Transcript Building a Sustainable Care Coordination Program through Teams

“Managing Populations: Building a
Sustainable Care Coordination Program
Through Teams”
Lori A. Hinga, Nurse Consultant
Louisiana Public Health Institute
STARTLING STATISTICS
• Patients receive only 55% of recommended chronic and preventive
services
• About one-half of US adults have at least one chronic condition
• 50% of people with hypertension have uncontrolled blood
pressures
• More than 80% of people with hyperlipidemia have not attained
cholesterol control
• 43% of people with diagnosed diabetes have not achieved
glycemic control
EMPANELMENT
• Primary Care Physician Shortage = Excessive Patient Panel
Size
• The average primary care physician panel size is too large
for delivering consistently high quality care under the
traditional practice model
• Estimates suggest a PCP would spend 21.7 hours per day to
provide all recommended acute, chronic and preventive
care for a panel of 2,500 patients
• The average US PCP panel size is 2300
• The decreasing number of physicians entering adult
primary care will only increase PCP panel size
The Duke University Study
The Care Team Model with a panel of 2500 patients
• Time required for 1 physician to provide all grade A & B services of the US
Preventive Services Task Force = 1773 hours per year
• Time required for chronic disease care (10 most common chronic diseases) –
with high prevalence in primary care – with measured prevalence in the
population – with accepted guidelines – for 5 of the diseases, the percentage
of patients having achieved disease control = 2484 hours per year
• Time required to provide acute care (National Ambulatory Medical Care
Survey data) for a panel of 2500 patients = 888 hours per year
DUKE UNIVERSITY DEPARMENT OF COMMUNITY AND FAMILY MEDICINE STUDY
Estimated Panel Sizes Under Different Models of Physician Task Delegation to Non-Physician Team
Members
Non-delegated Model (Panel
= 983)
Type of Care
Time
Delegated %
Hours per
Patient/Year
Delegated Model 1 (Panel =
1,947)
Time
Delegated %
Hours per
Patient/Year
Delegated Model 2 (Panel =
1,523)
Time
Delegated %
Hours per
Patient/Year
Delegated Model 3 (Panel =
1,387)
Time
Delegated %
Hours per
Patient/Year
Preventive
0
0.71
77
0.16
60
0.28
50
0.35
Chronic
0
0.99
47
0.53
30
0.70
25
0.75
Acute
0
0.36
0
0.36
0
0.36
0
0.36
Total
-
2.06
-
1.04
-
1.33
-
1.46
Two Alternative Practice Models
• The mismatch between workload and PCP capacity to
deliver consistently high quality care has given rise to 2
alternative practice models
• Model #1
• Substantially reduce panel sizes to <1000 patients
• Not enough Primary Care Clinicians in the US to meet this
standard
• Would leave many people without primary care access
Two Alternative Practice Models
• Model #2
• The Organized Care Team Model
• Building of care teams that distribute the
responsibility for patient care among an
interdisciplinary team
• Allows physicians to practice high-quality care with a
reasonable workday while still maintaining large but
manageable panel size
The Care Team Model Fundamentals
• ALL team members perform at the top of their skill level
• Many tasks currently performed by primary care clinicians
are safely and effectively delegated to non-clinician
members of the team OR delivered through the use of
health information technology without requiring direct
primary care physician involvement
CAUTION: May require change…
• Engaged Leadership
• Change in providers/care team mindset
• Delegation and Empowerment
• Comprehensive ongoing training of all care team members
• Evaluated and efficient systems / processes / workflows
• High functioning performance / quality improvement team
• Creation and consistent use of standing orders
• Patients educated about team-based care
• Integrated electronic health record experts (super-users)
• Primary Care payment reform
OPTIMIZING THE CARE TEAM
• Critical to maximizing the daily flow of work
• Requires assessment of the current needs of patient populations
• Also requires identifying the ideal composition for the care team
• Specific mix/number of staff will vary from clinic to clinic
• Must understand the types of services provided
• Must decide how the work should be divided among the care team to ‘supply’
those services
• Begins with understanding the demand and adjusts supply to meet the
demand
• Within the limits of clinic resources
The Jelly Bean Exercise
THE JELLY BEAN EXERCISE
• Each participant has 60 jelly beans
• Each cup represents a member of a common care team and a cup labeled “No
one”
• Identify which care team member performs each task
• Drop a jelly bean into each staff member’s cup who currently performs the
following tasks
• Drop a jelly bean into the ‘No-one’ cup if you don’t think anyone is currently
performs the task
• If you think a task is currently performed by two physicians, a nurse
practitioner and a physician’s assistant put a jelly bean in each of the
corresponding cups
Which Care Team Member:
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SETS the intervals for blood monitoring for patients on warfarin?
