Medical Home: Changing care at every visit and integrating - - PowerPoint PPT Presentation

Teams in a high functioning Medical Home: Changing care at every visit and integrating Population Health

FESP site visit December 1, 2015

Agenda

• 1 PM Chronic Disease Management

– PCMH Base: Teams – Kirsten and Team (inreach)

– Population Management – Omar and Team (outreach)

• 2:30 PM Questions

Change Concepts for Practice Transformation

Wagner EH, Coleman K, Reid RJ, Phillips K, Abrams MK, Sugarman JR. The Changes Involved in Patient-Centered Medical Home Transformation. Primary Care: Clinics in Office Practice. 2012; 39:241-259.

This is how

• ur patient

visit fits into their day

Sleep Work/School Self Care Eating Buying things Caring for Family 15 min Visit

http://www.bls.gov/tus/tables/a1_2008.pdf

The value of the patient’s time

Traditional Methods of Managing Work Flow

Provider

Chronic Disease Monitoring

Customer

Preventive Med Intervention Mental Health Provider Referral to Specialist after Assessment Medication Refill New Acute Complaint

Customer Customer Customer Customer Customer Customer Customer

Certified Medical Assistant Case Manager Test Results

Customer

Healthcare Support Team Dietician Clinical Pharmacist

Instead: Parallel Work Flow Redesign

Healthcare Support Team Chronic disease monitoring Preventive med intervention Certified Medical Assistant Clinical Pharmacist Medication refill Undiagnosed or changing new consumer concern Provider Case Manager Management of study / test results Info In clinic point of care testing Chronic Disease Compliance Barriers Acute Mental Health Concern

Customer Customer Customer Customer Customer Customer Customer CustomerCustomer

Dietician Behavioral Health Consultant

Customer Customer Customer

Regional Leadership Structure

• 6 regions, each with a Medical Director, RN

Manager, each site has an Operations leader who stays on site

• 3 Operations Directors with 2 regions each
• All report up to Lynn (Ops), Sue (RNs) or Assaad

(MDs)

• Monthly meetings of the entire group
• Medical directors have weekly phone call
• RN managers have monthly meetings and one on
• nes with leadership
• Operations has weekly meetings

Change Concepts for Practice Transformation

Wagner EH, Coleman K, Reid RJ, Phillips K, Abrams MK, Sugarman JR. The Changes Involved in Patient-Centered Medical Home Transformation. Primary Care: Clinics in Office Practice. 2012; 39:241-259.

Quality Infrastructure

• Two parts to this – PDSA culture and data
• PDSA culture – Teams, process
• Data:

– What metrics are you currently following? – What do you have available that you are not currently following? – Take 5 minutes and discuss this with your neighbor

Continuous Quality Improvement

• How to make lasting changes in small

increments

• PDSA cycles

– Plan: New workflow designed by a team – Do: 2 week trial of the change – Study: Re-evaluation by the entire team and a patient if possible – Act: Spread the work to others

Change Concepts for Practice Transformation

Wagner EH, Coleman K, Reid RJ, Phillips K, Abrams MK, Sugarman JR. The Changes Involved in Patient-Centered Medical Home Transformation. Primary Care: Clinics in Office Practice. 2012; 39:241-259.

Empanelment

• Fundamental to defining the work, avoiding

duplication and risk and cost reduction

• Divides up a large number of patients and
• rganizes them
• Relatively easy for us with our EMR (EPIC) and the

new rule that all patients have to declare an APS Doctor

• What about your system?

Empanelment Exercise

• Share your thoughts on how to introduce this idea

to Doctors across your system, not just the APS doctors

• Tools – what do you use? Paper charts? EMR?

Databases? Disease Registry?

• Who will keep track of who is responsible for every

patient?

Change Concepts for Practice Transformation

Wagner EH, Coleman K, Reid RJ, Phillips K, Abrams MK, Sugarman JR. The Changes Involved in Patient-Centered Medical Home Transformation. Primary Care: Clinics in Office Practice. 2012; 39:241-259.

