How Far Will the Rubber How Far Will the Rubber Band Stretch?Band Stretch?

Implementing New Clinical Implementing New Clinical and Operational Concepts and Operational Concepts

without Additional without Additional ResourcesResources

Samantha Pelican Monson, PsyD, Clinical Samantha Pelican Monson, PsyD, Clinical PsychologistPsychologist

Cheryl Palsic, BSN, RN-BC, Family Practice NurseCheryl Palsic, BSN, RN-BC, Family Practice Nurse

Lauren Gray, DO, Family Medicine Chief ResidentLauren Gray, DO, Family Medicine Chief ResidentCollaborative Family Healthcare Association 13th Annual Conference

October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

Session D3October 28, 20113:30-4:15 PM

Faculty DisclosureFaculty Disclosure

We We have nothave not had any relevant had any relevant financial relationships during the financial relationships during the

past 12 months. past 12 months.

Need/Practice Gap & Need/Practice Gap & Supporting ResourcesSupporting Resources

Already strapped healthcare delivery Already strapped healthcare delivery systems are repeatedly expected to systems are repeatedly expected to

implement new cutting edge implement new cutting edge concepts without additional concepts without additional

resources.resources.

But how??? But how???

ObjectiveObjective

Process discussions (such as this Process discussions (such as this presentation) can promote the presentation) can promote the

creativity required to meet creativity required to meet implementation expectations without implementation expectations without

additional resources.additional resources.

Expected OutcomeExpected Outcome

You will leave with new You will leave with new implementation ideas for your implementation ideas for your respective healthcare delivery respective healthcare delivery

systems.systems.

Learning AssessmentLearning Assessment

As we share our process with you, As we share our process with you, we’ll be soliciting your thoughts we’ll be soliciting your thoughts about how it could inform your about how it could inform your

implementation approach.implementation approach.

Session AgendaSession Agenda

• Introduction/OrientationIntroduction/Orientation• What Stretched our Rubber Band?What Stretched our Rubber Band?

– Engaging StakeholdersEngaging Stakeholders– Re-visioning of Systemic OpportunitiesRe-visioning of Systemic Opportunities– ““One Step at a Time” ApproachOne Step at a Time” Approach

• Future DirectionsFuture Directions• Questions/DiscussionQuestions/Discussion

Community Health Services (CHS)

Community Health Services (CHS)

Our Healthcare Delivery Our Healthcare Delivery SystemSystem• Denver’s public safety-net Denver’s public safety-net

hospitalhospital

• 8 FQHCs8 FQHCs• 355,000+ patient 355,000+ patient

visits/yearvisits/year• 20,000+ patient 20,000+ patient visits/yearvisits/year

• Relationship with Relationship with state refugee state refugee clinicclinic

• 4-2-2 family 4-2-2 family medicine medicine residencyresidency

Our Practice’s New Our Practice’s New ConceptConcept

Our Practice’s Primary Our Practice’s Primary Implementation Implementation

ProcessesProcesses• Division of practice into two clinical Division of practice into two clinical

teamsteams• Establishment of two quality Establishment of two quality

improvement (QI) teamsimprovement (QI) teams• Identification of three clinically Identification of three clinically

important conditions: important conditions: – DiabetesDiabetes– HypertensionHypertension– AsthmaAsthma

• Green TeamGreen Team• 3-4 Medical Providers (F-NP , MD, and 3-4 Medical Providers (F-NP , MD, and

DO)DO)• 3 Residents3 Residents• 1 Behavioral Health Provider 1 Behavioral Health Provider • 1 RN1 RN• 3 Medical Assistants3 Medical Assistants• Part-time Patient NavigatorPart-time Patient Navigator• 2 Clerks2 Clerks

• Diabetes as designated clinically Diabetes as designated clinically important conditionimportant condition

Our Clinical/QI TeamOur Clinical/QI Team

Our “Diabetes Clinic”Our “Diabetes Clinic”

• ½ day per month ½ day per month • Patients = identified as uncontrolled Patients = identified as uncontrolled

(from registry and intra-clinic referrals)(from registry and intra-clinic referrals)• Medical Provider = initially attending Medical Provider = initially attending

with most diabetic patients, later with most diabetic patients, later expanded to residentexpanded to resident

• Behavioral health (psychologist) and Behavioral health (psychologist) and diabetes education (RN) follow medical diabetes education (RN) follow medical providerprovider

• Lab work completed ahead of timeLab work completed ahead of time• Emphasis on patient self-managementEmphasis on patient self-management

Session AgendaSession Agenda

• Introduction/OrientationIntroduction/Orientation• What Stretched our Rubber Band?What Stretched our Rubber Band?

