cambridge health alliance -...
TRANSCRIPT
3/12/2014
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Kirsten Meisinger, MDNitzali Rivera, LPNPatricia Alves, MA
Cambridge Health Alliance
Disclosures
Kirsten Meisinger has no disclosures
Nitzali Rivera has no disclosures
Patricia Alves has no disclosures
Objectives:
To allow participants time to hear a developed and experienced team care model
To then develop concrete plans to establish or extend team care in participants’ native context using guided and interactive workshop materials
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First: Who are you?
Cambridge Health Alliance
An academic public health safety net system outside of Boston
Largely public payer mix – 82%,almost all Medicaid
>50% patients speak language other than English
160,000 primary care visits for 92,000 patients
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Robert Wood Johnson designated “Learning from Effective
Ambulatory Practices” site 2013
Why teams? Teams are an essential part of care in multi‐cultural, indigent populations
Team members, when diverse, offer an opportunity for patients to choose a team member to bond to
Diverse team members allow for multi‐directional teaching
Teams distribute the work across many people, allowing for all of the prevention work to get done at any visit
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Change Concepts for Practice Transformation
Wagner EH, Coleman K, Reid RJ, Phillips K, Abrams MK, Sugarman JR. The Changes Involved in Patient-Centered Medical Home Transformation. Primary Care: Clinics in Office Practice. 2012; 39:241-259.
Next: What work are you doing?
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The World Health Organization (WHO) estimates that…
At least 80% of all heart disease, stroke, and type 2 diabetes, and
More than 40% of cancer
would be prevented if only Americans were to do three things:
Stop smoking Start eating healthy Get in shape
The vast majority of cases of chronic disease could be better prevented or managed.
http://www.fightchronicdisease.org/
This is how our patient visit fits into their day
Sleep
Work/School
Self Care
Eating
Buying things
Caring for Family
15 min Visit
http://www.bls.gov/tus/tables/a1_2008.pdf
The value of the patient’s time
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Don’t do this:Primary Care System Unsustainable
Acute Care 4.6 hours/day
Preventive Care 7.4 hours/day
Chronic Care 10.6 hours/day
22.6 Hours/day
This is the amount of time required to take perfect care of ONE patient!
In 15 minutes? By a single doctor?
N Engl J Med 2003; 348:2635-45
Next: Who is going to do the work?
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Do this:Parallel Work Flow Redesign
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Why teams?
Places patient at the center – MD not the center of staff attention
Entire staff know and own the care of the patient
Work is distributed according to level of staff training (e.g. RNs free to do RN level tasks)
Improves quality and efficiency of care
Makes primary care possible and ENJOYABLE!
There are many roads
Form follows Function: who is around to help with the work?
Teams need leadership direction and support but can grow organically (especially important when there are economic constraints)
Functions and roles of teams members change over time based on staffing and need
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How Team Care Developed at CHA
Micro Teams: Owning the Work
Initial teams of Medical Assistant, MD, RN Adequate staffing to use this model
Medical Receptionists added soon after The complex social relationships between our patients are key to both successful outreach and engaging a population
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Redesigning Care Delivery:Care is no longer based primarily on visits
How Teams Structure The Work‐Maintaining the Change
The work of the team is organized around four processes: pre‐visit, visit, post‐visit and between visits
All MA‐MD pairs “huddle” prior to and after each patient care session. Significantly improved the flow and productivity (#s of pts seen, what was done for each patient) of each session.
Meet regularly as a whole team to manage “between visit” work – weekly meetings of whole team Celebrate successes , discuss patients who are struggling, review quality goals, plan outreach, assign tasks
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Care Coordination ‐ inreach Patients have visits with multiple team members in one day
Who facilitates that?
Receptionist schedules so it can actually happen!
Medical Assistant makes the flow happen
Pharmacy to see pt, do medication reconciliation and make changes all before provider; RN does 1 hr teaching and makes plan with patient before MD visit; immunizations before MD visit
Care Coordination ‐ outreach
Patients most at risk with “hand offs” and when travel between parts of the system (consults, ER , Hospitalizations, testing)
Provider calls the Emergency Room when sending a patient there to coordinate care
Emergency Room visit follow up calls by team RN
Post Hospital Discharge visits with team within 1 week and telephone call within 48 hours
Integrated system of sharing visit notes (ER, consults, admissions)
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Voice of the Team
Starting the visit: Medical Receptionists Elisangela Barbosa
http://www.youtube.com/watch?v=wpJzYVSK2bA
Pre‐work and Visit work: Medical Assistant Patricia Alves
What is the difference between a Team “Meeting” and a “Huddle”?
