Presentation is loading. Please wait.

Presentation is loading. Please wait.

Patient Centered Medical Home: A Team Sport Katherine J. Jones, PT, PhD 1 Jane Potter, MD 1 Andrew Vasey, MD 1 Audrey Chun, MD 2 2011 Reynolds Grantee.

Similar presentations


Presentation on theme: "Patient Centered Medical Home: A Team Sport Katherine J. Jones, PT, PhD 1 Jane Potter, MD 1 Andrew Vasey, MD 1 Audrey Chun, MD 2 2011 Reynolds Grantee."— Presentation transcript:

1 Patient Centered Medical Home: A Team Sport Katherine J. Jones, PT, PhD 1 Jane Potter, MD 1 Andrew Vasey, MD 1 Audrey Chun, MD 2 2011 Reynolds Grantee 9th Annual Meeting Creating a Learning Community for Academic Geriatricians 1. University of Nebraska Medical Center 2. Mount Sinai School of Medicine

2 Objectives 1.Describe system redesign, culture change, and teamwork as foundational to the PCMH 2.Use the MOS to identify areas of culture in need of improvement to support the PCMH 3.Identify the key principles of teamwork taught in the TeamSTEPPS Curriculum 4.Describe examples of how results from the MOS have guided system redesign and implementation of teamwork to support PCMH at UNMC 5.Recognize universal barriers to implementing large scale organizational change such as PCMH University of Nebraska Medical Center 2

3 PCMH Background 1960’s: American Academy of Pediatrics 1990’s: “Chronic Care Model” 2000’s: 1.AAFP demonstration projects 2.Patient-Centered Primary Care Collaborative (PC-PCC) made up of AAFP, ACP, AOA, AAP 3.NCQA charged with development of criteria PC-PCC: Joint statement on PCMH 1.What is it? 2.What should payment look like? University of Nebraska Medical Center 3

4 Joint Principles “The PCMH is an approach to providing healthcare” “The PCMH is a setting that facilitates partnership between provider and patients” http://www.ncqa.org/tabid/631/Default.aspx, last accessed May 21, 2010 University of Nebraska Medical Center 4

5 Joint Principles 1.Personal physician 2.Physician-directed medical practice (Team) 3.Whole person orientation: “All stages of life” 4.Care is coordinated and integrated 5.Quality and Safety 6.Enhanced Access 7.Payment reform http://www.ncqa.org/tabid/631/Default.aspx, last accessed May 21, 2010 University of Nebraska Medical Center 5

6 Definition of a Medical Home  One physician serves as the main point of coordination for a patient’s health care across the continuum of care including referrals to specialist physicians, hospital care, and post-acute care.  The purpose of the medical home is to enhance the coordination of care within the interprofessional team, improve the quality of the patient/physician relationship, and decrease overall health care costs. Rosenthal, T. C. (2008). The medical home: Growing evidence to support a new approach to primary care. Journal of the American Board of Family Medicine : JABFM, 21(5), 427- 440 University of Nebraska Medical Center 6

7 NCQA Certification Principles into Process: 1.Practice… …downloads material from NCQA …documents protocols, data, procedures, etc. …submits materials to NCQA 2.Practice receives a score and a “Tier” of certification http://www.ncqa.org/tabid/631/Default.aspx, last accessed May 21, 2010 University of Nebraska Medical Center 7

8

9 Geriatrics & PCMH A natural partnership Geriatrics: team-based, whole person care for older adults aligns with: 1.Joint principles of primary care collaborative 2.Potential increased reimbursements with demonstration projects, healthcare and insurance reform 3.Competencies/curricular redesign for residents and medical students and milestones project University of Nebraska Medical Center 9

10 Opportunities Improve patient care: transitions, access, education, self-management, avoid unnecessary hospitalizations, improve health and decrease overall healthcare costs. Imbed Geriatrics QI into standard care. Improve patient and staff satisfaction. Reduce burnout (and encourage trainees to explore primary care as desirable option). University of Nebraska Medical Center 10

11 Successful Implementation PCMH  Requires system redesign:  Practice organization  Health information technology  Quality measures  Consideration of the patient’s experience  Team approach to patient care  Is there a way to measure your current office culture and readiness for change? University of Nebraska Medical Center 11

12 MEDICAL OFFICE SURVEY ON PATIENT SAFETY CULTURE (MOS) AND THE MEDICAL HOME  Developed by AHRQ to provide outpatient medical offices with a valid tool to determine whether the office culture:  Emphasizes patient safety  Facilitates teamwork and discussion about mistakes  Engages in continuous learning & improvement  Pilot tested 2007 – 2009 with 10,567 staff from 470 medical offices - preliminary comparative database  Comparative database in development http://www.ahrq.gov/qual/patientsafetycultu re/mosurvindex.htm University of Nebraska Medical Center

13 Becoming a PCMH  Differences from practice to practice  Different accreditation organizations  NCQA  URAC  Joint Commission  AAAHC University of Nebraska Medical Center 13