– Engaging StakeholdersEngaging Stakeholders– Re-visioning of Systemic OpportunitiesRe-visioning of Systemic Opportunities– ““One Step at a Time” ApproachOne Step at a Time” Approach

• Future DirectionsFuture Directions• Questions/DiscussionQuestions/Discussion

Our StakeholdersOur Stakeholders

• Lowry Family Health CenterLowry Family Health Center– Support StaffSupport Staff– Clinical ProvidersClinical Providers– ResidentsResidents– PatientsPatients

• Community Health Services Community Health Services – Leadership TeamLeadership Team

Who are your stakeholders?Who are your stakeholders?

• HealthTeamWorks trainingHealthTeamWorks training•How to run an effective meetingHow to run an effective meeting•Group facilitation skillsGroup facilitation skills•QI processes & toolsQI processes & tools

• Motivational interviewing training for all staff Motivational interviewing training for all staff and providersand providers

• RN joined multidisciplinary Denver Health RN joined multidisciplinary Denver Health Diabetes CollaborativeDiabetes Collaborative

What community/institutional programs might What community/institutional programs might you access?you access?

Development Development OpportunitiesOpportunities

• Medical Director and Practice Medical Director and Practice Manager supported RN in becoming Manager supported RN in becoming leader of Green Teamleader of Green Team

Who in your practice has untapped Who in your practice has untapped leadership potential?leadership potential?

Fostering New LeadersFostering New Leaders

• Clinically important conditions identified Clinically important conditions identified through survey of all staff and providersthrough survey of all staff and providers

• Clinical and QI teams responsible for own Clinical and QI teams responsible for own plansplans

• All team members have a role in All team members have a role in accomplishing the most important goalsaccomplishing the most important goals– Patient self-management Patient self-management – Integrated behavioral healthcareIntegrated behavioral healthcare– Clinical outcomesClinical outcomes

How can you promote universal ownership?How can you promote universal ownership?

Sharing the VisionSharing the Vision

Individual PerksIndividual Perks

• RN involvement allowed for RN involvement allowed for promotion up her professional promotion up her professional ladder and diversification of job ladder and diversification of job dutiesduties

• Resident involvement fit with self-Resident involvement fit with self-identified learning objectivesidentified learning objectives

What individual rewards exist in your What individual rewards exist in your organization?organization?

Session AgendaSession Agenda

• Introduction/OrientationIntroduction/Orientation• What Stretched our Rubber Band?What Stretched our Rubber Band?

– Engaging StakeholdersEngaging Stakeholders– Re-visioning of Systemic OpportunitiesRe-visioning of Systemic Opportunities– ““One Step at a Time” ApproachOne Step at a Time” Approach

• Future DirectionsFuture Directions• Questions/DiscussionQuestions/Discussion

Alignment with Alignment with ResidencyResidency

• PP44 Program (Preparing the Personal Program (Preparing the Personal Physician for Practice) Physician for Practice)

• Long-standing behavioral Long-standing behavioral science curriculumscience curriculum

What programs within your system could What programs within your system could be leveraged?be leveraged?

Capitalizing on CultureCapitalizing on Culture

• Denver Health’s commitment to Lean Denver Health’s commitment to Lean Systems Improvement made QI Systems Improvement made QI process intuitiveprocess intuitive

• Minimal external behavioral health Minimal external behavioral health resources made the clinic “hungry” resources made the clinic “hungry” for integrationfor integration

How can you join instead of change the How can you join instead of change the culture?culture?

