1. session objectives by the end of this session participants will be able to: articulate the...

Session Objectives

• By the end of this session participants will be able to:• Articulate the definition and principles of

team-based care

• Outline the expanded roles and structure of team-based care models

• Identify the key components for the implementation of team-based care

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©1996-2015 HealthTeamWorks®

Reprint with Permission Only

Defining Team-Based Care Team-based health care is the provision of health services to individuals, families, and/or their communities by at least two health providers who work collaboratively with patients and their caregivers—to the extent preferred by each patient—to accomplish shared goals within and across settings to achieve coordinated, high-quality care.

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Our ever-changing world…


Reprint with Permission Only4

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Current state



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Evidence for Team Based Care• Many care and care-coordination activities are better

provided by non-physician members of a care team (Coleman & Reid, 2010).

• In fact, a 2006 evidence review of diabetes interventions found that providing team-based care was the single most effective intervention in improving intermediate diabetes outcomes (Shojania, et al., 2006).

• Most physicians only deliver 55 percent of recommended care and 42 percent report not having enough time with their patients (Bodenheimer, 2008).

• Providers spend 13 percent of their day on care coordination activities and only half of their time on activities using their medical knowledge (Loudin, et al., 2011).

• Team-based care decreases costs and increases revenue (Coleman & Reid, 2010).



http://www.ahrq.gov/professionals/prevention-chronic-care/improve/system/pfhandbook/mod19.html#coleman

http://www.ahrq.gov/professionals/prevention-chronic-care/improve/system/pfhandbook/mod19.html#shojania

http://www.ahrq.gov/professionals/prevention-chronic-care/improve/system/pfhandbook/mod19.html#bodenheimer2008

http://www.ahrq.gov/professionals/prevention-chronic-care/improve/system/pfhandbook/mod19.html#loudin

http://www.ahrq.gov/professionals/prevention-chronic-care/improve/system/pfhandbook/mod19.html#coleman

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..and lest we forget: the patient!



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Team-Based Care



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Team-Based Care Models Traditional Model

• Physician• MA• RN• Front Desk

Expanded Model

• Provider• Mid-level• MA• RN• Front Desk • Behavioral

Health• Care Manager• Social Work• Pharmacy • Health Coach• Diabetes

Educator• Scribe

Care by Design

• Provider• Advanced

Practice MA• RN• LPN• Nutritionist



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All TBC models expand roles To

p o

f Lic

en

sure With

expanded roles, each care team member is working to the top of their skillset, credentials, and/or licensure.

Task

Com

plet

ion Expanding

the roles of additional care team members allows tasks previously done only by providers or not done at all to be completed.

Eva

luat

e &

Tra

in Evaluate skill sets and properly train staff for their to new duties



HealthTeamWorks®’ Approach

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How does HTW do an assessment for TBC?

• Clinician/staff experience survey

• Practice observation template for current state

• PCMH monitor

• Quantitative surveys to understand:

• Practice demographics

• Patient demographics

• Payer mix

• Leadership survey:

• Triple AIM goals

• EHR capability

• Strategic priorities

• Current state of roles



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What do we generally find?• Workflows are provider or practice centric• Providers are doing many things they don’t need

to do• RNs are working below licensure• Front desk & MA roles are not maximized• Leadership has not analyzed panels & patient

needs• There is fear about delegating to “physician

extenders” – MAs, mid-levels, etc.• The implementation of team based care or

“workflow delivery redesign” is as much cultural as tactical



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Where do we start?

• Immediate implementation vs. right implementation• Empanelment• Risk stratification• Collect baseline patient & practice data • Determine access strategy• Determine resource allocation strategy• Staffing analysis & plan



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General recommendations



Centralize all activities that don’t have to be at the practice

Expand and define the role of the mid-level

Expand number and roles of MA staff wherever possible

• Care management• Pharmacy• Behavioral health • Nutritionist• CDE• Others?

Explore financial capability of adding a shared services model or partnership that COULD include :

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Centralized vs. DecentralizedLow relationship value with high impact value = centralized services, which are intended to:

• Meet low risk patient need (i.e. prevention outreach)• Meet moderate risk patient need (i.e. care gap outreach)• Decrease stress & chaos at the practice by removing all

activity that does not need to be there

High relationship value with low impact value = decentralized/practice-level services, which are intended to:

• Meet high risk patient need (i.e. complex care management & care transitions)

• Define & maximize care team roles• Provider role be only clinical, diagnostic & relationship

• Create meaningful engagement in QI/change management at the practice level



Potential Expanded Roles

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Front Desk

• Outreach to low risk patients for prevention gaps

• Outreach to moderate risk patients for reminders about care gaps

• Outreach to patients discharged from ED

• Implement empanelment guidelines and upkeep across business lines

• Participate in huddles

• Call to remind patients about group visits and/or PFAC meetings

• Lead PFAC meetings©1996-2015 HealthTeamWorks®


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MA/LPNs

• Implement standing orders

• Outreach to low risk patients for prevention gaps

• Outreach to moderate risk patients for reminders about care gaps

• Outreach to patients with uncontrolled chronic diseases

• Outreach to patients discharged from ED, hospital and/or SNIF

• Do pre-visit planning of getting all information that is reasonably possible ahead of visit that could include: directs for labs/results/hospital paperwork/medication reconciliation/building alerts for patient visit

• Implement empanelment/risk stratification guidelines and upkeep across business lines

• Facilitate a meaningful connection with practices when outreach efforts fail and/or information surfaces that needs to be communicated.



