1. The Community Health Center Association of CT
Team-Based Care
Webinar #3
Population Health, Care Management, Self Management Support & Care Coordination
Presented to
The Community Health Center Association of CT
Presented by
Susan Crocetti, RN &
Regina Neal, MPH, MS
March 30, 2012 1

2. Objectives
Explore the importance of and methods necessary to use team-based care in the successful delivery of:
understanding and acting on needs of populations of patients
meeting the needs of patients with conditions that respond well to evidence-based guidelines and care management
assisting patients to partner in the successful management of their conditions
coordinating the care of patients and providing continuity across various levels and transitions of care

3. When Providers Work Without a Team
Delivering all evidence-based guidelines for preventive and chronic disease care has been estimated to take 18 hours a day for an average sized patient panel (Yarnall et al 2009; Alexander et al 2005)
Most physicians only deliver 55% of recommended care, 42% report not having enough time with their patients
(Center for Studying Health System Change 2008; Bodenheimer & Laing 2007)
Providers are spending 13% of their day in care coordination and only using their medical knowledge 50% of the time (Gottschalk 2005; Margolis & Bodenheimer 2010)
Patient care is fragmented and patients are dissatisfied with the level of attention they receive in primary care (Bodenheimer 2008)

4. Who is On the Team and Who Can Support the Team?
Core Team: Provider, MA’s, LPN’s, Clerk
Internal Resources: RN’s, Referral Coord, Billing Staff, Dietician, Educators, IT Staff, Pharmacists, SW
External Resources: Community Health Workers, Insurance Nurse Disease/Case Managers, Vendors, Specialists, Hospitalist

5. Supporting the Work of the Team
Human Resources (core, internal and external)
Systems (PMS, Registry, E-Rxing, HER, Portal)
Clinical tools (flowsheets, structured notes, EMR templates and decision support functions, Standing orders)
Written Standards (Job descriptions, workflows)
Training Program
Evaluation and Feedback

6. Delivering Between Visit Support to Populations of Patients
Sub categories of patients by age, sex, diagnosis, etc. are identified
Have these patients received services as recommended in the evidence-based guidelines or are their outcomes in line with expectations?
Patients who are missing these services or are not in goal can be contacted for follow up or referred for more intensive management
This data can be used to understand how well we are providing care and if we are improving

7. So, How Do You Do This?
Analyze your patient panel and community demographics
Demographics (Age, Sex, Race, Ethnicity, Income & Education Level)
PMS, registry, EMR reports
Local census data
Clinical Information (Diagnosis, medications, allergies, clinical measurements
Risk Factors (smoking, family circumstances, drug use, mental health concerns, etc.)
How is a team able to achieve this?
Systems, IT resources, written training materials, admin support

8. But First You Have to Capture the Information…
Who collects the information and is it entered accurately?
Allergies, risk factors, preventive service updates, etc. can be captured by MA/LPN at beginning of visit
Are structured (mapped) fields being used to allow reports to be generated?
Does someone know how to set up and run the reports accurately and is there time dedicated to this?

9. Workflow Considerations for Comprehensive Health Assessments
Could patient self assessments be completed by the patient at home prior to visit; accessible as a form on the website or portal?
Would require pre-visit planning and staff assigned to mail the form or advise/remind patient to use portal
MA’s could assist with completion and data entry prior to provider portion of visit
Ideal if this information is also captured as structured data
Define when this is done initially and when updated (annually?)

10. Choosing Clinical Measures to Monitor Your Population
Use National Quality Forum sanctioned measures for standardization and benchmarking for quality improvement
Choose a balanced scope of measure “types”
Efficient to link with important conditions or high risk group
Consider vendor-ready MU CQM’s and UDS cross mapping
How complete or automated is the data?
Who makes the decision at the practice? Is the team included in the discussion and aware of the project from the beginning? They may have valuable information to help avoid some pitfalls.

