Transcript Medicare Updates

Team-Based Care
Webinar #3
Population Health, Care
Management, Self Management
Support & Care Coordination
Presented to
The Community Health Center
Association of CT
Presented by
Susan Crocetti, RN &
Regina Neal, MPH, MS
March 30, 2012
Objectives
• Explore the importance of and methods necessary to use teambased care in the successful delivery of:
– understanding and acting on needs of populations of patients
– meeting the needs of patients with conditions that respond well
to evidence-based guidelines and care management
– assisting patients to partner in the successful management of
their conditions
– coordinating the care of patients and providing continuity across
various levels and transitions of care
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When Providers Work Without a Team
• Delivering all evidence-based guidelines for preventive and
chronic disease care has been estimated to take 18 hours a day
for an average sized patient panel
(Yarnall et al 2009; Alexander et al 2005)
• Most physicians only deliver 55% of recommended care, 42%
report not having enough time with their patients
(Center for Studying Health System Change 2008; Bodenheimer & Laing 2007)
• Providers are spending 13% of their day in care coordination
and only using their medical knowledge 50% of the time.
(Gottschalk 2005; Margolis & Bodenheimer 2010)
• Patient care is fragmented and patients are dissatisfied with the
level of attention they receive in primary care
(Bodenheimer 2008)
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Who is On the Team and Who Can Support
the Team?
Core Team: Provider,
MA’s, LPN’s, Clerk
Internal Resources:
RN’s, Referral Coord,
Billing Staff, Dietician,
Educators, IT Staff,
Pharmacists, SW
External Resources:
Community Health
Workers, Insurance
Nurse Disease/Case
Managers, Vendors,
Specialists, Hospitalist
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Supporting the Work of the Team
• Human Resources (core, internal and external)
• Systems (PMS, Registry, E-Rxing, HER, Portal)
• Clinical tools (flowsheets, structured notes, EMR
templates and decision support functions,
Standing orders)
• Written Standards (Job descriptions, workflows)
• Training Program
• Evaluation and Feedback
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Delivering Between Visit Support to
Populations of Patients
• Sub categories of patients by age, sex, diagnosis, etc.
are identified
• Have these patients received services as recommended
in the evidence-based guidelines or are their outcomes
in line with expectations?
• Patients who are missing these services or are not in
goal can be contacted for follow up or referred for more
intensive management
• This data can be used to understand how well we are
providing care and if we are improving
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So, How Do You Do This?
• Analyze your patient panel and community
demographics
– Demographics (Age, Sex, Race, Ethnicity, Income & Education
Level)
• PMS, registry, EMR reports
• Local census data
– Clinical Information (Diagnosis, medications, allergies, clinical
measurements
– Risk Factors (smoking, family circumstances, drug use, mental
health concerns, etc.)
• How is a team able to achieve this?
– Systems, IT resources, written training materials, admin support
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But First You Have to Capture the
Information…
• Who collects the information and is it entered
accurately?
– Allergies, risk factors, preventive service updates, etc.
can be captured by MA/LPN at beginning of visit
– Are structured (mapped) fields being used to allow
reports to be generated?
• Does someone know how to set up and run the
reports accurately and is there time dedicated to
this?
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Workflow Considerations for Comprehensive
Health Assessments
• Could patient self assessments be completed by
the patient at home prior to visit; accessible as a
form on the website or portal?
– Would require pre-visit planning and staff assigned to
mail the form or advise/remind patient to use portal
• MA’s could assist with completion and data entry
prior to provider portion of visit
• Ideal if this information is also captured as
structured data
• Define when this is done initially and when
updated (annually?)
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Choosing Clinical Measures to Monitor Your
Population
• Use National Quality Forum sanctioned measures for
standardization and benchmarking for quality
improvement
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Choose a balanced scope of measure “types”
Efficient to link with important conditions or high risk group
Consider vendor-ready MU CQM’s and UDS cross mapping
How complete or automated is the data?
• Who makes the decision at the practice? Is the team
included in the discussion and aware of the project from
the beginning? They may have valuable information to
help avoid some pitfalls.
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Reporting is the Next Step
• Setting up the technical specifications
• Provider / Team attribution – clean up those panels!
• Data Quality – team members are the key!
– Manual data entry outside of visits
• Historical data / preloading the EMR
• Outside data
– Data entry during visits
• Using correct fields for data entry / mapping issues
– Interfaces
• Mapping issues or other technical concerns (POS vs. POC results)
– Data entry errors
– Timeliness (communication between those responsible for data
entry and those running reports)
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Testing and Transparency to Improve
Quality and Maintain Trust
• Test on one team first
• Share technical specifications of reports (numerator and
denominator definitions) with providers and teams
• QA initial reports before distribution to uncover major
errors (and hold onto your credibility!)