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NPs/PAs

• As providers in practices with standard panels

• As providers who provide acute access

• As providers with high risk patients as their panel

• As providers with a shared panel

• Lead group visits

• Other

Tools for TBC

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Standing Orders: A tool for TBC

• A standing order is a signed document that authorizes non-clinician staff to carry out a medical order according to the “practice-approved” protocol – without a provider’s examination (or requirement for approval) as permitted by state law.

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Benefits of Standing Orders

• Standing orders empower the appropriate practice staff to complete them and improve workflows and efficiency

• Standing orders allow care team members to function at the top of their licensure and/or skillset

• Research has shown statistically significant improvements in prevention measures when a related standing order was in place

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Common Standing Orders

• A1C• CBC• LDL

Labs

• Titration• RefillsMedication

• Colonoscopy • Mammogram

Preventive Screenings

• Podiatry• Ortho• OB/GYN

Specialty Referrals

• Monofilament Foot ExamDiabetic Care

• Flu• Pneumonia• Child

Immunizations

• Flu• Pharyngitis• UTI

Acute



Strategies for Implementing Standing Orders Develop policies and protocols that support the use

of standing orders Intentional staff education, communication, and

follow-up by practice leaders Collaboration and communication about expectations Standing orders are incorporated into the EHRDemonstrate application and use of templates to all

clinicians Consistent practice wide approach/repeated

messages A feedback and reminder system is in place for the

use of standing orders

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Discussion

Huddles: A tool for TBC

• Huddle: A brief meeting between teams or teamlets to increase efficiency and access within a clinic.

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Huddles: an effective TBC tool • Huddling encourages communication and facilitates the

delivery of key information to the care team.

• Spending a brief amount of time up front to discuss patient concerns and identify potential “road blocks” in your daily schedule can improve workflows

• Huddles help manage crises before they arise and allow the care team to better manage time and resources.

• Huddles can benefit practices of any size

• Huddles improve patient access

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Huddles help eliminate:

• Confusion about provider availability for scheduling• Lack of awareness of broken equipment or unavailable labs• Lack of preparation for patients that require extra time and

assistance• Staff shortages due to illness, vacations, emergencies • Chaos due to last minute schedule changes (cancellations,

no shows, transportation issues, hospital admissions)• Lack of awareness of how each care team members plays a

part in the smooth functioning of a practice



Steps for Huddle Implementation

1. Get provider buy-in

2. Settle on a time to meet consistently

3. Experiment with different participants

4. Limit huddles to 5 minutes or less

5. Hold the huddle in a central location

6. Stand the entire time

7. Designate a huddle leader and put together a structured agenda

8. Identify a huddle champion who can provide daily discipline

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Discussion

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Resources • Improving Primary Care: Team Guide

http://www.improvingprimarycare.org/

• The Chronic Care Model

http://www.improvingchroniccare.org/

• Center for Care Innovations

http://www.careinnovations.org/

• Safety Net Medical Home Initiative

http://www.safetynetmedicalhome.org/

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References• Bodenheimer T. (2008) The future of primary care: transforming

practice. New England Journal of Medicine, 359(20), 2086-9.

• Bodenheimer, T., Ghorob, A., Willard-Grace, R., & Grumbach, K. (2014). The 10 Building Blocks of High-Performing Primary Care. Annals of Family Medicine, 12(2), 166-171.

• Coleman K, Reid R. Safety Net Medical Home Initiative. Continuous and team-based healing relationships: improving patient care through teams. Implementation guide. 1st ed. Burton T, ed. Seattle, WA: MacColl Center for Health Care Innovation at the Group Health Institute and Qualis Health; December 2010

• Ghorob, A., & Bodenheimer, T. (2012). Share the Care : Building Teams in Primary Care Practices. The Journal of the American Board of Family Medicine, 25(2), 143-145.

• Goldberg, D., Beeson, T., Kuzel, A., Love, L., & Carver, M. (2013). Team-Based Care: A Critical Element of Primary Care Practice Transformation. Population Health Management, 16(3), 150-156.

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References• Loudin B, Gainer L, Mayor M, et al. (2011). Elevating the role of the

medical/clinical assistant: maximizing team-based care in the patient-centered medical home. Seattle, WA: MacColl Center for Health Care Innovation at the Group Health Institute and Qualis Health.

• Markova, T., Mateo, M., & Roth, L. (2012). Implementing Teams in a Patient-Centered Medical Home Residency Practice: Lessons Learned. The Journal of the American Board of Family Medicine, 25(2), 224-231

• Mitchell, P., M. Wynia, R. Golden, B. McNellis, S. Okun, C.E. Webb, V. Rohrbach, and I. Von Kohorn. 2012. Core principles & values of effective team-based health care. Discussion Paper, Institute of Medicine, Washington, DC. www.iom.edu/tbc.

• Shojania KG, Ranji SR, McDonald KM, et al. (2006) Effects of quality improvement strategies for type 2 diabetes on glycemic control: a meta-regression analysis. JAMA, 296(4):427-40.

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1. session objectives by the end of this session participants will be able to: articulate the...

Documents

care model910 teambased

caremany care

highquality care

care team coleman reid

carecoordination activities

care coordination activities

percent of recommended

structure of team