Reform and Transform:
Ensuring the Right Skill Mix for
Primary Care
Margaret Flinter
Vice President & Clinical Director
CHC Inc.
February 8, 2010
2/8/2010
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Federally Qualified Health Centers
• Serves as health‐care home for 17 million people in over 6,000 communities
• Largest primary healthcare system in the nation
• When 47 million people become newly insured‐ who will care for them?
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CHC Inc. and the State of CT
• Connecticut pop: 3,000,000 • Publicly Insured:
450,000 • Uninsured:
est. 30‐40,000
• State employees:
60,000
• FQHC Patients:
242,034
• CHC Inc. Patients
53,000
A state of contrasts: CT is the wealthiest state in the country but with urban areas equivalent to 3rd world poverty & Health status
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Transformational Care
1. Clinical Excellence
2. Research & Development
3. Training the Next Generation
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Profile Of Patients
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Definition of Primary Care
The provisional definition of primary care adopted by the IOM Committee on the Future of Primary Care follows:
“Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”
…or as defined by Barbara Starfield (1992) – “care that is characterized by first contact, accessibility, longitudinality and comprehensiveness.”
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What Does Primary Care Look Like In FQHC?
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CHC Model of Care
 Eliminate waits, waste and delays: advanced access scheduling
 Improve clinical outcomes: team‐based, planned care and chronic care model:
 Make the automatic, automatic‐checklists, protocols, standing orders
 Incorporate prevention and health promotion into every visit, every time
EMR, Patient Portal and Health Information Exchange 2/8/2010
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Creating the Primary Care Team
• Primary Care Provider (MD or APRN) 1: 1500
• Primary Care RN (1 RN:2 PCPs) • Medical Assistants (1:1 PCP)
• Clinical Receptionists (1:1 PCP)
• Behavioralist (1:3 PCPs) *
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Supporting Primary Care Teams
In House
•
•
•
•
•
•
•
•
2/8/2010
Psychiatry Podiatry
Nutrition
HIV/AIDS Specialist
OB/Gyn
Dentists, Hygienists Pharmacist
Specialty RNs (CDE, HIV, Care Coordinator)
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External Support for Primary Care
• Hospitalists
• Specialists
• Lab and Pharmacy
• eConsults access to specialists
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Building Healthy Communities
CHC’s AmeriCorps Team Launches Stamford Outreach
Mobile Dental
2/8/2010
Vinnie’s Jump & Jive
Family Resource Center
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What the eye sees…
New Britain Site
NB New Building – Frontal Facade
Meriden Site
2/8/2010
NB Reception Area
Waiting Area
Clinton Site
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Skill Sets in Primary Care
• Panel Management of complex patients
• Expert use of information technology (EMR, HIE, eConsults, virtual encounters)
• Ability to apply all elements of planned‐care/chronic care model
• Self‐management goal setting/management • Patient coaching and engagement
• Care Coordination and Transition management
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Primary Care Provider
• “Owns” the panel, continuous relationship
• Coordinator of complex care
• Delegates and support care within a team
• Medical decision maker
• And…expert in managing the complex problems of substance abuse, mental illness, pain management • Supports new primary care providers
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Provider Panel
PCP
Weighted panel
all visits
Visits w PCP Continuity Rate
Avg Visits per patient (all visits) 12 months Blankson APRN, Mary‐FP
1359
1282.19
6,545 4399
67%
3.65 Borgonos MD, Ovanes‐FP
1477
1501.86
7,309 5588
76%
3.83 Channamsetty MD, Veena‐FP
1040
1020.8
4,768 2644
55%
3.62 Decker APRN, Patricia‐FP
1458
1427.61
7,524 5232
70%
4.11 Doerwaldt MD, Hartmut‐FP
1712
1718.74
7,125 3660
51%
3.35 Dudley MD, Robert‐PD
1439
1242.36
5,793 4701
81%
