Delivery System Design
Cory Sevin RN, MSN, NP
Nancy Gilliam
Anaheim, California
February 12, 2005
HDC Learning Session 1 2005
© 2004 Institute for Healthcare Improvement
Goal of the Session
For you all to be excited to go home and
test breakthrough changes in how
your care processes are designed!
© 2004 Institute for Healthcare Improvement
Chronic Care Model
Community
Resources and Policies
SelfManagement
Support
Informed,
Activated
Patient
Health System
Health Care Organization
Delivery
System
Design
Productive
Interactions
Decision
Support
You
are
here
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
Functional and Clinical Outcomes
© 2004 Institute for Healthcare Improvement
Our systems are not designed to
get quality outcomes in anything
other than acute care.
• We know that many
patients do not receive
evidence based care
and do not feel listened
to
• We know that patients
are often not active
participants in their care
• We know that many
health care providers
and staff are working
very hard
© 2004 Institute for Healthcare Improvement
Observation of organizations making
breakthrough outcomes shows they
have……
• Clearly identified
care teams for
patients
• Clear roles for all
team members
• Continuity
• Cleared system of
chaos and waste
© 2004 Institute for Healthcare Improvement
To Improve Outcomes:
• Patients must be prescribed and taking proven
therapies
• Patients must be managing their illness well
• Patient course must be followed for changes in
status and reinforcement
• Interactions must be productive
• I believe, health care workers must enjoy and
get satisfaction out of what they do every day
• Our systems of care must be efficient and
effective.
© 2004 Institute for Healthcare Improvement
How would I recognize a
productive interaction?
Informed,
Activated
Patient
Productive
Interactions
Prepared
Practice
Team
•Assessment of self-management skills and
confidence as well as clinical status
•Tailoring of clinical management by stepped
protocol
•Collaborative goal-setting and problem-solving
resulting in a shared care plan
•Active, sustained follow-up
© 2004 Institute for Healthcare Improvement
Delivery System Design
Key Leverage Points!
• Define roles and distribute tasks amongst team
members.
• Use planned interactions to support evidencebased care.
• Provide clinical case management services.
• Ensure regular follow-up.
• Give care that patients understand and that fits
their culture
© 2004 Institute for Healthcare Improvement
Leverage Point 1
Define roles and tasks
All team members have a role.
© 2004 Institute for Healthcare Improvement
Define Roles and Tasks
• Team development: is there an identified team
for each patient?
• Are all clinic staff seen as being on the team?
• Review process for care: who is doing what?
• Is this the best use of their time?
• Assign tasks, matching licensure and skills.
• Cross train staff
• Use protocols and standing orders
© 2004 Institute for Healthcare Improvement
Reduce Chaos and Waste to
create resources for planned care
• Create processes so that the patient, provider,
information, room and equipment are ready at the
same time.
• Providers do provider work and everything else gets
done by others
• Predict and anticipate needs:know your slow and
busy seasons, have plans for repeat tasks like school
physicals, etc.
• Subtract unnecessary work
• Optimize rooms and equipment: standardize
© 2004 Institute for Healthcare Improvement
Examples: Roles and Tasks
Ensuring follow-up for depression patients
• Providers (both PCPs and BHCs) place red “dots” on
medical record for patients they place into the
collaborative
• Medical Records staff identifies collaborative patients
based on the red “dots” and places blank PECS
encounter notes on the chart when a follow-up has
been scheduled
•
Nursing staff identifies collaborative patient and checks
for lapsed appointments and informs providers
• BHC either sees patients as a walk-in or schedules
follow-up appointment while patient is in the clinic
© 2004 Institute for Healthcare Improvement
Roles in Team Care
To ensure follow-up appointments are scheduled:
Role
PCP
BHC Nursing Clerical Dec
Supp
Identify pts for Collab
X
X
Screen pts for Depression
X
X
Provide pt care
X
X
X
Produce report for patients
needing follow-up
Schedule follow-up appts
X
X
© 2004 Institute for Healthcare Improvement
Test Roles and Tasks
PDSA
• PDSA the MA doing
LEAP exams
A P
• PDSA MA’s filling out
forms
• PDSA the nurse calling
back about some lab
results
S D
A P
S D
• Other ideas?
