Washington Association of Community & Migrant Health Centers
PCMH Learning Community Learning Session
Evolving the PCMH Care Team
Presented by:
Bonni Brownlee, MHA CPHQ CPEHR
April 25, 2013
Advancing Healthcare
Improving Health
Objectives
Participants will be able to:
• Describe the characteristics of an effective care team
• Define and roles and delegation to redistribute the work
of care delivery
• Define the key elements of care coordination in PCMH
implementation for your organization
• Define the work of care management in PCMH
implementation for your organization
• Take away 1 or 2 two care coordination strategies to test
with your staff
• Network with and steal shamelessly from other Learning
Community and CHC participants
2
Challenges in Primary Care
• Delivering all evidence-based guidelines for preventive and
chronic disease care has been estimated to take 18 hours a day
for an average sized patient panel
(Yarnall et al 2009; Alexander et al 2005)
• Most physicians only deliver 55% of recommended care, 42%
report not having enough time with their patients
(Center for Studying Health System Change 2008; Bodenheimer & Laing 2007)
• Providers are spending 13% of their day in care coordination
and only using their medical knowledge 50% of the time.
(Gottschalk 2005; Margolis & Bodenheimer 2010)
• Patient care is fragmented and patients are dissatisfied with the
level of attention they receive in primary care
(Bodenheimer 2008)
3
What is Team-Based Care?
• A model of health care delivery that
utilizes individual staff members in
various roles, each functioning at
their highest level according to
credentials and competencies.
• Shared accountability for overall
patient health outcomes within a
framework of clearly defined roles and
responsibilities under the leadership
of the Primary Care Provider.
4
What does a
Patient Care Team look like?
• A team is defined as a group of people working
together toward a common goal.
• High functioning teams demonstrate the
following characteristics:
–
–
–
–
–
Flattened hierarchy
Shared mental model
Clear roles and responsibilities
Effective communications
Conflict resolution skills
5
Imagine a High Functioning
Clinical Team
• Providers assess, diagnose and treat,
always doing something that requires their
clinical knowledge.
• Nursing role is re-established
– Clinical expertise, leadership and educating
becomes their focus, extending their reach
• The MA/LPN role is enhanced
– Using standards and training provided by
providers and RN’s, they function more
independently and enhance team delivery
• Upward mobility strategy
– Opportunities for stars to shine!
6
Engagement is the Key
• Engaged team members work with passion.
• Not-Engaged team members do the work
expected of them, but do not put in extra effort.
• Actively Disengaged team members aren’t
just unhappy, but are spreading their
unhappiness to other staff.
7
What makes a team successful?
• Care organized through daily huddles
• Brief, frequent meetings to review and plan
PDSA cycles
• Continuous attention to improvement eventually
becomes part of the care team’s thought
process, culture and daily work
• Regular communication with leadership to
discuss successes and barriers
8
Clinician Satisfaction with Teams
NO TEAMS
(work with different MAs)
TEAM
(work with group of MAs)
TEAMLET
(work with same MA)
Provider Confidence in Panel Management
for Cancer Screenings using Teams
Source: Tom Bodenheimer 2012
9
Roles and Responsibilities
10
Who is on the Care Team?
