Presentation on theme: "The Community Health Center Association of CT"— Presentation transcript:
1 The Community Health Center Association of CT Team-Based CareWebinar #3Population Health, Care Management, Self Management Support & Care CoordinationPresented toThe Community Health Center Association of CTPresented bySusan Crocetti, RN &Regina Neal, MPH, MSMarch 30, 20121
2 ObjectivesExplore the importance of and methods necessary to use team-based care in the successful delivery of:understanding and acting on needs of populations of patientsmeeting the needs of patients with conditions that respond well to evidence-based guidelines and care managementassisting patients to partner in the successful management of their conditionscoordinating 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, ClerkInternal Resources: RN’s, Referral Coord, Billing Staff, Dietician, Educators, IT Staff, Pharmacists, SWExternal 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 ProgramEvaluation and Feedback
6 Delivering Between Visit Support to Populations of Patients Sub categories of patients by age, sex, diagnosis, etc. are identifiedHave 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 managementThis 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 demographicsDemographics (Age, Sex, Race, Ethnicity, Income & Education Level)PMS, registry, EMR reportsLocal census dataClinical Information (Diagnosis, medications, allergies, clinical measurementsRisk 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 visitAre 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 portalMA’s could assist with completion and data entry prior to provider portion of visitIdeal if this information is also captured as structured dataDefine 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 improvementChoose a balanced scope of measure “types”Efficient to link with important conditions or high risk groupConsider vendor-ready MU CQM’s and UDS cross mappingHow 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 specificationsProvider / Team attribution – clean up those panels!Data Quality – team members are the key!Manual data entry outside of visitsHistorical data / preloading the EMROutside dataData entry during visitsUsing correct fields for data entry / mapping issuesInterfacesMapping issues or other technical concerns (POS vs. POC results)Data entry errorsTimeliness (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 firstShare technical specifications of reports (numerator and denominator definitions) with providers and teamsQA 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 WhatWho, When, HowConsiderationsPhone CallsPersonal vs. automatedFront office vs. backblock of time vs. “fit in”centralized vs. team –basedVendor vs. internalWrong numberHIPAA – leaving message on VM or with another personHow many attemptsLettersWrong addressLooks like a billAutomated errorsSecure Electronic CommunicationNames distributed to team for further actionProvidersCare ManagersEducatorsReferral CoordinatorPatient NavigatorClearly define expectationsF/u to ensure actions were takenShare ideas
14 Everyone Must Be Involved in Supporting the Team’s Population Management Work with Contingency Plans Wrong letterDeceasedPatient got the service alreadyPatients call but can’t get through / in (consider timing with back to school or flu season)You run out of vaccineStaff 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 responsesandWording of outreach lettersGet feedback from all staff so the wording is done in a way that the patients will understandUse 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 metricsAsk staff and patients what they liked or didn’t like about the initiative; get their thoughts on how to do it better next timeCelebrate 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 overdueNo 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)
22 Is Care Management a Position or a Concept? How can a team accomplish the components with or without a designated RN Care Manager positionIdentify criteria for intensified services; at-risk individualsAdopt evidence-based guidelines of care; pre-visit planningEstablish plan of care with patient/family input, goals, assessment of progress toward goals; exploring barriers, acting to remove barriersCoordinate services from all care givers to ensure continuityFollow-up for care provided in facilitiesCoordinate medically necessary referral servicesFacilitate proactive communication; interdisciplinary team conferencesDisease-specific and preventive health educationSelf-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 ToolsPrompts for servicesStanding ordersPrompts for H&PDecision support for treatmentsOrder setsCondition specific flowsheetsPatient EducationCare PlansGoal setting and assessmentTemplates in condition specific progress notesStaff workflow and training materialsAlerts
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 formsConsolidate actions onto one screen/form or provide links between templates or functions in EMR for team efficiencySmart phrases/quick text options for efficient documentationChoose 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 orderedWho tracks depends on:Type of testWhere the test was performedHow results are receivedElectronic systems to support the processMethods includeFully automated order/result reconciliationPartially automated reportsManual logs, accordion file or spread sheetsSituations that could result in a test not being performed or communicated appropriately:Failure to order the test correctlyFailure to meet insurance coverage criteriaFailure to contact and schedule the patient for testFailure of the patient to show up for testTechnical issue resulting in incomplete testing (QNS, for example)
34 Communicating Test Results Normal & abnormal resultsEstablish timeframe for communicating to patients and let them know what to expectProactive vs. reactive communicationWho 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 patientWho 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 PCPTransition from pediatric service to adult medicineWho does this and when?
37 When Will the Care Management Services Be Delivered? What staff are qualified and available?RN’s for complex patientsLPN’s and MA to follow specific guidelines approved by providers and RN’s for preventive, straight forward education and managementWhen can these services be provided?Incorporating into visit cycleExploring alternative visit typesTelephonic consultationMailings
38 Pre-visit Planning Care Coordinator reviews : Health Maintenance services dueMedication Reconciliation RecordsLab Log to determine outstanding labsReferral Log to determine outstanding consultsComplex Needs to be referred internal or externalHuddles 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 VisitPCP, demographics, missing reports, preventive services, risk factors, med rec, test & referral tracking, SMS, basic pt ed, agendaDuring the Provider Portion of the VisitAssess, diagnose, care plan, deliver servicesAfter the Provider Portion of the VisitReinforce care plan and SMS plan, complex education and SMS by others
40 In Between Visits is KEY!! Population management reports & outreachData entryQA of reportsF/u phone callsPre-visit planningTest & referral trackingCommunication of test resultsF/u after transitionsEstablishing external resources and community servicesEnhance technologyTraining & 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 examInterval determined by conditionTightly choreographed agenda so nothing is missedFollow up phone callMulti-disciplinary to bring in other perspectivesNutritionExercisePharmacistDaily 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 requirementsThree 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 drawnTwo 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 teamImproves productivity and enhances efficiency of a healthcare teamEnhance the patient’s visit by offering a therapeutic approach – time for education and self management supportPatients teach patients by sharing experiences and helpful information who may be dealing with the same issuesAgenda 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 rechecksVaccines given in a seriesHearing and vision screeningPatient teachingAnticoagulation managementOthers?
46 Just one more outreach call…. Questions??Just one more outreach call….