© 2004 Institute for Healthcare Improvement
Leverage Point 2
Use planned interactions to
support evidence-based
care
One-on-one, group, telephone,
email, outreach….the possibilities
are endless
© 2004 Institute for Healthcare Improvement
Set up system so the
default, when possible, is
to provide evidence based
care, planned care.
© 2004 Institute for Healthcare Improvement
Create your system to
make planned interactions
easy!
• Make sure all patients are connected to a
PCP and a care team.
• Measure continuity
• Use daily huddles
• Systematize to reduce waste and chaos…the
time can be spent actually working with
patients!
© 2004 Institute for Healthcare Improvement
What is a Planned Care?
• Planned Care is when the patient receives the
right interaction at the right time by the right
person. It is a system issue…….
• A Planned Visit is an encounter with the patient
initiated by the practice to focus on aspects of
care that typically are not delivered during an
acute care visit.
© 2004 Institute for Healthcare Improvement
What does Planned Care look like?
• The provider team knows the patients who
need evidence based care and proactively
reach out to the patient.
• Delivery of clinical management and patient
self-management support are the key aspects
of care.
• The care team is ready and prepared to
provide evidence based care at all times.
• Visits occur at regular intervals as determined
by provider and patient.
© 2004 Institute for Healthcare Improvement
Potential Planned Care
PDSA’s
• PDSA real time
communication
methods (colocation of team
members, walkie
talkies)
• PDSA inviting
patients to a
Planned Visit or a
Group Visit
• Other ideas?
• PDSA how registry
reports inform the
care team
© 2004 Institute for Healthcare Improvement
How do you do a Planned Visit?
You Plan It!
© 2004 Institute for Healthcare Improvement
Patients with higher suicide risk Step
1
• Identify patients with higher suicidal risk
based on a score greater than 0 on question
9 of the PHQ
• For Decision Support, generate a list of
patients meeting the criteria
• PCPs and BHCs are provided the list and can
ensure appropriate follow-up is conducted
based on the treatment guidelines
© 2004 Institute for Healthcare Improvement
Step Two: Patient Outreach for
Depression
• Receptionist/Patient Account Rep identifies last
visit by the patient and if a follow-up has been
scheduled (in the appropriate time frame)
• If no follow-up has been scheduled the PAR
works with the patient to schedule an appointment
• Patient is offered the opportunity to talk to the
BHC at that time if things aren’t going well
• The appointment is scheduled with the phrase
Depression Follow-up in the reason code
© 2004 Institute for Healthcare Improvement
Step Three: Preparing for the
Depression Follow-up Visit
• Medical Records sees that the patient is a
collaborative patient and attaches the blank
PECS encounter note
• Both the nursing staff and the providers see
that the reason for the visit is a follow-up for
Depression so they can ensure that the
patient receives a depression screen
© 2004 Institute for Healthcare Improvement
Step Four: The Depression Visit
• Review how the patient is doing/feeling
• Adjust remaining medications as needed
• Review the self-management goals
• Problem solve barriers to treatment
• Adjust self-management goals
• Schedule follow-up with the BHC and/or the
PCP
© 2004 Institute for Healthcare Improvement
Step 5: Depression Follow-up
• Follow-ups are generally scheduled with the
BHC
• Phone follow-ups by the BHC are conducted
within 1-2 weeks of initial visit
• Patients that are unwilling to see the BHC are
scheduled a depression follow-up with the
PCP
• Lapsed appointments are tracked and
patients that haven’t had a follow-up in 4-6
weeks are contacted to schedule an
appointment.
© 2004 Institute for Healthcare Improvement
Group Visits
• Patients brought in by clinically relevant
groups
• Patients can receive:
Specialty service as needed/available
One-on-one with medical provider
Medication counseling
Self-management support training
Social support
• Multiple Models for Group Visits
© 2004 Institute for Healthcare Improvement
Group Visits: Success
• Weekly depression groups are conducted.