DECIDES when to call a patient with diabetes to come in for a visit?
SELECTS the vaccines to be given to an 18 month-old baby?
DECIDES to arrange a diabetes retinal screening referral?
ORDERS the mammogram for 55 year-old woman with severe hypertension and
heart disease?
INITIATES diabetes microfilament foot testing?
FINDS patients with severe persistent asthma who are not on controller medications
and brings them in for an appointment?
DECIDES which children with ADHD should come for a visit?
DECIDES when a patient with major depression (PHQ 17) should come back for a
visit?
PROVIDES Self Management Support for diabetes patients?
Discussion…
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What did you observe about this exercise?
What did you learn from it?
Why are there jelly beans in the “No one” cup? What can be done about it?
What should the distribution of jelly beans look like to be real team-based
care?
• What changes would need to be made to progress toward team-based care?
• How would this affect the workflow?
• Are there goals which could be included in your quality/performance
improvement plan based on this exercise?
KEY PRINCIPLES OF TEAM-BASED CARE
• Every patient is assigned to a care team that, at the very least, includes a primary care provider,
nurse, medical assistant and receptionist
• The team huddles daily to care for patients in a proactive way
• Teams meet at least monthly to proactively manage the work of population health and to
discuss high risk patients
• The usual care team interfaces seamlessly with the complex care management team
• Session Team – The team that is seeing the patient on any given day (at the very least, includes the
Provider and MA working together that day; ideally includes the RN and receptionist). Participates in
the daily huddle. Ideally, the session team would be the same people as the Planned care team.
• Patient’s Planned Care Team – The patient’s “go to” team. This team is accountable to and for a panel
of patients and manages all of the care of the 95% of usual care patients.
• Coverage Team or Pod – a structure to support a higher level of access and continuity for patients and
sharing of staff; usually contains one-three planned care teams. When the patient’s PCP is not
available, the patient may see another provider in this group.
• Complex Care Management Team – The team who is responsible for managing the care of the top 5%
highest risk patients in collaboration with patient’s planned care team.
ADDITIONAL PRINCIPLES…
• Ensure that clinical and administrative systems support team members in their defined work
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Procedures for providing prescription refills
Procedures for informing patients of laboratory results
Procedures for making patient appointments
Policies on how decisions are made in the practice o Work schedules allow time for team members
to perform all parts of their job o
• Adequate level of permissions in EHR which allow teams to perform
• Create communication structures and processes
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Schedule team meetings and/or “huddles”
Hold team members accountable for attending and participating in team meetings and “huddles”
Clearly communicate expectations, assignments, tasks, roles to all team members
In between team meetings, routinely communicate through electronic information
• These communications will help team members know the work is getting done.
• In between meetings, share important information through brief verbal interactions among team members
• Provide feedback to care team members on a daily basis re: work well done and opportunities for
improvement
• Decide on a process for conflict resolution among team members and implement the process
CARE TEAM TASK REASSIGNMENT
TASK
WHO DOES IT NOW?
IN A PERFECT WORLD…
WHO WOULD DO IT?
