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How Far Will the Rubber Band Stretch? Implementing New Clinical and Operational Concepts without Additional Resources Samantha Pelican Monson, PsyD, Clinical Psychologist Cheryl Palsic, BSN, RN-BC, Family Practice Nurse Lauren Gray, DO, Family Medicine Chief Resident Collaborative Family Healthcare Association 13 th Annual Conference October 27-29, 2011 Philadelphia, Pennsylvania U.S.A. Session D3 October 28, 2011 3:30-4:15 PM Slide 2 Faculty Disclosure We have not had any relevant financial relationships during the past 12 months. Slide 3 Need/Practice Gap & Supporting Resources Already strapped healthcare delivery systems are repeatedly expected to implement new cutting edge concepts without additional resources. But how??? Slide 4 Objective Process discussions (such as this presentation) can promote the creativity required to meet implementation expectations without additional resources. Slide 5 Expected Outcome You will leave with new implementation ideas for your respective healthcare delivery systems. Slide 6 Learning Assessment As we share our process with you, well be soliciting your thoughts about how it could inform your implementation approach. Slide 7 Session Agenda Introduction/OrientationIntroduction/Orientation What Stretched our Rubber Band?What Stretched our Rubber Band? Engaging Stakeholders Re-visioning of Systemic Opportunities One Step at a Time Approach Future DirectionsFuture Directions Questions/DiscussionQuestions/Discussion Slide 8 Community Health Services (CHS) Our Healthcare Delivery System Denvers public safety-net hospitalDenvers public safety-net hospital 8 FQHCs8 FQHCs 355,000+ patient visits/year355,000+ patient visits/year 20,000+ patient visits/year20,000+ patient visits/year Relationship with state refugee clinicRelationship with state refugee clinic 4-2-2 family medicine residency4-2-2 family medicine residency Slide 9 Our Practices New Concept Slide 10 Our Practices Primary Implementation Processes Division of practice into two clinical teamsDivision of practice into two clinical teams Establishment of two quality improvement (QI) teamsEstablishment of two quality improvement (QI) teams Identification of three clinically important conditions:Identification of three clinically important conditions: Diabetes Hypertension Asthma Slide 11 Green Team Green Team 3-4 Medical Providers (F-NP, MD, and DO) 3-4 Medical Providers (F-NP, MD, and DO) 3 Residents 3 Residents 1 Behavioral Health Provider 1 Behavioral Health Provider 1 RN 1 RN 3 Medical Assistants 3 Medical Assistants Part-time Patient Navigator Part-time Patient Navigator 2 Clerks 2 Clerks Diabetes as designated clinically important condition Diabetes as designated clinically important condition Our Clinical/QI Team Slide 12 Our Diabetes Clinic day per month day per month Patients = identified as uncontrolled (from registry and intra-clinic referrals)Patients = identified as uncontrolled (from registry and intra-clinic referrals) Medical Provider = initially attending with most diabetic patients, later expanded to residentMedical Provider = initially attending with most diabetic patients, later expanded to resident Behavioral health (psychologist) and diabetes education (RN) follow medical providerBehavioral health (psychologist) and diabetes education (RN) follow medical provider Lab work completed ahead of timeLab work completed ahead of time Emphasis on patient self-managementEmphasis on patient self-management Slide 13 Session Agenda Introduction/OrientationIntroduction/Orientation What Stretched our Rubber Band?What Stretched our Rubber Band? Engaging Stakeholders Re-visioning of Systemic Opportunities One Step at a Time Approach Future DirectionsFuture Directions Questions/DiscussionQuestions/Discussion Slide 14 Our Stakeholders Lowry Family Health Center Lowry Family Health Center Support Staff Clinical Providers Residents Patients Community Health ServicesCommunity Health Services Leadership Team Who are your stakeholders? Slide 15 HealthTeamWorks training HealthTeamWorks training How to run an effective meeting How to run an effective meeting Group facilitation skills Group facilitation skills QI processes & tools QI processes & tools Motivational interviewing training for all staff and providers Motivational interviewing training for all staff and providers RN joined multidisciplinary Denver Health Diabetes Collaborative RN joined multidisciplinary Denver Health Diabetes Collaborative What community/institutional programs might you access? Development Opportunities Slide 16 Slide 17 Slide 18 Medical Director and Practice Manager supported RN in becoming leader of Green Team Medical Director and Practice Manager supported RN in becoming leader of Green Team Who in your practice has untapped leadership potential? Fostering New Leaders Slide 19 Clinically important conditions identified through survey of all staff and providersClinically important conditions identified through survey of all staff and providers Clinical and QI teams responsible for own plansClinical and QI teams responsible for own plans All team members have a role in accomplishing the most important goalsAll team members have a role in accomplishing the most important goals Patient self-management