Balancing Costs and Balancing Costs and BenefitsBenefits

• Absence of reimbursement for team-based Absence of reimbursement for team-based care offset by institutional benefitcare offset by institutional benefit• Collaborative care helpful for Collaborative care helpful for

Magnet designationMagnet designation

• Staff and provider time justified by Staff and provider time justified by institutional initiativeinstitutional initiative• Denver Health was seeking PCMH National Denver Health was seeking PCMH National

Committee for Quality Assurance (NCQA) Committee for Quality Assurance (NCQA) recognitionrecognition

How could your institution benefit from your How could your institution benefit from your project?project?

Creation of Work-Creation of Work-AroundsArounds

• Registry limitations were supplemented by Registry limitations were supplemented by development of a spreadsheetdevelopment of a spreadsheet

• Job duty re-allocation allowed for staff to Job duty re-allocation allowed for staff to practice “at top of license” on project practice “at top of license” on project componentscomponents

• Turn-over of and time restrictions on patient Turn-over of and time restrictions on patient navigator position addressed by RN vigilancenavigator position addressed by RN vigilance

How could your system flex around its How could your system flex around its limitations?limitations?

Session AgendaSession Agenda

• Introduction/OrientationIntroduction/Orientation• What Stretched our Rubber Band?What Stretched our Rubber Band?

– Engaging StakeholdersEngaging Stakeholders– Re-visioning of Systemic OpportunitiesRe-visioning of Systemic Opportunities– ““One Step at a Time” ApproachOne Step at a Time” Approach

• Future DirectionsFuture Directions• Questions/DiscussionQuestions/Discussion

• Diabetes clinic began with only eight patients per Diabetes clinic began with only eight patients per monthmonth

• Anecdotal clinical improvement celebratedAnecdotal clinical improvement celebrated• Patient feedback highly valuedPatient feedback highly valued• ““I don’t know what it was, but something clicked in me I don’t know what it was, but something clicked in me

after you all were askin’ me how I was gonna take care after you all were askin’ me how I was gonna take care of myself. I’ve totally changed how I eat, and my of myself. I’ve totally changed how I eat, and my daughter’s helpin’ me!”daughter’s helpin’ me!”

Around what small changes could your system build Around what small changes could your system build momentum?momentum?

Start SmallStart Small

• Regular meetings and huddles Regular meetings and huddles allowed for timely problem-solvingallowed for timely problem-solving

• Resident allowed to participate in Resident allowed to participate in diabetes QI processes and clinical diabetes QI processes and clinical initiativesinitiatives

What areas of rigidity in your system What areas of rigidity in your system could be re-considered?could be re-considered?

Be FlexibleBe Flexible

Session AgendaSession Agenda

• Introduction/OrientationIntroduction/Orientation• What Stretched our Rubber Band?What Stretched our Rubber Band?

– Engaging StakeholdersEngaging Stakeholders– Re-visioning of Systemic OpportunitiesRe-visioning of Systemic Opportunities– ““One Step at a Time” ApproachOne Step at a Time” Approach

• Future DirectionsFuture Directions• Questions/DiscussionQuestions/Discussion

• Applying diabetes clinic principles to Applying diabetes clinic principles to standard patient carestandard patient care

• Broadening care focus (e.g., vision and Broadening care focus (e.g., vision and podiatry)podiatry)

• Making diabetes education more interactiveMaking diabetes education more interactive• Increasing resident involvementIncreasing resident involvement• Impacting future generations of providersImpacting future generations of providers

What’s in your future?What’s in your future?

Onward!Onward!

Session AgendaSession Agenda

• Introduction/OrientationIntroduction/Orientation• What Stretched our Rubber Band?What Stretched our Rubber Band?

– Engaging StakeholdersEngaging Stakeholders– Re-visioning of Systemic OpportunitiesRe-visioning of Systemic Opportunities– ““One Step at a Time” ApproachOne Step at a Time” Approach

• Future DirectionsFuture Directions• Questions/DiscussionQuestions/Discussion

Questions/DiscussionQuestions/Discussion

Session EvaluationSession Evaluation

Please complete and return thePlease complete and return theevaluation form to the classroom evaluation form to the classroom

monitor before leaving this session.monitor before leaving this session.

Thank you!Thank you!