have any questions? 24 The Six Health Home Services 1 Comprehensive care management 2 Care coordination 3 Health promotion 4 Comprehensive transitional care 5 Individual and family support 6 Referral to community and social support services

TRAINING 25 1 Comprehensive Care Management 1. Provides in-person periodic follow-up using face-to-face visits and telephone calls 2. Includes state approved required and optional screenings and assessments 26

1 Comprehensive Care Management (cont.) 3. Assesses the clients readiness for self-management and promotes self-management skills so the client is better able to engage with health and service providers 4. Offers assistance in establishing an advance directive with the client and family (with the clients consent) and documents this discussion in the clients narrative record 27 1

Comprehensive Care Management (cont.) 5. Monthly (or more often as needed) contacts: Provides continuity of care Supports the achievement of self-directed health goals Improves functional or health status or prevent or slow declines in functioning 28 2

Care Coordination 1. Provides cross-system care coordination to assist the client to access and navigate needed services 2. Uses the Health Action Plan (HAP) as the client directed care management plan 29 2 Care Coordination (cont.) 3. Fosters communication between the providers

of care including: Primary Care Physicians (PCPs) Medical and behavioral health specialists Entities authorizing behavioral health and Long Term Services and Supports (LTSS) 30 2 Care Coordination (cont.)

4. Is the bridge between all of the clients systems of care, including non-clinical support such as food, housing, legal services and transportation 31 2 Care Coordination (cont.) 5. Community health workers, peer counselors, or other non-clinical and administrative staff may be used to facilitate the work of the assigned Health Home Care Coordinator 6. Provides informed interventions that recognize and are

tailored for the medical, social, economic, behavioral health, functional impairment, cultural and environmental factors impacting a clients health and health care choices 32 2 Care Coordination (cont.) 7. Care Coordinators promote: Optimal health outcomes, including a description of how progress

toward outcomes will be measured through the Health Action Plan Outreach and engagement activities that support the clients participation in their care to promote continuity of care 33 2 Care Coordination (cont.) 8. Promotes health education and wellness coaching to increase self-management skills to improve health outcomes for their clients 9. Uses peer supports, support groups and self-care programs to increase the clients knowledge about their health care

conditions and improve adherence to prescribed treatment 34 3 Health Promotion 1. Uses self-management, recovery, and resiliency principles including supports identified by the client 2. Uses the clients activation level to determine the coaching, teaching and support plan for the client 35

3 Health Promotion (cont.) 3. Provides opportunities for mentoring and modeling communication with health care providers By participating in joint office visits Modeling or monitoring phone conversations with health care staff 36 3

Health Promotion (cont.) 4. Care Coordinators Provide wellness and prevention education to include routine and preventative care (e.g. immunizations) Link the client with resources to promote a healthier lifestyle 37 4

Comprehensive Transitional Care 1. May prevent avoidable readmission after discharge from an inpatient facility (hospital, rehabilitative, psychiatric, skilled nursing, substance use disorder treatment facility or residential habilitation setting) 2. Ensures proper and timely follow-up care 38 5 Individual and Family Support 1. Recognizes the unique role the client may give family,

identified decision makers and caregivers in assisting the client to access and navigate the health care and social service delivery system 2. May support health action planning 39 5 Individual and Family Support (cont.) 3. Identifies the role that families, informal supports and paid caregivers provide to:

Educate and support self-management, self-help and recovery Achieve self-management and optimal levels of physical and cognitive function 40 5 Individual and Family Support (cont.) 4. Educate and support family informal supports and caregivers

Increase their knowledge of chronic conditions Promote the clients engagement and self-management Help the client adhere to their prescribed medications and treatment 41 5 Individual and Family Support (cont.) 5. May include:

Discussion about advance directives with clients and their families Communication and information sharing with clients and their families and other caregivers Consideration of language, activation level, literacy and numeracy and cultural preferences 42 6 Referral to Community and Social Support Services

1. Provides assistance to obtain and maintain eligibility for health care services, disability benefits, housing, Long Term Services and Supports (LTSS) and legal services 2. Care Coordinators will: Identify community based resources Actively manage referrals Advocate and assist on behalf of the client to access care and community and social supports 43 6

Referral to Community and Social Support Services (cont.) 3. Care Coordinators complete referrals to community and social support services to support the client in achieving health action goals including: Long Term Services and Supports Mental health Substance use disorder providers

Other community and social services support providers as needed 44 Multidisciplinary Care Teams and Allied Staff As a Care Coordinator you may coordinate and facilitate multidisciplinary care teams:

Care Coordination: establish a team to provide cross systems care coordination on behalf of the client Care Transitions: establish or work with an multidisciplinary care team at the facility to discuss discharge plans from hospitals and nursing facilities As a Care Coordinator you may work with allied staff: Care Coordinators may enlist the help of allied staff including: Community Health Workers, mental health peer support specialists, outreach specialists, Community Connectors, wellness coaches, and any other lay staff 45

Health Home Tiers Tier One Tier Two Tier Three Initial engagement and action planning Intensive level of care

coordination Low level of care coordination TRAINING 46 Tier One Services Tier One Tier Two

Tier Three Requires a face-to-face visit to: Introduce Health Home services Assess the clients health and other needs Confirm the clients agreement to participate Obtain consent and release of information Complete required and optional screenings

as clinically indicated 47 Tier One Services (cont.) Tier One Tier Two Tier Three Develop the first Health Action Plan (HAP) Document activities Complete the HAP within 90 days that the client was enrolled

with the Lead Organization Bill one time only 48 Tier Two Services Tier One Tier Two Tier Three Requires at least one face-to-face visit each month

Typically includes multiple calls to client, family, caregivers, legal representatives, and providers Includes other activities as needed: Health education and coaching Referrals to providers Care transitions planning and follow up Consultation with care providers and medical and behavioral healthcare providers

49 Tier Three Services Tier Three Care Coordinator supports maintenance of the clients self-management skills with periodic face-to-face visits and/or phone calls Client may request fewer contacts

Tier Two Low level Health Home care coordination Tier One Movement to this tier is not for the Care Coordinators convenience The clients chronic condition stabilizes and demonstrates a high level of activation in self-management of health

50 Tier Three Services (cont.) Tier One Tier Two Tier Three The HAP must be reviewed with every contact:

The HAP is the foundation of your relationship Review progress toward goals Identify new or unidentified care opportunities At least one of the six Health Home services must be provided: When a client requests fewer contacts they may not want to be contacted each month so do not bill for months when no contact or no services were provided 51 Billing for Services

Contact may not occur monthly depending on the clients needs and the Health Action Plan (HAP) Bill only for months when service was provided The HAP must be reviewed at least once during each four month activity period or more often as needed to monitor and update the goals and action steps and administer the required screenings Document the core service/s provided to support billing

52 Lets Pause to Check for Understanding Do you have any questions about the six core services or the 3 payment tiers? 53 Outreach Client outreach Client enrollment materials Consent and opting out Client engagement

54 Client Outreach Using smart assignment the Lead Organization will provide the CCO with a list of clients who meet the eligibility requirements for Health Home services The Health Care Authority (HCA) will send Fee-for-Service clients the Health Home letter and Your Washington State Health Home Booklet Lead Organizations that are Managed Care Organizations (MCO) will send their enrollment materials to their members TRAINING 55

Welcome Booklet for Fee-for-Service Clients Flyers and brochures are available under the HCAs website: http://www.hca.wa.gov/billers-providers /programs-and-services/resources-0#car e-coordinator-training 56 Participation Authorization and Information

Sharing Consent Form TRAINING 57 Participation Authorization and Information Sharing Consent Form Best practice is to take it to face-to-face visits and appointments to amend as needed

Use the back of the form to add and delete providers If able, scan a copy into the client electronic health record (EHR) for other staff and providers to access Enter the date and have the client initial Clients may pay participate even if they refuse to sign the form 58

Outreach to Foster and Adoptive Children The DSHS Fostering Well Being Unit (FWB) must be contacted before contacting foster parents Adoptive Children