Integrated behavioral healthcare Clinical outcomes How can you promote universal ownership? Sharing the Vision Slide 20 Individual Perks RN involvement allowed for promotion up her professional ladder and diversification of job duties RN involvement allowed for promotion up her professional ladder and diversification of job duties Resident involvement fit with self-identified learning objectives Resident involvement fit with self-identified learning objectives What individual rewards exist in your organization? Slide 21 Session Agenda Introduction/OrientationIntroduction/Orientation What Stretched our Rubber Band?What Stretched our Rubber Band? Engaging Stakeholders Re-visioning of Systemic Opportunities One Step at a Time Approach Future DirectionsFuture Directions Questions/DiscussionQuestions/Discussion Slide 22 Alignment with Residency P 4 Program (Preparing the Personal Physician for Practice) P 4 Program (Preparing the Personal Physician for Practice) Long-standing behavioral Long-standing behavioral science curriculum science curriculum What programs within your system could be leveraged? Slide 23 Capitalizing on Culture Denver Healths commitment to Lean Systems Improvement made QI process intuitive Denver Healths commitment to Lean Systems Improvement made QI process intuitive Minimal external behavioral health resources made the clinic hungry for integration Minimal external behavioral health resources made the clinic hungry for integration How can you join instead of change the culture? Slide 24 Balancing Costs and Benefits Absence of reimbursement for team-based care offset by institutional benefit Absence of reimbursement for team-based care offset by institutional benefit Collaborative care helpful for Collaborative care helpful for Magnet designation Staff and provider time justified by institutional initiative Staff and provider time justified by institutional initiative Denver Health was seeking PCMH National Committee for Quality Assurance (NCQA) recognition Denver Health was seeking PCMH National Committee for Quality Assurance (NCQA) recognition How could your institution benefit from your project? Slide 25 Creation of Work-Arounds Registry limitations were supplemented by development of a spreadsheet Registry limitations were supplemented by development of a spreadsheet Job duty re-allocation allowed for staff to practice at top of license on project components Job duty re-allocation allowed for staff to practice at top of license on project components Turn-over of and time restrictions on patient navigator position addressed by RN vigilance Turn-over of and time restrictions on patient navigator position addressed by RN vigilance How could your system flex around its limitations? Slide 26 Session Agenda Introduction/OrientationIntroduction/Orientation What Stretched our Rubber Band?What Stretched our Rubber Band? Engaging Stakeholders Re-visioning of Systemic Opportunities One Step at a Time Approach Future DirectionsFuture Directions Questions/DiscussionQuestions/Discussion Slide 27 Diabetes clinic began with only eight patients per monthDiabetes clinic began with only eight patients per month Anecdotal clinical improvement celebrated Anecdotal clinical improvement celebrated Patient feedback highly valued Patient feedback highly valued I dont know what it was, but something clicked in me after you all were askin me how I was gonna take care of myself. Ive totally changed how I eat, and my daughters helpin me! I dont know what it was, but something clicked in me after you all were askin me how I was gonna take care of myself. Ive totally changed how I eat, and my daughters helpin me! Around what small changes could your system build momentum? Start Small Slide 28 Regular meetings and huddles allowed for timely problem-solvingRegular meetings and huddles allowed for timely problem-solving Resident allowed to participate in diabetes QI processes and clinical initiativesResident allowed to participate in diabetes QI processes and clinical initiatives What areas of rigidity in your system could be re-considered? Be Flexible Slide 29 Session Agenda Introduction/OrientationIntroduction/Orientation What Stretched our Rubber Band?What Stretched our Rubber Band? Engaging Stakeholders Re-visioning of Systemic Opportunities One Step at a Time Approach Future DirectionsFuture Directions Questions/DiscussionQuestions/Discussion Slide 30 Applying diabetes clinic principles to standard patient careApplying diabetes clinic principles to standard patient care Broadening care focus (e.g., vision and podiatry)Broadening care focus (e.g., vision and podiatry) Making diabetes education more interactiveMaking diabetes education more interactive Increasing resident involvementIncreasing resident involvement Impacting future generations of providersImpacting future generations of providers Whats in your future? Onward! Slide 31 Session Agenda Introduction/OrientationIntroduction/Orientation What Stretched our Rubber Band?What Stretched our Rubber Band? Engaging Stakeholders Re-visioning of Systemic Opportunities One Step at a Time Approach Future DirectionsFuture Directions Questions/DiscussionQuestions/Discussion Slide 32 Questions/Discussion Slide 33 Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!