1. The Senior Health Model - Patient Centered Medical Home Model of continuum of care for older adults. James E. Bonson PA Neela K. Patel, MD, MPH, CMD UT Medicine Senior Health Primary Care Center University of Texas health Science Center as San Antonio

2. Objectives Specify steps in transforming primary care practices to be patient centered Describe the impact of patient centered care on patient satisfaction and access. Discuss strategies for population management such as chronic care management, transitions of care, group education for Medicare wellness exams, pharm D medication management sessions to manage diabetics with HbA1 C higher than 9 and other chronic disease management. Demonstrate team building and improving exercises in relation to continuous process improvement.

3. Steps in transformation Building a common mission and vision Process Improvement Time for reflection and course adjustment Accountability Safe work environment Electronic health record optimization Building a medical home neighborhood

4. Building a common mission and vision Why are we here? Would we bring our family here?

5. Process Improvement What needs to change in our practice? What we need to keep because it is working well? What we need to change? What we need to STOP?

6. Sharing an example of our process improvement Reducing wait times

7. Clinical Safety & Effectiveness Cohort # 17 Reducing Wait Time at the UT Medicine Senior Health Clinic DATE

8. ACT: Sustaining the Results DO: Implementing the Change PLAN: Intervention STUDY: Results/Impact

9. To err is human; to forgive, divine. Alexander Pope Alexander Pope To Err is Human: Building a Safer Health System. Institute of Medicine; 1999 To wait for e’er is inhumane. J Bonson

10. Pre-intervention Survey

11. Process Analysis Tools Fish Bone diagrams Flowchart with Swim lane –to show all steps involved in “Arrival Time” 11

17. Pre Intervention Epic Template 17

18. Post Intervention Epic Template 18

19. Post intervention templates

20. Post intervention reduction in wait times

21. Post Intervention NRC Picker Survey

22. Time for reflection and course adjustment Daily workflow preparation and adjustment Daily Huddles Regular ”all hands” meetings Patient feedback review

23. Time for reflection and course adjustment Scheduled regular team meetings Daily huddles Continue, stop, change, start Glad, Mad, Sad

24. Accountability Defined roles and responsibilities of all team members What is my responsibility? Who does what? How does my work affect the work of others? How does it affect patients?

25. Safe work Environment Respect and Trust for diversity of opinions and team engagement Are you afraid of telling it as you see it?

26. Adaptive Reserve Model Relationship-centered practice adaptive reserve model. Relationship Characteristics Mindfulness = Openness to new ideas and different perspectives; continuous creation of new categories. Respectful Interaction = Honest, tactful, and mutually valuing interchange where each person brings meaning and value to the other. Heedful Interrelating = Interaction where individuals are especially sensitive to the way their role and others fit into the larger group and its goals. Channel Effectiveness = Appropriate use and mix of rich (eg, face-to-face) and lean (eg, e-mail) communications where rich channels are used when messages are highly ambiguous, complicated, or emotionally charged and lean channels are used when messages are clear, simple, and emotionally neutral. Mix of Social and Task Relatedness = Social relatedness includes non–work-related conversations and activities that are often based on friendships and family, whereas task relatedness consists of work-related conversations and activities. Diversity = Differences in mental models and in age, sex, and ethnicity. Trust = Belief that you can depend on the other and the associated willingness to be vulnerable to another.

27. Senior Health Adaptive Reserve Measures

28. Electronic health record optimization Ongoing optimization of use and integration into workflow, roles and responsibilities Virtual care management Addressing patient needs – Transition of Care – Medicare Wellness visits – Chronic care management – Same day access – Direct patient admissions

29. Building the medical home neighborhood Consultants Home health agencies & Hospices DME companies Adult day centers & Senior Centers Alzheimer's association, Local Area Agency on Aging Adult Protective Services Local hospitals Local transportation Senior networking resources and groups

30. Senior Health Model – Build PCMH Neighborhood

31. Impact of PCMH transformation Excellent Access Financial stability Effective team – Patient satisfaction – Adaptive Reserve Population Management Quality of care – PQRS, Meaningful Use ( MACRA)

32. Excellent Access Work in teams – MD/NP, MD/PA Maximize virtual care management Use our partners Pharm D, Transition of care program, increase same day access

33. Effective teams Team building Staff Appreciation Frequent personal affirmation and feedback

34. Team Building

36. Patient Satisfaction

37. Population Management Chronic care management Transition of Care program High Risk Patients - Pharm D visits Medicare Wellness visits Actively manage your patients who are not seen in the last year Due for health maintenance and prevention _ letters and secure messaging

38. Group Medicare Wellness Education

39. Team Building Process Improvement Glad, Mad, Sad Continue, change, stop, start

40. Signal lights

41. Prioritization

42. Team Activity What is working in your practice? What is a challenge and is frustrating in your practice that you would like to change? Discuss in your small groups look at your process and do a root cause analysis.

43. Debriefing the team activity

44. PCMH Transformation – Journey not a destination!! No one size fits all, you have to identify what is your “size” depends on your patient population Small achievable goals – one step at a time

45. PCMH Transformation – Get on the journey!!! Build a mission vision Process improvement Reflect on mission and processes – consensus & engage Accountability – appreciation, consequences Safe work environment – have fun, celebrate Electronic health record optimization Collaborate/Partner with virtual neighbors

46. Questions? Enjoy your journey of transformation!!! Be the change you want to see happen!!