delivery system design

© 2004 Institute for Healthcare Improvement

Delivery System Design

Cory Sevin RN, MSN, NPNancy Gilliam

Anaheim, CaliforniaFebruary 12, 2005

HDC Learning Session 1 2005


For you all to be excited to go home and test breakthrough changes in how your care processes are designed!

Goal of the Session


Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

Functional and Clinical Outcomes

DeliverySystemDesign

Decision Support

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community

Health Care Organization

Chronic Care ModelYou are

here


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


• Clearly identified care teams for patients

• Clear roles for all team members

• Continuity

• Cleared system of chaos and waste

Observation of organizations making breakthrough outcomes shows they have……


• 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.

To Improve Outcomes:


•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

Informed,ActivatedPatient

ProductiveInteractions

PreparedPractice Team

How would I recognize aproductive interaction?


• Define roles and distribute tasks amongst team members.

• Use planned interactions to support evidence-based care.

• Provide clinical case management services.

• Ensure regular follow-up.

• Give care that patients understand and that fits their culture

Delivery System Design

Key Leverage Points!


Define roles and tasks

All team members have a role.

Leverage Point 1


• 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

Define Roles and Tasks


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


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

Examples: Roles and Tasks


Roles in Team Care

Role PCP BHC Nursing Clerical Dec Supp

Identify pts for Collab X X

Screen pts for Depression X X X

Provide pt care X X

Produce report for patients needing follow-up

X

Schedule follow-up appts X

To ensure follow-up appointments are scheduled:


Test Roles and Tasks

• PDSA the MA doing LEAP exams

• PDSA MA’s filling out forms

• PDSA the nurse calling back about some lab results

• Other ideas?

PDSA

A P

S D

APS

D

D SP A

A P

S D


Use planned interactions to support evidence-based

careOne-on-one, group, telephone,

email, outreach….the possibilities are endless

Leverage Point 2


Set up system so the default, when possible, is to provide evidence based

care, planned care.


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!


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.


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.


Potential Planned Care PDSA’s

• PDSA real time communication methods (co-location of team members, walkie talkies)

• PDSA how registry reports inform the care team

• PDSA inviting patients to a Planned Visit or a Group Visit

• Other ideas?

PDSA’s


How do you do a Planned Visit?

You Plan It!


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


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


• 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

Step Three: Preparing for the Depression Follow-up 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

Step Four: The Depression Visit


• 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.

Step 5: Depression Follow-up


Group Visits

• Patients brought in by clinically relevant groups

• Patients can receive:Specialty service as needed/availableOne-on-one with medical providerMedication counselingSelf-management support trainingSocial support

• Multiple Models for Group Visits


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


Provide clinical case management services for

complex patients.Knowing who needs more support

and finding a way to deliver it.

Leverage Point 3


Many different things to different people

• Resource coordination

• Utilization management

• Follow-up

• Patient education

• Clinical management

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

Key Changes for 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

Features of effective Casemanagement


• 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.

Who can be a casemanager?


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

Casemanagement


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.


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?


Ensure regular follow-up by the primary care team

The alternative to lost to follow-up…there is strong evidence that it makes a

big difference in chronic illness.

Leverage Point 4


• 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 follow-ups.

Make Follow-Up Work for You


• Face-to-face

• Clinical case manager

• Outreach worker

• In groups

• Phone

• E-mail

Think out of the box….


• 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

City of Austin Depression Results


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


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…..


For you all to be excited to go home and test breakthrough changes in how your care processes are designed!

Goal of the Session

delivery system design

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