11
The Team Identity
•
•
•
•
•
•
Name your team – Blue team; Team A; etc
Color-coded scrubs
Name tags
Team identification on handouts, appt cards, etc
Signs and/or team photos in exam rooms
Individual phone lines for each care team
12
Staffing Model
To fully meet the needs of patients in the PCMH,
the optimum staffing model is:




1.0 Provider
1-5 – 2.5 Support Staff (MA, CNA, LVN)
0.5 RN
3 Exam rooms
13
Use Stages of the Care Cycle to Define
Team Member Roles and
Responsibilities
•Rooming
•Exam / Assessment
•Treatment Goals
•Self Management Support
• Scheduling
• Pre-Visit Planning
• Team Huddle
• Nurse follow-up
• Care Management
• Support for care transitions
• Population Mgmt / outreach
Before
the Visit
During
the Visit
Inbetween
Visits
After the
Visit
• Referrals
• Lab/imaging studies
• Education / Support
14
Re-Evaluate Workflows
Identify best practices and standardize work based
on continuous quality improvement:
• Flow charting processes for new workflows
• Cycle Time studies – patient cycle time, provider
cycle time
• PDSA Cycles
• Process and outcomes data by PCP/care team
15
Provider Time Study
41 min
Check-in
Vital Signs
Med reconciliation
Update PSFHRF
3 minutes
MD-Patient Bonding/History/Exam/Plan
15 minutes
Operationalize Decisions
5 minutes
1 minute
Mini-huddle
1 minute
Documentation
Follow-up
6 minutes
10 minutes
Modified from Kim Davis MD, MUSC
16
Impact of a Strong Support Team
22 minutes
Pre-appt
tests
Check-in
Vital Signs
Med reconciliation
MD-Patient Bonding/History/Exam/Plan
15 minutes
Operationalize Decisions
Update PSFHRF
and follow standing
orders
Mini-huddle
1 minute
Documentation
6 minutes
17
Provider Role – beyond clinical care
• Will understand and work to standards of evidencebased care, review data, and receive feedback
• Will understand the training protocols for support staff,
will participate in evaluation of core competencies, and
will become comfortable delegating tasks
• Will be involved in development of workflows, offering
ideas, opinions, and concerns; will have “ownership”
• Will be accountable for implementation and
sustainability of processes and workflows for the care
team
18
RN Role
The expertise and license of an RN can provide
strong support to patients, providers and staff:
•
•
•
•
•
•
•
•
RN Care Manager
Patient educator
Staff orientation and training
Verification of clinical skills competencies
Clinical Policy and Procedure development
Triage via phone and for walk-in patients
Supervises clinical support staff (if permitted by law)
Committee chair (clinic operations, CQI, health
education)
19
Administrative Responsibilities
• Receives population management reports, reviews
with Care Team / Care Manager, and conducts patient
outreach
• Follows up with patients who have missed important
appointments
• Performs Referral Management for the care team
• Conducts patient check-out (prints visit summary, care
plan, education, self management tools according to
standards or as directed)
• Is an Active participant in pre-visit planning and
huddles
• Develops a relationship with patients as well as the
clinical team
20
The Enhanced
Medical Assistant Role
Team Partner, Care Coordinator, Health Coach
• Allows team members to function
at their highest level
• Provides trusting relationships with
patients, practice advice on self
management when cultural
background is shared
• Improves job satisfaction, potential
for upward mobility, and retention
of excellent staff
21
California Scope of Practice - MA
• Defined by Medical Practice Act (Business and Professions
Code sections 2069-2071)
• Performs basic administrative, clerical, and technical
supportive services
• May administer medication by intradermal, subcutaneous,
or intramuscular injections, perform skin tests, and other
technical supportive services upon the specific
authorization and supervision of a licensed physician and
surgeon or podiatrist.
• May work from standing orders
22
MA Scope of Practice (cont’d)
MAY PERFORM
MAY NOT PERFORM
•
•
•
•
•
•
•
• Start IV or administer meds
through IV line
• Chart pupillary responses
• Interpret skin tests
• Independently conduct
telephone triage
• Inject collagen
• Perform laser hair removal
• Administer chemotherapy
Injections
Skin tests
Bandaging
Suture removal
Ear lavage
Exam preparation
Shaving and disinfection
of treatment sites
• phlebotomy
23
Examples of Standing Orders
• Lab testing
– Pregnancy test, Rapid Strep, PPD placement
– Random glucose (fingerstick)
– In-house HbA1C
• Well Child Check procedures
– Hearing and vision screenings
– Lead tests
– Flouride varnish
• Immunizations
– Childhood
– Flu, pneumovax
• Preventive Health screenings, including depression and
risk assessments
• Disease management protocols (DM, HTN, asthma, etc)
24
Team Time: Optimizing the Care Team
Part 1: Evaluation of Provider’s Work Activity
Part 2: Redistribution of Work Activity
Part 3: Identifying Barriers
25
Care Coordination
and Care Management
26
Care Management - Defined
• Care management programs apply systems, science,
incentives, and information to improve medical practice
and assist consumers and their support system to
become engaged in a collaborative process designed to
manage medical, social, and mental health conditions
more effectively.