“HUDDLES”
Goal: before each session (AM & PM) )
Minimum: once a day
Ideal: In addition, post‐session quick huddle for f/u tasks
Average 10 minutes or less!
* Who’s coming in today: what do they need?
* Who was in the hospital/ED and what is the plan for f/u?
A provider and the MA who are working together to see the patient that day.
The receptionist joins the team if at all possible to assist with scheduling of appointments.
The team RN connects with this team either during the huddle or sometime during the day to review the hospital/ED f/us.
Planning for care of the patients scheduled to receive care during the session/day by the provider.
Includes planning for flow of the session (i.e. provider informs RN that this patient on the schedule will be a quick follow up and an add on can be double booked in this slot)
Includes planning for patient’s:
Health Maintenance issues
Chronic Care issues
Urgent Care issues (i.e.provider informs MA that this patient will need an EKG, this one a throat culture, etc.)
TEAM MEETINGS
Goal: weeklyMinimum: biweekly
30‐60 minutes depending on weekly/biweekly
This meeting time should occur during a time when team members CAN ATTEND and coverage for their work is available. Team meetings are part of administrative time for providers.
All assigned members of the Planned Care TeamRequired participants: Provider, Nurse, Medical Assistant,
Medical Receptionist, Planned Care Coordinator, and Complex Care Managers (for high risk case discussions)
Support team participants: Clinical Pharmacist, Nutrition, Mental/Behavioral Health, Social Work, Patient Navigators, Community Resource Specialists
Planning for care of a panel/population of patients. This includes patients who touch
the health care system regularly (during appointments and phone contacts) and those who do not touch the health care system regularly.
Includes planning for patient’s:Health Maintenance issues
Chronic Care issuesSocial and Resource issues
High risk patients
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Workshop activity
Design a huddle for your clinical site(s) using the worksheet:
Who needs to be present?
Where will they meet?
What work will get done?
Do you have the tools they need or do you have to develop more?
Or, without data, we are nothing!
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What happens when the patient is not at the clinic?
Population Health (MA, MR, panel manager)
Care Management (team for everyone, RNs for the high risk, CCM for the highest risk)
Responsible for the patient even when they are interacting with other components of the Health Care System (everyone at the site)
Planned Care Team Meetings/Prevention GroupsClinic: Union Square Family HealthDate/Time of Monthly ALL STAFF meeting: 4th Wednesday of Every MonthPlanned Care Coordinator (PCC) Name: Vanessa DolyresGroup Visits: Wheeler DM (2nd Wed – Monthly 4:15-6:30pm); Demasi 6 weeks Tues evesPrenatal group Monday eves (Vogel); Baby Group 1st Wednesday of the month (Meisinger)Paula Coutinho (SW) and Joan Byrne (RN), CCM teamPharmacist: Joeseph Falinski, PharmD
Care Team Name
Date/Time of Team Meetings
Mtg Place
Provider RN(s) MA(s) Front Desk Staff
PA
Thackrey Friday 1:00-1:30pm
USFH Dr. Michael Thackrey
Monica Tague
Veronica Miranda
Judith Roc
Juliane
Cohen Tuesday 1:30-2 USFH Dr. Bonnie Cohen
Susan Gesing
Veronica Miranda
Judith Roc
Janice
Demasi Thursday 1-1.30PM
USFH Dr. Monica Demasi
Autumn Roy
Patricia Alves Eli Barbosa
Amy
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Cycle of Team Meetings
Week 1: Diabetes
Week 2: “Watch List”/Depression
Week 3: Complex Care Management
Week 4: Abnormal Pap/Abnormal Mammo/PSA/Pulmonary Nodules
Week 5: Well Child/Prenatals
Voice of the Team
Panel Management:
Nitzali Rivera, LPN
and
Patricia Alves, MA
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Team Orientation and Training
First, who will do what? Define the Roles
Clear hiring strategy to identify candidates who will succeed in this model
Every new staff member spends time shadowing different team members
Concept of patient care teams and their expected role is a focal point of new staff orientation
https://www.dropbox.com/sh/ru8mwwt2e6yjorl/o‐51RvKjIF#/
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RNs as team leaders Role change on the team from reactive to proactive Triad of RN/Pharmacy and PCP – divide and conquer!