3.11 Eddinger APRN, Ann‐FP
669
685.39
3,270 2260
69%
3.62 1436
1318.59
4,973 3194
64%
2.82 978
985.73
3,732 3093
83%
3.51 Huddleston MD, Matthew‐FP
1160
1125.31
6,074 5289
87%
3.95 Kirby MD, Jacqueline‐PD
1326
1260.58
6,603 4267
65%
3.83 Kucharchik MD, Thomas‐FP
1596
1619.79
6,310 5696
90%
3.16 Lecce MD, Carl‐FP
1454
1412.66
5,901 5186
88%
3.20 909
824.73
3,195 2956
93%
3.39 1497
1556.27
7,660 5215
68%
3.79 279
272.13
914 222
24%
3.17 Pathman MD, Anandhi‐‐IM‐PD
1915
1873.81
6,844 5948
87%
2.87 Thomas APRN, Bernadette‐‐FP
1076
1128.58
5,568 1956
35%
4.17 Vitale MD, Marie‐‐FP
1133
1056.67
5,788 4922
85%
4.18 Wilensky MD, Dan‐‐FP
1352
1346.09
6,165 4745
77%
3.54 Farb MD, Alan‐PD
Gollnick APRN, Rachel‐FP
Long APRN, Sarah‐FP
Monroe, Jr. MD, John‐FP
Olayiwola MD, Nwando‐FP
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Panel
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Training for Primary Care
Clinical Receptionist
Receptionist Competency Checklist
Competency
Operational definition
Make announcement on overhead page system
Answer telephone promptly
Uses correct code/"[Name], please call ext. xxxx"
Within 30 sec.
Verbally interact with patients per CHC scripts
Follows dental, medical and behavioral health script.
Use appointment allocation guidelines correctly
Appointment Allocation Guidelines.
Measurement method
Verbalizes/
Initials of
Demonstrates
Reviewee
Correct BehaviorDate
Simulated skill demo
Service level in ACD by individual
Phone monitoring and direct
observation
Use the language line
Follows written instructions.
Correct language identified and
translator on line.
Transfer telephone calls
Successful transfer.
Skill demo
Record telephone encounters with pertinent information Uses written English adequate to clearly communicate content of message; brevity;
Check with Shanti. Review of five
in ECW and on paper as appropriate. Hub update
lack of ambiguity; timely transmission, list pharmacy; record name of person calling and appts on five different days.
pharmacy.
tel. number where they can be reached. Spell checks. Appropriate content.
Route messages to triage nurse or providers
Timeliness of routing. Follows appt allocation guidelines. Follows guidelines for paging Review of messages.
nurse.
Update patient pharmacy information in ECW
Complete and accurate info.
Feedback from pts
Apply advanced access guidelines to schedule
appointments
Schedule, cancel and reschedule appointments
Process check-in and no show patient appointments
Respond appropriately to walk-in appointments
Register patient in Centricity, fully populating required
fields
Respond appropriately to angry or agitated patients
Obtain medical release as needed
Obtain and scan required documents into ECW
Fax info from ECW (medical receptionist/medical
records clerk only)
Update patient information in Centricity
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Confirm appointments with patients
Feedback from nurses , providers
and supervisor
Appropriate mix of appts. Smart scheduling process. Balanced schedule for providers. Visual check based on color
codes of one day's schedule.
Acceptable/Unacceptable rating.
Apts are correctly entered and documented in Centricity: appropriate appt type
Review of five appts on five
selected, note in appt as to appt reason, apt scheduled with appropriate provider, recall different days.
is attached, pt demographic info verified, authorization for Beh. Health attached.
Correct in notation in system. Ensure correct demographic, pharmacy and insurance
Direct observation of a patient
Info .Record no shows in encounter for provider if appropriate.
check-in.
Says, "We discourage walk-in appts. Our preference is to schedule an appt for the
Anecdotal review and skill
provider you want to see. " or "If you would like to establish care here, we will set you practice
up with an ATC appt who can register you for care here."
Name, address, DOB, sex, SS #, insurance, tel #, guarantor info if under 18 yo, release Pull five pt records
of info, HIPAA form, current sliding fee scale. Obtains email address or populates field
with “none” or “refused."
Treats angry or agitated patients with respect, and refers patient to senior receptionist Observation/Patient feedback
or supervisor if needed.