Foster parent contact information is confidential and can only be released by the Childrens Administration Social Worker The FWB unit can identify the social worker assigned to the child so care coordinators can reach out to them regarding the child The Foster Care Medical Team at HCA can also assist with identifying the childs adoptive parents. Call the HCAs Customer Service line at: 1-800 562-3022 Ext. 15480 Adoptive and Foster Care Children Adoptive and foster care children receive managed care through Coordinated Care of Washington (there are a few exceptions) 59

Special Release of Information for Adolescents Children ages 13 through 17 years must sign a consent form to release their information related to: Mental health Reproductive health Chemical dependency 60 Adolescent Consent Form

For children 1317 years of age TRAINING 61 Release of Information Form for Substance Use Disorders HCA form 13-335 (3/16) TRAINING 62

Tribal Relations Each tribe is a sovereign nation Work with your Lead to determine the process for contacting tribal members Each tribe will have different processes and contact people Always respect tribal policy when entering tribal lands even if your client is not a tribal member 63

Federally Recognized Tribal Reservations 64 Motivational Interviewing and Coaching 65 The Spirit of Motivational Interviewing (MI) Empathic way of being Collaborative Partnership of experiences

Evocation Draw out, elicit ideas, identify barriers, and explore solutions Encourages autonomy and provides support 66 Engagement Setting the Agenda Begin with an attitude of curiosity and a desire to understand more Learn how the clients behaviors or concerns fit into the persons situation or world view Be transparent and communicate your intentions and purpose 67

Join the Client on their Health Path Explore: GOALS VALUES IMPORTANCE CONFIDENCE BARRIERS MOTIVATION AND ABILITY 68 Join the Client on their Health Path (cont.) ENGAGE

Five Steps for Success: FOCUS EVOKE PLAN REVIEW 69 Keys to Successful Care Coordination Meeting the client where they are

Engagement Collaboration Consistent and regular contacts Transitional care supports Confidence and skill building for self-management of chronic disease/s 70 Develop Your Outreach Script Tips for effective outreach calls: Keep it brief Dont rush Ask questions and listen Ask if someone else should be present at the first visit Wrap up, confirming the visit date and time

Thank them for their time and interest 71 Due Diligence TRAINING 72 Due Diligence (cont.) Three telephone calls must be attempted: note in narrative One introduction letter must be mailed If unable to reach by phone a second letter must be mailed Document all of these efforts and discuss with your Lead

73 Involuntary Disenrollment If the client has not been engaged and has had a PRISM score of under 1.0 for at least six consecutive months talk to your Lead about disenrollment 74 Opting Out Clients have the right to: Opt out of the program before services begin Opt out at any time after services begin

Once opted out a client may return to the program as long as: They maintain eligibility for Medicaid Have a PRISM score of 1.5 or higher 75 Opt Out Form TRAINING 76

Client Vignettes We will use these vignettes throughout our training activities: Sacha Carmella Luchita Tom Jacob TRAINING

77 Small Group Work Review the profile of your client Record the following on your flip chart: Client profile: briefly describe your client What actions would you take to reach out to the client and engage them in the program? 78 Lets Pause to Check for Understanding What experiences have you had when you have initially contacted new clients in the

past? What worked for you? Do you have any questions? 79 PRISM A Care Coordination Tool Predictive Risk Intelligence SysteM 80 Todays Presenter Candace Goehring, MN, RN

Director of Residential Care Services Dept. of Social and Health Services Aging and Long Term Support Administration 81 PRISM A Decision Support tool designed to support care management interventions for high-risk clients Identification of clients most in need of comprehensive care coordination based on risk scores developed through predictive modeling and other indicators Integration of information from medical, social service, behavioral health, and long

term care payments and assessment data systems Intuitive and accessible display of client health and demographic from administrative data sources 82 Risk Tools 1. Future Medical Cost Risk Score Calculates expected level of future costs relative to a comparison group

2. Inpatient Admission Probability Calculates the probability of an inpatient admission in the next 12 months 3. Mental Illness Flag 4. Substance Use Flag 83

Defining High Future Medical Cost Risk 84 Prospective Inpatient Admission Probability Example condition within risk group Sickle-cell d... Dialysis catheter inf... Pneu... Hemophilia/von Wille... Lung tran... Secondary malignant ne... Congestive heart f...

Age 85 or... Chronic skin... Liver tran... Chronic renal f... Ulcerative c... Diabetes, type 1 with complic... Sept... Chronic obstructive ... Chronic nep... Decubitis... Heart tran... Rx for Liver D... Alcohol depe... 27.7%

21.4% 18.7% 15.6% 12.9% 11.2% 9.4% 8.8% 8.0% 8.0% 7.1% 6.1% 6.0% 5.3% 5.3% 5.2%

5.1% 5.0% 5.0% 4.9% 85 Prospective Inpatient Admission (cont.) Hospital Admission Impact . . . 9.8% Additional impact per hospital admission in prior 30 days 5.8%

Additional impact per hospital admission in prior 31-90 days 4.2% Additional impact per hospital admission in prior 91-182 days 2.1% Additional impact per hospital admission in prior 183-365 days Outpatient Emergency Room Utilization Impact . . . 1.7% Additional impact per OP ER visit in prior 30 days

Additional impact per OP ER visit in prior 31-90 days 0.9% Additional impact per OP ER visit in prior 91-182 days 0.3% Additional impact per OP ER visit in prior 183-365 days 0.2% PATIENT EXAMPLE Jane Doe has been diagnosed with congestive heart failure (9.4%), poorly controlled type 1 diabetes (6.0%), and chronic obstructive asthma (5.3%)

She was hospitalized once in the prior 31-90 days (5.8%), and twice in the prior 183-365 days (2 x 2.1% = 4.2%) She has been to the Emergency Department twice in the past month without being admitted to the hospital (2 x 1.7% = 3.4%) Her risk of an inpatient admission in the next 12 months is 28.3% 86 Risk Profile 87 Risk Factors 88

Risk Factor Methodology for Identifying Eligible Clients: Medical expenditure risk factors include the following: Age Gender Diagnoses Prescriptions

Note: the Health Home program was designed only to identify the top 5-7% of the Medicaid population and cannot accommodate everyone who could benefit from care coordination 89 Why Do We Focus on Risk? 90 What We Have Learned About Dual-Eligible Clients Chronic conditions are more prevalent for dual-eligible clients

91 Duals with High Risk Scores Disproportionate share of Medicare Inpatient costs High-Risk Dual Elders High-Risk Dual Disabled 89% 87% Share of total Medicare

Inpatient dollars spent 38% 34% Percent of the population 0% Share of total Medicare

Inpatient dollars spent Percent of the population $s $s 92 Pharmacy Profiles: High-risk Dual Eligibles Persons with at least 1 month of dual Medicaid/Medicare enrollment in SFY 2010

93 Why Focus on Coordination Across Delivery Systems? High-risk clients are likely to have service needs in multiple delivery systems Dual elders 7% Alcohol/drug treatment services 55% Treatment for serious mental illness 78% Long term care or developmental disability services

Dual disabled Alcohol/drug treatment services 27% 67% Treatment for serious mental illness 47% Long term care or developmental disability services Medicaid only, disabled Alcohol/drug treatment services

30% 37% Treatment for serious mental illness 25% Long term care or developmental disability services Medicaid only, not disabled 10% Alcohol/drug treatment services 10% Treatment for serious mental illness

6% Long term care or developmental disability services 94 Accessing PRISM 95 PRISM User Responsibilities Your Lead Organizations PRISM coordinator will:

Instruct you on the registration process Determine the type of access you receive Keep contents confidential and private Dont share your password Annually update your agencys IT security and HIPAA

confidentiality training Contact your Lead Organization if your profile information changes 96 PRISM Use Only access, use, and disclose the minimum amount of data to perform your job and assist the client

Report and suspected or actual security breaches to your Lead Organization immediately PRISM is monitored continuously and access may be suspended or terminated for unusual or potentially unauthorized activity Violations of RCW and HIPAA may result in severe criminal or civil penalties

97 How Do I Use PRISM in my Role as a Care Coordinator? 98 Uses of PRISM Triaging high-risk populations to efficiently allocate scarce care management resources

Identification of health risk indicators for high-risk patients Identification of behavioral health needs Medication adherence monitoring Identification of other potential barriers to care

Homelessness Hearing impairment Limited English proficiency 99 Uses of PRISM (cont.) Access to treating and prescribing provider contact information for care coordination Creation of health summary reports to share with providers Identification of care opportunities

100 Keys for Effective PRISM Use Be bold! You cant hurt anything Check eligibility tab to determine completeness and coverage gaps Consider possibility of false positive diagnoses

Can include Rule Out diagnoses Diagnoses reflect standard uses of medications, not off-label uses 101 Keys for Effective PRISM Use (cont.) Consider lag times PRISM updates weekly but providers may be slow to submit their claims

Out of pocket payments or private insurance payments will not display in PRISM Alcohol and drug treatment services are redacted and will not appear. If alcohol or substance use have been noted by a provider in other health services events then a flag (yes) will display 102 Keys for Effective PRISM Use (cont.)