Book Appointments
Nurses and Clerical
Clerical Support
Take Incoming Calls
Everyone
Clerical Support
Triage
Nurse and Provider
RN
Medication Refill Requests
Provider, Nurse, Clerical
Clerical with Provider Signature
Orders Flu Vaccine
Provider
Clinical Staff by Standing Order
Diabetes Self Management
Provider / Care Manager
Clinical Staff / Group Visits
Referral Tracking
Referral Coordinator / Nurse /
Provider (during visit)
Clerical Support / Team Clinical
Staff
Results Tracking
Clinical Staff / Nurse / Provider
Clerical Staff
BROAD CATEGORY ASSIGNMENT
Clinical
Support
(Intake /
Rooming)
Provider
Pre-Visit Planning
X
Patient Assessment
X
X
Goal Setting
X
X
Care Plan
Management
Licensed
Clinical
(RN,
LPH/LVN)
Social
Worker
Counselor
Care
Manager /
Coordinator
Diabetes
Educator
X
X
X
Patient Education
X
X
Care Coordination
X
X
Referrals
X
X
Results Tracking
X
X
Missed Appt F/U
X
X
X
X
X
X
ASSIGNMENT DETAILS
Pre-Visit Planning
Patient Assessment
Patient Education
Care Plan Management
Develops Reports
Vital Signs
HT / WT / BMI
Ensures patients
understand the plan
of care and
medications
Assesses Care Plan Goals
Reviews Reports &
Identifies Evidence-Based
Gaps in Care
Medication Reconciliation /
Compliance / Barriers
Diabetic
Medication
Management
Education
Updates Plan of Care
Notifies Patient and
Schedules Appointment
Assesses Smoking Status
Orders Pre-Visit Labs
H&P / Physical Exam
Updates Health Maintenance – Foot
Exam, eye exam, lipid profile, A1C
etc.
IS IT HAPPENING?
• Assigned roles and responsibilities require monitoring to ensure compliance
• Implement SMART (Specific, Measureable, Attainable, Realistic, Timely) goals where /
when appropriate
• Reviews reports and identifies evidence-based gaps in care
(pre-visit planning task)
• Identify which Evidence-Based Guidelines (EBG) will be followed for which population of patients
• Identify pre-built (vendor) /develop reports for each EBG ensuring all patients with gaps in care are
identified (Provider specific)
• Determine how often each report will be run/reviewed
• Create a quality/performance dashboard incorporating each EBG (by condition)
• Include national benchmarks (for data comparison and measurement)
• Establish organizational benchmarks to track/trend improvement AND compliance with role and
responsibility assignment
• When significant improvement is visible the planned/reassigned responsibilities are on track
• When little/no improvement is visible –
• Consider a Root Cause Analysis
• PDSA or another performance improvement tool
IS IT HAPPENING?
• When the Root Cause indicates a physical / electronic workflow issue
• Assess each step of the process
• Electronic Workflow –
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Information entered electronically into more than one field
Information entered electronically into a non-reportable field
Information entered as a ‘free text’
Information ‘scanned’ into the EMR without proper filing or updating (health maintenance)
Information ‘scanned’ into EMR – not associated with original order etc. (Results/Referral Tracking)
Information is not entered
Task is not being done/addressed
• Physical Workflow –
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Identify ‘bottlenecks’ in the process
Identify unassigned/missing steps in the process
Identify building/layout issues
Identify system/process wastes (re-work/duplicate work/defects, inventory, motion, over
production, waiting, not clear/confusion, transporting, excess processing)
Attributes of High Performing Care
Teams
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Standardized and efficient systems/processes
Ongoing provider delegation
Empowered clinical/non-clinical care team members
Population health management
Coordinated patient care
Same-day patient access for routine and urgent care
Informed, responsible, accountable patients
Established patient / care team relationships
Improving health outcomes
Reasonable work life for physicians and other team members
WHAT IS POPULATION
HEALTH MANAGEMENT?
Population Health Management (PHM)
The proactive application of strategies and
interventions to defined groups of individuals
across the continuum of care in an effort to
improve the health of the individuals within the
group at the lowest necessary cost.
Population Health Management
• Proactively identify patients who need evidence-based chronic or preventive
care using health data collected and stored in patient registries.
