Facilitating Primary Care Practice
Transformation
Nursing Research Symposium
November 12, 2011
Sandra M. Robinson, MS, RN, Practice Facilitator
Nancy H. Abernathey, MSW, LICSW, Practice Facilitator
Laura Carleu, RN, MS, MPH, Practice Facilitator
Theresa Fortner, RN, Practice Facilitator
Elise McKenna, RN, MPH, MSEd., Practice Facilitator
Miriam Sheehey, RN, Practice Facilitator
Facilitating Primary Care Practice
Transformation
Blueprint Expansion
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Legislative mandate (Act 128)
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Vermont Act 128 of 2010 requires Commissioner of Vermont
Health Access to expand the Blueprint for Health to at least two
primary care practices in very hospital service area no later
than July 1, 2011 and no later than October 1, 2013 to primary
care practices statewide whose owners wish to participate (Multipayer Advanced Primary Care Practice Demonstration Project application, 8/11/2010)
Facilitating Primary Care Practice
Transformation
Blueprint Expansion
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545 physicians and 239 APRNs, CNMs and PA-Cs
in 220 primary care practices in Vermont
12 practice facilitators deployed throughout state
with “caseload” of 4-10 practices each; work with
practice 6-12 months
46 practices scored in last 12 months since
facilitators began work in 11/10.
Adding approximately 6 practices per month to those
recognized as patient-centered medical homes;
another 90 practices are scheduled to be
scored/recognized in 2012. (Multi-payer Advanced Primary Care Practice
Demonstration Project application, 8/11/2010)
Facilitating Primary Care Practice
Transformation
Blueprint Assumptions/Principles
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Advanced Model of Primary Care can result in better
health outcomes and reduced expenses for costly ED
and hospital visits
Foundation of primary care is a long-term relationship
with one provider (for continuity and consistency)
Team-based approach to primary care utilizes all team
members in a patient-centered approach, engaging
patient to participate and/or direct his/her care (selfmanagement)
Facilitating Primary Care Practice
Transformation
Blueprint Assumptions/Principles
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Managing a panel or population of patients is an
organized, systematic approach to primary care
that measures success:
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Process measures (eg Asthma panel: # patients who do
not have an asthma action plan)
Outcomes measures (eg Asthma panel: # patients who
had ED visit in a defined time period)
“Care gaps” are addressed by improving processes for
care
Facilitating Primary Care Practice
Transformation
CHANGE
“It is not the strongest of the species that survives, nor the most
intelligent that survives, it is the one that is the most adaptable to
change.”
Charles Darwin
Facilitating Primary Care Practice
Transformation
Characteristics of effective change
champions
Responsive to data
Encourage open exchange of ideas
Not always the “expert” – ask for help
Organized
Available/visible
Action-oriented
Approachable
Reliable
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Source: HealthTeamWorks
Facilitating Primary Care Practice
Transformation
Statewide revolution of grass-roots,
local process improvement work
Small businesses
 Small staff
 Small/No budget
 Big ambition
 Huge commitment
 Spectacular results
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Facilitating Primary Care Practice
Transformation
Facilitator role is an opportunity to be part of this “moment in
time,” “grand experiment”
Challenge/opportunity requires:
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Commitment to making primary care better for all Vermonters
High tolerance for ambiguity
Confidence and humility (insight to know when to show which)
Generosity and team spirit (share everything you know and do with
everyone!)
Sense of humor
Facilitating Primary Care Practice
Transformation
What do we do?
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Assess the practice
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Clinical microsystems – how does the system work?
 Visit cycle time
 Through the Eyes of Patients
 Patient Satisfaction
 Staff Satisfaction
 Core process assessment
Facilitating Primary Care Practice
Transformation
Assess the practice
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NCQA Standards
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Access and Continuity
Panel Management
Focus on chronic conditions important to practice
 Evidenced-based guidelines
 Self-management
Test/referral tracking and follow-up
Coordination of care/transitions
Performance Improvement/measurement
Facilitating Primary Care Practice
Transformation
What do we do?
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Identify gaps
Facilitating Primary Care Practice
Transformation
What do we do?
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Plan improvements
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Access
Data integrity
Care coordination
Panel/population management
Self-management
Facilitating Primary Care Practice
Transformation
What do we do?
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Examples of improvements
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Evidence-based guidelines in EHR visit templates –
improved adherence to guidelines
Panel management improvements:
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Mammograms
Hgb A1Cs for patients with diabetes
Installation of kiosk for registration to free up time staff
time for telephones
Facilitating Primary Care Practice
Transformation
What do we do?
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Measure success
Waterbury Medical Associates
Goal: to increase the % of diabetic patients with
documented data on 4 core variables to 85% during
the pilot period
The Intervention:
• Decision to measure heights on all patients at nonacute visits
•Review documentation rules (where each measure
should be documented in the EMR)
•Patient “flow sheet” printed out for all patients with a dx
of diabetes the evening before the visit for the provider to
review. The flow sheet contains longitudinal data from
the last 5 visits
Waterbury Medical Associates
Results
Provider 1: Phase I
(n=10)
Provider 2: Phase II
(n=15)
St. Albans Primary Care
Kiosk check-in Improvement Plan
AIM:
Free up one front desk person to focus on timely answering
of phones so as to put patients/callers on hold less. Kiosk installed
for patients to use to check in independently so that one less
person is needed to at front desk.
St. Albans Primary Care
Kiosk check-in Improvement Plan
Results
St. Albans Primary Care
Kiosk check-in Improvement Plan
Results
Facilitating Primary Care Practice
Transformation
Where do we work?
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Hospital-owned practices
Facilitating Primary Care Practice
Transformation
Where do we work?
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Small, independent practices
Facilitating Primary Care Practice
Transformation
Where do we work?
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Federally-qualified health centers
Facilitating Primary Care Practice
Transformation
Where do we work?
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Multi-practice corporations with sites throughout
state
Facilitating Primary Care Practice
Transformation
Nursing skills required:
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Knowledge of evidenced-based guidelines
Understanding of IT and how EHRs work
Data management
Creativity/ingenuity
Are practice facilitators making a difference?
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Sustainability – building capacity in practices
What is the future role for facilitators?
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Consultant to primary care practices for ongoing process
improvement support
Support future Blueprint Expansion
Thank you!