1. Continuous Team RN based Care Management Union Square Family Health Center

2. Disclosures It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/ invitation of participation. Disclosure documents are reviewed for potential conflicts of interest and if identified, they are resolved prior to confirmation of participation. Only these participants who have no conflict of interest or who agree to an identified resolution process prior to their participation were involved in this CME activity. All individuals in a position to control content for this activity have indicated they have no relevant financial relationships to disclose.

3. Outline Chronic Care Management is necessary to improve patient outcomes Relationship based interventions are a powerful way to manage chronic disease Team RNs can effectively manage patients with chronic diseases Here is how

4. Cambridge Health Alliance An academic public health safety net system outside of Boston 12 medium-sized community health centers, 3 school-based clinics, 3 hospitals, specialty clinics Largely public payer mix – 82%,almost all Medicaid >50% patients speak language other than English 600,000 outpatient visits/year 160,000 primary care visits for 92,000 patients Academic and public health mission

5. Union Square Family Health Award Winning Ambulatory Care Center 2012 Full spectrum Family Medicine Care 9 Family Medicine MDs, 3 Physician Assistants Founded 1998 23,000 patient visits/yr Onsite Services also include Nutrition, Parenting/Child Counseling, Adult and Child Psychiatry, Social Work, Family Planning, Pharmacy, Lab, Referral Coordinator Team care since 2005

7. Why teams? Places patient at the center – MD not the center of staff attention Entire staff know and own the care of the patient Work is distributed according to level of staff training (e.g. RNs free to do RN level tasks) Improves quality and efficiency of care Makes primary care possible and ENJOYABLE!

9. Do this: Parallel Work Flow Redesign

11. Cycle of Team Meetings Week 1: Well Child Outreach/Pediatric Asthma Week 2: Diabetes/Depression Week 3:MA/FD:Normal PAP/Mammography Outreach RN/MD: High Risk patient case review Week 4: Abnormal Cancer Screening Follow up

12. RN Role on the team RNs co-manage multiple chronic diseases: depression, diabetes, HTN, anxiety, abnormal cancer screening Monthly review of High Risk, depression and diabetes, abnormal cancer screen lists with the team Self structured review of lists in between to outreach to patients

13. RN Training CDE based training using our larger system and specialty RN (endocrinology) Multi-disciplinary case conferences (pharmacy, CDE, PCP, SW) Co-management with the PCP and team engenders continual learning in both directions Motivational Interviewing training Diabetes updates

14. RN Visits Dedicated time for RN visits LPN hired to get them off the floor (shots, limited triage, supplies and stocking, faxing!) Two RNs seeing visits all sessions, evenings still a challenge Chronic Care visits 30/60 min and urgent care 15/30 min Dedicated time for outreach for depression patients and the home bound

15. Voice of the Team Monica Tague, RN extra-ordinaire: http://youtu.be/dbl0s_bZsKE

16. Supporting the work PCP needs to encourage this new relationship Alignment with the staff so return visits are scheduled with RN or pharmacist for HTN, Diabetes (esp flu shots) Patient education materials to teach about team model and the different roles

18. What about the insanely complex? Complex Care manager hired November 2012 Teams identified highest risk patients for her to follow in partnership with SW (max of 50 at this time) Goals of improving patient outcomes, reducing hospitalizations and re- hospitalizations, ER visits

19. The Story of RK, a Patient with Diabetes R K established care 11/30/11 with HGBA1C of 10.1, LDL 182 Diabetes mellitus with chronic kidney disease [250.40] –Primary Renal insufficiency [593.9] –Diabetic neuropathy [250.60] –Hypertension [401.9] –Anemia [285.9]

20. The Story of RK, a Patient with Diabetes Had RN care management who connected with him over a few visits Got him –nutrition appt – renal consult –Ophthalmology –Pharmacy (Joe) to control his BP –Today Joe was SO EXCITED as his BP was 120/70. His latest HGBA1C is 6.8, LDL 61 !!!! Lots of TEAM involvement with this pt and he is finally doing really well and maybe will avoid dialysis for awhile!

21. Outcomes RNs have taken on direct patient education for high risk patients, esp. diabetics

23. Diabetes “Perfect Care”

24. Lessons Learned Long ramp up time with training when there is turnover Relationship based systems take time to see big results in chronic disease (outcomes), but the little ones come right away (process measures) RN advice: http://youtu.be/bbb7sX0SjA4

25. Hitting Target: Rock vs. Bird Copyright © 2011 Southcentral Foundation. All Rights Reserved.