PCMH: FOCUS ON
THE CARE TEAM &
HUDDLES
Session 2 July 18, 2014
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Quick Review of NEW
2014 PCMH Standard
on Team Based Care
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Quick Review PCMH:
What is it?
• A care model that focuses on the primary care
practitioner (PCP) directed coordination of care
• PCP coordinates a multidisciplinary team, takes
responsibility for the care provided to the patient, and
tracks care over time and across settings, including with
other practitioners
• Organizes care around a patient’s unique needs
• Improves quality, patient experience and reduces total
costs
• Focus on prevention & managing chronic conditions
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Goal of PCMH
High Quality Care
Increased Patient Satisfaction
Increased Staff Satisfaction
Eliminate gaps in care
Reduced Costs
National Recognition
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PCMH 2 – Team Based Care
Element A Continuity
Element B Medical Home Responsibilities
Element C
(CLAS)
Culturally and Linguistically Appropriate Services
Element D The Practice Team
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Element D
Factor Number
1 Defining roles for
clinical &
nonclinical team
members.
2 Identifying the
team structure &
the staff who lead
& sustain team
based care.
Documentation
Explanation
Job roles & responsibilities
emphasize a team-based
approach to care & support each
member of the team being
trained to meet the highest level
of function allowed by state law.
NCQA reviews dated
descriptions of staff positions
or policies & procedures
describing staff roles &
functions. The practice may
provide an organizational
chart or description of the
team structure & team
members.
The practice delineates
responsibilities for sustaining teambased care, & specifies how care
teams align to provide patientcentered care. Specific team units
may focus on providing care
coordination across & beyond the
practice (factor 5). An organizational
chart may be used to illustrate how a
care team fits in the practice.
NCQA reviews an overview of
the staffing structure for
team-based care.
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Element D Factor
Number
Explanation
Documentation
Critical factor
3 Holding scheduled
patient care team
meetings or a
structured
communication
process focused on
individual patient
care.
Team meetings may be informal daily
meetings or review daily schedules,
with follow-up tasks. A structured
communication process may include
regular e-mail exchanges, tasks or
messages about a patient in the
medical record and how the clinician or
team leader is engaged in the
communication structure.
NCQA reviews the practice’s
documented process for
structured communication
between the clinician and other
care team members, which states
the frequency of communication;
and reviews at least three samples
of meeting summaries, checklists,
appointment notes or chart notes
for evidence that the practice
follows its process.
4 Using standing
Standing orders (e.g., testing
protocols, defined triggers for
prescription orders, medication refills,
vaccinations, routine preventive
services) may be clinician preapproved
or may be executed without prior
approval of the clinician, as permitted
by state law.
NCQA reviews at least one
example of written standing
orders.
orders for services.
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Element D Factor
Number
Explanation
Documentation
5 Training and assigning
members of the care team
to coordinate care for
individual patients.
Care coordination may
include obtaining test and
referral results and
communicating with
community organizations,
health plans, facilities and
specialists
NCQA reviews dated
descriptions of staff
positions or policies and
procedures describing staff
roles and functions. The
practice may provide an
organizational chart or
description of the team
structure and team
members.
6 Training & assigning
members of the care team
to support patients/families/
caregivers in selfmanagement, self-efficacy
& behavior change.
Care team members are
trained in evidence-based
approaches to selfmanagement support, such
as patient coaching and
motivational interviewing.
Same as above
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Element D
Factor Number
7 Training and
assigning
members of the
care team to
manage the
patient
population.
Explanation
Documentation
Care team members are trained in
managing the patient population &
addressing needs of patients &
families proactively. Population
management assesses & manages
the health needs of a patient
population, such as defined groups of
patients (e.g., patients with specific
clinical conditions such as
hypertension or diabetes, patients
needing tests such as mammograms
or immunizations).
NCQA reviews dated
descriptions of staff positions
or policies & procedures
describing staff roles &
functions. The practice may
provide an organizational
chart or description of the
team structure & team
members.
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Element D
Factor Number
Explanation
Documentation
8 Holding
scheduled team
meetings to
address practice
functioning.