• The goal of care management is to achieve an optimal
level of wellness and improve coordination of care while
providing cost effective, non-duplicative services.
Center for Health Care Strategies
27
© Qualis Health 2010
4
The Evidence is Clear
Team Involvement in the Care of the Chronically-Ill
is the Single Most Powerful Intervention
Effects of QI Strategies for Type 2 Diabetes on Glycemic Control
JAMA. 2006;296:427-440.
28
Hierarchy of Care Management Support
Higher
Complex Case Management
Chronic Illness Management
Level of Support
Clinic-Based Care Management
Clinic-Based Care Coordination
Health and Wellness Support
24-Hour Nurse Line (episodic)
Lower
29
© Qualis Health 2010
5
Care Coordination
An Essential Complement of Services
for All Patients
30
Care Coordination
Pre-Visit Planning supports the Team Huddle
• Care Coordinator reviews :
⁻
⁻
⁻
⁻
Lab Log to determine outstanding labs
Referral Log to determine outstanding consults
Health Maintenance services due
Medication Reconciliation Records
31
Team Huddles
Huddles enhance communication
Why ?
• Sets the tone for the day
• Establishes competence
• Disavows perfection
• Predicts what will happen
later
When ?
• Start of the day
• Prior to a procedure
• On the spot – as the
situation changes
• When joined by a new
team member
32
Medication Reconciliation
•
•
Updated at every encounter and transition of care
•
•
New medications are added to the list
•
•
•
•
No duplicates (generic vs. trade)
Changes made by other providers are communicated
and medication list in PCP record is updated
Discontinued medications are removed from the list (or
stop date documented)
Herbals and supplements must be included
Allergy list is up to date
Ensure patient / family agrees with list!
33
Closed-Loop Test Tracking
Ensures that results are
received, reviewed by
provider, and acted upon for
every lab or imaging test
ordered
34
What can be tracked – and how?
•
•
•
•
•
All tests ordered
Which tests were scheduled
Which tests were done
Turn-around times
Outliers
Tracking tools include:
• Manual log
• Excel spreadsheet
• Computer software
35
Communicating Test Results
• Normal results
• Abnormal results
• Establishing a timeframe for communicating
results to patients
36
Closed-Loop Referral Tracking
• Types of Referrals
⁻ Internal vs external referrals
⁻ Opinion
⁻ Procedure (imaging, endoscopy)
⁻ Assume care
• Ensures that the patient
completed a visit and a note
was received back from the
specialist each time a
specialty referral is ordered
37
Transitions of Care
• After ED visit
• After hospital admission and
discharge
• Coordination with other care
facilities (rehab, SNF, etc.)
• Transfer to new PCP
• Transition from pediatric
service to adult medicine
38
Why Focus on Care Transitions?
• 2/3 of Medicare patients are re-hospitalized or die within
one year of index hospitalization.
• Half of Medicare patients are not seen in the outpatient
setting within 30 days of discharge.
• Care transitions are error prone
• Poor care transitions have the hardest effect on the most
vulnerable, causing suffering, disability and death.
• Failures reflect a lethal system design flaw.
• No national improvement progress since 2003.
39
Care Transitions Tasks
Managing care across settings is an important
care coordination effort. It requires:
• Communication with other settings
– Knowing when patients have been seen in the
emergency department or hospital
– Receiving and sending appropriate documentation
between settings
• Medication reconciliation and management
• Availability of follow-up appointments
• Knowledge of about community resources
40
GROUP DISCUSSION
• Do you use huddles?
• Who provides the lab and imaging tracking in
your office? Who notifies patients of results?
• Do you have a referral coordinator?
• Who is responsible for managing care
transitions?
• How do these individuals interact with the Care
Team?
