Conflict of Interest Disclosure From Small Rural Clinic to Modern - PDF document

3/12/19 Conflict of Interest Disclosure From Small Rural Clinic to Modern Patient Centered I have no financial relationships with commercial Medical Home entities that produce health care-related products or services relevant to the content I am redesigning team structures, workflows, and space planning, developing, or presenting. during a time of transition and expansion Matthew Libby, DO, FAAFP Medical Director, Harwich Port Health Center Clinical Director of Informatics Outer Cape Health Services, Inc. Objectives Outline Ø Be able to define core components of a Ø Who is Outer Cape Health Services? successful team-based care model Ø Identify motivations to change care model Ø Identify key steps in implementing systems Ø Forming a pilot team and changing workflows changes using a Pilot Team Ø Exploring effect on Quadruple Aim outcomes Ø Understand how team-based care can support Ø Designing new workspaces around the model Quadruple Aim healthcare improvement goals Ø Scaling up changes to a multi-site system Ø Explore challenges with scaling up local Ø New challenges and future directions changes across an organization Mission: Wellfleet Health Center: 1966 – 2018 To provide a full range of healthcare and supportive social services that promote the health and well-being of all who live in or visit the ten outermost towns of Cape Cod. We are a unique rural FQHC Ø HPSA score of 16 (primary care) Ø Only Masshealth provider in most of our service area Ø Only healthcare provider from Eastham to Provincetown Ø Socioeconomically diverse patient base Ø Medically and socially complex patients Ø Remote from Hospital: Ø 33 miles from Wellfleet Ø 47 miles from Provincetown Ø Summer visitor population with urgent care needs 1

3/12/19 Motivation for Change Quadruple Aim Ø Challenges with burnout and retention Ø Challenges with recruitment Ø Need for expansion Ø Meet community need Improve Improve Improve Ø Financial sustainability Lower cost Patient health of staff of care Ø Need for updating outdated facilities Experience population engagement Ø Payment landscape is changing Ø Technology capabilities are improving Original Patient-Centered Medical Team-Based Care Home Principles - 2007 Ø Personal physician Ø Physician directed medical practice Ø Whole person orientation Ø Care is coordinated and/or integrated Ø Quality and safety Ø Evidence-based care Ø Quality improvement Ø Shared decision-making Ø Optimal use of information technology Ø Enhanced access Ø Payment Ø Advocated payment for care coordination, telemedicine, etc. Schottenfeld L, Petersen D, Peikes D, Ricciardi R, Burak H, McNellis R, Genevro J. Creating Patient-Centered Kellerman R, Kirk L. Principles of the patient-centered medical home. Am Fam Physician. 2007 Sep Team-Based Primary Care. AHRQ Pub. No. 16-0002-EF. Rockville, MD: Agency for Healthcare Research and 15;76(6):774-5. Quality. March 2016. Starting from Scratch: Empanelment Pre-work: Defining the Team Physician Physician Mid-Late 2016: Mid-Late 2016: empanelment empanelment project project MA PA/NP Patient Patient Nov 2016: Pilot Team formed RN MA PA/NP 2

3/12/19 Phase 1: Weekly Team Meetings Phase 1: Evolving Team Roles Physician Physician Mid-Late 2016: Mid-Late 2016: empanelment empanelment project project MA PA/NP MA PA/NP Patient Patient Nov 2016: Nov 2016: Pilot Team Pilot Team formed formed RN MA RN MA All team members meet for 30 minutes once a week Goal: Each team member working to the top of their license Evolving Team Roles: Evolving Team Roles: The Nurse The Medical Assistant Clinical patient Relay test questions results Triage Prep Rx refills RN Visits Needs referral - Run the huddle - Room patients - Obtain records Vaccine and No appts - Patient outreach med admin available - Complete forms - Perform point of - Prompt health - Relay test results care testing screenings due Patient - Assist the nurses Need records Education RN Care Other random Management questions Phase 1: Co-location Many Organizational Changes in 2017 July 2017: Site Medical Spring 2017: Director, centralized new schedule scheduling, templates, Mid-Late 2016: Jan 2017: medical panel Empanelment Wellfleet records, management project referrals colocation time May 2017: Nov 2016: new CMO Pilot Team formed 3