The practice holds scheduled team
meetings routinely to improve care
for all patients (factor 3 addresses
care of specific patients). Meetings
include clinical staff (e.g., MDs &
RNPs) & nonclinical staff. The purpose
of these meetings is to discuss
practice & staff functions —what is
working well & what may need
improvement. E.g., there could be an
ongoing discussion about staff roles &
responsibilities, performance
measurement data & related quality
improvement efforts, team member
training & areas for improvement.
Meeting frequency can vary (e.g.,
monthly, bimonthly, quarterly) but
are part of the practice’s routine
operations.
NCQA reviews a description
of team meetings, the
frequency of these meetings
& at least one example of
meeting minutes, agendas or
staff memos.
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Element D
Factor Number
Explanation
Documentation
9 Involving care
team staff in the
practice’s
performance
evaluation and
quality improvement
activities.
The practice has a documented process
for quality improvement activities that
includes a description of staff roles and
involvement in the performance
evaluation and improvement process.
The care team receives performance
measurement and patient survey data to
identify areas and methods for quality
improvement. The team may participate
in regular quality improvement meetings
or in action plan development.
NCQA reviews the practice’s
documented process for quality
improvement.
10 Involving
patients/families/
caregivers in quality
improvement
activities or on the
practice’s advisory
council.
The practice has a process for involving
patients and their families in its quality
improvement efforts. At a minimum, the
process specifies how patients and
families are selected, their role on the
quality improvement team and the
frequency of team meetings.
NCQA reviews the
organization’s documented
process for involving
patients/families/caregivers in
QI teams or on an advisory
council (e.g. meeting notes,
agenda, committee structure)
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VIDEOS
Cedars-Sinai proprietary DVD on PCMH
https://www.youtube.com/watch?v=Wttxm7jAnb4
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CARE TEAM ROLES
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Definition of a Care Team
A care team is a small group of clinical and non-clinical
staff who, together with a provider, are responsible for
the health and well-being of a panel* of patients.
Who is on the care team and their specific roles will vary
based on patient needs and practice organization.
* NOTE: EMPANELMENT is a precursor for teams – teams must be
informed about the set of patients for whom they are responsible!
http://www.safetynetmedicalhome.org/change-concepts/continuous-team-basedhealing-relationships
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Care Team Roles
Core Team
Provider/Team Leader & Medical Assistant
Responsible for most care & care coordination
Other Team Members may include:
LVN/RN
Care Coordinator who’s role is to oversee the medical assistants, care managers for panels
of high-risk patients, performing health coaching and connecting patients with
information and resources
Appointment staff
Referral Coordinator
Receptionist
Behavioral Health Specialist
Nutritionist/ Patient Educator
Pharmacist
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Basics Needed
• Standardized Protocols/Evidence Based Guidelines
• Easily Accessible
• Clear Expectations
• Respectful Work Place
• Staff & Patients
• Time Management
• Appropriate Training to Optimize Scope of Practice
• Optimal Utilization of EHR to Enhance Patient Centered
Care
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Rewards
• Increased efficiency
• Increased staff satisfaction -> retention
• Increased patient satisfaction -> retention
• Role expansion – seen as a team by the patient
• Fewer gaps in care
• Receptionist/Appt staff ask about Urgent Care or ED visits and
obtains records where appropriate
• Providers talk with referral specialty physicians
• Incentivize & acknowledge improvements & goal
achievement
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JOB DESCRIPTIONS
AND SCOPE OF
PRACTICE
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Medical Assistant
Unlicensed individuals
Perform non-invasive routine technical support services under
the supervision of a licensed physician and surgeon, podiatrist,
physician assistant, nurse practitioner, or nurse midwife in a
medical office or clinic setting
The supervisor must be on the premises in order for the medical
assistant to perform those non-invasive technical support
services
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Medical Assistant, cont.
 Medical assistants may obtain "certified" status through
private agencies approved by the Medical Board of
California
 A list of "Frequently Asked Questions" addressing the
appropriate training, supervision, and scope of practice
issues:
http://www.mbc.ca.gov/Licensees/Physicians_and_Surg
eons/Medical_Assistants/
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Medical Assistant Training
The California Business and Professions Code Medical Practice Act outlines
laws related to medical assistance practice as well as minimum
requirements for training institutions to establish accreditation and
graduate students.