11. Reporting is the Next Step
Setting up the technical specifications
Provider / Team attribution – clean up those panels!
Data Quality – team members are the key!
Manual data entry outside of visits
Historical data / preloading the EMR
Outside data
Data entry during visits
Using correct fields for data entry / mapping issues
Interfaces
Mapping issues or other technical concerns (POS vs. POC results)
Data entry errors
Timeliness (communication between those responsible for data entry and those running reports)

12. Testing and Transparency to Improve Quality and Maintain Trust
Test on one team first
Share technical specifications of reports (numerator and denominator definitions) with providers and teams
QA initial reports before distribution to uncover major errors (and hold onto your credibility!)
Give report detail to providers/teams to verify that a “No means No” (and not a problem with how the data was collected / report set up)
Give feedback to teams on what you’ve learned about the reporting process – good and bad

13. Once You Have Confidence in the Reports, Take Action – But Be Prepared
What
Who, When, How
Considerations
Phone Calls
Personal vs. automated
Front office vs. back
block of time vs. “fit in”
centralized vs. team –based
Vendor vs. internal
Wrong number
HIPAA – leaving message on VM or with another person
How many attempts
Letters
Wrong address
Looks like a bill
Automated errors
Secure Electronic Communication
Names distributed to team for further action
Providers
Care Managers
Educators
Referral Coordinator
Patient Navigator
Clearly define expectations
F/u to ensure actions were taken
Share ideas

14. Everyone Must Be Involved in Supporting the Team’s Population Management Work with Contingency Plans
Wrong letter
Deceased
Patient got the service already
Patients call but can’t get through / in (consider timing with back to school or flu season)
You run out of vaccine
Staff aren’t aware of outreach and don’t know how to handle questions or complaints

15. Words of Encouragement
Scripting of outreach call or contingency responses
and
Wording of outreach letters
Get feedback from all staff so the wording is done in a way that the patients will understand
Use this as an opportunity to remind the patients that they are part of your team!

19. Did It Make a Difference?
Keeping track of who responded because of the outreach – how will you know?
Compare pre and post clinical metrics
Ask staff and patients what they liked or didn’t like about the initiative; get their thoughts on how to do it better next time
Celebrate the success of this team effort!!

20. Population Management, Meet Quality Improvement…
If patients got the service in the first place there would be fewer names on those lists to outreach!!
Involve the team (and patients!) in ideas of how to get the patient to complete the service before it’s overdue
No such thing as a crazy idea (well, yes there is, but it’s ok, because it might lead to an idea that’s not so crazy)

21. Moving From Population Generalized Needs to a Focus on Individuals with Specific Needs
Care Management
Assuming responsibility for the patient’s care needs
Ensuring continuity of care
Utilizing evidence-based guidelines as care delivery standards
Coordinating necessary specialty care
Following transitions to and from care outside the practice
© Qualis Health 2010 4

22. Is Care Management a Position or a Concept?
How can a team accomplish the components with or without a designated RN Care Manager position
Identify criteria for intensified services; at-risk individuals
Adopt evidence-based guidelines of care; pre-visit planning
Establish plan of care with patient/family input, goals, assessment of progress toward goals; exploring barriers, acting to remove barriers
Coordinate services from all care givers to ensure continuity
Follow-up for care provided in facilities
Coordinate medically necessary referral services
Facilitate proactive communication; interdisciplinary team conferences
Disease-specific and preventive health education
Self-management plan and support

23. How to Help the Team Provide Care Management
How to Help the Team Provide Care Management? Choosing Guidelines and Implementing Tools
Prompts for services
Standing orders
Prompts for H&P
Decision support for treatments
Order sets
Condition specific flowsheets
Patient Education
Care Plans
Goal setting and assessment
Templates in condition specific progress notes
Staff workflow and training materials
Alerts

24. Mercy Clinics, Inc. Des Moines, Iowa

29. Example of Written Plan of Care
Denmark D. Patient-physician partnering to improve chronic disease care. Fam Pract Manag. May 2004:55-56

30. Self-Management Plan/Tool

31. Are The Tools User Friendly?
Consider the affect on workflows of all team members – get their input!
Establish the best sequence for templates and forms
Consolidate actions onto one screen/form or provide links between templates or functions in EMR for team efficiency
Smart phrases/quick text options for efficient documentation
Choose key areas for prompts to avoid alert or “click” fatigue in EMR’s

32. Sustaining Use of EMR Templates
Allow for customization whenever possible: Users appreciate the ability to customize applications to their own work processes and are more likely to adopt and continue using the system if such capabilities exist.
Engage patients in the technology: Showing the computer screen to the patient and collaboratively writing notes can enhance the patient–physician interaction, thus making physicians more likely to continue using the system. To maintain patient support for the system, make it clear that care recommendations are based on individual health needs.
AHRQ Health Care Innovations Exchange / Schnipper, JL McColgan KE, Linder JA, et al. Improving management of chronic diseases with documentation-based clinical decision support: results of a pilot study. AMIA Annu Symp Proc. 2008; 1050.