• Provide planned care and outreach based on patient diseases or conditions.
• Provide patient self-management support.
• Monitor patient progress, identify appropriate care plans, and recommend
changes to care plans by including prompts in the electronic health record.
• Monitor practice performance by tracking patient data and comparing it with
national guidelines or internal benchmarks.
RISK STRATIFICATION
• Risk-stratified care management (RSCM) is the process of assigning a health risk
status to a patient
• Using the patient’s risk status to direct and improve care
• The goal of RSCM is to help patients achieve the best health and quality of life
possible
• Preventing chronic disease
• Stabilizing current chronic conditions, and
• Preventing acceleration to higher-risk categories and higher associated costs
• Identifying a patient's health risk category is the first step toward planning,
developing, and implementing a personalized care plan by the care team, in
collaboration with the patient
• The plan may address a need for more robust care coordination with other
providers, intensive care management, or collaboration with community resources
WHERE IS YOUR ORGANIZATION?
PHM Best Practice Implementation Levels for Primary Care Clinicians
Patient Population
Identification
Risk Stratification
Engagement
Patient-centered
Interventions
Level V
Clinician auto-notified
Clinician receives real-time,
of new or conflicting
patient & population
info requiring
specific data at point of care
resolution
Valid tools autostratify patients &
population across all
clinicians; gaps flagged
for action
“Medical home”;
clinician monitors,
optimizes care plan &
care team across all
settings
Clinician/patient
collaborative care plan;
1, 2, 3 prevention
focus; coordinated
team
Level VI
Patient health, values,
Patient information
preferences assessed;
available from all clinicians
clinician receives info
– ID, risks, condition control
for consideration
Stratification lists
available based on
claims, HA, labs,
screening info
Clinician engages with
patient in “medical
home,” coordinates
across connected
settings
Clinician aware of &
responds to patient
needs/preferences
focus on 1, 2, 3
preventions
Clinician receives
patient outcome info;
performance goals set
in peer organization
Level III
Clinician registry – key
diagnosis, tests, Hx and
condition control
Clinician evaluates
health risks based on
year-over-year
comparing
assessments
New health risks
identified through
health assessments
and via registry lists
Clinician engages with
patient focusing on
both past and newly
identified risk
Clinician focuses on 1,
2, 3 preventions;
strategies for risks
identified
Clinician unaware of
patient outcome
unless directly involved
in care
Level II
Clinician has patient list
with diagnosis
Clinician asks patients
for baseline health
assessment; assesses
patient at the visit
Risk based on
“frequent flier” status
& clinician lists with
diagnosis
Clinician engages with
patient episodically at
patient presentation
Intervention based on
current patient need
and known health risk
Clinician unaware of
patient outcome
unless directly involved
in care
Level I
Clinician identifies patient
through direct interaction
and hard copy records
Clinician assesses
patient at the visit
Clinician aware of high- Clinician engages with
risk patients based on patient especially at
“frequent flier” status patient presentation
Intervention based on
current patient need
and known health risk
Clinician unaware of
patient outcome
unless directly involved
in care
Health Assessment
Impact Evaluation
Real-time feedback;
outcomes meet &
exceed patient, peer,
population goals
COORDINATION
THROUGH TEAMS?
CARE COORDINATION
"Care coordination is the deliberate organization of
patient care activities between two or more
participants (including the patient) involved in a
patient's care to facilitate the appropriate delivery
of health care services.”