Administer Injections
10 hours Training
IM, SQ, ID
10 demonstrations of each, dose checked by
Provider
Perform Venipuncture
10 hours training & 10 demonstrations
Administer Inhalation Therapy
10 hours training & 10 demonstrations
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Training Topics
• Anatomy & Physiology related to Procedure
• Proper Sterile Technique
• Hazards & Complications
• Patient Care following test/procedure
• Awareness of emergency procedures
• Capacity to choose appropriate equipment
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General MA Job Description
Perform administrative and certain clinical duties under
the direction of physician/Health Care Provider.
Administrative duties may include
• scheduling appointments,
• maintaining medical records,
• billing, and coding for insurance purposes.
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Summary of Clinical Duties
Obtaining patient history and vital signs such as blood
pressure, pulse, height and weight
• Preparing & maintaining examination and treatment areas
• Preparing patients for examination
• Assisting with procedures and treatments
• Preparing and administering medications and
immunizations
• Recognizing and responding to emergencies
• Screening and following up on patient test results
• Collecting and processing specimens for diagnostic tests
•
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Care Manager Job Description
LVN Care Manager : Ensuring the accurate documentation of patient care
activity, maintaining a quality standard of care, anticipating daily workload,
prioritizing activities, and coordinating the workload of other employees.
Provides patient care to patients ranging in age from infancy to geriatric
Assists physicians with examinations and diagnostic testing
Maintains appropriately stocked work areas
Completes special projects or other duties as assigned
Registered Nurse Case Manager participates in all phases of the Case
Management Program (CMP) and ensure that the CMP meets established case
management (CM) standards of care. Assist in coordinating a multidisciplinary
team to meet the health care needs, including medical and/or psychosocial
management, of specified patients.
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Care Manager Job Description, cont.
• Serve as consultant to all disciplines regarding CM issues. Provide nursing
expertise about the CM process, including assessment, planning,
implementation, coordination, and monitoring. Identify opportunities for
CM and identify and integrate local CM processes.
• Develop and implement local strategies using inpatient, outpatient, onsite
and telephonic CM; develop and implement policies and protocols for
home health assessments and outcome measures.
• Develop and implement tools to support case management, such as those
used for patient identification and patient assessment, clinical practice
guidelines, algorithms, CM software, databases for community resources,
etc.
• Integrate CM and utilization management (UM) and integrate nursing case
management with social work case management. Prepare routine reports
and conduct analyses.
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Care Manager Job Description, cont.
• Assist in establishing and maintaining liaison with appropriate
community agencies and organizations.
• Maintain adherence to JCAHO, URAC, CMSA and other regulatory
requirements. Apply medical care criteria (e.g., InterQual).
• Ensure accurate collection and input of patient care data and
ensure basic CM budgetary management.
• Provide input on hospital's CM resources and make
recommendations to the Command as to how those resources can
best be utilized.
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Care Manager Job Description, cont.
• Collaborate with the multidisciplinary team members to set patient-
specific goals. Develop treatment plans including preventive, therapeutic,
rehabilitative, psychosocial, and clinical interventions to ensure continuity
of care toward the goal of optimal wellness.
• Establish and implement mechanisms to ensure proper implementation of
patient treatment plan and follow-up post discharge in ambulatory and
community health care settings.
• Provide nursing advice and consultation in person and via telephone.
• Ensure appropriate health care instruction to patient and/or caregivers
based on identified learning needs.
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Care Manager Job Description, cont.
• Alert physicians to significant changes or abnormalities in patients and
provide information concerning their relevant condition, medical history
and specialized treatment plan or protocol.
• Facilitate multidisciplinary discharge planning and other professional staff
meetings as indicated for complex patient cases and develop a database
and knowledge of local community resources.
• Develop and implement mechanisms to evaluate the patient, family and
provider satisfaction and use of resources and services in a qualityconscious, cost-effective manner.
