Transcript Building the Right Generalist Team for the Right Prevention Care

Building the Right Generalist
Team for the Right Prevention
Care
Mike Davies MD FACP
Mark Murray and Associates
The two ways to improve are…
• Increase speed
• Improve reliability
• Clinical care is about both speed and
reliability: “…the right care…at the right
time…..”
What is “Primary Care”?
…Responsible for providing or coordinating
the majority of the patient’s care…
Panel Size 2000
66 have Diabetes
360 Patients are
Over 65
113 have Asthma
60 Patients had
more than 10 Office
Visits Last Year
248 have Arthritis
130 are Clinically
Depressed
228 have
Hypertension
160 have Heart
Disease
Operational and Clinical Teams
Clinical Teams: What to do?
Far from agreement on
WHAT to do (what
prevention and chronic
disease guidelines to
implement)
XX
Far from agreement on
HOW to do it (how to
implement guidelines, how
to support provider’s
efficiency)
Close to Agreement
Operational Teams: How to do it?
XX
Learning's
• The RIGHT care prolongs and enhances
lives
• The best centers have teams of people
partnering to deliver the right care
• The best clinics measure their own
performance
• The best clinics compare their
performance to others to find the best
ideas for improvement
Quandary
• How to assure prevention care is done for every
patient in the panel
• How to adapt the clinic processes to changing
recommendations
• How to do it efficiently
Questions
• Are we responsible for prevention of
illness in our patients?
• Do we do it?
• Do we do it well?
• Do we measure it?
• Are patients aware of their own prevention
results?
• Are patients queued to ask for their
prevention care?
WHAT prevention care should
we provide?
Society Recommendations –
Chinook Recommendations –
Other Options
Case
• A 61 year old female presents to your office for her
yearly physical examination. She has no significant past
medical or surgical history and currently uses no
medications. She denies alcohol intake greater than 2
glasses of wine per day and smokes currently 1ppd for
at least 35 years. On review of your chart, there is a
family history of postmenopausal breast cancer. She is
mildly overweight (greater than 5% but less than 15%
above ideal body weight).
Which of the following would be
appropriate at this office visit
(Recommended)?
A.
B.
C.
D.
E.
Screening Fasting Plasma Glucose
TSH screening
Pneumococcal Vaccination
Hepatitis B Vaccination
Counseling on Seat Belt use
Which of the following screenings would not be
recommended without reservations for this patient?
A.
Bilateral Mammograms
B.
Pap Smear for cervical cancer screening
C.
DEXA scan for osteoporosis screening
D.
Lipid screening
E.
Chest X-ray for pulmonary nodules given her smoking
history
Preventative Services
Recommendations
From USPSTF and others as
summarized by Loyola Medical
School for Adults
• Health Guidance
• Immunizations/Chemoprophylaxis
• Screening
Health Guidance
…some organizations recommend
counseling
• Sexual Behavior/AIDS
(esp. adolescents)
• Violence and Gun Use
• Family Planning
• Folate Use in Women
(preconception counseling)
Health Guidance
•
•
•
•
•
•
Smoking
Diet
Exercise
Injuries/Motor vehicle accidents
Alcohol and Drug Use
Aspirin Use for Primary Prevention of MI
Did Not Receive Counseling About
Exercise and Diet in Past Year
Base: Adults with chronic health condition
75
50
45
50
36
36
31
29
25
0
AUS
CAN
GER
2005 Commonwealth Fund International Health Policy Survey
NZ
UK
US
Adult Immunizations
•
•
•
•
•
•
•
Tetanus-Diphtheria
Pneumococcal
Influenza A
Hepatitis B
Hepatitis A
MMR
Vericella
Screening for Disease
•
•
•
•
•
Cardiovascular
Oncologic
Endocrine
Vision/Hearing
Oral Examination
Cardiovascular
• Hypertension – BP Q 1-2 yrs
• Abdominal Aortic Aneurysm - Men >65 with
history of any tobacco use
•
•
•
•
Carotid Artery Disease - no
Coronary Artery Disease – no ETT
Peripheral Vascular Disease - no
Dyslipidemia - Total non fasting cholesterol for
men 35-65 and women 45-65.
Screening for Endocrine Diseases
• Diabetes Mellitus
– Individuals with “high clinical risk” (Class II)
– Cardiovascular disease (Class I)
• HTN or Dyslipidemia
– Strong family history (Class II)
– Obesity (Class III or Stage I)
• Thyroid Disease – Indeterminate Recc.
– Screening is effective, treatment available
– Unsure of long term effects of over treatment and
asymptomatic diseas
• Osteoporosis - Routine DEXA scan is recommended
by USPFTS every three years, except in some higher risk
populations should be yearly.