14 Becoming a PCMH  NCQA and MOS 1.Access/communication 2.Patient tracking/registries 3.Care management 4.Patient self management support 5.Test tracking 6.Electric prescribing 7.Referral tracking 8.Performance reporting and improvement 9.Advanced electronic communication University of Nebraska Medical Center 14

15 Definition of Safety Culture  Enduring, shared, LEARNED 1 beliefs and behaviors that reflect an organization’s willingness to learn from errors 2  Beliefs consistent with goals of PCMH 3  We use teamwork to coordinate care for patients  We communicate effectively  We close the loop…test results, preventive care, monitoring  We use standard processes to work efficiently and share information with patients, families, other providers  We report and learn from mistakes University of Nebraska Medical Center 1. Schein, E. Organizational Culture and Leadership. 4 th ed. San Francisco, CA: John Wiley & Sons; 2010. 2. Wiegmann. A synthesis of safety culture and safety climate research; 2002. http://www.humanfactors.uiuc.edu/Reports&PapersPDFs/TechReport/02-03.pdf http://www.humanfactors.uiuc.edu/Reports&PapersPDFs/TechReport/02-03.pdf 3. Rosenthal, 2008; Bodenheimer, Wagner, & Grumbach, 2002; American Academy of Family Practice http://www.aafp.org/online/en/home/membership/initiatives/pcmh.html 15

16 MOS – 52 Items in 12 Dimensions 1. Communication about Error 2. Communication Openness 3. Information Exchange with Other Settings 4. Office Processes and Standardization 5. Organizational Learning 6. Overall Perceptions of Patient Safety and Quality 7. Owner/Managing Partner/Leadership Support for Patient Safety 8. Patient Care Tracking/Followup 9. Patient Safety and Quality Issues 10. Staff Training 11. Teamwork 12.Work Pressure and Pace University of Nebraska Medical Center 16

17 “…in many organizations, values reflect desired behavior but are not reflected in observed behavior.” Schein, E.H. Organizational Leadership and Culture 4 th ed. San Francisco: John Wiley & Sons; 2010, p.24, 27. University of Nebraska Medical Center http://search.dilbert.com/search?w=values&view=list&filter=type%3Acomic&x=44&y=19

18 The MOS (Cont.)  Two overall rating questions  Health care quality (effective, patient-centered, timely, efficient, equitable)  Patient safety  Ten items to assess TeamSTEPPS at Baseline (Modification of the MOS by UNMC to assess impact of TeamSTEPPS program on culture)  Team Training experience  Knowledge of TeamSTEPPS Tools (alpha=0.71)  Adoption of Team Behaviors (alpha=0.79) University of Nebraska Medical Center 18

19 MOS Methodology  Feb. – March 2011 Baseline assessment  Personalized paper surveys using Dillman 4- contact method  Population Surveyed  Geriatric clinic (n=18)  Resident-run Mid-Town clinic (n=54)  Response Rates 18/25 = (72%) 54/74 = (73%)  Scanned and entered in database University of Nebraska Medical Center

20

21 Implementing Key Elements of Medical Home Require Teamwork 1.Sustained relationships 2.Manage complexity of chronic conditions 3.Focus on patient/caregiver self- management 4.Maintain complete record of care University of Nebraska Medical Center 21

22 “Initiative based on evidence derived from team performance…leveraging more than 25 years of research in military, aviation, nuclear power, business and industry…to acquire team competencies” Team Strategies & Tools to Enhance Performance & Patient Safety University of Nebraska Medical Center 22 http://teamstepps.ahrq.gov/

23 Outcomes of Team Competencies Knowledge 1.Shared Mental Model Attitudes 1.Mutual Trust 2.Team Orientation Performance 1.Adaptability 2.Accuracy 3.Productivity 4.Efficiency 5.Safety University of Nebraska Medical Center 23 http://teamstepps.ahrq.gov/

24 Fundamentals Course April 30, 2011 Module 1—Introduction Module 2—Team Structure Module 3—Leadership Module 4—Situation Monitoring Module 5—Mutual Support Module 6—Communication Module 7—Summary—Pulling It All Together University of Nebraska Medical Center 24 http://teamstepps.ahrq.gov/

25 University of Nebraska Medical Center *p=.678 *p <.001 25

26 TeamSTEPPS BaselineGeriatrics (n varies) Midtown (n varies) No formal team training experience29%46% Some experience in team skills; not TeamSTEPPS35%52% Completed some training in TeamSTEPPS35%1% Completed all TeamSTEPPS modules0% Correctly defined Brief0%12% Correctly defined SBAR71%50% Correctly defined CUS6%2% Correctly defined STEP0%6% Use SBAR within clinic Most of time/Always0%11% Use CUS within clinic Most of time/Always0%7% Use SBAR or I PASS the BATON to communicate with other organizations Most of time/Always 0%16% Use huddle to adjust plans Most of time/Always29%16% Use debrief to discuss improvements Most of time/Always29%20% University of Nebraska Medical Center 26