• Implement strategies to ensure smooth transition and continued health
care treatment for patients. Develop a policy for, and assist with,
relocation/change of health plan.
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Care Manager Job Description, cont.
• Plan for professional growth and development as related to the
case manager position and maintenance of CM certification.
• Establish cost containment/cost avoidance strategies for case
management and develop mechanisms to measure its cost
effectiveness.
• Assist with the Electronic Health Record
and interface or other
database designed to support CM.
• Participate in video teleconferences and other meetings as
required.
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Other Team Members
• Appointment Staff:
Training on pt. centered care, appt. preps,
checking on UC or ED visits, appointment reminders, language
services, using EHR to communicate
• Receptionists:
Training on pt. centered care, optimizing flow,
checking on Urgent Care or ED appointments, & appointment prep
(blood draw? See Social Worker first?)
• Social Worker/Nutritionists/ Referral Coordinator:
Part of team,
Recommendations, Communication!
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Scope of Practice
• Primarily an issue for the MA
• Most MAs won’t know their scope of practice
• Want to please, want to help
• Experience in private offices, on-the-job skills
• Need to ensure are trained and comfortable with
procedures
• Return demonstrations
• Orientation period for new employees
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Scope of Practice
Check FAQs on California Medical Association website
• Can only give medications after verification by a physician,
podiatrist or another appropriate licensed person.
•
http://www.mbc.ca.gov/Licensees/Physicians_and_Surgeons/Medical_As
sistants/Medical_Assistants_FAQ.aspx#2
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Can medical assistants be supervised by a nurse
practitioner, nurse midwife, or physicians assistant in
the absence of a physician and surgeon?
Per Business and Professions Code section 2069 (a)(1), a
supervising physician and surgeon at a "community clinic"
licensed under Health and Safety Code section 1204(a)
may, at his or her discretion, in consultation with the nurse
practitioner, nurse midwife, or physician assistant provide
written instructions to be followed by a medical assistant in
the performance of tasks or supportive services. The written
instructions may provide that the supervisory function for
the medical assistant in performing these tasks or
supportive services may be delegated to the nurse
practitioner, nurse midwife, or physician assistant and that
those tasks may be performed when the supervising
physician and surgeon is not on site.
http://www.mbc.ca.gov/Licensees/Physicians_and_Surgeons/Medical_Assistants/Me
dical_Assistants_FAQ.aspx#2
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What isn’t within the MA Scope?
• Invasive Procedures
• Cannot insert urinary catheters
• Assessments/Triage
• Check pupillary response
• Cannot read, interpret or diagnose symptoms or test results
• No phone triage
• Cannot apply splints, casts, or other external devices,
but can remove them if trained
• Cannot interpret skin test results
• But can measure and describe the test reaction and make a
record in the patient's chart
• Cannot call in new prescriptions or prescription changes
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LVN Scope of Practice
• The licensure and practice of vocational nurses is authorized by the
California Business and Professions Code and regulated by the Board of
Vocational Nurse and Psychiatric Technicians (BVNPT).
• The LVN must practice under the direction of a licensed physician or
Registered Nurse (RN) at all times. Such direction may be provided
verbally, telephonically, or by written order.
• The LVN may assist in the collection of data during the assessment
process. VALIDATION of assessment data, however, must be done by
the RN.
• The LVN may perform that part of the triage process that includes
interview, observation, the collection of subjective and objective data,
and the recognition of problems or abnormal conditions specific to the
patient
• Perform lifesaving nursing procedures. Such procedures include basic
CPR and management of assaultive behavior
http://www.cphcs.ca.gov/docs/imspp/imspp-v05-ch05.pdf
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What Can’t the LVN Do?
• May not independently determine or initiate a course of
clinical action.
• May not administer intravenous medications
• May not dispense medications
• Dispensing medication is defined as the interpretation of a
physician’s order for a drug and the proper selection, measuring,
packaging, labeling, or in any way filling a prescription for a
patient. This includes counting stock medications, placing them in
a container with the patient name and issuing the medication to
the patient.
• May not perform that part of the triage process that
includes independent evaluation, interpretation of data,
and determination of treatment priorities and levels of
care.