Patients attend and the success stories from
the groups are impressive. Patients that
couldn’t get out of bed are now able to
successfully hold down a job. The patients are
supportive of one another.
• Keys to success:
– Involve the providers in the referral process
– Utilize open group format
– Develop curriculum that empowers patients
– Utilize community resources
© 2004 Institute for Healthcare Improvement
Leverage Point 3
Provide clinical case
management services for
complex patients.
Knowing who needs more support
and finding a way to deliver it.
© 2004 Institute for Healthcare Improvement
Casemanagement
Many different things to different people
• Resource coordination
• Utilization management
• Follow-up
• Patient education
• Clinical management
© 2004 Institute for Healthcare Improvement
Key Changes for
Casemanagement
• Develop patient selection criteria: who needs
what kinds of services?
• Who can provide casemanagement?
• Review team roles and tasks and fill in gaps.
• Assure that patients receive CM services.
• Link into community resources
© 2004 Institute for Healthcare Improvement
Features of effective
Casemanagement
• Regularly assess disease control,
adherence, and self-management status
• Either adjust treatment or communicate
need to physician immediately
• Provide self-management support
• Provide more intense follow-up
• Assist with navigation through the health
care process
© 2004 Institute for Healthcare Improvement
Who can be a
casemanager?
• Evidence suggests that non-professionals
can be trained to perform follow-up and
assessment.
• That alone when linked to a physician or
nurse case manager has improved
outcomes in depression and arthritis
• Automatic Voice Response telephone
systems can perform this function.
© 2004 Institute for Healthcare Improvement
Casemanagement
Use combination of resources. For
example:
• For Decision Support, produce reports
that show patients needing follow-up
• Clerical Staff can review schedules and
contact patients that need appointments
• BHC contacts patients needing early
follow-up, interventions or referrals
© 2004 Institute for Healthcare Improvement
Casemanagers: examples
• Trained lay health professionals provide:
• Follow-up
• Patient education
• Registry management
• Self-management support
• Facilitate group visits
• Liaison to community resources
• Can be an important link to cultural issues affecting
outcomes.
© 2004 Institute for Healthcare Improvement
PDSA’s for
casemanagement
• PDSA front desk staff to use registry to
identify and call patients who need
follow-up appointments
• PDSA a lay health professional to help
patients develop self-management
goals
• Other ideas?
© 2004 Institute for Healthcare Improvement
Leverage Point 4
Ensure regular follow-up by
the primary care team
The alternative to lost to followup…there is strong evidence that it
makes a big difference in chronic
illness.
© 2004 Institute for Healthcare Improvement
Make Follow-Up Work for
You
• Develop process for follow-up
• Tailor follow-up to patient and provider
needs
• Eliminate unnecessary follow-ups
• Schedule follow-up.
• Monitor for missed follow-up.
• Reach out to those not attending followups.
© 2004 Institute for Healthcare Improvement
Think out of the box….
• Face-to-face
• Clinical case manager
• Outreach worker
• In groups
• Phone
• E-mail
© 2004 Institute for Healthcare Improvement
City of Austin Depression
Results
• Improved identification of depression patients
• Improved teamwork between providers
• Improved self-management goal setting (11%
to 91%)
• Improved scheduling of follow-ups,
implementing early phone follow-ups
• Standardized use of tools
© 2004 Institute for Healthcare Improvement
Example: Patients with higher suicide
risk Step 1
• Identify patients with higher suicidal risk
based on a score greater than 0 on question
9 of the PHQ
• For Decision Support generate a list of
patients meeting the criteria
• PCPs and BHCs are provided the list and can
ensure appropriate follow-up is conducted
based on the treatment guidelines
© 2004 Institute for Healthcare Improvement
Leverage Point 5
• Give care patients
understand and fits
their culture
• Connect patients to
a care team who will
get to know them
and they trust
• It is more than just
translating…..
© 2004 Institute for Healthcare Improvement
Goal of the Session
For you all to be excited to go home and
test breakthrough changes in how
your care processes are designed!
© 2004 Institute for Healthcare Improvement