Site team structures

• APS Doctor panel (list of patients) is the basic

structural unit

• 4000 pts on a POD (2-3 APS Doctors depending
• n FTE)
• Staffed by 1.5 Nurse, one receptionist and 3-4

Medical Assistants

• Continuity is over 90 percent for the APS Doctor

and 99 percent for the POD

• Creates a smaller practice within the practice

Provider (empanelled) * Prepares for, attends and participates in team meetings and huddles * Collaborates in developing team priorities to maintain quality goals * Direct patient visits * Collaborates with patients and the care team around care plans * Keeps problem list, medication list and patient care plan updated  Approves orders and referrals for health maintenance  Provides education and guidance for team members around clinical issues Nurse  Prepares for, attends and participates in team meetings and huddles  Collaborates in developing team priorities to maintain quality goals  Active in patient education, goal setting, self management teaching & coaching through direct patient visits and telephone/patient portal interactions  Medication reconciliation and education  Chronic disease care management for the panel in collaboration with the team Medical Assistant  Prepares for, attends and participates in team meetings and huddles  Responsible for patient flow on day of visit:

• Completes required pre-visit and visit preparation using the MA Standards of Care checklist
• Reviews and completes any overdue health maintenance and open orders at every visit in

collaboration with the care team

• Completes appropriate documentation of screening flowsheets
• Completes follow up work after visit

 Completes planned care team outreach assignments between visits and before each team meeting  Schedules patients for pre-visit lab work and works with care team to ensure open orders are in EPIC  Maintains room stocking  Other appropriate administrative work as necessary to support the team Medical Receptionist  Prepares for, attends and participates in team meetings and +/- huddles  Responsible for maintaining up to date patient contacts and insurance information  Responsible for initiating pre-visit packet and screening flowsheets to patients during the visits  Completes team outreach assignments including phone, patient portal contacts, appointment scheduling, and letters  Schedules appointments to maximize patient access and max-packing of visits  Other appropriate administrative work as necessary to support the team Planned Care Coordinator  Facilitates team meetings and participates in follow up for tasks generated during the meetings  Outreaches patients as necessary  Manages quality dashboard, prepares reports for team meetings and tracks quality results for all panels  Provides support and coaching for core care teams  Works with team members to organize group visits  Responsible for maintaining empanelment guidelines Provider (unempanelled) * Supports multiple teams of PCP panels * Prepares for, attends and participates in team meetings and huddles * Collaborates in developing team priorities to maintain quality goals * Direct patient visits * Collaborates with patients and the care team around care plans * Keeps problem list, medication list and patient care plan updated  Approves orders and referrals for health maintenance  Provides education and guidance for team members around clinical issues

Site based resources (extended team)

• Pharmacist (direct patient visits, not staffing a

pharmacy in our model)

• Referral Coordinator
• Nutrition
• Psychiatry
• On site behaviorist (therapist)
• On site care partner (smoking cessation, relaxation

exercises, patient education)

Role of the extended Team

Clinical Pharmacist  Attends team meetings for chronic disease management in coordination with the team and participates in development of patient care plans  Direct patient visits for AMS and chronic disease management, medication consults  Collaborates with providers on medication management  Medical Record Review regarding medication management at the request of the teams  Patient education on medications Community Health Educator for Family Planning  Direct patient visits around contraception, family planning decisions, confidential STD testing and healthy relationships  Patient education via telephone, mail and patient portal in coordination with the team  Confidential and low cost visits for patients with limited access to the above based on insurance coverage Mental Health Specialist  Assists patients with resources  Provides counseling, facilitates support groups for patients living with chronic conditions.  Provides expert consultation and supports the work of the primary care teams  Make changes based on BH integration? MH specialist and CRS to licensed and un licensed care partners? Patient Resource Coordinators  make supportive, short-term relationships with patients to address social problems which impact patients’ health and psycho-social functioning  Build supportive relationships with patients to help them access primary care, mental health care, and social services to improve their health status and address their personal health goals  Ensures paperwork and applications are completed by or for patients to address: transportation, SNAP benefits, housing subsidies, immigration, school-related forms, insurance and disability benefits, etc.  Connect patient to CHA and community-based resources which address a broad range of social needs  Works collaboratively to identify systemic barriers to care and develop strategies to reduce barriers to accessing healthcare  Serves as liaison to CHA’s Patient Financial Services to resolve insurance issues.  On rare occasions, this may require accompanying a patient to a visit or meeting. Nutritionist  Assists patients with nutritional counseling in direct visits and by patient portal and telephone  Facilitates and participates in group visits for patients living with chronic disease conditions  Provides expert consultation for the primary care team Complex Care Manager-Nursing  Receives Complex Care Management referrals, assesses appropriateness for Complex Care, works with patient/caregiver/co-learner to develop goals, informs care team if inappropriate for complex care and makes recommendations for care plan in usual care team  Attends team meetings  Provides clinical support and direct care management including patient education, goal setting, self management teaching and coaching for the care team’s top 5% highest risk patients  Provides care coordination, follow up, and population management  Assess readiness for transition back to usual care team or to more intensive level of care such as ESP, SNF  Works in coordination with CCM Social Worker Complex Care Manager-Social Work  Receives referrals for acute high risk patients with refractory mental illness and substance use disorders, and/or with co-occurring medical conditions  Build self-management skills for health improvement, through motivational interviewing, behavior modification, coaching and brief psychiatric interventions where needed  Assist with referrals to community social service agencies  Coordinate medical and behavioral health care across continuum of care  Attends team care meetings