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BREAK!
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Huddle/Patient Care Team
Meeting P&P Review
• Policy: Team Huddle
• Purpose
• Procedure
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Overall High Level Workflow
Pre-Visit
Patient makes
appointment
Patient receives
reminder call (auto)
Chart Prep
• Chart Review
• List of Huddle
discussion
items
• List of followup items
Chart Prep
and
Huddle
Worksheet
Xxxx
Xxx
Xxx
Xxx
Xxx
xxx
Huddle
• Provider
direction /
decisions
• List of followup items
• List of intake
orders, tags,
activities
Visit
Patient receives
call for X
Follow-up as needed
• Reschedule / call
patient
• Ensure equipment,
supplies, forms
• Other f/u activities
Xxxx
Xxx
Xxx
Xxx
Xxx
xxx
Patient arrives
Registration
• Consents
• Forms
Rooming
Sheet
Intake
• Intake Activities
• Post Tags as needed
• Pend orders
• Notes on Rooming Sheet
• Shred Chart Prep Sheet
Order:
Xxx
Xxx
Tag:
Xxx
Other:
xx
Patient
Patient Service Representative
Medical Assistant /LVN
Physician
Patient leaves
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Physician Visit
• Review pended orders
• Review tagged items
• Usual care processes
• Ensure AVS information
Out Processing
• Appointments
• Referrals
Xxxx Order:
Xxx Xxx
Xxx Xxx
Xxx Tag:
Xxx Xxx
xxx Other:
xx
Rooming
Sheet
xxx
xxx
Discharge
• Check and process orders
• Complete documentation
• AVS
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Chart Prep Grid Example – General Preparation for all patients
scheduled to see a physician
Activity /
Purpose
Workstep / Criteria
Next Step / Huddle Activity
Schedule
Check
• Compare schedule to
reason for visit and
notes to ensure patient
on correct schedule
• If a mismatch, discuss in huddle so PSR can change if patient not on
correct schedule (Physician or Clinical Support)
Reason for
Visit
• Review the Visit Type
Area on the Schedule
• Review the PCP’s Last
Progress Note if
needed
• Plan to prepare Exam
Room based upon the
Reason for Visit
• Pre-op (note or appointment type)
• Access orders during huddle
• If order includes EKG, Chest X-ray , labs, note what is due based on
specific orders
• During huddle, MD determines which pre-op tasks are needed
• If EKG ordered, make sure there is paper in machine, gel, patches
available
• Physical – ask which labs will probably be needed
• Follow-up from recent Urgent Care, ED Visit or Hospitalization – note
date of discharge and reason. Check for report In huddle, notify MD of
discharge or visit .
• Clear for work, DMV or other visit where a form is needed (notes). Ask
PSR to fill out demographics, MA/LVN to fill out as appropriate, attach
to Huddle list for MD signature
• Pap (notes) – ensure supplies / equipment available and plan for set-up
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Intake (as
needed)
• Complete EKG
• Pend orders
*Tag visit report
• Attach form to
Rooming Sheet
for signature
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Name: __________________________________
MRN: _______________
DOB: _______________
Gender:  Male  Female Age: ____________
Chart Preparation-Huddle-Task Form for MA
Appointment Date and Time: ____________________
Date of last physical exam: _______________
CHART REVIEW
Schedule check
Any outstanding: (since last visit)
Procedures
Yes
No
Labs
Yes
No
Pathology
Yes
No
Imaging
Yes
No
Cardiology
Yes
No
Referrals
Yes
No
Future/standing orders Yes No
HUDDLE
Reason for visit: _____________
Need for schedule change?
What is outstanding?
(Procedures, labs, pathology,
imaging, cardiology, other
orders, referrals, future or
standing orders)
(Date/result)
LDL __________, __________
Syncope history
What would you like to order?
