Circles of Care: A Transition to Patient Care Teams Story

Presenters Laurel Domanski Diaz, MNO, Director of Business Operations Dan Gauntner, CNP, Director of Clinical Operations Marianella Napolitano, RN, MBA, Clinical Quality Coordinator

Objectives Participants will understand how safety net practices can implement a systematic approach to caring for their communities Participants will learn how to organize a practice to allow staff members to work at the top of their licenses. Participants will become familiar with how implementing care teams can improve the quality of care.

NFP Background A Federally Qualified Community Health Center founded in 1980 Last year served 13,400 patients on the near west side of Cleveland 17 Providers on staff--8 Family Practice MDs, 6 Family Practice CNPs, 3 Certified Nurse Midwives Focus on the medically underserved Serve a large Hispanic population

Partnering with the community for everyone’s best health NFP has always believed that partnering with a patient is the best way to achieve healthy outcomes. NFP sees that the services provided to patients are each just one stop in a constant continuum of care that envelopes every patient into their own medical home. NFP developed a model, Circles of Care, to transform our Community Health Center into a Care Team and EMR driven practice focused on Patient Centered Care.

Redesign Activities Care Teams EMR Optimization Continuous Improvement Processes

Why Care Teams? Working from NFP’s Strategic Plan, NFP identified the following areas to be addressed: Improvement of patient’s health and safety Improvement in NFP’s financial performance Increased provider, staff and patient satisfaction Becoming an NCQA Patient Centered Medical Home

Care Teams A Care Team has been defined as: A panel of patients who usually see or choose a particular group of providers for their care AND the group of staff who generally work together for the care of that panel of patients.

NFP Circles of Care Patient Contract IT Staff OCHIN/ Epic Information Technology NFP IT Staff & Medical Records Nurses, MAs, Patient Advocates Clinical Providers & Behavioral Health Community Agencies Front Office Billing & PBS Administrative Management & Executive Leadership

Care Team Composition Three Providers—combination of Family MDs, Family CNPs, (one team’s providers consists of 3 Certified Nurse Midwives) One to two RNs One to two Patient Advocates Medical Assistant for each Provider Front Office representative at each team meeting

Care Teams Developing new procedures around scheduling, registering patients & directing phone calls to teams Conducting training activities to facilitate team communication, structure and creating ongoing team meetings Redesigning of nursing staff structure to provide individual nurses to care teams. Organizing providers and support staff into integrated care teams. Adding a Patient Advocate to each team

Team Training Promoting the idea of team across the organization Team formation activities prior to implementation Team trainings help decrease hierarchical systems (TEAMSTEPPS, Practice Coaching) Practice Coaching and facilitation

Team Meetings Goal: Improve communication and increase efficiency across all disciplines Commitment from the leadership Financial investment More frequently initially Outside facilitator present at the beginning Internal staff facilitates meetings

Team Huddles Daily meetings at the beginning of the morning, may include the entire team, Provider and MA Approximately 10 minutes Provides MA with clear path of what needs to be done to prepare for the Providers entrance in the exam room

Patient Service Representative Role Accurate team scheduling Directing of patient inquiries (phone and in-person) to the appropriate team Reinforcing PCMH message: scheduling with PCP, we do not operate as an urgent care Serves as a member of the Care Team for Team meetings

Patient Advocates Initially grant funded Started with a focus on specific populations Our Patient Advocates range from recent college grads to members of our community who have a background in activism or social work Use of standing orders and protocols allow PAs to unload the provider and nursing workload Each PA has a specialized area—Hispanic patients, women’s health, refugees, computer expertise Increase patient’s access to the Care Teams by helping with patient communication and correspondence

Patient Advocate Role Paperwork Processing requests for disability, physical forms, utilities, faxing, copying, mailing forms, letter processing. Population Management DM,HTN,WCC, Hospital follow up, Hunt groups 2005, 2000 coverage, Nurse messages Case Management Meeting with patients at provider request, community resource coordination, making appointments for urgent referrals, Huddle participation, No-Show follow up coordination Referrals X-rays, ultrasounds, specialists and DME, some urgent—nothing requiring prior authorization Other Responsibilities Interpreting, Coordination of Centering, Coordination of Refugee Clinic, grant funded responsibilities, PDSA activities Order Entry DX--DM, HTN, Adult Physical, Hypothyroidism, Hyperlipidemia, heart issues. Entering standard orders routine labs, immunizations, referrals.

Nurse Role Care Team Support Preparing forms for provider signature, calling in Rx, calling patients with lab or test results Patient Triage Speaking with patients on the phone about their symptoms and concerns, triaging patients in the waiting room that may need to be seen immediately or may need to be overbooked. Patient Visits Seeing patients in the health center for immunizations, INR, something that is not a new concern. Patient Education Educating patients with diabetes and hypertension, answering questions about medications, done on the phone or in person.

Medical Assistant Role Rooming Patients Taking Vitals, entering in chart: medications, chief complaint, review allergies, PHQ scores, complete tobacco, substance, sexual abuse history, enter diagnosis, check for Pharmacy, goal sheets. Maintain Provider Rooms Keep rooms stocked with appropriate supplies, tests, do inventory every 2 weeks Back Office Labs Order and Result back office labs--UA, Strep, INR, Glucose, Hemoglobin, HbA1c, icon Immunizations Complete immunization consent forms, Review past immunizations given, Print out IMPACT sheet to review what is needed, Review old chart, Order and pend immunizations needed- provider to review and sign, Enter into IMPACT, Historical immunizations must be entered into EPIC Order Entry & Release Female Physicals—order mammogram, Fit Test—women and men over 50, WCC—lead and HGb for 1 to 6 YO, DM—foot exam, last eye exam, enter referral, HTN—do EKG, Others--PAP, Urine culture, Chlamydia/ Gonorrhea

Ancillary Support Services Available In-Office Support includes: On-site Behavioral Health On-site Clinical Pharmacist RNs provided by insurance companies Wellness Coordinator Medication Assistance Program Diabetes Educational Sessions provided by local Diabetic Assoc.

Optimization Enabling Providers to practice at highest scope Professionals will work at the top of their licenses if: They have people they can delegate to. At NFP this was done by increasing the skill set of: Medical Assistants Patient Advocates There are effective communication methods In-basket messages within the EMR to make clinical communication efficient Team meetings for peer and cross professional feedback

Optimization (cont.) Patient Advocates Use evidence based protocols to address health disparities Use registries to identify gaps in healthcare Identify high risk patients for case management by nurses Tracking and monitoring goals of the Health Center Operational Clinical Developing policies and procedures for EMR system and Care Teams at NFP

Outcomes of the Circles of Care Project NFP achieved Level 3 NCQA PCMH Accreditation with a score of 99% In a Medicare Pilot Program on PCMH, NFP was the top scoring FQHC in the country. Improved communication Increased coordination Improved quality of care for our patients

Patient Satisfaction – Decreasing wait time

Continued Wait Time Improvement

Financial Performance Improvement

HbA1c less than 8 Increased from 48% to 62%

BP control in DM patients Increased from 72% to 79%

DM patients who had a Foot Exam Challenges tracking this information Increase coordination and communication with all team members

Questions?