[d1]BH integration

Redesigning Care Delivery:

Care is no longer based primarily on visits

Previsit

The time of recognized need or risk by system

• r time of patient

contact to check-in Care team plans for the encounter

Visit

Time of check-in to departure from health center Patient’s encounter with clinician and care team

Post-visit

Departure to completion of visit plans/actions

Between visit

Completion of visit plans/actions to previsit Care management

MA and Nurse roles on the team

• Flow, warm handoffs to Nurse, Pharmacist and

Psychiatry especially important

• Labs, vaccines
• Patient education and reinforcement of team

messages

• Coordination of care – make appointments, direct

patient to referral coordinator etc.

• Pharmacy calls and clarifications

The Clinical Encounter – Pre-visit work

• Nurse reviews all appointments for the week on and

starts the documentation

• Medical Assistant reviews the chart and enters in pre-

visit work before the session (usually the day before)

• MD does the same
• Any team member who sees it is not done yet will

start the process

Tools

The Clinical Encounter - Huddle

• 2-3 minutes with MA and APS Doctor and Nurse
• Nurse co-located so if not able to be present at the

first one, uses the “rolling huddle” approach

• Nurses focus on telephone management of patients

who do not need an appointment and those who are post-hospitalization, high risk or acutely ill

• Nurse also does ER follow up letters, calls and

appointments and sends to the APS Doctor

The Clinical Encounter – post visit

• Medical Assistant makes certain all tests and

appointments requested by the APS Doctor during the visit get done BEFORE the patient leaves

• Use tools like folders to organize papers
• Integrated Laboratory Services at every site
• Patients can also get labs done at any site in the

system

• All results go the APS Doctor who will send a letter to

the patient – – no need for patient to run around getting results and NO follow up appointment to review results

Let’s walk through that!

https://www.dropbox.com/sh/ru8mwwt2e6yjorl/o-51RvKjIF

TEAM MEETINGS “HUDDLES” Meeting Frequency

• Goal: weekly
• Minimum: biweekly

Goal: before each session (AM & PM) ) Minimum: once a day Ideal: In addition, post-session quick huddle for f/u tasks Amount of Meeting Time 30-60 minutes depending on weekly/ biweekly This meeting time should occur during a time when team members CAN ATTEND and coverage for their work is

• available. Team meetings are part of administrative time

for providers. Average 10 minutes or less! * Who’s coming in today: what do they need? * Who was in the hospital/ED and what is the plan for f/u? Attendees All assigned members of the Planned Care Team Required participants: Provider, Nurse, Medical Assistant, Medical Receptionist, Planned Care Coordinator, and Complex Care Managers (for high risk case discussions) Support team participants: Clinical Pharmacist, Nutrition, Mental/Behavioral Health, Social Work, Patient Navigators, Community Resource Specialists  A provider and the MA who are working  together to see the patient that day.  The receptionist joins the team if at all possible to assist with scheduling of appointments.  The team RN connects with this team either during the huddle or sometime during the day to review the hospital/ED f/us. Focus of meeting Planning for care of a panel/population of patients. This includes patients who touch the health care system regularly (during appointments and phone contacts) and those who do not touch the health care system regularly. Includes planning for their:

• Health Maintenance issues
• Chronic Care issues
• Social and Resource issues
• High risk patients

Planning for care of the patients scheduled to receive care during the session/day by the provider. Includes planning for flow of the session (i.e., provider informs RN that this patient on the schedule will be a quick follow up and an add on can be double booked in this slot) Includes planning for patient’s:

• Health Maintenance issues
• Chronic Care issues
• Urgent Care issues (i.e., provider

informs MA that this patient will need an EKG, this one a throat culture, etc.)

