Session D3
October 28, 2011
3:30-4:15 PM
How Far Will the Rubber Band
Stretch?
Implementing New Clinical and
Operational Concepts without
Additional Resources
Samantha Pelican Monson, PsyD, Clinical Psychologist
Cheryl Palsic, BSN, RN-BC, Family Practice Nurse
Lauren Gray, DO, Family Medicine Chief Resident
Collaborative Family Healthcare Association 13th Annual Conference
October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.
Faculty Disclosure
We have not had any relevant financial
relationships during the past 12 months.
Need/Practice Gap &
Supporting Resources
Already strapped healthcare delivery systems are
repeatedly expected to implement new cutting
edge concepts without additional resources.
But how???
Objective
Process discussions (such as this presentation) can
promote the creativity required to meet
implementation expectations without additional
resources.
Expected Outcome
You will leave with new implementation ideas for
your respective healthcare delivery systems.
Learning Assessment
As we share our process with you, we’ll be
soliciting your thoughts about how it could
inform your implementation approach.
Session Agenda
• Introduction/Orientation
• What Stretched our Rubber Band?
– Engaging Stakeholders
– Re-visioning of Systemic Opportunities
– “One Step at a Time” Approach
• Future Directions
• Questions/Discussion
Our Healthcare Delivery System
• Denver’s public safety-net hospital
Community Health Services
(CHS)
• 8 FQHCs
• 355,000+ patient visits/year
• 20,000+ patient
visits/year
• Relationship with state
refugee clinic
• 4-2-2 family medicine
residency
Our Practice’s New Concept
Our Practice’s Primary
Implementation Processes
• Division of practice into two clinical teams
• Establishment of two quality improvement (QI)
teams
• Identification of three clinically important
conditions:
– Diabetes
– Hypertension
– Asthma
Our Clinical/QI Team
• Green Team
• 3-4 Medical Providers (F-NP , MD, and DO)
• 3 Residents
• 1 Behavioral Health Provider
• 1 RN
• 3 Medical Assistants
• Part-time Patient Navigator
• 2 Clerks
• Diabetes as designated clinically important
condition
Our “Diabetes Clinic”
• ½ day per month
• Patients = identified as uncontrolled (from
registry and intra-clinic referrals)
• Medical Provider = initially attending with most
diabetic patients, later expanded to resident
• Behavioral health (psychologist) and diabetes
education (RN) follow medical provider
• Lab work completed ahead of time
• Emphasis on patient self-management
Session Agenda
• Introduction/Orientation
• What Stretched our Rubber Band?
– Engaging Stakeholders
– Re-visioning of Systemic Opportunities
– “One Step at a Time” Approach
• Future Directions
• Questions/Discussion
Our Stakeholders
• Lowry Family Health Center
–
–
–
–
Support Staff
Clinical Providers
Residents
Patients
• Community Health Services
– Leadership Team
Who are your stakeholders?
Development Opportunities
• HealthTeamWorks training
• How to run an effective meeting
• Group facilitation skills
• QI processes & tools
• Motivational interviewing training for all staff and
providers
• RN joined multidisciplinary Denver Health
Diabetes Collaborative
What community/institutional programs might you access?
Fostering New Leaders
• Medical Director and Practice Manager
supported RN in becoming leader of Green
Team
Who in your practice has untapped leadership potential?
Sharing the Vision
• Clinically important conditions identified
through survey of all staff and providers
• Clinical and QI teams responsible for own plans
• All team members have a role in accomplishing
the most important goals
– Patient self-management
– Integrated behavioral healthcare
– Clinical outcomes
How can you promote universal ownership?
Individual Perks
• RN involvement allowed for promotion up her
professional ladder and diversification of job
duties
• Resident involvement fit with self-identified
learning objectives
What individual rewards exist in your organization?
Session Agenda
• Introduction/Orientation
• What Stretched our Rubber Band?
– Engaging Stakeholders
– Re-visioning of Systemic Opportunities
– “One Step at a Time” Approach
• Future Directions
• Questions/Discussion
Alignment with Residency
• P4 Program (Preparing the Personal Physician
for Practice)
• Long-standing behavioral
science curriculum
What programs within your system could be leveraged?
Capitalizing on Culture
• Denver Health’s commitment to Lean Systems
Improvement made QI process intuitive
• Minimal external behavioral health resources
made the clinic “hungry” for integration
How can you join instead of change the culture?
Balancing Costs and Benefits
• Absence of reimbursement for team-based care
offset by institutional benefit
• Collaborative care helpful for
Magnet designation
• Staff and provider time justified by institutional
initiative
• Denver Health was seeking PCMH National
Committee for Quality Assurance (NCQA)
recognition
How could your institution benefit from your project?
Creation of Work-Arounds
• Registry limitations were supplemented by
development of a spreadsheet
• Job duty re-allocation allowed for staff to
practice “at top of license” on project
components
• Turn-over of and time restrictions on patient
navigator position addressed by RN vigilance
How could your system flex around its limitations?
Session Agenda
• Introduction/Orientation
• What Stretched our Rubber Band?
– Engaging Stakeholders
– Re-visioning of Systemic Opportunities
– “One Step at a Time” Approach
• Future Directions
• Questions/Discussion
Start Small
• Diabetes clinic began with only eight patients
per month
• Anecdotal clinical improvement celebrated
• Patient feedback highly valued
• “I don’t know what it was, but something clicked in
me after you all were askin’ me how I was gonna
take care of myself. I’ve totally changed how I eat,
and my daughter’s helpin’ me!”
Around what small changes could your system build
momentum?
Be Flexible
• Regular meetings and huddles allowed for timely
problem-solving
• Resident allowed to participate in diabetes QI
processes and clinical initiatives
What areas of rigidity in your system could be
re-considered?
Session Agenda
• Introduction/Orientation
• What Stretched our Rubber Band?
– Engaging Stakeholders
– Re-visioning of Systemic Opportunities
– “One Step at a Time” Approach
• Future Directions
• Questions/Discussion
Onward!
• Applying diabetes clinic principles to standard
patient care
• Broadening care focus (e.g., vision and podiatry)
• Making diabetes education more interactive
• Increasing resident involvement
• Impacting future generations of providers
What’s in your future?
Session Agenda
• Introduction/Orientation
• What Stretched our Rubber Band?
– Engaging Stakeholders
– Re-visioning of Systemic Opportunities
– “One Step at a Time” Approach
• Future Directions
• Questions/Discussion
Questions/Discussion
Session Evaluation
Please complete and return the
evaluation form to the classroom monitor
before leaving this session.
Thank you!