A NEW APPROACH TO PATIENT- CENTERED CARE Family Health & Sports Medicine Albert Puerini, MD

A NEW TEAM  PRACTICE REORGANIZATION BEGAN IN OCTOBER 2008 WITH THE ADDITION OF THE NURSE CARE MANAGER.  THE PRACTICE PROMOTES SHARED RESPONSIBILITY FOR PROVIDING QUALITY CARE TO ALL OF OUR PATIENTS.  ALL OF OUR STAFF HAS NEW ROLES AND BECOME VALUABLE MEMBERS OF OUR NEW “TEAM”!!

ROLE OF THE NCM  INTEGRATION INTO THE PRACTICE WAS EASY.  SHE BEGAN SEEING PATIENTS ALMOST IMMEDIATELY BY REVIEWING THE REGISTRY AND ALSO MD REFERRAL.  WORKED VERY CLOSELY WITH THE MEDICAL ASSISTANTS TO GAIN A BETTER INSIGHT INTO THE DAY TO DAY OPERATIONS OF THE OFFICE AND THEY ALSO HELPED KATHY GET TO “KNOW THE PATIENTS”!!!

ROLE OF THE NCM  NCM CONTINUES TO EVOLVE OVER THE PAST TWO YEARS TO INCLUDE: DEVELOPMENT OF REFERRAL TRACKING AND TEST TRACKING POLICIES TO ENSURE PATIENTS ARE RECEIVING FOLLOW-UP IN TIMELY MANNER.  ASSISTING THE PHYSICIANS IMPLEMENT EVIDENCE-BASED GUIDELINE TEMPLATES INTO THE EMR.

ROLE OF THE NCM  HAS COMPLETED BOTH DIABETES GROUP VISITS AND MAKES HOME VISITS AS NEEDED. WORKING ON GROUP SMOKING VISITS FOR  COMPLETED LEVEL 3 SUBMISSION FOR NCQA.

ROLE OF THE MA  RESPONSIBILITIES PRIOR TO CSI:  PREPARING THE ELECTRONIC CHART  FINDING MOST RECENT LAB RESULTS  SETTING DISCHARGE SCREENS/DIAGNOSIS  VITAL SIGNS, BLOOD GLUCOSE CHECKS, PFT FOR SMOKERS, EKG ON ALL CPE.

EXPANDED MA ROLE  PRE-VISIT PLANNING:  THE NCM AND THE MA ARE BOTH REVIEWING THE MD SCHEDULES AND ARE NOW MEETING WEEKLY WITH THE PROVIDERS TO PLAN PATIENT CARE.  MA REVIEWS RECORDS THREE WEEKS PRIOR TO PATIENT APPOINTMENT AND LAB SLIPS ARE SENT.

EXPANDED MA ROLE  ONE DAY PRIOR TO THE PATIENT APPOINTMENT, THE MA NOW REVIEWS RECORD AGAIN AND ADDS MOST RECENT LAB RESULTS TO PREVENTIVE CARE SCREEN, AS MD USES THIS SCREEN TO DISCUSS LABS, PREVENTIVE EXAMS WITH PATIENT.

EXPANDED MA ROLE  MORE CHANGES:  RESPONSIBLE FOR DEPRESSION SCREENING QUESTIONAIRE.  YEARLY MONOFILAMENT FOOT EXAM. INSTRUCTED BY NCM WHO IS CERTIFIED DIABETES EDUCATOR HOW TO PROPERLY DO THIS EXAM.  MA MEGAN CONVERSE AND KATHY WORKED TOGETHER TO DEVELOP THE TOOL USED FOR THIS EXAM. A FOOT CARE INFO SHEET IS ALSO GIVEN TO OUR PATIENTS AT THIS TIME.

EXPANDED MA ROLE  FOLLOW UP FAXES FOR DIABETIC EYE EXAMS AND MAMMOGRAMS  IN COLLABORATION WITH THE NCM FAX LETTERS HAVE BEEN DEVELOPED TO IMPROVE OUR COMMUNICATION WITH SPECIALISTS ENSURING OUR PATIENTS HAVE COMPLETED NECESSARY PREVENTATIVE TESTS.

EXPANDED MA ROLE  MA MEGAN CONVERSE UNDERTAKES A NEW RESPONSIBILITY!  SHE DEVELOPED OUR NEW WEBSITE:  WE ARE NOW LIVE AT FHSMRI.COM !!!  OUR NEW WBSITE PROVIDES INFORMATION ABOUT OUR STAFF, HEALTH RESOURCES, INSURANCE PLANS, EDUCATIONAL HAND-OUTS, AND PATIENT PRIVACY.  FUTURE PLANS FOR PATIENT PORTAL

HOW DID WE DO IT??  TEAMWORK AND COMMUNICATION RIGHT FROM THE BEGINNING. EVERYONE HAS TO TAKE RESPONSIBILITY.  BRAIN-STORMING AS A GROUP TO IMPROVE UPON A PROCESS.  WEEKLY MEETINGS WITH THE MA AND NCM.  MONTHLY “FAMILY MEETINGS”

QUESTIONS ???