KEY COMPONENTS OF CARE
COORDINATION
• Essential care tasks and responsibilities
• Assessment of a patient’s care coordination needs
• Development of a coordinated care plan
• Identification of team members responsible for coordination
• Information exchange across care interfaces
• Interventions that support care coordination
• Monitoring and adjustment of care
• Evaluation of outcomes, including identification of care
coordination issues
BUILDING A CARE TEAM
• Define goals and develop a shared purpose
• Example: Improvement of patient’s health based on evidence based practices
• Define specific, measurable outcomes and objectives
• Example: >= 90% of patients with a dx of diabetes will have >= 2 HgbA1C results in
12 month period
• Assign roles for each team member and define responsibilities
• Maximize the role of each team member within the scope of their licensure and
skill
• Ensure each team member is competent to perform their defined and
delegated role/responsibilities
• Develop competencies for all tasks and test, at least, annually
BUILDING A CARE TEAM
• Ensure that, clinical and administrative systems, support team member in
their defined work
• Example: Policy and procedure for prescription refills
• Develop communication structures and processes
• Example: Scheduled team meeting and/or ‘Huddles’ and accountability for
attendance and participation
• Review data to assess progress toward outcomes/goals on a scheduled basis
and share it with the team
• Practice Teamwork!
ORGANIZING A CARE TEAM
Pre-visit
Visit
Between
Visits
• Time of recognized need or risk by system
• Time of patient contact to check-in
• Care Team plans for encounter
• Time of check-in to departure from clinic
• Patient’s encounter with clinician and care team
• Completion of visit plans/action to pre-visit
• Care Management
CARE TEAM COORDINATION
Complex Care Coordination
5% of patient population
Patient, RN, Social Worker,
Community Health Worker
Chronic Condition Coordination
Patient, Team Nurse, MA, Front Office
Pharmacist, Nutritionist, MBH –
Sometimes
95%
Planned Care
Health Maintenance / Chronic Conditions
Patient, Clinician, MA, Nurse, Front Office
COMPLEX CARE MANAGEMENT RISKS
HIGHER RISK DRIVERS
MODERATE RISK DRIVERS
FUNDAMENTAL RISK DRIVERS
UTILIZATION: Inpatient or ED visits for
medical or psychiatric reason in the past
three months
DISENGAGEMENT: Patient has chronic
condition(s) AND has been disengaged from
primary care > 1 year
CHRONIC CONDITION: Patient has one or
more uncontrolled / severe physical health
conditions
ACTIVE SUBSTANCE ABUSE DX
PHYSICAL / MENTAL / LEARNING DISABILITY
CHRONIC PAIN
HOMELESSNESS
PRESCRIPTION MEDICATIONS (EXCLUDING
OTC): Patient has 10 or more active
prescription medications OR has newly
prescribed, changed OR unstable high risk
medications such as anticoagulants or
insulin
PHQ 9 SCORE > = 15 over 2 screenings
within the previous 6 months
MENTAL HEALTH CONDITION: Sever,
persistent and/or uncontrolled
SOCIAL SUPPORT: Patient has no active
social supports OR patient has social
supports that are inconsistent, chaotic or
detrimental
PAYER RISK: Patient has been identified by
payer as ‘At Risk”
FEDERAL POVERTY PROGRAM INVOLVED OR
ELIGIBLE
SAFETY: Patient / team has concerns for
patient safety
LITERACY AND LANGUAGE NEEDS
OTHER: Issues or concerns not otherwise
specified
BENEFITS OF CARE TEAM
COORDINATION
• Established patient relationships
• Assessment knowledge
• Personalize care plan and interventions
• Anticipate patient needs
• Trust
• Increased compliance
• Accountable for patient panel
• Outcomes
• Access to point-of-care reminders during visits
• Access to and ability to apply standing orders
• Have direct communication with all team members
Essentials of High Performing Primary
Care Practices
• Manageable panel sizes
• Standardized systems/processes
• Electronic workflows
• Patient flow
• Electronic registry
• High-level personal / electronic communication
• Clearly defined and understood care team roles and responsibilities
• Professionals working at the ‘top of their license’
• Engaged and informed patients/families
• Patient/families responsibilities
• Comprehensive performance/quality improvement plan and oversight
QUESTIONS?