Mental Health: this is created as a flag that the client may need mental health services. It is based on either prescriptions or diagnoses from other health service events. Tailor how you will use PRISM data with your client How much information will you share? Will this information serve to activate your client and reinforce their changes?

103 PRISM Data 104 PRISM Screens Events Event timelines for Inpatient, Outpatient, ED, Medicare and Medicaid AD Drug adherence timelines for all prescription drugs Risk Factors Key Medical and Behavioral Health Risk Areas Eligibility

Detailed eligibility and demographic data Claims All medical claims and encounters OP Outpatient claims RX Prescriptions filled IP Inpatient admissions ER Outpatient emergency room visits LTC Long term care services Lab Laboratory

Providers Provider list with links to contact information MH Mental health services CARE Long-term care functional assessments HRI Health risk indicators (for Children) 105 Lets Look at a De-identified Case TRAINING 106

PRISM Screens PRISM can assist you in your care coordination duties 107 Use the Eligibility Screen to Verify Current Coverage and Gaps Has the client been previously

covered by another MCO? If so there may be a HAP already in the system? Is the client currently eligible? Are there any gaps in coverage? 108

Identifying Long Term Care Services: the CARE Tab 109 Long Term Care Payments Payments may also be located under Claims screens 110 Identifying the LTSS Case Manager Click on these links for name and contact

information 111 Another way to find the PCP 112 PRISM Health Report See your training manual for an example for John Doe in the Reference section of your manual

Value of these reports: Helps promote self-management Supports the client as their own historian Provides a snapshot of the various look-back periods for the various screens Promotes continuity of care between health care providers 113 Lets Pause the Video to Check for

Understanding Have you used PRISM in the past and what was your experience? How did you use the information about your client? Do you have any questions? 114 How to Make a Referral If a Care Coordinator identifies someone who may benefit from Health Home services the Care

Coordinator may: Contact your Lead Organization Leads have universal access and can access all client records If the client does not have a PRISM score of 1.5 consider if there are recent major changes to health which may qualify Refer the case to their Lead Organization and include any additional information that may support the referral

115 How to Make a Referral (cont.) The Lead will submit the referral to the Health Care Authority (HCA) The Lead may be aware that the client is already assigned to another CCO The Lead may refer the case to a different CCO if HCA approves services

The HCA may not approve the services The HCA may choose to refer the case to another Lead 116 Reminder: Contact Requirements for Foster Children

To identify if a child is receiving foster care check the PRISM eligibility screen Contact Childrens Administration, not the foster parent for initial outreach TRAINING 117

Final Thoughts on PRISM Use this tool to optimize Health Action Planning and client support Report all suspected or actual security breaches to your Lead Organization immediately PRISM is monitored continuously and access may be

suspended or terminated for unusual or potentially unauthorized activity 118 Final Thoughts on PRISM (cont.) Review your clients only: violations of RCW and HIPAA may result in severe criminal or civil penalties Do not release the clients reports without the clients written consent to release PRISM information

119 Where to Turn for Assistance 120 Where to Turn for Assistance PRISM Support (DSHS Research and Data Analysis) [email protected] Health Care Authority Health Home Program [email protected] 121

Practice Using PRISM Lets return to our vignettes and begin our small group activity Sacha Jacob 122 Small Group Work Navigate and review the Excel spreadsheet to analyze your clients use of services What did you note about your client in reviewing the screens

in PRISM? What issues or gaps in care* did you identify that you would like to discuss with your client? *Gaps in care means the identification, coordination and processing of needed referrals to meet a clients medical, behavioral health and social service needs. 123 Lets Pause to Check for Understanding If you have used PRISM in the past which screens did you find most helpful? Do you have any questions?

124 The Patient Activation Measure Coaching and Action Plan Development 125 Review of the Patient Activation Measure The PAM1 is a behavior measurement tool that Reliably measures activation and the behaviors that underlie activation Provides insight into how to improve unhealthy behaviors and grow/sustain healthy behaviors Allows us to improve activation levels /behaviors, lower medical spending and improve health

Offers a powerful metric with which to assess the effectiveness of other health and wellness programs 1 All references to the Patient Activation Measure in this presentation are the property of Insignia Health (copy and trademark). Parts of this presentation were adopted from Insignia Health training materials. TRAINING 126 Types of PAMs Patient Activation Measure PAM

Caregiver Activation Measure CAM assesses the clients activation level assesses the caregivers activation level in caring for their client Parent Patient Activation Measure PPAM

assesses the parents activation level in caring for their child 127 What is Client Activation? Having the knowledge, skills, emotional support and belief to: Self manage health Collaborate with providers Maintain function and prevent declines Access appropriate high quality care 128 Administering the PAM Emphasize that the tool is a health survey

It is all about helping the client It is neither used to judge nor reduce or deny any benefits 129 PAM 13 Question Survey Lets review the 13 Patient Activation Measure Statements now TRAINING 130 Tips for Administering the Assessment Tool

It does not require a face-to-face contact to complete This survey can be administered over the telephone It could be mailed and completed in advance of the first face-to-face visit Check with your Lead regarding their policies related to administering this and other assessments 131 Tips for Administering the Assessment Tool (cont.)

Some people do a better job completing it themselves Consider asking the caregiver to complete a CAM if the client is unable to respond If a client refuses offer again at a later date You could provide a copy of the tool and ask the questions and record the answers This is helpful for clients with limited reading ability 132 Tips for Administering the Assessment Tool (cont.)

Ask the client how much they agree or disagree with the 13 statements Always start with strongly disagree to strongly agree Always ask the questions in order Do not change the questions Statements become increasingly more difficult to agree with 133 Tips for Administering the Assessment Tool (cont.) Do not discuss responses to the statements while administering the PAM this may improve scores Allow the client to consider the statements, silence may

indicate that they are thinking about their response 134 Tips for Administering the Assessment Tool (cont.) If a client is unable to complete the survey or refuses document in the HAP

The date the assessment was offered and declined The reason the assessment was not administered When a client, caregiver or parent do not complete the tool offer it at a subsequent visit 135 Tips for Administering the Assessment Tool (cont.) Use the clients responses as a springboard for further discussion (only after they have completed the survey) Consider using the responses to individual statements as

a starting place for discussing health concerns which the client may wish to address in their HAP 136 Interpret PAM Results Client Response Agree Strongly Agree Disagree/Strongly Disagree NA Interpretation Yes the question is true about me. This is a definite yes.

