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.

The value of the patient’s time This is how our patient visit fits into Sleep their day Work/School Self Care Eating Buying things Caring for Family 15 min Visit http://www.bls.gov/tus/tables/a1_2008.pdf

Traditional Methods of Managing Work Flow Preventive Chronic Med Disease Medication New Acute Intervention Monitoring Refill Complaint Test Results Customer Customer Customer Customer Customer Provider Customer Customer Customer Customer Referral to Mental Specialist Certified Healthcare Case Health after Medical Clinical Support Manager Provider Assessment Assistant Dietician Pharmacist Team

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

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 ones 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 organizes 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 on 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

Prepares for, attends and participates in team meetings and huddles * Provider (empanelled) 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  Prepares for, attends and participates in team meetings and huddles Nurse  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  Prepares for, attends and participates in team meetings and huddles Medical Assistant  Responsible for patient flow on day of visit: o Completes required pre-visit and visit preparation using the MA Standards of Care checklist o Reviews and completes any overdue health maintenance and open orders at every visit in collaboration with the care team o Completes appropriate documentation of screening flowsheets o 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  Prepares for, attends and participates in team meetings and +/- huddles Medical Receptionist  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  Facilitates team meetings and participates in follow up for tasks generated during the meetings Planned Care  Outreaches patients as necessary Coordinator  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 Supports multiple teams of PCP panels Provider (unempanelled) * 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