Labs/Imaging:
CBC CMP
TSH Vit D
Lipid Panel
EKG Xray
Others: _____________________
Referrals:
Due:
Diabetes
Yes* No
Hgb A1C __________, __________
INTAKE TASKS
Hgb A1C (Lab5626 or POC4)
Lipid Panel (Lab18)
Microalbumin/Creatinine Ratio
(289438)
Ophthalmology Referral (Ref57)
Monofilament Foot Exam (HM7)
(Date/result)
Microalb/Crea Ratio __________, _________
(Date/result)
Retinal Exam _________ (Date)
Monofilament foot exam
__________ (Date)
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Chart Prep Form (side 2)
Health Maintenance
Needs:
Referral(s):
 Colonoscopy _______________ (Date)
 Colonoscopy (REF5023)
 Bone Density (Dexa) _______________ (Date)
 Bone Density—Dexa (IMG1153)
 Mammogram _______________ (Date)
 LDL Direct/Lipid Panel __________, __________ (Date/result)
 Mammogram (IMG1965 or IMG1283)
Screening Diagnostic
 LDL Direct (Lab102)
 Lipid Panel (Lab18)
 Persistent Medications
 Potassium _________, _______ (Date/result)
 BUN _________, _______ (Date/result)
 Creatinine _________, _______ (Date/result)
 Persistent Medications
 Potassium (Lab114)
 BUN (Lab140)
 Creatinine (Lab66)
 PSA _______________, ________ (Date/result)
 PSA
 PAP _______________ (Date)
 PAP
 GC/Chlamydia _______________ (Date)
 GC/Chlamydia
 BMP (Lab15)
 CMP (Lab17)
Immunizations
 Flu _______________ (Date)
 Flu
 TDaP _______________ (Date)
 TDaP
 Pneumovax _______________ (Date)
 Pneumovax
 Zoster _______________ (Date)
 Zoster
 Gardasil _______________ (Date)
 Gardasil
Revised 03.23.2011
WS
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Successful Huddles/Patient Care Team
Meetings
•
Huddle (Patient Care Team Meetings) standing Agenda Items
1.
2.
3.
4.
5.
6.
MA: Specific items/ questions from chart prep
Receptionist (R): Appointment related discussion items – i.e. changing appointments,
fasting for physicals
MA, R: Outstanding patient calls/messages
MA: Any referral question
R: Any opportunities for double booking/ working in walk-in’s
Care Manager: Outstanding patient issues / questions
•
Ask for clear direction and specific orders, confirm understanding
•
Summarize after each patient
•
Receptionist may have some follow-up such as changing appointment type
or calling patients
•
Consider having a team weekly debrief when starting huddles to discuss
what works, what doesn’t, and refine process
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Documenting Huddles/Pt. Care
Team Meetings
• Policy and Procedure
• Save prep sheets examples
• Document in EHR
(pt discussed in huddle - to have lab
work prior to appt.)
• Keep copies of huddle schedule
• Keep minutes of meetings where operation of huddles
is discussed and refined
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Documenting Huddles/Pt. Care
Team Meetings
NCQA reviews the practice’s documented process for structured
communication between the clinician and other care team
members, which states the frequency of communication; and
reviews at least three samples of meeting summaries, checklists,
appointment notes or chart notes for evidence that the practice
follows its process.
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Huddle Schedule Example
Monday
Tuesday
Wednesday
15 minutes prior
to start of AM
clinic- Win
Thursday
Friday
9:45 Ho
12:30/12:45
Smith, MD
12:30 Ong, RNP
12:30
Mawashiri.
PA(for Wed
pts.)
12:30/12:45
Smith, MD
12:30 Ong
11:45 Ho
11:45 Ruiz
12:30/12:45
Smith, MD
12:30 Ong
12:30 Mawashiri
(for Thurs. pts.)
15 min. prior to
start of PM
clinic Win
4:30 (for Wed)
Ruiz
4:30 Ho
4:45 James
End of Day (for
Thurs) Ruiz
4:45 James
4:45 James
12:30/12:45
Smith, MD
12:30 Ong
12:30 Mawashiri
(for Mon. pts)
15 minutes prior
to start of PM
clinic- Win
4:30 Ruiz
4:45 James
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Q&A
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Thank you!
Susan Chen: schen@greenconsultinggroup.net
Susan Green: sgreen@greenconsultinggroup.net
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