Correctly completes medical release in terms of date, person providing info, what info is All reqd info is included and
needed, to whom request is going, reason for request, statement that pt is transferring correct
out, patient signature, length of time for release, witness.
Proof of income, insurance cards, profile and HIPAA. Scanned to correct pt record and Direct pt record audit -- frequency
assigned to appropriate person.
based on perf. Record of
employee
Uses FAX prompt in ECW.
FAX completion records in ECW
Name, address, DOB, sex, SS #, insurance, tel #, guarantor info if under 18 yo, release Feedback from pts, Pt Accounts
of info, HIPAA form, current sliding fee scale. Obtains email address or populates field and nurses
with “none” or “refused."
Pts called day before appt. and message left if person not reached.
Pull five pt records
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Initials of
Reviewer
FQHC Based Residency Training for Nurse Practitioners
• Provide new nurse practitioners with a depth, breadth, volume, and intensity of clinical training necessary to serve as primary care providers in the complex setting of the country’s FQHCs. • Train new nurse practitioners to a model of primary care consistent with the IOM principles of health care and the needs of vulnerable populations
• Create a nationally replicable model of FQHC‐based Residency training for primary care nurse practitioners
• Prepare new NPs for practice in any FQHC setting—rural, urban, large or small
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Measure and Improve
• Customer/Patient Service
• Utilization vs. Capacity
• Clinical Outcomes
 Process
 Outcome
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Measure and Improve
ACD queue name
ACD contacts offered ACD contacts handled NB MEDICAL
1711
1502
734
582
NL MEDICAL ENGLISH
1977
1843
653
318
MR MEDICAL
1801
1635
871
593
MT MEDICAL ENGLISH
1379
1187
451
383
CL MEDICAL
748
739
258
231
GROTON MEDICAL
804
709
269
174
ENFIELD
561
477
202
151
DANBURY
470
370
179
156
Agency Capacity
Additional Provider Filled Service Answe
time Slot r %
needed ‐ level %
using slots available 1.
605
65.1
87.8
28 2.
69 381
67.9
93.2
1.
672
60.7
90.8
97 0.
379
59.2
86.1
71 0.
182
89.4
98.8
75 0.
184
62.1
88.2
84 0.
28 174
53.3
85.0
0.
163
51.9
78.7
16 Stamford Medical
Total 88
9451
80
8462
30
3647
70
2658
35
2775
Week of Jan 11th
2/8/2010
104%
Appts Slots Scheduled Availabl
Provider only e (0.05)
8.68 81.8
64.8
90.9
89.6
All PCP Appts for Week No Shows‐
PCP % of No Shows 872
137
16%
701
123
18%
1193
203
17%
590
127
22%
297
35
12%
276
29
11%
232
18
8%
306
6
2%
48
5
10%
15%
4515
683
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Measure and Improve
Quality Care Indicators/Health Outcomes and Disparities ‐ CHC Baseline UDS DATA CY 2008
2/8/2010
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Measure and Improve
Immunizations (Over 65) Current
Pull Sept 2009
Last Pull (June 2009)
% of patients
35%
30%
28%
41%
48%
50%
38%
37%
41%
% of patients
48%
15%
28%
35%
57%
47%
40%
39%
43%
% of patients
49%
25%
36%
32%
58%
54%
52%
35%
45%
Influenza
OrgName
CHC of Clinton
CHC of Danbury
CHC of Enfield
CHC of Groton
CHC of Meriden
CHC of Middletown
CHC of New Britain
CHC of New London
Agency
Denom
Num
211
47
43
333
394
270
546
562
2406
74
14
12
135
188
136
208
210
977
All patients with medical visit in last 18 months over the age of 65 with Flu vaccine during most recent flu season (september ‐February)
Pull Sept Last Pull (June Pneumonia
Current
2009
2009)
% of % of OrgName
Denom
Num
% of patients
patients
patients
CHC of Clinton
211
150
71%
71%
64%
CHC of Danbury
47
12
26%
21%
17%
CHC of Enfield
43
19
44%
44%
46%
CHC of Groton
333
89
27%
24%
21%
CHC of Meriden
394
326
83%
83%
77%
CHC of Middletown
270
206
76%
80%
72%
CHC of New Britain
546
408
75%
79%
75%
CHC of New London
562
361
64%
60%
50%
Agency
2406
1571
65%
65%
59%
