CSI-RI: Best Practice Sharing
Meeting
A continuum of change…
August 19, 2011
The Practice Sites
Hillside
Avenue Family
& Community
Medicine
Family Health
& Sports
Medicine
Thundermist
Health Center
(Woonsocket)
Coastal
Medical, Inc.
(Greenville)
University
Medicine
Governor St.
The Practice Sites
Memorial
Hospital
Family Care
Center
Kristine A.
Cunniff, DO
Coastal
Medical, Inc.
(Wakefield)
Thundermist
Health Center
(Wakefield)
Stuart V.
Demirs, MD
South County
Family
Medicine
Dr. Henseler
South County
Internal
Medicine
South County
Independents
Overview of Events
November
2010
December
2010
Clinical
Team
Building
Group
Visits
January
2011
February
2011
Using Data Creating
to Improve Clinical
Your CSI Sessions
Outcomes
that
Work for
You
March
2011
April
2011
May
2011
Reducing
Pearls from
Readmissions
IHI’s 12th
&
Annual
Unnecessary International
ED Visits:
Summit on
Practical Best
Improving
Practices
Patient Care
in the Office
Practice & the
Community
June
2011
Sharing
Strategies
to Improve
Blood
Pressure
Control
July
2011
Sharing
Strategies
to
Improve
HbA1C
Control
Hillside Avenue Family
& Community Medicine
• MA utilizing a template (past and present vitals, smoking status,
depression screen status, etc.) and meets with all patients prior
to MD to appropriately screen patients to ensure a more focused
visit with MD
– Increase pre-visit planning and improve quality of care
• ER and hospital notifications directed to quality office and
reviewed by NCM. Appropriate forms are included in EHR and
sent for electronic signature to MD.
– Increased follow-up with patients and less paperwork for MD
“The best practices shared stimulated
great conversations and ideas.”
Family Health & Sports Medicine
• Monthly educational breakfasts for MAs by physicians
– Topics: Cardiovascular, EKG, diabetes, and hypertension
– YMCA provided motivational interview training
• Expansion of Medical Assistant role and responsibilities
– Include patient education on self-management and screening
“Our best practice of BP control involved the
MA, Physician, and RN in developing slides
together. The BP meeting was very positive
for the MA, Megan Converse, as she was able
to interact with the group in sharing her role
as an MA and the patient with hypertension.”
Coastal Medical, Inc. - Greenville
Improvement in data collection and reporting:
• Meet to discuss data with team and brainstorm plans for
improvement.
• Creating staff memos regarding outcomes data to identify gaps
visually.
• Utilizing implementation teams for making changes to processes
to improve patient outcomes.
Thundermist Health Centers
Woonsocket and Wakefield
• Utilization management workflows and high-risk patient
identifiers
– Implementing use of a template to complete on telephone outreach for ER
and post-hospital follow up (RNs and NCMs)
– Started labeling for high risk/high utilization within in EHR
• Increase patient education and engagement efforts with
patients.
– Posters in waiting rooms to ask patients to think about 1-2 concerns of
highest priority for their visit
– Provider champions participating in exercise programs with patients and
accompanying patients to farmers markets.
Thundermist Health Centers
Woonsocket and Wakefield
• Data use for clinical improvement:
– Pre-visit planning reports including many of MA responsibilities
related to outcome measures
– Weekly missed opportunities reporting
– Quarterly provider level reporting are posted and distributed
• Highlight areas of focus and PDSA activities
NCMs better incorporated into team,
data distribution increases team
awareness of outcomes, and we have
had positive patient feedback
regarding new engagement activities.
University Medicine – Governor St.
Primary Care Center
• Pre-visit planning with each provider and care team each
week
– Provider, NCM and MA determine needs of patients for the following
week
• Planning sessions prepare everyone for more productive
patient visits. Helps to achieve goal of creating activated
patients.
“One great take-away from the sessions has been
how others have maximized their use of the same
EHR to support clinical practice and reporting. For
example, the use of the flow-sheets to track
diabetes care and preventative health.”
Memorial Hospital
Family Care Center
• NCMs
– Follow-up on hospitalized patients
– Ensure care of the high risk patients for DM, hyperlipidemia, CAD,
Depression, tobacco abusers with direct care, phone call care and
Logician notes
• PCMH residents work on transition of care following
hospitalization
• Monthly faculty meetings for clinical updates of the PCMH
• Implementation of a CAD summary sheet, DM summary sheet
for patients at their visit as patient self-management tool
• Increase staff (resident) education outside of normal business
hours and via telephone
Kristine A. Cunniff, DO
• Implementing PCMH bulletin board in waiting room:
educational material and good health tips.
– Encourages self-management resources
• Weekly huddles and CSI meetings within practice emphasizing
team work
• Creates increased attention to entering and managing patient
prevention data daily.
Each person in the practice is an
important part of the team
Stuart V. Demirs, MD
• Increased team collaboration to improve patient care:
– Physician: Initial patient education and prescribing of appropriate
disease-state medications.
– Nurse Practitioner: Increased role in patient education and recording
data in EMR.
– NCM: Greater patient education & communication with physician and
nurse practitioner for lab or medication changes.
• Ensures compliance with medications and diet, especially for diabetic
patients.
• Regular monthly CSI meetings to review data and look at ways
to improve our measures.
• Offering combined patient education opportunities free to
patients within the medical home (Dr. Cunniff, Dr. Demirs, and
Coastal Medical of Wakefield)
South County Family Medicine
Dr. Henseler
• Modification of “visit time” to improve the overall patient
experience
• NCM and practice staff contact patients seen in ER or
admitted to hospital post discharge to coordinate necessary
follow-up
• Patients with chronic conditions referred to NCM for
additional support in patient self management, medication
adherence and community resources
Coastal Medical, Inc. - Wakefield
• Monthly team meetings incorporating anonymous questions on
index cards to be addressed or answered within a week
• Questions alternate between negative (“what is driving you
crazy”) to positive (“what one thing can you say that is positive, is
working for you”)
• On site psychologist, nurse care manager, and access to a
pharmacist as a resource now
• Team meetings may also include short in-service and discussion of
CSI data
“These new strategies empower staff
and encourage teamwork.”
South County Internal Medicine
• Medication Reconciliation starts when patients arrive
– Front desk staff prints medication list from EMR and patients are asked to
review and note any changes
– Physician notes any medication changes and records in EMR and patient is
given an updated medication list
• Practice is utilizing a disease registry to proactively manage
chronic disease
– 50 patients contacted by NCM every 4-6 weeks
– NCM coaches patient for self management, discusses adherence with
medications and nutrition
• ER and Hospital utilization monitored by NCM
– NCM contacts patients who have been in the ER or admitted to hospital and
coordinates PCP follow-up
South County Independents
• Increase in meaningful use of EMR to help create data reports
to show areas for improvement.
• Patients with chronic conditions have become well-known to
NCM and are appreciative of extra support.
• The NCM or another staff member contacts every patient
seen in the hospital within 72 hours of discharge.
• Monthly meetings improve communication.
“We continue to improve upon our relationship with VNS services and
various departments throughout South County Hospital which
strengthens our patient centered medical community.”
Facilitating Change
• How far have you come along in the process
of change?
• What challenges do you face when making
changes in your practice?
• How have you conquered these challenges?
• What advice would you have for those ready
to make changes to improve?
Thank you for your ongoing commitment to
improving care for your patients. Your
innovations and achievements continue to
drive the evolution of the PCMH.
Quality Partners of Rhode Island
CSI-RI Training & Technical Assistance Team