Transcript Cultivating a Robust Primary Care Home Team at Mosaic

Cultivating a Robust Primary
Care Home Team
Team-Based Care
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Who We Are, Early Steps and Successes
Developing Staff Buy-In
Work Streams and Barrier Analysis
Roles Definition Process
Our Team-Based Care Model and Roles
Next Steps
Who We Are
• Mosaic Medical is a 501(c)3 non-profit
organization operating Federally-Qualified
Health Centers since 2002.
• Our health centers are located in Prineville,
Bend, and Madras, Oregon (and soon to be
Redmond!).
Mission-Driven
• The mission of Mosaic is “to improve the
lives and health of individuals and families
in the communities we serve.”
• In 2011, Mosaic served over 14,000 patients.
As from the beginning, each of our clinics offer highquality, comprehensive, culturally competent
primary care services, regardless of age, healthcare
insurance coverage, language of origin or any other
demographic characteristic.
Care: From volume driven to
value driven
Early Steps
• Empanelment
Empanelment process at Mosaic was developed – a cultural
shift
Significant education provided to all staff and patients
regarding importance of continuity of care with one PCP
Increased clinic access by adding a second evening clinic
• Electronic Medical Records
Went live with Epic EMR Spring 2011
• PCPCH Tier 3 Recognition
All three Mosaic Sites Recognized as Tier 3 Fall 2011
PCMH Pilot
Our Pilot Project
• 100 Medicaid patients with the HIGHEST medical
bills in early 2010
• Stay in regular contact with the patient
• ER Diversion by: Setting up standing orders, Nurse
Visits, Care Coordination, Same-Day Access,
Monthly planning meetings with ER Staff, Frequent
―Huddles with PCP, RNCC, ERCM, CHW, On-going
―connection‖ with primary care team
PCMH Pilot Successes
A Success Story…
A Rare Win-Win
When the medical home program began, the
goal was to reduce hospitalizations and
emergency room visits by 5%
• By fall, 24% fewer emergency room visits &
20% fewer hospitalizations
• Reported in the Bulletin on 07-01-2011: Our
program “Decreased medical system costs by
$621,000”
Developing Staff Buy-In
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Initial PCPCH Meetings
Monthly Site Meetings
New Employee Orientation
Huddle Boards
Next Steps: Increasing Provider Participation
Clinical Improvement Teams
Teams:
Team
Members:
Tentative
Topics:
Clinical Team – MA
Focus
2 Providers
1 Clinic Medical
Director
1-2 Medical Assistants
1 RN
1 Team Care Assistant
PCPCH Specialist
Huddles, Chart
Scrubbing, Registries,
Advanced Directives,
After Visit Summary
Clinical Team – RN
Focus
2 Providers
1 Clinic Medical Director
1 MA
1-2 RN Care
Coordinators
1 Team Care Assistant
CHW & Referrals PRN
PCPCH Specialist
Transitions of Care, Care
Plans, Referral Tracking,
Pt Room Resources,
Patient SelfManagement
Epic Workflows
2 Providers
1 Clinic Medical Director
Epic Site Specialists
Billing Manager
IT Director
Clinic Managers
Nursing Supervisor
PCPCH Specialist
Health Information
Exchange, Test and
Referral Tracking,
MyChart, Implementing
new facets of EPIC,
Systematizing decisions
made by other clinical
groups
Barrier Analysis
Work Stream Analysis
Challenges Along the Way
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Leadership transition
Remote locations
Balancing patient care and meeting time
Epic limitations
Defining Our Teams: Basic Model
• All team members
operating at the
top of their scope.
• Care Services,
Education &
Support also
available to
multiple teams.
Roles Definition
Team-Based
Planning
Worksheet
Full document available through Safety Net Medical Home Initiative
Elevating the Role of the MA Training Materials
Who Does What?