All patients with medical visit in last 18 months over the age of 65 with pneumonia vaccine in lifetime
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Data Unites Us – Anecdotes Divide Us Colorectal Cancer Screening OrgName
Denom
CHC of Clinton
CHC of Danbury
CHC of Enfield
CHC of Groton
CHC of Meriden
CHC of Middletown
CHC of New Britain
CHC of New London
Agency
Num
724
320
348
795
1422
1249
1781
1804
8443
Current
Pull Sept 2009
Pull (June 2009)
% of patients
% of patients
% of patients
445
119
87
270
876
756
1112
1079
4744
61%
37%
25%
34%
62%
61%
62%
60%
56%
63%
35%
27%
32%
62%
60%
62%
60%
56%
60%
25%
33%
25%
64%
56%
57%
59%
54%
CHC patients with Medical visit in last 18 months ‐ age 51‐80 ‐ colonoscopy <=10 years or FOBT <=1 year Mammogram Screening
OrgName
CHC of Clinton
CHC of Danbury
CHC of Enfield
CHC of Groton
CHC of Meriden
CHC of Middletown
CHC of New Britain
CHC of New London
Agency
Current
Denom
Num
613
366
420
587
1321
1047
1503
1605
7462
Pull Sept 2009 Last Pull (June 2009)
% of patients
488
164
202
359
1067
907
1255
1211
5653
80%
45%
48%
61%
81%
87%
83%
75%
76%
% of patients
75%
44%
46%
59%
82%
87%
83%
76%
76%
% of patients
70%
33%
50%
56%
83%
83%
82%
75%
75%
Women age 42‐69 with Medical visit in last 18 months with Mammogram in last 2 years
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Improving Chronic Disease Care
Health Outcomes and Disparities ‐ CHC Baseline UDS DATA CY 2008
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Improving Chronic Disease Care
Health Outcomes and Disparities ‐ CHC Baseline UDS DATA CY 2008
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It is not easy…
The Community Health Center, Inc. (CHC) implemented a system‐wide (12 sites, 70,000 patients) tobacco cessation intervention based on the U.S. Department of Health and Human Services’ Treating Tobacco Use and Dependence: 2008 Update Clinical Practice Guideline # of women
Screened for smoking and advised to quit
8,190 Received intensive counseling as part of provider visit
1,920 Received intensive counseling and qualified for program
1,238
Enrolled in Program
520
Completed Program
155
Available for follow‐up
72
Study Results
31% of the women in the study had quit smoking. The study also found that while there was no significant difference between the amount of cigarettes smoked by pregnant women and non‐pregnant women at program initiation, at program completion, there were statistically significant differences between smoking rates of pregnant and non‐
pregnant women, with pregnant women showing a decrease in numbers of cigarettes smoked. The final finding of the study was that there were no disparities in smoking cessation rates across racial and socio‐economic groups.
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Infrastructure
•
•
•
•
•
Human Resources
Facilities
Practice Management
Information Technology
Leadership
 Clinical leadership
 Executive leadership
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Health Reform in CT
Based on the work and recommendations of many groups, Connecticut created “Sustinet”
1.Will rationalize payment for publicly insured and privately insured
2.Will “bake in” requirements for patient centered medical home
3.Will make medical home services available to small practices on a “utility” or community based model
4.Provides support and coaching to practices for implementing IT and medical home
5.Creates common outcome reporting and benchmarks
6.Integrates public health priorities (tobacco/obesity) into private insurance plans
7.Combines all publicly funded healthcare, including state employees into one plan
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Comments or Questions ?
Please Contact:
Margaret Flinter, APRN, MSN, FAANP
Vice President and Clinical Director &
Director, Weitzman Center for Innovation
Community Health Center, Inc. www.chc1.com
margaret@chc1.com 860.347.6971 ext. 3622
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