BEST PRACTICES FOR CARE TEAM
DEVELOPMENT
• http://www.integration.samhsa.gov/workforce/teammembers/Cambridge_Health_Alliance_Team-Based_Care_Toolkit.pdf
• http://www.ihi.org/resources/Pages/Changes/OptimizetheCareTeam.aspx
• http://www.ahrq.gov/professionals/prevention-chroniccare/improve/system/pfhandbook/mod19.html
• http://www.safetynetmedicalhome.org/sites/default/files/Implementation-GuideTeam-Based-Care.pdf
• http://www.safetynetmedicalhome.org/sites/default/files/Implementation-GuideSupplement-Team-Based-Care.pdf
A PRACTICAL EXERCISE
• Assume you are working in a primary care practice setting
• The provider you are working with has a panel of 2000 patients
• 10% of the patient panel has a diabetes type II diagnosis
• Workflows have been evaluated and are highly efficient
• Chronic Condition templates are (EBG) in place
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Confidence has been reached with data validity
Specific patient populations have been identified
Risk stratification is complete and understood
Patient lists are easily accessible and are built for each condition and by by assigned
provider including gaps in care reports
• Standing orders are in place
• Point of Care reminders are established
• Gaps in evidence-based care are visually identified
THE PATIENT
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Patient is 53 year old, Latino woman
Language: Spanish with very little english
Diagnosis: Diabetes Type II / Hypertension
Last Visit: < 180 days ago
Last A1C: 8.7 Last BP: 156/98 Both > 6 months ago
Last Retinopathy Exam: None documented
Last Comprehensive Foot Exam: None documented
Last Depression Screening: None documented
Last Dental Exam: < 3 years ago
Last Visit: Ht: 5’5” Wt: 234 BMI: None documented
Medications appropriate for diabetes diagnosis
Diabetes Self Management Support: None documented
Risk Factors Discussed: None
Patient Education Provided: None
DISCUSSION QUESTIONS…
• Population Health Considerations:
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Would this patient benefit from evidence-based chronic condition and/or preventive care?
How would this patient be identified?
Is this patient a candidate for outreach?
Is this patient a candidate for a planned visit?
• Care Coordination Considerations:
• What might be care coordination needs of this patient?
• Would developing a care plan be helpful?
• What interventions might be identified?
• Care Team Considerations:
• What can be done prior to the patient’s scheduled appointment? By whom?
• What specialist/community resource referrals could be considered? By whom?
• Does this patient require Complex Care Coordination?
REFERENCES
1. Care Continuum Alliance.2012.Implementation and Evaluation: A Population Health Guide for Primary Care Models. Available from:
http://www.exerciseismedicine.org/assets/page_documents/PHM%20Guide%20for%20Primary%20Care%20HL.pdf
2. Daaleman TP, Fisher EB, Annals of Family Medicine. Enriching Patient-Centered Medical Homes Through Peer Support. 2015; Vol. 13,
Supplement 1
3. Cambridge Health Alliance (CHA) Team-Based Care Leadership Team. Cambridge Health Alliance Model of Team-Based Care
Implementation Guide and Toolkit. Available from: http://www.integration.samhsa.gov/workforce/teammembers/Cambridge_Health_Alliance_Team-Based_Care_Toolkit.pdf
4. Altschuler J, Margoius D, Bodenheimer T, Grumbach K. Annals of Family Medicine. Estimating a Reasonable Patient Panel Size for
Primary Care Physicians WithTeam-Based Task Delegation. 2012; Vol. 10, NO. 5. September/October
5. Taylor EF, Machta, RM, Meyers DS, Genevro J, Peikes, DN. Annals of Family Medicine. Enhancing the Primary Care Team to Provide
Redesigned Care: The Roles of Practice Facilitators and Care Managers. 2013. Vol. 11. NO. 1. January/February
6. Moorhead T. Jefferson School of Population Health. Prescriptions for Excellence in Health Care. Care Coordination in the Context of a
Population Health Management Model. 2010. Issue 8. Spring
7. Myers D, Peikes D, Genevro J, Peterson Greg, Taylor EF, Tim Lake T, Smith K, Grumbach K. The Roles of Patient-Centered Medical
Homes and Accountable Care Organizations in Coordinating Patient Care. AHRQ Publication No. 11-M005-EF. Rockville, MD: Agency for
Healthcare Research and Quality. December 2010.