Sometimes this is true about me or is potentially true about me. This is not true for me. This does not apply to me. I do not know how to answer. I refuse to answer. 137 Scoring Scoring is the same for the PAM, CAM and PPAM Ask your Lead Organization for the scoring guide

Most Leads have software that will score the tool The activation score is converted to an activation level 138 PAM Segmentation Characteristics Level 1: Disengaged and overwhelmed Starting to take a role. Clients do not yet grasp that they must plan to take an active role in their own health. They are disposed to being passive recipients of care. Level 2: Becoming aware, but still struggling

Building knowledge and confidence. Clients lack the basic health related facts or have not connected these facts into larger understanding of their health or recommended health regimen. 139 PAM Segmentation (cont.) Level 3: Taking action Clients have the key facts and are beginning to take action but may lack confidence and the skill to support their behaviors. Level 4: Maintaining behaviors and pushing further Clients have adopted new behaviors but may not be able to maintain them in the face of stress or health choices. 140

PAM Segmentation Characteristics Roughly 45 to 50% of all Medicaid clients who have completed the measure score at a Level 1 or Level 2 Level 1: Disengaged and overwhelmed Level 2: Becoming aware, but still struggling Review the client's activation score and level to tailor coaching that is appropriate to the client. 141 Elicit the Clients Story Using Responses to PAM Questions Select an item where their answers begin to move away

from strongly agree. Help the client discover: What led them to select the response? Why this level and not a lower level? What would it take to reach the next level? Is this something we could work on together? 142 Elicit the Clients Story Using Responses to PAM Questions (cont.) With self-reflection the client makes an assessment of: What the problem is What will have to happen to alter this assessment

How the Care Coordinator can coach the client to pursue behavioral changes 143 Tailor Your Coaching Use responses to individual PAM items to get them to explain what is going on. The client will make statements indicating what they think are the barriers or challenges. Use perceived barriers to jointly problem solve throughout the coaching process. 144

Analyze the Results Incorporating Motivational Interviewing Techniques Notice when your client begins to disagree or strongly disagree with the statements This can be a good place to begin discussion about identifying areas where the client or representative may want to consider the type of goal them may be interested in pursuing Consider using motivational interviewing techniques to draw the client or representative out 145 Motivational Interviewing Strategies Start with where the person is and try to understand how the client understands their own situation Be empathetic and ask open ended questions

Listen and do reflective listening It sounds like you are feeling So, you are saying that you believe 146 Motivational Interviewing Strategies (cont.) Express acceptance and affirmation of the clients freedom of choice and self-direction Elicit and selectively reinforce the client's own self motivational

statements, expressions of problem recognition, concerns, desire, intention to change and ability to change When it is necessary to limit choice explain clearly why for example: It is really important for you to stay on your medications, they will help control your blood pressure. 147 PAM Activation Level 1 GOAL Build self-awareness and confidence Examples

Self-monitoring and awareness (e.g. how much they walk or how they cope with stress) Start pre-behaviors (e.g. reading labels on food) Cope with stress Understand their role in the care process 148 PAM Activation Level 2 GOAL Increase knowledge, confidence and initial skill development Examples

Make sure the knowledge dots are connected Start with small behavioral steps (one step at a time) Stress management and coping skills Build problem solving skills 149 PAM Activation Level 3 GOAL Initiation of new behaviors and develop problem solving skills

Examples Initiation of specific realistic behaviors (e.g. walking 10 minutes 3 times a week) Problem solving as it relates to the issues that emerge with the new behavior goals 150 PAM Activation Level 4 GOAL Maintain behaviors and techniques to prevent relapse

Examples Build confidence for coping and problem solving when situations throw them off track; self-monitor for those situations (e.g. new staff at the doctors office) Plan for handling a specific type of situation (e.g. using medications while traveling) Problem solve together 151 Perspectives on the PAM

The initial PAM score can be higher than subsequent PAM scores The client does not know what they do not know It is important to place the surveys side by side over time and work with the client on changed responses Look and listen for change talk and change opportunities Anticipate if the client may experience a decline or improvement in score to coach and support them Be aware of individual successes and failures and how they impact confidence with developing new or different skills 152 Where Do I Get Copies of the Tools? Lead Organizations are required to purchase a license for these products through Insignia For copies of the PAM, PPAM and CAM, the translated tools

and scoring guide contact your Lead to get Insignias: Website address User name Password 153 Website Hosting PAM Versions Ask your Lead Organization for the following to access this site: URL: https://healthhomes.insigniahealth.com User Name: - - - - Password: - - - - - 154 PAM Small Group Work

What is the PAM score for your client? What is your clients Level of Activation? What did you note about his/her responses to the PAM? If available should the caregiver complete the CAM? How would you begin to work with your client in relation to their responses and Level of Activation? 155 Lets Pause to Check for Understanding How will being aware of a clients PAM level help you when working with your

client? Do you have any questions? 156 Goal Setting Moving Toward Health Action Planning 157 Moving Toward Health Action Planning Consider the clients responses by reviewing and discussing the activation measure results Responses may provide a clue as to changes the client would like to make Consider using the Goal Setting and Action Planning Worksheet

158 A Tool for Starting the Conversation The Goal Setting and Action Planning Worksheet TRAINING 159 Coaching and Action Planning Goal Setting and Action Planning Worksheet Start where the client is Determine what the client wants to change The action plan is negotiated and tied to the discussion

about the level of activation 160 Coaching and Action Planning (cont.) Goal Setting and Action Planning Worksheet The action plan is something achievable given the client's level of activation At Levels 1 and 2 action plans focus on knowledge, belief, awareness and pre-behaviors At Levels 3 and 4 action plans focus on the initiation of new behaviors and maintaining behaviors 161

Developing an Action Plan Coach the client to select the Action Steps with the least number of barriers and prioritize them. Save the list of Action Steps so alternatives can be tried if the first ones are not successful; reassure client that many problems are not easily solved and may take time and multiple approaches. 162 Develop Action Steps Describe What the client has agreed to do What the Care Coordinator has agreed to do Where they will do it

How often(each day/week)? For how long? 163 Questions to Consider How important is it for you right now to...? On a scale from 0 - 10... what number would you give yourself? 0_________________________________________________________________________10 CONVICTION SCALE If you did decide to change, how confident are you that you would succeed? On a scale from 0 - 10... what number would you give yourself? 0_________________________________________________________________________10 CONFIDENCE SCALE If you did decide to change, how ready are you to make this change? On a scale from 0 - 10...

what number would you give yourself? 0_________________________________________________________________________10 READINESS SCALE 164 Coaching and the Health Action Plan Use your Coaching for Activation training and professional skills to guide the client to: Appropriate choices Attainable goals Action steps Improved health 165

The Health Action Plan (HAP) Establishes: Client and Care Coordinator identified: Long term goal Short term goal/s Action steps 166 Key Skills for Health Action Planning Demonstrate positive belief in the clients ability to take an

active role to accomplish appropriate goals and action steps Emphasize stress management and coping and resiliency skills Ask the client to recall a former success: how did it feel? 167 Key Skills for Health Action Planning (cont.) Elicit the clients story Build rapport Obtain a behavioral history, including past attempts to change behavior Identify barriers

Use open-ended questions Focus on feelings Use reflections 168 Analyze! What do you think drives poor health and high costs for your client? 85% of avoidable costs are due to behavioral, not

medical factors Consider: Clients perspective Results from assessment and screening tools PRISM Risk Factors Clients Level of Activation 169 Use Active and Reflective Listening That you can see the persons point of view Acknowledge the struggles or difficulty involved Acknowledge the clients success and their skills, abilities, and strengths

Thoughts Beliefs and values Behaviors Use you statements You sound determined. 170 Consider What Values Lie Behind These Statements I want to feel better

I want to be more independent I want to be able to attend church with my family I want to see my grandchildren grow up Keep these in mind so you can later link these values to their long term goals, short term goals, and action steps 171 Emphasize Problem Solving A Health Action Plan requires addressing problems through action steps Adults learn best by doing rather than through reading materials or hearing information Working through a problem using health coaching increases and enhances retention Identify their capacity for change and self-efficacy

172 Identify Barriers to Change Ambivalence? Understanding? Support system?

Energy levels/sleep quality/pain? Depression? Health literacy? Financial?

Confidence? Social isolation? 173 Explore Possible Solutions ASK the client to review possible solutions, but not make a decision just yet ASK the client to identify possible solutions, do you have any ideas on how you could solve this problem?