Change Concepts for Practice Transformation

Wagner EH, Coleman K, Reid RJ, Phillips K, Abrams MK, Sugarman JR. The Changes Involved in Patient-Centered Medical Home Transformation. Primary Care: Clinics in Office Practice. 2012; 39:241-259.

Change Concepts for Practice Transformation

Wagner EH, Coleman K, Reid RJ, Phillips K, Abrams MK, Sugarman JR. The Changes Involved in Patient-Centered Medical Home Transformation. Primary Care: Clinics in Office Practice. 2012; 39:241-259.

Organized, Evidence Based Care: What is an AQG?

• Ambulatory Quality Goals (AQG) are measures that realize
• ur Population Health strategy
• AQGs are based on evidence based practices (HEDIS, NQF,

etc.)

• AQGs have strong alignment with external measurement

requirements

Prevention Screening Disease Management Complex Care

AQG Summary

Prevention Screening Disease Management Complex Care

• Pediatric

immunizations

• Tobacco use

screening and intervention

• Cancer screening
• Mental health

screening

• 50% reduction in PHQ-

9 depression scores

• ADHD optimal

contacts

• DM optimal outcomes
• DM optimal process
• CV optimal outcome
• Asthma optimal

process

• Care plan usage
• Hospitalization follow

up

• ED follow up

Perfect care immunization for children ages 0-2 HPV, tetanus, & menactra immunizations for adolescents Breast, cervical, & colorectal cancer screening PEDS & PSC screens for children Depression screening for adults Substance abuse screening at intervention sites Follow up PHQ9s and optimal contacts for patients with depression Optimal contacts for ADHD patients (both for initiation and continuation) Care plans for pts. with uncontrolled diabetes (HbA1c ≥ 8), depression (PHQ9 ≥15), persistent asthma, & complex care Contact f/u within 2 days and 7 days of hospitalization Contact f/u within 7 days of ED visit HbA1c < 8, BP < 140/90, & non smoker 2 HbA1c tests, 1 microalbumin, 1 screen and intervention (if needed) for tobacco, & 1 PHQ9 depression screen Pts with hypertension diagnosis whose last BP is < 140/90 Long-term meds prescribed, ACT, ACP, & Flu vaccine given Screening for both adults patients, as well as for patients ages 11-17; plus counseling interventions when needed

AQG Design Structure*

“What has been done to date”

a.k.a. Dashboard or Business Objects (BO) reports

“What needs to be done”

a.k.a. Outreach or Epic Reporting Workbench (RW) reports *Note: more information can be found in Appendix

“How is the AQG satisfied in Epic”

AQG

PCC Quality Dashboard

AQG Cheat Sheets

• Cheat sheets complemented

by On Line Training (OLC) in:

• Health Maintenance
• Reporting Workbench
• Empanelment

PCMH Site

AQG Pursuit

Outreach reports Cheat Sheets

AQGs

Dashboard reports

Care Team Activities

• Pre Visit Work
• Daily Huddles
• Planned Care Meetings

“Effective combination of care team and clinic based activities is key in pursing AQGs at every PCMH site”

Clinic Based Activities

• PIT Meetings
• Staff Meetings

TEAM MEETINGS “HUDDLES” Meeting Frequency

• Goal: weekly
• Minimum: biweekly

Goal: before each session (AM & PM) ) Minimum: once a day Ideal: In addition, post-session quick huddle for f/u tasks Amount of Meeting Time 30-60 minutes depending on weekly/ biweekly This meeting time should occur during a time when team members CAN ATTEND and coverage for their work is

• available. Team meetings are part of administrative time

for providers. Average 10 minutes or less! * Who’s coming in today: what do they need? * Who was in the hospital/ED and what is the plan for f/u? Attendees All assigned members of the Planned Care Team Required participants: Provider, Nurse, Medical Assistant, Medical Receptionist, Planned Care Coordinator, and Complex Care Managers (for high risk case discussions) Support team participants: Clinical Pharmacist, Nutrition, Mental/Behavioral Health, Social Work, Patient Navigators, Community Resource Specialists  A provider and the MA who are working  together to see the patient that day.  The receptionist joins the team if at all possible to assist with scheduling of appointments.  The team RN connects with this team either during the huddle or sometime during the day to review the hospital/ED f/us. Focus of meeting Planning for care of a panel/population of patients. This includes patients who touch the health care system regularly (during appointments and phone contacts) and those who do not touch the health care system regularly. Includes planning for their:

• Health Maintenance issues
• Chronic Care issues
• Social and Resource issues
• High risk patients

Planning for care of the patients scheduled to receive care during the session/day by the provider. Includes planning for flow of the session (i.e., provider informs RN that this patient on the schedule will be a quick follow up and an add on can be double booked in this slot) Includes planning for patient’s:

• Health Maintenance issues
• Chronic Care issues
• Urgent Care issues (i.e., provider

informs MA that this patient will need an EKG, this one a throat culture, etc.)