41
Care Management
An Individual Patient Focus
42
Care Management
• Supplements the care of complex patients
• Helps identify at-risk individuals
• Utilizes evidence-based care guidelines and chronic
disease management strategies
• Establishes a plan of care with patient/family input, goals,
assessment of progress toward goals; exploring barriers,
acting to remove barriers
• Coordinates services from all care givers to ensure
continuity
• Provides disease-specific and preventive health education
• Promotes and supports self-management
43
Care Management Program Benefits
•
•
•
•
Improve quality and reduce cost
Reduction in acute inpatient admissions and LOS
Reduction in 15 and 31 day readmissions
Reduction in ED utilization
and PCPs report :
• Time savings of up to 30 minutes daily
• Improved patient engagement
• “I can do a much better job as a physician with this
level of support for myself and my patients.”
44
Care Management Roles
Care Coordinator / Health Coordinator
• MA or LVN
• Tracks tests and referrals
• Facilitates communication with facilities and continuity
of care at transitions
• Organizes and maintains health information and
registry data for population management and
implementation of evidence-based guidelines
• Assists in patient education and self-management
support
• Contributes to medication reconciliation
45
Care Management Roles
Care Manager
• Licensed RN or LCSW/MSW
• Identifies and manages a small number of high risk/high
cost or complex patients utilizing evidence-based guidelines
• Works collaboratively with PCP, patient, family, and care
team to develop and implement a care plan
• Coordinates care with/for patient, family, and team
• Provides education and self-management support
• Guides Care Coordinators and Health Coaches in
implementing protocols for education and self-management
support
• Facilitates team conferences and communication
46
Who Needs Care Management?
• Consider clinically important conditions
• Identify “at-risk” patients
–
–
–
–
–
Social or economic challenge
Multiple chronic conditions
High utilizers
Mental/behavioral problems
Other?
• Allow non-providers to suggest referrals to Care
Management
47
Care Management Activities
• Establish plan of care
– Set goals, assess progress, remove barriers
•
•
•
•
Self-management support
Coordinate services
Provide health education
Increasing patient/family activation
48
What is a Care Plan?
• A collaborative tool used by:
– Patients as a road map
– The Care Team in goal setting, followup, issue
resolution
– The Provider in setting treatment goals based on
evidence-based guidelines
• Content should include:
– Treatment Goals
– Referrals (specialty and community resources)
– Responsibilities of patient, medical home/care team,
and specialists
49
Care Plans vs. Clinical Summaries
CARE PLAN
CLINICAL SUMMARY
Longitudinal focus
Focused on today’s visit
Long-term plan for managing chronic
illness
Addresses today’s complaint; may or
may not include chronic care issues
Reviewed by Care Team in pre-visit
planning
Prior clinical summary may be
reviewed by Care Team in pre-visit
planning
Reviewed with patient at every
relevant visit and updated as
necessary
Generally not reviewed with patient
during the visit
PCMH 3C2, 3C3, 3C4, 4A3, 4A4, 4A5
PCMH 1C3, 3C5
50
Documenting the Care Plan
• Structure
–
–
–
–
Formal vs. informal
What level of detail do we need?
Should it be condition-specific?
Whose responsibility is it?
• Identify immediate needs, short term goals and
ongoing needs
• Set goals with patient
– specific, meaningful, measurable
– Determine readiness for change (confidence, importance scales)
– Establish appropriate and realistic actions
51
Components of the Care Plan
I want the person working with me to know:
• I have challenges with : Transportation, Vision,
Hearing, Mobility, ESL, other
• I have issues with Diet
• My religion/spirituality impacts my health care
• I live : alone, partner/spouse, extended family,
other
• I learn best by : reading, show & tell, listening to
tapes, pictures/books/video
52
Implementing the Care Plan
• Develop written self-management care plan in
collaboration with patient and provider
• Confirm/coordinate testing and other
appointments, then later follow-up with patient to
ensure that test was completed and
appointments kept
• Discuss preventive care needs
• Plan for additional teaching as needed
53
Evaluating the Care Plan
• Have needs been met? Goals achieved?
• Address barriers and resolve them to enable
patient to receive needed care
• Is the patient in the right care setting with
adequate support?