ASK the client if they would like you to share your thoughts and/or provide ideas using Health Home resources. ASK the client if they would like you to provide additional health education information; if so, review and discuss the information with them at the next visit. 174 Resistance Its human nature! Taking one side of a conflict can cause a person to take the opposite stance. Its normal 175 Behavioral Change Trying to convince another person to make a behavior

change can actually cause the person to be less likely to make a change. Even if you are successful in convincing someone to make a behavioral change, the change is not be likely to last. 176 Resist the Righting Reflex Exercise Pair up and take turns as the speaker and the listener Speaker Share your thoughts and feelings about a behavioral change you have thought about making or a change you previously made but are having trouble maintaining

Listener Ask open-ended questions No closed-end questions Neither agree nor disagree Avoid sharing your opinions or experiences 177 How Did It Go?

What was it like to be the listener did you want to interject your experiences or thoughts? Were there times when you wanted to jump in and offer advice or fix it? What was that like for you as the speaker did you feel understood? How did it feel to have someone place all of their focus on you and your concerns for even 5 minutes? What did you learn from this interaction about your own style? 178

Cultivate a Sense of Hope Demonstrating a positive belief in your client has a positive impact on the clients ability to accomplish their goals and action steps and sustain behavioral change. Hope is one of the greatest contributions you can make to your client as their Care Coordinator. 179 The Day in Review Health Home fundamentals Client outreach and engagement PRISM

The Patient Activation Measure Goal setting and action planning: moving toward the Health Action Plan 180 Lets Pause to Check for Understanding How is your role different than those you may have had in the past? What benefits do you see for your clients who engage in the program? Do you have any questions about what we covered today? 181

Welcome to Day Two Do you have any questions about what we covered on Day One? HH Fundamentals Outreach and engagement PRISM PAM Moving toward health action planning

182 The Health Action Plan TRAINING 183 Most People Desire Better Health and Quality of Life Each client is in charge of their own health Their own Health Action Plan, and Whether or not they make lifestyle changes

184 Help Identify a Long Term Goal Use a person-centered approach to help the client identify: What would they like to happen as a result of their health changes? What would they like be able to do that they cant currently do?

What is their level of activation and how it will help or hinder their ability to achieve their goal/s? 185 Help Identify a Long Term Goal (cont.) Long term goals may relate more to social goals but by achieving them the client may: Reduce medical costs Slow the progression of chronic disease Delay the onset of another chronic disease Reduce avoidable ED visits and hospital admissions and readmissions 186

Health Action Plan: Page 1 Note: most Lead Organizations have a data platform that is used to capture the HAP. These platforms can print the HAP but it may not look like the paper form. TRAINING 187

HAP Instructions TRAINING 188 Additional Training on the HAP Your Lead/s will provide operational training on how to use their software programs Dont hesitate to ask for technical assistance Meetings are sponsored by the Leads to supplement this training

DSHS sponsors monthly webinars and a quarterly newsletter with information related to the program and your work 189 HAP Form 10-481 and Instructions The HAP form and Instructions are located at the DSHS forms Website: http://forms.dshs.wa.lcl/ 190 HAP Form and Instructions

The revised HAP and Instructions are located at the HCA Website: https:// www.hca.wa.gov/billers-providers/programs-and-services/resources-0#c are-coordinator-training 191 HAP Form Instructions Each HAP spans a 12 month enrollment period consisting of three separate four month updates or activity periods All other documentation goes in the client record or file TRAINING 192

HAP Form Instructions (cont.) The Health Action Plan is updated and modified at each monthly contact by the Care Coordinator and when necessary to support a care transition or when the client opts-out of the Health Home program. The Health Action Plan is updated and modified as needed according to: A change in the clients condition New immediate goals to be addressed Completion of a short term goal and action steps

193 What is an Activity Period? 194 Activity Periods First Activity Period Second Activity Period Third Activity

Period There are three activity periods in a yearly (12 month) cycle Each activity period or trimester is four months There are 120 to 123 days within an activity period Number of days in a month varies from 28 or 29 days for February and 30 to 31 days for other months 195 Activity Periods Example Opts in 2/1/18 First activity period 2/1/2018- 5/31/2018

Second activity period 6/1/2018- 9/30/2018 Third activity period 10/1/2018- 1/31/2019 Start date of the next HAP is 2/1/2019 February March April May June July August September October November December January Start date of next HAP is February 1, 2019 196

Individual or Group Activity Activity Periods Worksheet First Activity Period Second Activity Period Third Activity Period 197

Worksheet 3: Activity Periods Opts in 5/1/18 First activity period for initial HAP Second activity period Third activity period Start date of the new HAP yearly cycle If the client opts in May 1, 2018: 1. What are the dates for the first activity period?

2. What are the dates for the second activity period? 3. What are the dates for the third activity period? 4. What is the start date for the next HAP year cycle? January February March April May June July August September October November December 198 Worksheet 3: Activity Periods Opts in 5/1/18 First activity period for initial HAP Second activity period Third activity period

Start date of the new HAP yearly cycle May 1 thru August 31 September 1 thru December 31 January 1, 2019 thru April 30 May 1, 2019 January February March April May June July August September October November December 199 Worksheet 3: Activity Periods Opts in 7/13/18

First activity period for initial HAP Second activity period Third activity period Start date of the new HAP yearly cycle If the client opts in July 13, 2018: 1. What are the dates for the first activity period? 2. What are the dates for the second activity period? 3. What are the dates for the third activity period? 4. What is the start date for the next HAP year cycle? January February March April May June July August September October November December

200 Worksheet 3: Activity Periods Opts in 7/13/18 First activity period for initial HAP Second activity period Third activity period Start date of the new HAP yearly cycle

July 13 thru November 12 November 13 thru March 12, 2019 March 13 thru July 12 July 13, 2019 January February March April May June July August September October November December 201 Worksheet 3: Activity Periods 1. What is the end date of the HAP if the client notifies the Care Coordinator that he no longer wants to participate in the program during a phone call on May 10, 2018? May 10, 2018 2. The Care Coordinator made several calls to the client and sent a letter with no

response from the client and the Lead approves closure of the HAP. The letter was mailed to the client on August 13, 2018 and the final call was made on August 17, 2018. What is the end date for the HAP? August 17, 2018 202 HAP Form Instructions (cont.) Demographic data fields for name, gender, date of birth and ProviderOne ID Date the HAP begins Date the client Opts-in

This is the date the client agrees to participate in the program and begins development of the HAP. This date becomes the clients anniversary date. It triggers the start of a new HAP for the next HAP reporting year. 203 HAP Form Instructions (cont.) Date the HAP ends: At the end of a one year cycle (do not prepopulate this field) The day the client opts out of the program The date the HAP ends for other reasons as listed in the Reason for

Closure of the HAP data field (check the appropriate box if one of the reasons apply) 204 HAP Form Instructions (cont.) If a client is transferring for one of the reasons listed, then do not enter a HAP end date as the HAP is still active until the end of the one year cycle even though it may be transferred. Reasons for transfer of the HAP include: Client choice to change CCO or Lead Organization Eligibility changed:

Client was enrolled with a Managed Care Organization (MCO) and transferred to a Fee-for-Service (FFS) Health Plan Was enrolled with as FFS and transferred to an MCO Health Plan 205 HAP Form Instructions (cont.) Options for gender include: Because clients have a right to change Lead Organizations or Care Coordination Organizations the names and phone numbers are provided

206 HAP Instructions (cont.) Write a brief statement about the client Develop a long term goal that is person-centered, based on what the client wants to achieve Enter the diagnosis or diagnoses that are pertinent to the long term goal 207 Help the Client Identify Long Term and Short Term Goals

Physically, what can you do best? Where (or when) are you strongest? Who do you contact when you arent feeling well? Which health concerns have the biggest impact on your life? What are some ways you may increase your wellness? 208 HAP Form Instructions (cont.) Required screenings: enter the dates and scores of the screening on the HAP PHQ-9 Patient Health Questionnaire (Depression Screening) or Pediatric Symptom Checklist 17 (PSC-17) ages 4-17 BMI Body Mass Index Katz Activities of Daily Living Patient Activation Measure