• Give report detail to providers/teams to verify that a “No
means No” (and not a problem with how the data was
collected / report set up)
• Give feedback to teams on what you’ve learned about
the reporting process – good and bad
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Once You Have Confidence in the Reports,
Take Action – But Be Prepared
What
Who, When, How
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Phone Calls
Letters
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Personal vs. automated
Front office vs. back
block of time vs. “fit in”
centralized vs. team –
based
Vendor vs. internal
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Wrong number
HIPAA – leaving message
on VM or with another
person
How many attempts
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Wrong address
Looks like a bill
Automated errors
• Wrong address
Secure Electronic
Communication
Names distributed to team
for further action
Considerations
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Providers
Care Managers
Educators
Referral Coordinator
Patient Navigator
• Clearly define
expectations
• F/u to ensure actions
were taken
• Share ideas
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Everyone Must Be Involved in Supporting
the Team’s Population Management Work
with Contingency Plans
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Wrong letter
Deceased
Patient got the service already
Patients call but can’t get through / in (consider
timing with back to school or flu season)
• You run out of vaccine
• Staff aren’t aware of outreach and don’t know
how to handle questions or complaints
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Words of Encouragement
Scripting of outreach call or contingency responses
and
Wording of outreach letters
Get feedback from all staff so the wording is done
in a way that the patients will understand
Use this as an opportunity to remind the patients
that they are part of your team!
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Did It Make a Difference?
• Keeping track of who responded because of the
outreach – how will you know?
• Compare pre and post clinical metrics
• Ask staff and patients what they liked or didn’t
like about the initiative; get their thoughts on how
to do it better next time
• Celebrate the success of this team effort!!
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Population Management, Meet Quality
Improvement…
• If patients got the service in the first place there
would be fewer names on those lists to outreach!!
– Involve the team (and patients!) in ideas of how to get
the patient to complete the service before it’s overdue
– No such thing as a crazy idea (well, yes there is, but
it’s ok, because it might lead to an idea that’s not so
crazy)
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Moving From Population Generalized Needs
to a Focus on Individuals with Specific
Needs
• Care Management
• Assuming responsibility for the patient’s care needs
• Ensuring continuity of care
• Utilizing evidence-based guidelines as care delivery
standards
• Coordinating necessary specialty care
• Following transitions to and from care outside the practice
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© Qualis Health 2010
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Is Care Management a Position or a
Concept?
• How can a team accomplish the components with or without a
designated RN Care Manager position
– Identify criteria for intensified services; at-risk individuals
– Adopt evidence-based guidelines of care; pre-visit planning
– Establish plan of care with patient/family input, goals, assessment of progress
toward goals; exploring barriers, acting to remove barriers
– Coordinate services from all care givers to ensure continuity
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Follow-up for care provided in facilities
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Coordinate medically necessary referral services
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Facilitate proactive communication; interdisciplinary team conferences
– Disease-specific and preventive health education
– Self-management plan and support
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How to Help the Team Provide Care
Management? Choosing Guidelines and
Implementing Tools
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Prompts for services
Standing orders
Prompts for H&P
Decision support for
treatments
• Order sets
• Condition specific
flowsheets
• Patient Education
• Care Plans
• Goal setting and
assessment
• Templates in condition
specific progress notes
• Staff workflow and
training materials
• Alerts
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Mercy Clinics, Inc. Des Moines, Iowa
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Example of Written Plan of Care
Denmark D. Patient-physician partnering
to improve chronic disease care. Fam
Pract Manag. May 2004:55-56
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Self-Management Plan/Tool
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Are The Tools User Friendly?
• Consider the affect on workflows of all team
members – get their input!
• Establish the best sequence for templates and
forms
• Consolidate actions onto one screen/form or
provide links between templates or functions in
EMR for team efficiency
• Smart phrases/quick text options for efficient
documentation
• Choose key areas for prompts to avoid alert or
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“click” fatigue in EMR’s
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Sustaining Use of EMR Templates
• Allow for customization whenever possible: Users appreciate the
ability to customize applications to their own work processes and are
more likely to adopt and continue using the system if such
capabilities exist.
• Engage patients in the technology: Showing the computer screen
to the patient and collaboratively writing notes can enhance the
patient–physician interaction, thus making physicians more likely to
continue using the system. To maintain patient support for the
system, make it clear that care recommendations are based on
individual health needs.