Oncologic Diseases
• Ovarian using ultrasound PPV is 2.6% with per
100,000 screened 40 TP, 5398 FP and 160 laparotomy
complications
• Testicular
if 1500 male patients in practice would see 1 case
every 20 years
•
•
•
•
Lung – no reccs
Pancreatic – no reccs
Bladder – periodic UA after 60
Skin – “sun” counseling
Oncologic Diseases
• Breast – many organizations: Screening
Mammography and Clinical Breast exam in
women ages 50-69.
• Cervical – common reccs: Screening Pap
Smears at age 18 or sexually active then every 3
years until age 65.
• Colorectal – screen: FOBT, Sigmoid, or
Colonoscopy
• Prostate - Education
Another way to approach
screening: Tests and Exam
Tests:
• BP, Height and Weight, Cholesterol, Hearing,
Mammograms, Pap smear, PSA, FOBT or
Sigmoidoscopy or Colonoscopy, Urinalysis
Exam:
• Dental, Eye, Breast, Cancer exams (thyroid,
oral, ovaries, testicles, lymph nodes, rectum,
prostate
• Orals are questionable but no harm,
• vision biyearly if no impairment
Women’s Preventive Care Guide
Women’s Prevention Tests
Men’s Prevention Issues
Men’s Prevention Tests
Healthy People 2010
•
•
•
•
•
•
•
•
•
•
Physical Activity
Overweight and Obesity
Tobacco Use
Substance Abuse
Responsible Sexual Behavior
Mental Health
Injury and Violence
Environmental Quality
Immunization
Access to Health Care
Clinical Care: Possible Choices
• Prevention
– Flu Vaccination
– Pneumonia
Vaccination
– Breast Cancer
– Cervical Cancer
– Colon Cancer
True
Positives
F/U Positives
Screen
All
Of
The
Panel
For
A
Few
Things
Prevention and
Screening
Entire Panel
Screen some of panel for everything
Clinical Teams: What to do?
Operational and Clinical Teams
Close to agreement on WHAT
to do in
Prevention
Far from agreement on
HOW to do it (how to
implement guidelines, how
to support provider’s
efficiency)
XX
Close to Agreement
Operational Teams: How to do it?
XX
Team
Doctor’s Office Has a Nurse
Regularly Involved in Care Management
Base: Adults with chronic disease
Percent have nurse involved
75
50
25
52
47
41
36
16
19
AUS
CAN
0
GER
2005 Commonwealth Fund International Health Policy Survey
NZ
UK
US
Options
•
•
•
•
What
Don’t do any prevention
Do prevention sporadically
Do prevention systematically with few topics
Do prevention systematically with all topics
•
•
•
•
HOW
Doctor does it all
RN or LPN does it all
MA does it all
Team splits the work
Options
•
•
•
•
None
Sporadically
Systematically – few
Systematically - all
• MA
• Nurse
• Doc/Provider
Options
• Systematically – few
• Systematically - all
•
•
•
•
MA
LPN
RN
Doc/Provider
Financial Implications of Team
Choices
MA? LPN? RN? APN?
Variables…
• How much work is there?
• What level of staff is needed to do the
work? (and who is paying the bill!?)
• What is the process for doing the work?
– Supplement
– Substitute
• What tools are needed to do the work?
Prevention Bundle (5 topics)
as an example…..
Prevention Bundle Topics
– Flu Vaccination
– Pneumonia Vaccination
– Breast Cancer
– Cervical Cancer
– Colon Cancer
Prevention Bundle Tasks
• Assess compliance with prevention bundle
(Immunization and Cancer Screening Care)
• Provide Care
– Do Screening Exam (breast, cervical)
– Educate on options (for colon cancer screen)
(FOBT, Flex Sig, or Colonoscopy) and choose
one
– Order or provide appropriate test
• Document Care
Time for Each Task (Estimate)
Tasks
Time (min)
Assess
2
Exam
10
Educate
4
Order
2
Document
2
Total
20
Who Could Perform Tasks?
Tasks
Provider
APN
RN
LPN
Assess
X
X
X
Exam
X
X
Educate
X
X
X
X
Order
X
X
X*
X*
Document
X
X
X
X
MA
X
* = under protocol
X
Thought Experiment….Doc
• Doc does it all
– Cost = Doc time @ $1.42/min X 20 min= $28.40
– Doc doing work someone else could do! (Not doing
other high value work)
– Quality good
– Access may be poor for other patients
– Income ++ for pay-by-visit
– Income – - for pay-by-panel
– Time spent relatively low value (others could do it)
Thought experiment….Nurse
• Nurse does it all
– Cost = Nurse time @ $0.66/min X 20 min = $13.20
– Nurse not able to do all parts of the work
(order/interpret)…although APN may…..
– Quality presumably good
– Access to doc probably better
– Value of doc visits probably higher
– Access to nurse may be poor if not enough nurses
Thought Experiment MA
• MA does it all
– Cost = MA time @ $0.24/min X 20 = $4.80
– MA cannot do all parts of the work (assess, or
order tests)
– Quality poor since all tasks not completed
– Access to doc and nurse both probably better
if MA takes some of work away
– Value of doc and nurse time both higher
Who Should Perform Tasks?