Patient Activation Measure (PAM) or Caregiver Activation Measure (CAM) or Parent Patient Activation Measure (PPAM) 209 HAP Form Instructions (cont.) Enter the date the screening was completed or offered but declined Enter the activation score and level of activation for each type of activation measure completed If the client, caregiver or family decline or are unable to complete the

screening enter the date and the reason the screening was not completed Screening must be completed at least once during each four month activity period or more often as clinically indicated 210 Patient Activation Measures The PAM is required for clients Note the date, the activation score and activation level on the HAP

If the client cannot complete the PAM Note the date the screening was offered and note the reason the PAM was not completed on the HAP OR Complete the CAM or PPAM (see next slides) The PAM dates may not be the same as the start date of the HAP or updates for each four month activity period 211 Caregiver Activation Measure The CAM may be administered when the client is unable

or unwilling to complete the PAM Caregivers may be informal or formal caregivers, or paid or unpaid caregivers Document in the case record the name and relationship of the person who completed the CAM Note the date the CAM was completed, the activation score, and activation level on the HAP

212 Parent Patient Activation Measure The PPAM must be administered to the parent or guardian of children under the age of 18 years Parents include: biological, adoptive, or foster Note the date the PPAM was completed, the activation score and activation level on the HAP

Document in the case record the name and relationship of the person who completed the PPAM If the parent or guardian declines to complete the PPAM note the date the assessment was offered and the reason the parent/guardian did not complete the screening 213 The Katz ADL Score one point for each of the six ADLs that client reports that they can perform independently without assistance

If a client indicates that they are dependent and could use assistance with two or more ADLs consider a discussion about applying for Long Term Services and Supports (LTSS) Referring the client to the DSHS Developmental Disabilities Administration or Home and Community Services Office in your area is an appropriate service for you to offer 214 Katz Activities of Daily Living (ADLs) Link to 29 minute training video: https://consultgeri.org/try-this/g eneral-assessment/issue-2

215 PHQ-9 and PSC-17 Screens Patient Health Questionnaire: nine item screening tool for depression 18 years and older Pediatric Symptom Checklist: 17 item screening tool for moods and behaviors Ages 4 through 17 years 216 PHQ-9 and PSC-17 (cont.)

The Care Coordinators role is to screen for possible behavioral health issues Care Coordinators do not diagnose, counsel, or treat; they refer to qualified professionals and behavioral health resources for further assessment and treatment 217 The PHQ-9 is a Required Screening Your manual also contains a copy of the GAD-7 TRAINING

218 Guide Sheet on Depression Screening and Suicide Guide Sheet offers general guidelines Your agency may also have their own policies, procedures, and reporting requirements

Interpretation of results of PHQ-9: a score of 10 or higher indicates moderate depression Offer a referral to PCP or a behavioral health provider If a client expresses that they have thought out suicide, have a plan, and have the means seek help immediately TRAINING 219 Pediatric Symptom Checklist 17

The PSC-17 must be completed for children ages 4 to 17 years of age The screening is completed by the parent or guardian Scoring is based on the parents report of current behaviors A child age 13 and over may self-administer the screening Note in the comment section the name of the person who completed the screening and their relationship to the child. Enter the parents score in the HAP and note the childs score in the case narrative

220 DSHS Form 10-509 PSC-17 & Instructions TRAINING 221 PSC-17 Considerations The screening tool should not be used for diagnosing A score of 15 or higher may indicate the need for further evaluation by a qualified professional The screening tool offers three subscales for: Internalizing behavior Externalizing behavior

Attention 222 PSC-17 Website For translations of the tool visit the Massachusetts General Hospital website located at: http://www.massgeneral.org/psychiatry/services/psc_home. aspx 223 Body Mass Index (BMI) This is required on the HAP BMI chart is located in the Classroom Training Manual BMI is not required for children under 2 years of age

If you are unable to get a recent or accurate weight record the BMI and make a comment in the comment box TRAINING 224 BMI Online Charts BMI Calculator for Children and Teens (2-19) http://nccd.cdc.gov/dnpabmi/Calculator.aspx BMI Calculator for Adults http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/ english_bmi_calculator/bmi_calculator.html 225

HAP Form Instructions (cont.) Optional screenings Enter the dates and scores of the screenings on the HAP DAST Drug Abuse Screening Test GAD-7 Generalized Anxiety Disorder 7 item scale AUDIT Alcohol Use Disorders Identification Test Falls Risk My Falls-Free Plan identifies risk and provides suggestions to prevent falls Pain Scales Administration of appropriate pain scale TRAINING 226 When to complete an optional screening

Use your clinical judgment to determine the need and frequency for offering additional screenings Examples: If a client identifies a goal related to pain: one of the three pain screenings

If a client voices concerns about their use of alcohol or drugs: the AUDIT or DAST If a client reports falls or fractures: falls risk If a client identifies a goal to reduce stress or anxiety: GAD-7 If the HAP includes goals or action steps related to one of the optional screenings then the screening must be offered and documented on the HAP 227 PHQ-9 and GAD-7 Anxiety and depression are the most common mental disorders and often appear together. Screening tools often used include: The PHQ-9 which can identify potential depression GAD-7 which can help identify potential anxiety

Both tools are most reliable when self-administered A positive screening for either or both should lead to a referral to a behavioral health provider or PCP depending on client preference 228 PHQ-9 and GAD-7 Screening Tips Normalize the screening; dont make it a big deal Some people respond better to terms like stress when talking about their anxiety or sadness rather than depression Everyone experiences sadness and this tool might help identify how it might be impacting you Remember the power that stigma holds- many people do not

want to self-identify Treatment can be very effective 229 Translations of PHQ-9 and GAD-7 The website sponsored by Pfizer is located at: http:// www.phqscreeners.com/ select-screener/36 230 HAP Form Instructions (cont.)

Enter the date the screening was completed Enter the score Screening may be completed at any time during each four month activity period or more often as clinically indicated 231 HAP: Pages 2 Through 7 232 Short Term Goals Enter the short term goal

Enter the short term goal begin date When a goal ends enter the date and check the reason the goal ended Enter the action steps, specifying who will complete the step and the start date

Goals that are not completed may be carried over to the next four month period Goals may be revised at any time to reflect changes with the client 233 The Health Action Plan (HAP) Develop goals and action steps that are SMART: Specific Level of Activation

Measurable Achievable Importance SMART Relevant to the client Goals Time-limited Confidence Readiness 234

Health Action Plan First Short Term Goal Long Term Goal Participate in church activities with my family. Short Term Goal # 1 Debbie would like to improve stamina and gain strength and be able to remain out of her bed for four hours or more each day. Action Steps 1. 2. Debbie and Care Coordinator will brainstorm common events in Debbies life that promote activity as well as those that promote inactivity.

Debbie will maintain activity log for two weeks and review with Care Coordinator during next visit on 7/7/17. 235 Health Action Plan Second Short Term Goal Long Term Goal Participate in church activities with my family. Short Term Goal # 2 Debbie would like to decrease use of pain medication. Action Steps 1. 2.

3. Debbie will document use of pain medications, her activity and functional ability daily starting 8/1/17 using the pain log provided by the Care Coordinator. Debbie will make an appointment with PCP to discuss chronic pain management options by 8/25/17. Care Coordinator will review the pain log and inquire about Debbies appointment with her PCP during the home visit schedule on 8/28/17. 236 Lets Pause to Check for Understanding What experiences have you had offering and administering these screenings in the past?

