Transcript Patient Centered Medical Home Quality Patient Care In The

2011 Patient Centered
Medical Home
Monthly Webinar Series
PCMH and
Coordinated Care:
A Team Based Approach
February 16, 2011
12:15 – 1:15 pm
Bob Lyon MD
Annette Gagnon BSN
Problem
Consider the following patient…
• 55 yr. old female with DM, HTN
• Everyday she needs to :
-Take insulin, other medications, record
BS’s
-Follow a diabetic and low salt diet
-Exercise
-Monitor and respond to her symptoms
-Carry on with other daily responsibilities
as best as she can
M Heisler
The Problem
Consider the following doctor…
• 48 yr. old physician with a panel of 1500
patients
• Each day they need to spend:
-7.4 hours providing recommended
Preventive Care
-10.6 hours following recommended
chronic care guidelines
-Address the acute care needs of their
patients
M. Heisler
Current State of Chronic Disease
Management
• 100 million Americans have a chronic
disease
• 80% health care costs
• Only 50% of those with chronic illnesses
get accepted treatments
• <50% have satisfactory levels of disease
control
• Physicians and patients are frustrated with
state of chronic disease management
M Heisler
What does work?
• Cochrane Collaborative review of trials of
System change interventions
• 40 studies – mostly randomized
• Interventions classified as decision support,
delivery system design, information systems,
self management
• 19/20 studies which included self management
support showed improved outcomes
• All 5 studies with all 4 domains showed
improved outcomes
Renders et al, Diabetes Care,
2001:24:182
Bodenheimer,Wagner,
Grumbach, JAMA 2002; 288:1910
Coordinating Care: What Does it
Mean?
1. Know your patient – Population
management and registries
2. Proactively engage your patient
3. Educated patients and staff on “Self
Management” principles
4. Clear roles for team members – for
internal and external coordination of care
5. Systems in place to evaluate team
functioning and outcomes
Know your patients: Registries
• The first and most important step is to
develop an ACCURATE, READER
FRIENDLY, REPRODUCIBLE registry
• It should be:
-Physician specific
-Contain patient specific data
-Compare to peer and national standards
-Updated at frequent intervals
Develop Clear Team Roles:
• DM team – MD, MA, RN
MA – Assures labs, vaccinations, referrals,
appointments, planned visits all through
the use of Standing Orders
RN – Provides education, interval f/u,
medication adjustments, f/u of self
management goals (case management).
MD – Sets the agenda and prioritizes patient
care issues
Patient Self Management
• Staff education on Motivational
interviewing, coaching, goal setting, action
plans and stages of change theory
• Advance “self management” principles for
patients with monthly group visits in DM
• Connect with community resources
(YMCA Stanford model, Living Well
through AHEC)
RN Care Coordinator
• 60% FTE position whose sole responsibility is to
develop Patient Care Plans with Physician
input. This includes:
- Education
- Motivational Interviewing
- Stages of Change behavioral assessment
- Actions plans/goal setting
- Case management
- Connection with community resources
- Follows up on health status changes- i.e.
admissions
MA binder
• Contains registry of patients who need
chronic disease management or
preventive screening (mammograms,
colon cancer screening, immunizations)
Preventive Screening Rates
80
70
CCR Screen
60
Mammography
Pneumovax
50
40
July, Jan, April, July, Sept, Dec, March, June, Sept. Dec.,
2008 2009 2009 2009 2009 2009 2010 2010 2010 2010
Examples of External Care
Coordination
• Referrals
• Inpatient care
• Laboratory testing follow up
Systems needed for Care
Coordination
•
Central source of information for all team
members
1) Data Flowsheet
2) Care Plan management EHR template
Where do you get the time?
• Q 2 mths, registry data and team meeting
• 30 minutes every 2 months during patient care
time the RN and MD get together to develop
Care Plans for high risk patients. (5-7)
• Warm handoffs during patient visits
• Follow up and documentation is done through
the EHR workflow and Care Plan Templates
• Is there a loss of Revenue?
How to develop effective
teams?
• Chronic disease management and PCMH
education to entire staff
• Culture shift must occur from physician
centered episodic care to team centered,
continuous and patient centered care
• Regular team meetings to distribute data
and outcomes, review difficult cases and
assess team processes and functioning –
every 2 months
Practical tools
• Chronic disease and prevention
registries – example of MA binder with
DM, Mammography, Colon cancer
screening and influenza and pneumovax
• Standing orders – Labs, immunizations,
mammograms, colonoscopy or FOBT,
referrals (DM eye exams), office visits.
Practical tools
• Centralized access to disease and care
plan templates
• Stratification of patients by risk –
HgA1c>9, or BP >160/100
• Utilization of Community resources –
YMCA, AHEC Living Well, etc.
• Team Incentives, awards and recognition
Our results- after 14 months
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600 patients, 70% Mcaid, uninsured
HgA1c: 8.86 to 7.97
HgA1c in past 12 months 64% to 79%
LDL in past 24 months 71% to 82%
LDL <100 32% to 41%
Pneumovax rate- 61% to 80%
BP <130/80 34% to 37%
Key Points
• Take things that don’t require an MD degree out
of physicians hands – Standing orders
• Define team members roles and responsibilities
• Educate entire staff to create a culture of team
based patient centered care - Ownership
• Make sure registry data is accurate and easily
accessible to all team members
• Make time to meet
• Incentivize success
References
Coleman EA, Eilertsen TB, Kramer AM, Magid DJ, Beck A, Conner D.
Reducing emergency visits in older adults with chronic illness: a
randomized controlled trial of group visits. Effective Clinical Practice
2001;4(2):49-57.
McCulloch DK, Price MJ, Hindmarsh M, Wagner EH. A populationbased approach to diabetes management in a primary care setting:
early results and lessons learned. Effective Clinical Practice
1998;1(1):12-22.
The Robert Wood Johnson Foundation. Improving Chronic Illness Care
Program: Group Visit Starter Kit.
http://www.improvingchroniccare.org/improvement/docs/startkit.doc
Accessed 4 March 2004.
Wagner EH, Grothaus LC, Sandhu N, Galvin MS, McGregor M, Artz K,
et al. Chronic care clinics for diabetes in primary care: a systemwide randomized trial. Diabetes Care 2001;24(4):695-700.
http://www.improvingchroniccare.org/downloads/group_visit_starter_kit
_copy1.doc
End of PowerPoint
Presentation
210 Green Bay Road
Thiensville, WI 53092
Phone: (262) 512-0606
Email: [email protected]
www.wafp.org/pcmh
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