Improve continuity of care: pts able to get appt with their team more quickly since RNs and pharmacy are an additional provider/team member
Engages RNs as team leaders
Engaging RNs as Care Managers Increase the time for RNs to focus on:
Care management, specifically with high risk patient groups; choose first group of High Risk patients to focus on: Diabetics
Direct patient care time to increase patient engagement, patient education, etc.
Hired LPN to assist in task oriented jobs (manages all immunization tasks like ordering, stocking, shots, outreach/panel management of those behind on immunizations).
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Other Concepts of Team: Performance Improvement Team
Members include front end staff member, medical assistant, nurse, office manager, nurse manager and a physician
Work of the workflow team – examples Ongoing practice flow improvement
Ongoing quality improvement
How to implement new initiatives Colorectal cancer
Health Care Proxy
Meets every other week and has executive ability to change workflow of the clinic
Best Practices Library
PITs
X‐PIT
Amb. Leadership
Site LeadershipSite leadership leads implementation of
agreed upon solutions
Joint Ambulatory
recommendations
Joint Ambulatory Leadership
approves/rejects/pendsX‐PIT
recommendations
X‐PIT recommends potential project solutions (best
practices) that can be spread to all sites
X‐PIT selects specific projects to develop into best practices
PITs share their projects into a common repository easily
accessed by PITs, X‐PIT, Amb. Leadership, Site Leadership
Best Practices are logged as resource
for PITs and leadership teams
X‐Pit may ask PITs to refine best practices
X‐PIT Process Flow
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Continuous Quality Improvement
How to make lasting changes
PDSA cycles
Plan: New workflow designed by a team
Do: 2 week trial of the change
Study: Re‐evaluation by the entire team and a patient if possible
Act: Spread the work to others
Union Square Example
Health Care Proxy Form
New work for Medical Assistants sent to them in email
Discussed with providers and leadership
Medical Assistants printed the form, reviewed it with the patients, signed as a witness and provide a copy to patients; pended the order in the computer for the Doctor
Small changes over email then was permanent
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Workshop Activity Design your Quality structure for your clinical site(s) using the worksheet:
planned care meetings (weekly recommended)
Workflow team or Performance Improvement Team
Reporting process – where do you get your data?
For each of these that you deem appropriate to your site(s), specify what roles will be required to attend and what function they will perform during the meeting
Maintaining the Work Survey of the USFH Care Teams performed in 2014 by N. Rivera and P. Alves
5 Question survey intended to probe how USFH has maintained high functioning care teams since 2005
Themes:
Fun
Staff feel supported in their work at all times
Passionate, caring, loving, commitment
Unique
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Pithy Quotes “All team members truly believe in the common goal of patient care and do what is best for the pt.”
“We communicate well about what we expect of each person’s role in the team.”
“Teams function when they get encouragement, have the tools to succeed and strong, fair, competent leadership.”
“Everyone is willing to take one for the team.”
“Relationship is the foundation.”
Our Favorite
T – together
E – everyone
A – achieves
M – more
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Measures of success: Quality
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Measures of Success – Work Environment
Provider and staff satisfaction
Extremely low rate of avoidable turnover despite very challenging financial hurdles as an organization
Professional development of staff
Easy to recruit new staff members to the site
Staff‐led visioning and initiatives
Providers identified this as a best practice site in organization‐wide survey
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Traps
Important for people to own the work ‐ clear communication, role definition, empowerment
Important to preserve a sense of teamwork across care teams – vacations, sick days, etc
Appropriate prospective staffing and scheduling really matters
Personality management – help each person to succeed
1 Year Results
RNs have taken on direct patient education for high risk patients, esp. diabetics
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“Teams can work if your whole team loves the patient as much as you do.”
Lucy Candib
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