Do you have any questions? 237 Small Group Work Considering your clients PRISM results, PAM responses and Level of Activation: Fill out the HAP form (make up scores as needed for this activity) Write the following on the flip chart: One long-term goal

One short-term goal Actions steps to reach the short-term goal Who will complete the step and by when? Which of the 6 health home services might the client need now and in the near future? Which of the optional screenings might be helpful for your client? 238 Maintaining Behavioral Change Sustaining the gains with healthy strategies Maintaining behavioral change takes time (usually 6 months to two years) Monitoring using relapse prevention and resiliency planning Progressing by realizing that relapse is one step forward on the

clients journey Pursuing new goals and activities 239 Final Notes About the HAP A copy of the HAP should be provided to the client, parent or legal representative The HAP may be: Printed and mailed

Delivered at the face-to-face visit E-mailed using secure mail and/or encryption Each face-to-face visit or telephone contact provides an opportunity to discuss and review progress on the HAP The HAP is a fluid document that changes with the clients needs and preferences 240 Lets Pause to Check for Understanding Do you have any questions about the HAP? How can you work with

your client to increase the value of the HAP? 241 Care Transitions Health Care Without Complications All materials in this section are adopted from the Reducing Readmissions: Care Transitions Toolkit from the WASHINGTON STATE HOSPITAL ASSOCIATION. To download a copy of the toolkit go to http://www.wsha.org/wp-content/uploads/WSHACareTransToolkit.pdf TRAINING 242

Hospital Readmissions As of January 1st, 2017, our regions 30-day readmission rate of 31.3 per 1,000 Medicare beneficiaries is better than the national average (52.5 per 1,000). Research shows that 20% of patients in the U.S. are re-hospitalized within 30 days of discharge. Addressing social and resource barriers early in the admission not only prevents unnecessary readmissions, but also proactively prevents delayed discharges and unnecessary increases in the length of stay 243 What Causes Readmissions?

Unresolved social or resource issues: Medical issues are not always the reason Lack of strategies that incorporate both social and medical factors resulting in poorly executed transitions and poor outcomes for the client which impact: Family and support systems

Caregivers: paid and unpaid Clients health and stability 244 Washington State Care Transitions Washington State Care Transitions is a state-wide initiative to foster safe, timely, effective, and coordinated care as clients move between settings Care Coordination includes collaborating on the discharge Plan of Care with the primary care physician (PCP) and

multidisciplinary care team 245 How Will You Know if a Client Has Been Hospitalized? Review PRISM data: there is a lag in submission of billing claims Emergency Department Information Exchange (EDIE): find out if your Lead or agency subscribe to this service Some Leads use PreManage, a system that notifies them of emergency dept. visits and hospital admissions and discharges Find out who at your agency receives these alerts 246 Six Strategies for Care Transitions

1 2 3 4 5 6 Consistent plan of care with the PCP and home health care (if applicable) upon arrival and discharge from the hospital Coordinated follow up call or visit at discharge Timely visit to PCP Reconciliation of medications soon after transition Client, family and caregiver education coordinated between

settings Support through increased care management for high-risk clients 247 Social/Resource Barriers Assessment Evaluate, assess, and complete a needs assessment of clients home-going needs and barriers to care including support requirements. The Katz ADL may be used as a tool for assessing the clients abilities and care needs. 248 Social and Resource Barriers

Personal care needs Other disabilities Limited income Financial reserves

Unstable or unsafe housing Inaccessible housing Coping skills Employment Health literacy or numeracy Lack of an advance directive

Religious or spiritual support Education Substance use history Psychiatric history Availability of mental health or SUD services Demands on other family members or caregivers Transportation 249 Client, Family, and Caregiver Follow-up

What are the discharge orders? Do they have a copy of the discharge orders and do they understand them? What warning signs or symptoms should be reported to the healthcare provider? Do they have the phone number to the 24 hour nurse line? What follow-up is necessary?

Have the follow-up appointments been scheduled? Is the client aware of these appointments and do they need transportation and/or an escort to the appointment/s? What are the current medications? 250

Does the Client or Caregiver Know Which Red Flags May Require a Call to the Provider? Chest pain or palpitations Cough

Infection Blurred vision, loss of vision Headache Fatigue Insomnia or problems sleeping Discharge Warmth to an affected area Fever

Pain Nausea and/or vomiting Poor appetite Weight loss or weight gain Bleeding Constipation or diarrhea Difficulty urinating or no urination Dizziness Falls 251

Triage Grid for Follow Up With PCP Clients who are at very high risk need a quicker and stronger communication process between providers while those at lower risk do not need as intensive of care. Created by WA physicians and hospitals with evidence from the Institute for Healthcare Improvement 252 Medication Reconciliation Defined Medication reconciliation is:

A process of comparing the medications a client took prior to admission to a hospital, nursing facility or other in-patient center with those ordered by the physician at the time of discharge. Should also be completed when the client visits their PCP to ensure that the medication record is accurate and up to date. Reduces the potential for administering the wrong dosage, administering a discharged medication, taking the same medication more than once (e.g. taking the name brand and the generic of the same medication), and/or using expired medications. 253 Medication Reconciliation During the hospital stay: anticipate needs

Within 5 days following discharge Care Coordinator will provide or ensure that it is completed by a qualified professional Note: clients who discharge from a facility against medical advice (AMA) do not receive their prescribed medications when they exit the facility. The need to follow up on medication orders and to fill prescriptions becomes even more critical. 254 Medication Reconciliation (cont.) Who can help reconcile medications? Primary care physicians (PCP)

The PCPs nurse or physicians assistant (PA) Family members Pharmacists Pharmacies that deliver bubble-packed medications to adult family homes Home Health nurses Adult Day Health Centers

Nurses in nursing facilities, assisted living, adult family homes and other institutions 255 Follow-up Scripts from Reducing Readmissions: Care Transitions Toolkit TRAINING 256 Teach Back Literature shows Teach Back is one of the most effective methods for educating clients. Teach Back involves asking the patient, family or caregiver to recall and restate in their

own words what they thought they heard during education or other instructions. Be aware of the client or caregiver activation level when teaching or using teach back techniques. An example of teach back is to ask your client if they know the 24 hour nurse helpline which all health plans must offer TRAINING 257 Lets Consider Our Vignettes If Carmella was hospitalized what transition services might you provide?

How would you work with Sacha if she admits to the hospital and then to the nursing facility and is returning home? NOTE: when entering a hospital, nursing facility, or other institution introduce yourself to staff each time you enter the facility so staff is aware of your role and services you may offer. 258 Lets Pause to Check for Understanding Do you have any questions about Care Transitions? What experience have you had professionally or personally with effective discharge from a hospital or other inpatient setting?

259 Documentation, Quality Assurance, and Time Management 260 Documentation Guidelines These are general guidelines

Ask your Lead/s for their guidelines Suggested practices Data platforms will vary Consult your supervisor What are requirements What are best practices

261 General Format for Documentation Date Type of contact Highlights from the conversation Objective observations Other relevant comments Plan for next steps or conclusion

Specific timeframe Who is responsible 262 Something to Consider If someone assumed your case could they find a case history? Would they know where to pick up after the previous Care Coordinator? What referrals need to be completed or need to be managed? What actions steps are the client, Care Coordinator, or others doing and by

when? 263 Quality Assurance Leads complete their audits for client records Ask for their checklist Health Care Authority (in partnership with DSHS)

Audits 10-15 files each year Proficiency rate is usually 90% Nine out of ten records reviewed meet the requirement Leads often use the results of their internal audits and findings from HCA to develop training

Ask your Lead for technical assistance 264 Core Services Does the case narrative indicate which core service/s was provided during the month? If a core service was provided by another entity note this and describe how the Care Coordinator is coordinating services with other providers

Care Coordinators do not duplicated services In this case the service provided by the Care Coordinator would be Care Coordination Indicate services provided by allied staff under the supervision or oversight of the Care Coordinator in the case narrative If allowed, allied staff should document their activities in the case narrative 265 Completion of Forms

Was the Participation Authorization and Information Sharing Consent Form completed, signed, and dated? If not is there a note in the case narrative citing the reason the form was not completed and signed by the client, parent, or guardian? Were additions and deletions dated and initialed by the client, parent, or client representative (POA, guardian)? Was the Opt-Out Form completed, signed, and dated?