Assuming everyone performs at highest level..
Tasks
Provider
APN
Assess
Exam
X
RN
LPN
MA
X
X
X
Educate
X
Order
X*
Document
X
X
X
* = under protocol
Team Cost
Tasks
Time (min)
Cost
Total Cost
Assess
2
0.24 * 2
0.48
Exam
10
1.42 * 10
14.20
Educate
4
0.44 * 4
1.70
Order
2
0.44 * 2
0.88
Document
2
1.42 *1 +
0.24 * 1
1.66
Total
20
18.92
Bottom Line Prevention Bundle
Cost Comparison
Time (min)
Cost ($)
Quality
Access
Doc Alone
Team
20
28.40
Good
Less
20
18.92
Good
More
Assuming 400 Panel Patients
• 400 patients X $10 savings = $4000
• 10 min Doc savings X 14.20 X 400 =
$5680
• Total improvement in $ = 9680
Time (min)
Cost ($)
Quality
Access
Doc Alone
Team
20
28.40
Good
Less
20
18.92
Good
More
Prevention Example: Process
Prevention Process: Option 1
History and
Physical
Appointment
Patient Calls
Receptionist
Nurse
or
MD
Treatment
Go to lab
Lab for
tests
Follow-up
Prevention Process: Option 2
Process: Option 3
Receptionist
Assess
Document
Nurse
Educate
Order
Document
Doc
Exam
Document
Process and Tasks linked
• Substitute
– Team members can do much of prevention
care
– Not possible to do independent of provider
• Supplement
– Only option
Clerk/MA
Old
• Update demographics
• Make appointments
• Answer phone and
refer calls
New
• Manage demand in
concert with team
• Assist with prevention
and chronic illness
care (health prompts)
• Collect D/S/SU info
Nurse
Old
• Check in patients
• Take VS
• Room patients
New
• Screen for prevention
• Screen for chronic
disease
• Order by protocol
• Basic patient education
• F/U phone calls for panel
patient tests
• Field phone calls and
give advice
Doctor’s new role
•
•
•
•
•
•
Evaluate and manage acute illness
Coordinate care for chronic patients
Promote prevention and wellness
Interact with other team members
Manage patients with non-visit care
Maintain access
Primary Care Core Competencies
•
•
•
•
•
•
•
•
. Screen blood pressure and recommend further evaluation if elevated. For
confirmed high
blood pressure, offer diet and exercise recommendations.
2. Diagnose and manage simple infectious diseases using commonly
recognized treatment standards. This would include such diseases as: a.
upper respiratory infections b. pharyngitis c. gastroenteritis (uncomplicated,
short-term diarrhea and/or vomiting) d. urinary
tract infections.
3. Be familiar with preventive medicine guidelines and be able to advise
patients about necessary procedures/tests based on the CIPS preventive
medicine screen. This would include reminding patients about flu shots,
mammograms, flexible sigmoidoscopy, etc, and
ordering as appropriate. "
4. Recognize alcoholism, cigarette addiction, substance abuse, depression,
and domestic
violence/sexual abuse and refer for appropriate management.
Indiana Hospital Prevention and
Chronic Disease Solutions
• Expand CM Activities to All Support Staff :
Function
Vital sign monitoring
Accuchek
Clinical guideline screening
Administring medications
Nursing assessment
Telehealth monitoring
Ordering medications
Medical
Assistant
X
X
X
LPN
X
X
X
X
RN
X
X
X
X
X
X
APN CM
X
X
X
X
X
X
X
Prevention Example: Space
Indiana Room Turnover Project
Calls Patient
Exam Room
Check-in
Exam Room
Exam Room
Provider
Charting
RN Station
Exam Room
Exam Room
Exam Room
Exam Room
Exam Room
Exam Room
Exam Room
Exam Room
Exam Room
Exam Room
Exam Room
Exam Room
“6+ Miles per Day”
Procedures
In My Experience…
• Doc responsible for all prevention care
• Doctor’s participation is:
– Choose topics
– Design process
– F/U positives
• Nurse and/or MA does majority of
prevention care
• Measurement and feedback regularly
occur
Tele-Eye Outcomes
• 68% reduction in demand for
diabetic eye exams in Eye
Clinic
– 93% of Primary Care Exams do
not require Eye clinic follow-up
• Increased diabetic screening
rate
75%  91% completed annual
exam
• Reduced eye clinic waiting time
80 days  11 days
The Future
Telehealth Overview
Tele-homecare
Peripheral
Devices
Data Analysis
&
Data Storage
Telehealth
Monitor
Case Manager
Reviews on
VA PC
Telephonic
Follow-up of
Alerts
Case Manager
Reviews on VA
PC
Group Visioning Exercise
• Split up into new groups
• Introduce each other
• Design the ideal prevention care clinic
– Choose topics
– Sketch out process
– Assign tasks
– Design measurements
• Competition: Best design gets prizes