AHRQ Health Care Innovations Exchange / Schnipper, JL McColgan KE, Linder JA, et al. Improving management of chronic
diseases with documentation-based clinical decision support: results of a pilot study. AMIA Annu Symp Proc. 2008; 1050.
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Care Coordination: Closed Loop Test
Tracking
• Ensures that results are
received, reviewed by
provider, and acted upon for
every lab or imaging test
ordered
• Who tracks depends on:
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Type of test
Where the test was performed
How results are received
Electronic systems to support
the process
• Methods include
– Fully automated order/result
reconciliation
– Partially automated reports
– Manual logs, accordion file or
spread sheets
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Situations that could result in
a test not being performed or
communicated appropriately:
• Failure to order the test
correctly
• Failure to meet insurance
coverage criteria
• Failure to contact and
schedule the patient for
test
• Failure of the patient to
show up for test
• Technical issue resulting
in incomplete testing
(QNS, for example)
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Communicating Test Results
• Normal & abnormal results
• Establish timeframe for communicating to
patients and let them know what to expect
• Proactive vs. reactive communication
• Who is responsible?
– EMR workflow can be standardized so that as
provider signs off on labs, a patient letter is created,
routed to the MA who prints and mails at the end of
the day
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Closed Loop Referral Tracking
Ensures that the patient
completed a visit and a note
was received back from the
specialist each time a specialty
referral given to the patient
Who does this, does type of
referral matter?
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Coordinating Transitions of Care
• How do you know there has been
an ER visit or hospitalization?
• Coordination with other care
facilities (rehab, SNF, etc.)
• Transfer to new PCP
• Transition from pediatric service to
adult medicine
• Who does this and when?
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When Will the Care Management Services
Be Delivered?
• What staff are qualified and available?
– RN’s for complex patients
– LPN’s and MA to follow specific guidelines approved
by providers and RN’s for preventive, straight forward
education and management
• When can these services be provided?
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Incorporating into visit cycle
Exploring alternative visit types
Telephonic consultation
Mailings
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Pre-visit Planning
• Care Coordinator reviews :
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Health Maintenance services due
Medication Reconciliation Records
Lab Log to determine outstanding labs
Referral Log to determine outstanding consults
Complex Needs to be referred internal or external
Huddles used for focused communication on
the day of the visit
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Incorporating Care Management By The
Team Into The Visit Cycle
• Before the Provider Portion of the Visit
- PCP, demographics, missing reports, preventive services, risk
factors, med rec, test & referral tracking, SMS, basic pt ed,
agenda
• During the Provider Portion of the Visit
– Assess, diagnose, care plan, deliver services
• After the Provider Portion of the Visit
– Reinforce care plan and SMS plan, complex education and SMS
by others
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In Between Visits is KEY!!
• In Between Visits
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Population management reports & outreach
Data entry
QA of reports
F/u phone calls
Pre-visit planning
Test & referral tracking
Communication of test results
F/u after transitions
Establishing external resources and community services
Enhance technology
Training & standard development!
How do you manage to get this done with a full day of
patients?
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Alternative Visit Option: Planned Care Visit
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Visit is structured similar to a physical exam
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Interval determined by condition
Tightly choreographed agenda so nothing is missed
Follow up phone call
Multi-disciplinary to bring in other perspectives
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Nutrition
Exercise
Pharmacist
Daily huddle is essential to efficient planned care
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Annual Planned Exam Workflow
• One month prior to appointment: Letter to the patient
with lab slips and notification of other Health
Maintenance requirements
• Three weeks prior to appointment: MA contacts
patient to schedule routine testing (e.g., mammogram,
bone density, etc.)
• One week prior to appointment: Patient has labs
drawn
• Two days prior to appointment: Place appointment
reminder call to patient and remind them to bring patient
questionnaire and medication list (better yet,
medications) with them
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Shared Medical Appointment
A shared medical appointment, also known as a
group visit, is a 90-minute visit when multiple
patients are seen as a group for follow-up, routine
or consult care.
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Team Based Care Delivered in a Shared
Medical Appointment or Group Visit
• Open more access to patients to be cared for by
the team
• Improves productivity and enhances efficiency
of a healthcare team
• Enhance the patient’s visit by offering a
therapeutic approach – time for education and
self management support
• Patients teach patients by sharing experiences
and helpful information who may be dealing
with the same issues
• Agenda setting is more flexible and the pace of
the visit is more relaxed
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Provider Support or Nurse Visits
• Used for follow up such as:
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Blood pressure rechecks
Vaccines given in a series
Hearing and vision screening
Patient teaching
Anticoagulation management
Others?
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Questions??
Just one more
outreach call….
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