If the client does not complete the form is there a narrative documenting the clients verbal request to opt-out? 266 Required and Optional Screenings Document in the HAP the date required screenings were completed and the score (and level for the Patient Activation Measures )

If the client, parent, or guardian decline to complete a screening document the date it was offered. Also include the reason if known For example, a parent declined the PPAM because the child was ill and needed the parents care Optional screenings become required when the HAP or something in the case record indicates that it should be offered If the client, parent, or guardian decline to complete the optional screening document the date it was offered and the reason, in known

267 HAP Were all fields completed? If not is there an explanation? Was the client, parent, or guardian given a copy of the HAP

Formats vary depending on the Lead 268 Key Considerations Was the HAP completed within 90 days of enrollment with the Lead? Does the case narrative support the Tier that was billed? Does the case file document an in-person visit in which the Care Coordinator met with the client to develop and finalize the HAP?

269 Key Considerations (cont.) Does the case narrative document periodic in-person and telephonic interactions with the client? Did the file contain an initial score and level for PAM, CAM, or PPAM as appropriate? Does the HAP document the required BMI, Katz ADL, PHQ-9 or PSC-17 scores or a reason the client declined the assessment or screening tools? 270

Key Considerations (cont.) Did the case file document demonstrate that the clients required screenings were updated at least during every four month activity period or when there was change in the clients health status? Does the HAP document the required BMI, Katz ADL, PHQ-9 or PSC-17 scores were updated at least one time during each activity period? 271 Key Considerations (cont.)

Did the HAP clearly identify action steps to be taken to achieve the clients prioritized short term goal and who is responsible to complete each step? Does the HAP identify optional screenings that were administered to assist in determining gaps in care or needed services as application to the clients health needs? 272 Key Considerations (cont.) Does the case file demonstrate evidence that the Care Coordinator facilitated communication and coordination

between the client and the clients service providers and other support systems to address barriers and achieve health action goals? Does the case file contain evidence that the Care Coordinator developed and executed a cross-system team as needed to review and provide assistance with the clients case? 273 Key Considerations (cont.) Does the case contain evidence that the Care Coordinator provided educational materials that promote improved clinical outcomes, increase self-management skill, or use of

peer supports to increase the client knowledge about their health conditions and adherence to treatment? Does the case record contain evidence of comprehensive transitional care to prevent avoidable readmissions after discharge from an inpatient facility and ensure proper and timely follow-up care? 274 Key Considerations (cont.) Does the case contain evidence that the Care Coordinator discussed advance directives with the client, parent, or collateral?

If this was not completed by the first Care Coordinator then it should be noted and discussion offered to the client, parent, or guardian and documented Did the case record contain evidence that the Care Coordinator provided the client or their family support with services or educational materials in a format they can understand if indicated? 275 Key Considerations (cont.)

Does the case record contain evidence that the Care Coordinator assisted the client as needed to maintain eligibility such as health care services, disability benefits, or housing? Does the case record contain evidence that the Care Coordinator provided services in an culturally competent manner? Does the case record identify and refer the client to available community resources to help achieve health action goals, such as legal or food bank needs? 276 Key Considerations (cont.)

Does the case record contain evidence of a notification process of the clients admission or discharge from an emergency department or an inpatient setting? Because we do not duplicate benefits, if another agency, such as the MCO, is providing care transitions note this is the case narrative Does the case record contain evidence that the Care Coordinator participated in all appropriate phases of care transition? 277

What Were the Six Strategies for Care Transitions? 1 2 3 4 5 6 Consistent plan of care with the PCP and home health care (if applicable) upon arrival and discharge from the hospital Coordinated follow up call or visit at discharge

Timely visit to PCP Reconciliation of medications soon after transition Client, family, and caregiver education coordinated between settings Support through increased care management for high-risk clients 278 Organizing Your Time Plan your day/week by scheduling:

Time for outreach calls and letters Follow-up calls Making and actively managing referrals Face-to-face visits Working with allied staff and multidisciplinary care teams Documentation Schedule time for responding to EDIE or PreManage alerts

Carve out time in your schedule each day and if no one has been hospitalized or ED use this time for the above activities 279 Lets Pause to Check for Understanding What tips can you share that have helped you better manage your caseload? Do you have any questions? 280 Resources Advanced Home Care Assistant Specialty Pilot Program

Non-emergency Medical Transportation (NEMT) Program Community Living Connections Community Integration for Adult Family Home Residents Care Coordinator Toolkit 281 Advanced Home Care Assistance Specialty Pilot Program Care Coordinators will be notified if their client enrolls in the program

Care Coordinators may need to answer questions about the program and could help the client fill out the enrollment form Care Coordinators may work with case managers, Individual Providers, and clients to incorporate the IP into the HAP 282 Community Integration Program

Adult Family Homes (AFH) may now receive a rate increase to participate with qualifying residents Four hours per month is added to the daily rate for the provider to assist the client to better integrate into their local communities Possible roles for the Care Coordinator:

Educate the client, family, or collaterals about this benefit Research opportunities for the client in their community Discuss with the AFH provider options Who will provide transportation? Who will make a referral or complete an application if needed? Integrate the activity into the HAP if appropriate

Establish a short term goal and action steps 283 Non-emergency Medical Transportation (NEMT) Program Transportation may be provided to Health Home clients for services when the client is homeless or lives in an unhealthy or unsafe environment A Care Coordinator may request NEMT to alternate locations to conduct care coordination services such as:

developing the Health Action Plan (HAP) obtaining consent to participate administering health assessments TRAINING 284 Working with Providers Consider offering this letter when visiting your client at nursing facilities, hospitals, and other residential providers

(assisted living facilities and adult family homes) 285 Community Living Connections (CLC) Easy to navigate: Website is located at: https://washingtoncomm unitylivingconnections.org /consumer

/ Enter zip for clients location and select type of service 286 Care Coordinators Toolkit Contains resources including: Educational materials for coaching and educating clients and collaterals Links to other online resources Links to DSHS programs and information Training opportunities and materials Website is locate at:

https://www.dshs.wa.gov/altsa/home-and-community-services/care-coordinator-too lkit 287 Developing Resources Lead Organizations have completed outreach activities with local hospitals and institutions Care Coordination Organizations are encouraged to complete their own outreach to community partners and medical and behavioral health providers to establish working relationships to aid in their care coordination activities 288

Review of the Learning Objectives What are the six core Health Home Services? Describe outreach and engagement strategies you will use. Describe the key uses of PRISM in care coordination. What is patient, parent, and/or caregiver activation and why is it important? 289 Review of the Learning Objectives (cont.) What are the required and optional screens used to assess the needs of Health Home clients? How does a Health Action Plan support improving the health of a client? What are the crucial activities of comprehensive transitional

care? 290 Lets Pause to Check for Understanding Do you have any questions about what we covered during Day One or Day Two? 291 Additional Training Required Special-topic Training Optional Training

292 Required Training for Fee-for-Service and MCO Health Home Program Special topic PowerPoints are located at the DSHS Duals website at: https://www.dshs.wa.gov/altsa/home-and-community-services/washington-health-h ome-program-going-training The mandated topics are: 1. 2. 3. 4. 5.

6. 7. Outreach and Engagement Strategies Navigating the LTSS System: Part 1 Navigating the LTSS System: Part 2 Cultural and Disability Competence Considerations Assessment Screening Tools Coaching and Engaging Clients with Mental Health Needs Medicare Grievance and Appeals (required if working for Duals) 293 Register and Join for Our 2018 Series Ask your Lead for the link to

register for each quarterly series beginning in January 2018 or visit the DSHS Care Coordinators website 294 HCA Website is Located At: http:// www.hca.wa.gov/billers-providers/programs-and-services/resources-0#care-coordinator-traini ng 295

DSHS Website is Located At: https://www.dshs.wa.gov/altsa/washington-health-home-program Resources for Care Coordinators and Allied Staff 296 Lets Pause to Check for Understanding Do you have any final questions? 297

Please Complete the Training Evaluation We appreciate your feedback! 298

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