Transcript National Priorities Partnership© Acting Together to Improve Safety

The Long and
Winding Road
to PCMH
Presenters
 Laurel Domanski Diaz, MNO, Director of Business
Operations
 Dan Gauntner, CNP, Director of Clinical Operations
 Marianella Napolitano, RN, MBA, Clinical Quality
Coordinator
Objectives
 Identify all of the workflows needed to implement
PCMH
 Deep dive into NFP PCMH application
 Identify the challenge areas within the application
 Describe how to overcome the challenges presented
due to limited ability to produce needed data
NFP Background
 A Federally Qualified Community Health Center
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founded in 1980
Last year served 13,400 patients on the near west side
of Cleveland
NCQA recognized as PCMH Level 3 under 2011
standards
17 Providers on staff--7 Family Practice MDs, 6 Family
Practice CNPs, 3 Certified Nurse Midwives
Focus on the medically underserved
Serve a large Hispanic population
What is a Care Team?
 A Care Team has been defined as: A panel of patients
who usually see or choose a particular group of providers
for their care AND the group of staff who generally work
together for the care of that panel of patients.
Our Care Team Composition
 Three Providers—combination of Family MDs, Family
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CNPs, one team’s providers consists of 3 Certified
Nurse Midwives
One to two RNs
One to two Patient Advocates
Medical Assistant for each Provider
Front Office representative at each team meeting
Care Team Implementation Activities
 Developing new procedures around scheduling, registering patients &
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directing phone calls to teams.
Conducting activities around team formation, structure and ongoing
activities.
Organizing providers and support staff into integrated care teams
Redesigning of Nursing staff structure to provide individual nurses to
care teams.
Adding a Patient Advocate to each team, vital role in the PCMH model
Extended Team Support includes:
 On-site Clinical Pharmacist
 CareSource RN
 Wellness Coordinator
 Refugee Health Services
 Medication Assistance Program
 Diabetes Education
The PCMH Team & Application Plan
 Identify the PCMH Application Team
 Identify Key Application Facilitators
 Delegation of different areas of application to relevant person
 Need to have a variety of people on team, clinical and non-
clinical
 Organization of application and documents
 Tackle each section, utilizing organization’s resources as
needed
 Weekly working sessions, day long sessions as submission
time approached
Survey & Intake –
What we needed to create
 Inventory of Policies and Procedures, update the manual with
EMR implementation, focused on PCMH relevant documents
 Inventory of reports that existed, what needed to be created,
etc.
 Surveyed current workflows and determined how they needed
to change to meet the requirements:
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Patient Advocate role and new responsibilities to meet requirements
Front Office no-show work
Clinical Teams work flow around self management goals and patient education
Referral follow up process
Deep Dive Into
the PCMH Application
Element 1: Enhanced Access &
Continuity
 A—Access During Office Hours:
 Phone reporting system was used to demonstrate
volume of incoming calls that RNs used to triage patient
calls
 B—After Hours Access:
 Reports from our Answering Service that shows when
the patients called NFP and at what time NFP providers
returned the call.
After Hours Documentation
Element 1: Enhanced Access &
Continuity
 E—Medical Home Responsibilities
 CareEverywhere capabilities allowed us to demonstrate
care coordination/communication across different
settings.
 G—The Practice Team
 Standing Orders Protocol Development
 Pre-Orders Workflow Implementation (insert
workflow)
Pre-Orders Workflow
Prior to the Visit
PA identifies patients
with Chronic
Conditions
PA scrubs the chart
and enters routine
labs/immunizations
per protocol
PA calls all DM, HTN
patients to remind
them of visit and to
bring blood sugar
readings and
medications
Documentation of
pre-visit / pre-order
preparation
Day of the Visit
Team Huddles
From documentation
in EPIC, team is aware
of pre-orders
MA releases preorders during the
patient’s visit
Pre-Order Protocol
Element 2- Identify and Manage
Populations
 A—Patient Information
 Primary Caregiver is defined as the name of the Emergency
contact for patients under 18
 NFP did not identify a legal guardian/health care proxy
 D—Use Data for Population Management
 Solutions (Chronic Care, Well Child Care, Coumadin report)
 Managed Care Plans registries
 Patient Schedule for pre-natal care outreach & chronic
disease management
 No Show report within EPIC
 Televox report for daily reminders
Element 3 – Plan and Managed Care and
Element 4 – Provides Self-Care Support and Community
Resources
 3A—Implement Evidence-Based Guidelines
 Defined guidelines used and inserted screenshots of
patient charts where they were used
 Health maintenance and best practice alerts
 3B–-Identify High Risk Patients
 High Risk Definition (Solutions)
 Rosters – Ability to analyze data using excel
 3C, 3D, 4A
 NFP Patient Examples
 NCQA Manual Chart Audit option
Element 5 – Track and Coordinate Care
 5B—Referral Tracking and Follow-up
 Access to portals for other Epic providers in the region
to obtain reports
 Item 7 - Providing an electronic summary of the care
record to another provider for more than 50 percent of
referrals
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NFP provides electronic access to outside providers through
Care Everywhere – which is used by majority of healthcare
providers in region.
Element 6 – Measure and Improve
Performance
 Leadership commitment to Quality
 FQHCs: used your Quality Management Plan from your
HRSA grant
 UDS reports and trends
 Solutions reports
 Utilization measures (preventative care measures)
 Reinforcement of workflows/training
 Immunization Registries
 Make mention of any Quality Collaborative that you are
currently participating
Questions?