33. Care Coordination: Closed Loop Test Tracking
Ensures that results are received, reviewed by provider, and acted upon for every lab or imaging test ordered
Who tracks depends on:
Type of test
Where the test was performed
How results are received
Electronic systems to support the process
Methods include
Fully automated order/result reconciliation
Partially automated reports
Manual logs, accordion file or spread sheets
Situations that could result in a test not being performed or communicated appropriately:
Failure to order the test correctly
Failure to meet insurance coverage criteria
Failure to contact and schedule the patient for test
Failure of the patient to show up for test
Technical issue resulting in incomplete testing (QNS, for example)

34. Communicating Test Results
Normal & abnormal results
Establish timeframe for communicating to patients and let them know what to expect
Proactive vs. reactive communication
Who is responsible?
EMR workflow can be standardized so that as provider signs off on labs, a patient letter is created, routed to the MA who prints and mails at the end of the day

35. Closed Loop Referral Tracking
Ensures that the patient completed a visit and a note was received back from the specialist each time a specialty referral given to the patient
Who does this, does type of referral matter?

36. Coordinating Transitions of Care
How do you know there has been an ER visit or hospitalization?
Coordination with other care facilities (rehab, SNF, etc.)
Transfer to new PCP
Transition from pediatric service to adult medicine
Who does this and when?

37. When Will the Care Management Services Be Delivered?
What staff are qualified and available?
RN’s for complex patients
LPN’s and MA to follow specific guidelines approved by providers and RN’s for preventive, straight forward education and management
When can these services be provided?
Incorporating into visit cycle
Exploring alternative visit types
Telephonic consultation
Mailings

38. Pre-visit Planning Care Coordinator reviews :
Health Maintenance services due
Medication Reconciliation Records
Lab Log to determine outstanding labs
Referral Log to determine outstanding consults
Complex Needs to be referred internal or external
Huddles used for focused communication on the day of the visit

39. Incorporating Care Management By The Team Into The Visit Cycle
Before the Provider Portion of the Visit
PCP, demographics, missing reports, preventive services, risk factors, med rec, test & referral tracking, SMS, basic pt ed, agenda
During the Provider Portion of the Visit
Assess, diagnose, care plan, deliver services
After the Provider Portion of the Visit
Reinforce care plan and SMS plan, complex education and SMS by others

40. In Between Visits is KEY!!
Population management reports & outreach
Data entry
QA of reports
F/u phone calls
Pre-visit planning
Test & referral tracking
Communication of test results
F/u after transitions
Establishing external resources and community services
Enhance technology
Training & standard development!
How do you manage to get this done with a full day of patients?

41. Alternative Visit Option: Planned Care Visit
Visit is structured similar to a physical exam
Interval determined by condition
Tightly choreographed agenda so nothing is missed
Follow up phone call
Multi-disciplinary to bring in other perspectives
Nutrition
Exercise
Pharmacist
Daily huddle is essential to efficient planned care

42. Annual Planned Exam Workflow
One month prior to appointment: Letter to the patient with lab slips and notification of other Health Maintenance requirements
Three weeks prior to appointment: MA contacts patient to schedule routine testing (e.g., mammogram, bone density, etc.)
One week prior to appointment: Patient has labs drawn
Two days prior to appointment: Place appointment reminder call to patient and remind them to bring patient questionnaire and medication list (better yet, medications) with them

43. Shared Medical Appointment
A shared medical appointment, also known as a group visit, is a 90-minute visit when multiple patients are seen as a group for follow-up, routine or consult care.

44. Team Based Care Delivered in a Shared Medical Appointment or Group Visit
Open more access to patients to be cared for by the team
Improves productivity and enhances efficiency of a healthcare team
Enhance the patient’s visit by offering a therapeutic approach – time for education and self management support
Patients teach patients by sharing experiences and helpful information who may be dealing with the same issues
Agenda setting is more flexible and the pace of the visit is more relaxed

45. Provider Support or Nurse Visits
Used for follow up such as:
Blood pressure rechecks
Vaccines given in a series
Hearing and vision screening
Patient teaching
Anticoagulation management
Others?

46. Just one more outreach call….
Questions??
Just one more outreach call….