Between Visits – planned care

Change Concepts for Practice Transformation

Wagner EH, Coleman K, Reid RJ, Phillips K, Abrams MK, Sugarman JR. The Changes Involved in Patient-Centered Medical Home Transformation. Primary Care: Clinics in Office Practice. 2012; 39:241-259.

Patient Centered Interactions

• Often feels difficult to do until the team culture is

firmly in place

• Staff relationships with patients means more points
• f feedback on what patients think about their care
• They will often tell staff things they will not tell

providers

• What do we do with this?
• Think about the change of care with the results and

the letters

Incorporating the Patient Voice into Workflows

• Surveys – a start

– What are the best questions to ask in a survey?

• Patient partners

– First you have to have a team structure to partner with! – USFH refill story – Choosing the right patient to work with

Change Concepts for Practice Transformation

Wagner EH, Coleman K, Reid RJ, Phillips K, Abrams MK, Sugarman JR. The Changes Involved in Patient-Centered Medical Home Transformation. Primary Care: Clinics in Office Practice. 2012; 39:241-259.

Cambridge Health Alliance Access

• Open 4 evenings a week plus Saturdays
• On call services when the clinic closes that get

you directly to a doctor

• Patient Portal for lab results, email and

medication refills

• Texting directly to patient for appointment

reminders and asking to contact us (DO NOT REPLY)

Care Coordination

• Part of the essential structure of the clinic but also

dependent on the extended team

• Centered around the nurse for the lower risk and

around the complex care team for the insanely complex

• Why?
• Who else is essential?

– Receptionists, referral coordinators

What about the insanely complex?

• Complex Care team of Regional RN and on site

SW hired November 2012

• Teams identified highest risk patients (panel of

150)

• Goals of improving patient outcomes, reducing

hospitalizations and re- hospitalizations, ER visits

• Has paid for itself twice over this year alone
• Built onto the relationships the teams have so team

RNs involved in even the CCM pts but don’t have to do the work directly

Change Concepts for Practice Transformation

Wagner EH, Coleman K, Reid RJ, Phillips K, Abrams MK, Sugarman JR. The Changes Involved in Patient-Centered Medical Home Transformation. Primary Care: Clinics in Office Practice. 2012; 39:241-259.

Supporting the work

• PCP needs to encourage this new relationship
• Alignment with the staff so return visits are

scheduled with RN or pharmacist for HTN, Diabetes (flu shots are a great way to start this new relationship)

• Role clarification
• Patient education materials to teach about

team model and the different roles

Team changes things!

• “All team members truly believe in the common goal of

patient care and do what is best for the pt.”

• “We communicate well about what we expect of each

person’s role in the team.”

• “Teams function when they get encouragement, have

the tools to succeed and strong, fair, competent leadership.”

• “Everyone is willing to take one for the team.”
• “Relationship is the foundation.”

Measures of Success – Work Environment

• Provider and staff satisfaction

– Extremely low rate of avoidable turnover despite very challenging financial hurdles as an

• rganization

– Professional development of staff – Easy to recruit new staff members to the site – Staff-led visioning and initiatives – Providers identified this as a best practice site in

• rganization-wide survey

Traps

• Important for people to own the work - clear

communication, role definition, empowerment

• Important to preserve a sense of teamwork

across care teams – vacations, sick days, etc

• Appropriate prospective staffing and

scheduling really matters

• Personality management – help each

person to succeed

Diabetes “Perfect Care”

10 20 30 40 50 60 70 2008 2009 2010 2011 2012 2013 2014 2015 Perfect care

Team Orientation and Training

• First, who will do what? Define the Roles
• Clear hiring strategy to identify candidates who

will succeed in this model

• Every new staff member spends time shadowing

different team members

• Concept of patient care teams and their

expected role is a focal point of new staff

• rientation
• https://www.dropbox.com/sh/ru8mwwt2e6yjorl/o-

51RvKjIF#/

This is where you wind up!

http://bcove.me/cqalrt65