3/12/19 Many Organizational Changes in 2017 Many Organizational Changes in 2017 July 2017: July 2017: Site Medical Site Medical Spring 2017: Spring 2017: Director, Director, centralized new schedule centralized new schedule Physician scheduling, templates, scheduling, templates, medical medical panel panel records, management records, management MA PA/NP referrals referrals time time Patient PSR MA May 2017: May 2017: new CMO new CMO RN identify specific patient service representative for each team Many Organizational Changes in 2017 Many Organizational Changes in 2017 July 2017: July 2017: Site Medical Site Medical Spring 2017: Spring 2017: Director, Director, centralized new schedule centralized new schedule scheduling, templates, scheduling, templates, Sept 2017: Sept 2017: medical medical panel panel first team first team records, management records, management referrals quality reports referrals quality reports time time May 2017: Aug 2017: May 2017: Aug 2017: new CMO pharmacy call new CMO pharmacy call center for center for refills refills Updated Quality Program Pilot Team Refocus 2018 Metric FY2019 Exclusions Baseline Dec Goal Breast Cancer Screening All Female Patients age 50-74 Bilateral Mastectomy 60% 62% Winter 2018: Breast Cancer Screen in last 2 years Z90.13 April 2018: Hospice Patients outreach for well Z51.5 child and go live with Colorectal Cancer Screening All patients Age 50-75 Total Colectomy 64% 66% pneumonia advanced PVP vaccine lists checklists FIT in last One Year Z90.49 Colonoscopy in last 10 years Hospice Patients Z51.5 Diabetes Control All Diabetics age 18-84 Hospice Patients 67% 69% A1c < 8 is controlled if measured Z51.5 in last one year Gestational Diabetes Feb-Mar No result = not controlled O24.419 2018: Pneumoccoccal Vaccination All Patients age 67 and older Allergy to Pneumonia 58% 60% team Received BOTH Vaccines: Vaccine develops Pneumovax 23 Z88.7 advanced pre- Prevnar 13 visit planning Well Child Checks All Patients birth to age 20 inclusive None 84% 86% checklists One Preventive Vist in Last 15 months 4

3/12/19 Pilot Team Refocus 2018 Pilot Team Refocus 2018 Winter 2018: Winter 2018: April 2018: April 2018: outreach for well outreach for well child and go live with child and go live with pneumonia pneumonia advanced PVP advanced PVP vaccine lists checklists vaccine lists checklists Feb-Mar Feb-Mar 2018: 2018: team team develops develops advanced pre- advanced pre- visit planning visit planning checklists checklists Pre-visit Planning Checklists Pre-visit Planning Checklists Pilot Team Refocus 2018 The Care Team Grows Winter 2018: April 2018: Physician outreach for go live with well child and advanced MA PA/NP pneumonia PVP vaccine lists checklists Patient Navigator MA Feb-Mar Spring 2018: 2018: navigators team and care develops managers PSR RN advanced join pre-visit meetings RNCM planning checklists 5

3/12/19 Pilot Team Refocus 2018 Quadruple Aim Winter 2018: April 2018: May 2018: outreach for go live with automated well child and advanced monthly pneumonia PVP quality vaccine lists checklists reports Improve Improve Improve Lower cost Patient health of staff of care Experience population engagement Feb-Mar Spring Summer 2018: 2018: 2018: Team navigators Un-blinded develops and care data on advanced managers white pre-visit join board in planning meetings team room checklists What Does the Literature Say? Quadruple Aim Ø Questionable Ø “CONCLUSIONS: The PCMH was associated with improvements in patients' experience with access to care but not other domains of care. This study, Improve Improve Improve which took place in a multi-payer community, is Lower cost Patient health of staff one of the first to find a positive effect of the of care Experience population engagement PCMH on patient experience.” Kern LM, Dhopeshwarkar RV, Edwards A, Kaushal R. Patient experience over time in patient-centered medical homes. Close affiliations The American Journal of Managed Care [01 May 2013, 19(5):403-410] Whole Group Core Provider Measures What Does the Literature Say? 97 *Rolling 4 Quarters – started Q2 2017 Ø Questionable 96 95 Ø “CONCLUSIONS More than 80% of patients perceived high quality of care in health centers. 94 PCMH attributes related to access to care and communication were associated with greater 93 likelihood of patients reporting high-quality care.” Pilot Team All Oute r Cape 92 Lydie A. Lebrun-Harris, PhD, MPH, et.al. Effects of Patient-Centered Medical Home Attributes on Patients’ Perceptions of Quality in Federally Supported Health Centers. Ann Fam Med November/December 2013 vol. 11 no. 6 508-516. 91 201 7 Q2 201 7 Q3 201 7 Q4 201 8 Q1 201 8 Q2 6