• Is the patient progressing? If not,
–
–
–
–
why not?
Reassess patient willingness to address goals
Re-educate, reinforce
Re-negotiate timelines and/or expectations with
patient
54
Self-Management Support
Self Management Support helps people to:
• Understand:
– Their condition and what will happen
– Recommended treatments
– What they can do to manage their condition / disease
• Become activated, confident, and engaged in their care
• Decide among treatments
• Set goals
• Identify their health behaviors
• Adopt and/or change behaviors
• Cope and overcome barriers
• Develop strategies to live as fully and productively as they can
• Follow-through
55
Self-Management Support is NOT…
• Lecturing
• Inducing fear
• Finger-wagging
• “You should”
• Shaming
• Waiting for a
patient to ask
56
What is a Self-Management Goal?
• Self-management goals are the specific steps
and behavior changes a patient agrees to make
in order to meet the treatment goal(s).
• Self-Management goals can be a part of a
patient’s care plan.
57
Self-Management Tasks –
Examples
• Self-Monitoring
– Blood glucose, blood pressure, peak flow,
checking feet
• Recognizing red flags; managing
symptoms and signs
– Fatigue, pain, wheezing
•
•
•
•
•
Taking medication as prescribed
Diet and physical activity
Medical visits, lab and diagnostic tests
Coping and managing emotions and stress
Avoiding or quitting risky behaviors
58
Things to Consider
•
•
•
•
Receptiveness of patient to learn
Health literacy
Language barriers
Appropriateness of materials to be used
– Cultural, linguistic, reading/numeracy level
•
•
•
•
Family involvement (or not)
Confidentiality
Privacy
Sensitivity
59
If you have DIABETES, here are some things you can talk about with your
health care provider
Choose to talk about changing any of these and add other concerns in the
blank circles.
Taking
medications
to help control
blood sugar
Blood
glucose
monitoring
Physical
activity
Diet
Taking
insulin
Daily foot care
Depression

Losing weight
Smoking
Adapted from Stott et al, Fam Practice, 1995 by Barbara Kondilis of the RI Chronic Care Collaborative
60
Skills to promote
Patient Engagement & Self Management
• Communications
– Motivational Interviewing
– Open-Ended Inquiries
– Reflective Listening
•
•
•
•
Coaching
“Teach Back”
Health Literacy
Cultural Competency
61
Assessing Importance
“How convinced are you that it is important to
monitor your blood sugars?”
Not at all
convinced
Totally
convinced
• “What makes you say 4?”
• “What leads you to say 4 and not zero?”
• “What would it take (or have to happen) to move
it to a 6?”
62
Assessing Confidence
“How confident are you that you can meet your
goal of exercising 5 days a week?
Not at all
convinced
Totally
convinced
• “What makes you say 6?
• “What might help you to get to a 7 or 8?”
• “What could I do to help you to feel more
confident?”
63
64
Some level of Self-Management
Support should occur at every Visit
• Print the After Visit Summary from EHR
• Offer medication refills, if needed
• Use “Teach-back” to ensure patient understanding
– New medications and problems
– Self-management support
– Follow-up plans
• Review action plan (is it mutual?)
• Gather patient education materials and self-monitoring
tools
• Schedule follow-up visits
• Schedule follow-up phone call
65
66
Began Patient Follow Up Phone Calls
67
Working Together to Impact Outcomes
Interventions
Process
Measures
Clinical
Outcomes
68
Extending the QI Agenda to Care Teams
EXAMPLE: TEAM MEETING STRUCTURE
Week 1:
Well Child Outreach/Pedi-asthma
Week 2:
Diabetes/Depression
Week 3:
MA/FD: Normal PAP/Mammo
RN/MD: High-Risk patient case review
Week 4:
Abnormal Pap/Abnormal Mammo/PSA
69
Build an Action Plan…
LIST THE STEPS NECESSARY TO
ADVANCE YOUR WORK IN CARE
COORDINATION AND CARE
MANAGEMENT
PERSON RESPONSIBLE
(WHO)
WHEN
WHERE
1.
2.
3.
4.
5.
70
Questions
71