The Problem of Multiple Hats: Providing efficient and safe team-based care with providers who are not always in the clinic. Frank Babb, MD David RM Trotter, PhD Department of Family and Community Medicine Texas Tech University Health Sciences Center

Learning Objectives On completion of this session, the participants should be able to: Enumerate the challenges associated with providing timely clinical advice in a busy residency teaching clinic. Describe the “Point Provider” system; a novel PCMH team-based workflow that facilitates the delivery of timely clinical advice to patients. Discuss the benefits and challenges associated with implementing the “Point Provider” system.

Overview The goal of providing team based care The challenges of team based care in an academic practice The “Point Provider/Nurse” solution Implementation Lessons learned

The Goal National Committee on Quality Assurance: Patient Centered Medical Home Criteria A mandate for team based care

The Goal NCQA, PCMH Standard 1, Element B, Factors 2 and 3 “The practice has a written process and defined standards for providing access to clinical advice and continuity of medical record information at all times, and regularly assesses its performance.” Includes communication via telephone, secure electronic means, fax, etc…

The Goal Our Goal: to increased the speed at which we respond to patient inquires WITH OUT sacrificing quality and safety of advice given

The Challenge How do you provided timely clinical advice in a busy academic practice? Resident clinic schedules vary wildly by year in training AND monthly rotation All physician faculty have “other” responsibilities Time in clinic varies from 5% to 80%

The Challenge Some activities pull physicians away from clinic for extended periods of time E.g. Family Medicine Service, Conferences, Interview Season Considerable variability in how and when physicians responded to messages

The Challenge Pre-PCMH 24-Hour Message Return Rates (2014) Team March April May June 4 Month Ave Double T 41.26% 52% 83.30% 81.25% 64.45% Raider Red 37.30% 55.50% 45.80% 58.30% 49.23% Masked Rider 59.50% 72.20% 70.80% 87.50% 72.50% Matador 65.10% 47.20% 84.70% 62.50% 64.88%

The Solution: The Point Provider/Nurse System Each care team will have a designated “Clinical Team Message Pool” in the electronic health record. Patient Services Staff will document communications from or about patient requests for care and clinical advice in an in-clinic communication. The communications will be sent to the appropriate team message pool. Patients who are registered for the electronic patient portal are capable of sending requests for care and clinical advice via the portal. Patients select the provider they wish to communicate the request to. The message will be routed to the appropriate team message pool based on the provider selected. Each care team will have a point nursing staff and point provider assigned during each half day of clinic. The point nursing staff will monitor and review communications sent to their team.

The Solution: The Point Provider/Nurse System The point nursing staff will address and clear any communications they can under their license and per pertinent clinic policy. Responses will be documented in the electronic health record. Communications requiring physician review/signature will be delivered to the point provider for review, signature, or triage. It will be the responsibility of the point provider to address all communications during the half day of clinic. While it is the point provider’s responsibility to address all communications, other providers in clinic are encouraged to assist them to ensure that issues are addressed in a timely manner. Responses will be documented in the electronic health record. All communications should be addressed same day. Monthly audits of same day response performance will be conducted monthly. Results will be communicated at quarterly PCMH Team Meetings.

Implementation Organization: We went from two sides of clinic to four care teams. We asked for ideas for names of these groups and voted on them at a faculty retreat. We chose the beginning of a new academic year to make the change. Initially it was only faculty who were handling the messages but eventually upper level resident were assigned as point providers.

Implementation Initially faculty were asked to answer each message. Soon nurses started handling messages that were in their purview per clinic guidelines. Implementation started about three months before hydrocodone became a Schedule II drug.

Implementation Filling Schedule II medications became a significant challenge to our physicians. Different providers had different criteria for writing these medications and different protocols for following their patients on these medications. An agreement developed between the providers on what was expected in our practice.

Implementation: Data Post-PCMH Same Day Message Return Rates (2014) Team July August September October November Double T 57.10% 37.50% 93.30% 85.26% 78.7% Raider Red 89% 63.60% 100.00% 79% 76.50% Masked Rider 58.30% 54.50% 86.60% 82.96% 88.7% Matador 56.50% 100% 73.30% 69.46% 71.2%

Implementation: Data May June July Double T 64% 76% Raider Red 84% Post-PCMH Same Day Message Return Rates (2015)   May June July Double T 64% 76% Raider Red 84% Masked Rider 96% 72% 88% Matador

Lessons Learned Everyone needs to work at the upper limit of their license to care for our patient’s needs. Because any provider may be called on to fill a prescription for your patient better documentation of the ongoing plan was needed. Communication is key between physicians, residents, nurses, and front staff.

References National Committee Quality Assurance. Patient Centered Medical Home (PCMH), 2014 Guidelines. Washington, DC (Downloaded from http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH.aspx)