27 Midtown Clinic Selected areas needing improvement from Medical Office Survey and steps taken to achieve change 27

28 Midtown Clinic University of Nebraska Medical Center Site for resident continuity clinic 4 residents per staff MD Resident Board of Directors Onsite Social worker and mental health provider Pharmacy residents Nurse coordinator, RNs, LPNs, MAs, Radiology technician More than 10,000 patient visits annually 28

29 University of Nebraska Medical Center

30 Midtown Clinic (n=54) % Positive = Most of time/Always % Neutral = Sometimes % Negative = Never/Rarely University of Nebraska Medical Center 30

31 Midtown Clinic (n=54) % Positive = Most of time/Always % Neutral = Sometimes % Negative = Never/Rarely University of Nebraska Medical Center 31

32 Midtown Clinic (n=54) % Positive = Most of time/Always % Neutral = Sometimes % Negative = Never/Rarely University of Nebraska Medical Center

33 Midtown Clinic (n=54) % Positive = Most of time/Always % Neutral = Sometimes % Negative = Never/Rarely University of Nebraska Medical Center

34 Action Plan for the Midtown Clinic  Major Concerns:  Patient Care Tracking and Follow-Up  Action Plan:  Sent out reminders for annual check-up to patients around time of birthday.  Participated in call back trend analysis: calls received by the triage nurses from patients were tracked and categorized by topic of the call (such as medication information, appointment reminders, test result information, etc.) and the patient’s resident, in order to give the resident a better idea of ways to improve patient care and follow-up. University of Nebraska Medical Center 34

35 Midtown Clinic (n=54) Scale = Strongly Disagree – Strongly Agree University of Nebraska Medical Center 35

36 Action Plan for the Midtown Clinic  Major Concerns:  Office Processes and Standardization  Action Plan:  New resident orientation to the Mid-Town Clinic University of Nebraska Medical Center 36

37 Small group exercise Break into 4 groups assume a role during the discussion: Attending (2), resident/fellow (4), APRN (2), medical assistant (2), clinic nurse (2), receptionist/scheduler (2). Example University of Nebraska Medical Center 37

38

39 Geriatrics Clinic How the MOS identified problems and set us on a course for improvement using newly enhanced team skills 39

40 Overall MOS results(graphic) University of Nebraska Medical Center

41 Team STEPPS Team Training  Gave us the tools for improvement  Provided a common language and expectations  Made safety, quality and satisfaction (for patients and staff) a common goal University of Nebraska Medical Center 41

42 Change Team Who : Social Work, RN, NP, Front Desk, MD, Admin Support How: weekly, now 2-3x/month meetings What: address issues identified by the MOS; review what worked (or not); continue the process University of Nebraska Medical Center 42

43 Work Pressure and Pace Geriatrics Clinic (n=18) Scale %(+) = 0-2x past 12 mos.; %(N) = Monthly, Sev Xs/yr; %( -)= dly/wkly University of Nebraska Medical Center 43

44 How do we work with our patients more effectively and efficiently and feel less stressed in clinic? Implement: briefs, huddles, debriefs, situation monitoring, task assistance 1.Briefs: we know who you (the patient) are and why you are here; we know where schedule will be hectic (anticipate task assistance). 2.Huddles: when things aren’t going well, fix it immediately (need for huddles reduced with situation monitoring and offers of task assistance) 3.Debriefs: what worked, what didn’t, what are anticipated patient follow up needs University of Nebraska Medical Center 44

45 Office Processes and Standardization Geriatrics Clinic (n=18) Scale = Strongly Disagree – Strongly Agree University of Nebraska Medical Center 45

46 How do we improve workflow in this office and make sure work is done correctly? Reorganize into care teams for groups of patients 1.Nurse, NP, MD (SW and Pharmacy available) 2.All inter-visit communications is with a primary nurse who knows the patient 3.Team members communicate face-to-face at least once weekly and all other communication is through the electronic record University of Nebraska Medical Center 46

47 Summary “Getting a new idea adopted, even when it has obvious advantages, is difficult…a common problem for many individuals and organizations is how to speed up the rate of diffusion of an innovation.” Rogers EM. (2003). Diffusion of Innovations (5 th ed.). New York, NY: Free Press, p. 1. PCMH is an innovation University of Nebraska Medical Center

48 Challenges to Large Scale Change No sense of urgency Change is not presented as a clear advantage Change is overly complex No plan for role modeling and rewarding new behaviors Lack of management support No champion(s) No evidence the change is a priority (flavor of month) Lack of resources (time, $, people, equipment) Change not hard-wired into policies/procedures, job desc. Change is not evaluated University of Nebraska Medical Center 48

49 University of Nebraska Medical Center Helfrich CD, Weiner BJ, McKinney MM, Minasian L. (2007). Determinants of implementation effectiveness: Adapting a framework for complex innovations. Medical Care Research and Review;64(3):279-303. 49

50 University of Nebraska Medical Center Questions?


Download ppt "Patient Centered Medical Home: A Team Sport Katherine J. Jones, PT, PhD 1 Jane Potter, MD 1 Andrew Vasey, MD 1 Audrey Chun, MD 2 2011 Reynolds Grantee."

Similar presentations


Ads by Google