Providers
Registered Nurses
Clinical Support Staff
 Assess, diagnose and
treat patients
 Clinical advice expert
 Patient flow
 Prescribe, manage and
reconcile medications
 Triage
 Interpret reports and plan for
population management
 Collect information and
populate records
 Perform procedures
 Consult with specialists
and facilities
 Lead the team(s)
 Lead the practice’s
strategic QI plan
 Choose evidence based
guidelines and establish
standing orders
 Mentor, leader, role
model
 Cue up orders, referrals
 Planned care and group visit
organizer and participant
 Clinical list changes, RX refill
requests
 Care management, care
coordination, patient education
and self management support
for high risk and complex
patients
 Populate registry
 Train and supervise team
 Patient education and selfmanagement support for less
complex patients
 Assist with policies, guidelines,
standing order development
 Mentor, leader, role model
 Planned care and group visit
participant
 Care coordination
 Use guidelines and standing
orders to support evidence
based care
Source: Safety Net Medical Home Initiative Elevating the Role of the MA
Training Materials
Scheduler Operator
• Schedules patient
appointments
• Screens symptombased calls for
urgency
• Routes to
appropriate
department
Education & Support
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Billing
Front Desk
Interpreting
Health IT
Patient Navigator
Community Health
Worker
• Referral
Coordinator
• Medication
Assistance Program
Community Health Worker
• Integrated in Clinic Care Team.
• Case management, home visits and support for
high-need patients.
• Health promotion instructors.
• Staffing support for outreach events.
Referrals Coordinator:
• Processes and tracks all referrals.
• Coordinates authorized visits with patients and
specialty offices.
• Maintains logs and tracking mechanisms.
Medication Assistance Program
Coordinator:
• Serves as liaison between pharmaceutical
companies and the patient.
• Processes, tracks and dispenses all prescriptions
ordered through pharmacy assistance programs.
Care Services
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Lab/phlebotomist
RN Triage
RN Lead
Pharmacist (soon to
come)
• Behavioral Health
• Mental Health
Mental Health Specialist
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Comprehensive Mental Health care.
Individual/group counseling.
Case management.
Caseload consists of adults on OHP with a variety
of mental health and alcohol/drug problems.
• Predominant focus is on solution-focused brief
treatment, strengths based perspective, trauma
therapy, group treatment, and case management
responsibilities.
Longitudinal Care Plan Management
• RN Care
Coordinator
• Team Care Assistant
RN Care Coordinator
• Education, coaching and follow-up to improve
patients’ self-management skills.
• Manage a panel of complex patients
• Facilitates care coordination between others
involved in the care of the patient, including the
patient's primary care team, medical specialists,
hospitals and health plans.
• Uses Motivational Interviewing techniques for
education and health promotion.
Team Care Assistant
• Clinical and administrative support to optimize
care coordination for the panel of patients
assigned to the primary care team.
• Panel management
• Provider and patient support (including chart
reviews, processing pharmacy refill requests, and
assisting with patient messages)
• Assists with coordinating the patient’s care
between other members of the care team.
Visit-Level Care
• Provider
• Medical Assistant
Medical Assistant
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Patient-centered clinical support related to visit-level care.
Facilitates the coordinated planning of office visits
Initial rooming of patients during office visits (including
medication reconciliation, risk factor review, and health
maintenance review)
Provider support
Reviews with patient the plan of care and AVS
Assists with follow-up as needed.
In addition, the MA may also perform in-office testing and
clinic services (phlebotomy, EKG, hearing and vision
testing, etc.), preparation and maintenance of exam
rooms, maintenance of patient records, and other tasks as
requested by medical providers.
Next Steps
• Adoption of Clinical Guidelines and Standing
Orders across sites
• Clinical Improvement Teams develop
workflows
• Complex Care definitions
• Expanded Motivational Interviewing Training
• Continue to optimize Epic for team-based
care coordination
Team-Based Care Feedback
From the Staff
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My Diabetic patients HgA1Cs are quickly improving
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I am enjoying participating and being part of a team that is making a difference
each day‖
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Although we are not 100% Patient-Centered – but once we have our teams 100%
in place; we will be an amazing clinic.‖
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I feel important; my ideas about care and treatment plans can be shared with the
provider and nurses.‖
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I go home on time feeling effective and fulfilled, having had the time to do a good
job with each patient.‖
From the Patients
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I love knowing the face of the nurse always helping me.‖
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None of my friends have their own health advocates---I have a lot of fighters‘ for
me.‖
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I am treated as an individual at Mosaic Medical.‖
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I don‘t just get medical care at Mosaic Medical—I get life care.‖