Transcript Patient Centered Team Staffing Model: Dan Gaunter, Laurel

Circles of Care:
A Transition to
Patient Care Teams Story
Presenters
 Laurel Domanski Diaz, MNO, Director of Business
Operations
 Dan Gauntner, CNP, Director of Clinical Operations
 Marianella Napolitano, RN, MBA, Clinical Quality
Coordinator
Objectives
 Participants will understand how safety net
practices can implement a systematic approach to
caring for their communities
 Participants will learn how to organize a practice
to allow staff members to work at the top of their
licenses.
 Participants will become familiar with how
implementing care teams can improve the quality
of care.
NFP Background
 A Federally Qualified Community Health Center
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founded in 1980
Last year served 13,400 patients on the near west side
of Cleveland
17 Providers on staff--8 Family Practice MDs, 6 Family
Practice CNPs, 3 Certified Nurse Midwives
Focus on the medically underserved
Serve a large Hispanic population
Partnering with the community for
everyone’s best health
 NFP has always believed that partnering with a patient is
the best way to achieve healthy outcomes.
 NFP sees that the services provided to patients are each just
one stop in a constant continuum of care that envelopes
every patient into their own medical home.
 NFP developed a model, Circles of Care, to transform our
Community Health Center into a Care Team and EMR
driven practice focused on Patient Centered Care.
Redesign Activities
 Care Teams
 EMR
 Optimization
 Continuous Improvement Processes
Why Care Teams?
 Working from NFP’s 2009-2011 Strategic Plan, NFP identified
the following areas to be addressed:
 Improvement of patient’s health and safety
 Improvement in NFP’s financial performance
 Increased provider, staff and patient satisfaction
 Becoming an NCQA Patient Centered Medical Home
Care Teams
 A Care Team has been defined as: A panel of patients
who usually see or choose a particular group of providers
for their care AND the group of staff who generally work
together for the care of that panel of patients.
NFP Circles of Care
Front Office
Administrative
Management
& Executive
Leadership
NFP IT
Staff &
Medical
Records
Patient
Technology
Providers &
Behavioral
Health
Clinical
Information
OCHIN/
Epic
Billing &
PBS
Contract
IT Staff
Nurses, MAs,
Patient
Advocates
Community
Agencies
Care Team Composition
 Three Providers—combination of Family MDs, Family
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CNPs, (one team’s providers consists of 3 Certified
Nurse Midwives)
One to two RNs
One to two Patient Advocates
Medical Assistant for each Provider
Front Office representative at each team meeting
Care Teams
 Developing new procedures around scheduling, registering
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patients & directing phone calls to teams
Conducting training activities to facilitate team
communication, structure and creating ongoing team
meetings
Redesigning of nursing staff structure to provide individual
nurses to care teams.
Organizing providers and support staff into integrated care
teams.
Adding a Patient Advocate to each team
Team Training
 Promoting the idea of team across the organization
 Team formation activities prior to implementation
 Team trainings help decrease hierarchical systems
(TEAMSTEPPS, Practice Coaching)
 Practice Coaching and facilitation
Team Meetings
 Goal: Improve communication and increase efficiency
across all disciplines
 Commitment from the leadership
 Financial investment
 More frequently initially
 Outside facilitator present at the beginning
 Internal staff facilitates meetings
Team Huddles
 Daily meetings at the beginning of the morning, may
include the entire team, Provider and MA
 Approximately 10 minutes
 Provides MA with clear path of what needs to be done
to prepare for the Providers entrance in the exam room
Patient Service Representative Role
 Accurate team scheduling
 Directing of patient inquiries (phone and in-person)
to the appropriate team
 Reinforcing PCMH message: scheduling with PCP, we
do not operate as an urgent care
 Serves as a member of the Care Team for Team
meetings
Patient Advocates
 Initially grant funded
 Started with a focus on specific populations
 Our Patient Advocates range from recent college grads to
members of our community who have a background in
activism or social work
 Use of standing orders and protocols allow PAs to unload
the provider and nursing workload
 Each PA has a specialized area—Hispanic patients,
women’s health, refugees, computer expertise
 Increase patient’s access to the Care Teams by helping with
patient communication and correspondence
Patient Advocate Role
Paperwork
• Processing requests for disability, physical forms, utilities, faxing, copying, mailing forms, letter processing.
Population Management
• DM,HTN,WCC, Hospital follow up, Hunt groups 2005, 2000 coverage, Nurse messages
Case Management
• Meeting with patients at provider request, community resource coordination, making appointments for
urgent referrals, Huddle participation, No-Show follow up coordination
Referrals
• X-rays, ultrasounds, specialists and DME, some urgent—nothing requiring prior authorization
Other Responsibilities
• Interpreting, Coordination of Centering, Coordination of Refugee Clinic, grant funded responsibilities,
PDSA activities
Order Entry
• DX--DM, HTN, Adult Physical, Hypothyroidism, Hyperlipidemia, heart issues. Entering standard orders
routine labs, immunizations, referrals.
Nurse Role
Care Team Support
• Preparing forms for provider signature, calling in Rx, calling patients with lab or
test results
Patient Triage
• Speaking with patients on the phone about their symptoms and concerns,
triaging patients in the waiting room that may need to be seen immediately or
may need to be overbooked.
Patient Visits
• Seeing patients in the health center for immunizations, INR, something that is
not a new concern.
Patient Education
• Educating patients with diabetes and hypertension, answering questions about
medications, done on the phone or in person.
Medical Assistant Role
Rooming Patients
• Taking Vitals, entering in chart: medications, chief complaint, review allergies, PHQ scores, complete
tobacco, substance, sexual abuse history, enter diagnosis, check for Pharmacy, goal sheets.
Maintain Provider Rooms
• Keep rooms stocked with appropriate supplies, tests, do inventory every 2 weeks
Back Office Labs
• Order and Result back office labs--UA, Strep, INR, Glucose, Hemoglobin, HbA1c, icon
Immunizations
• Complete immunization consent forms, Review past immunizations given, Print out IMPACT sheet to
review what is needed , Review old chart, Order and pend immunizations needed- provider to review and
sign, Enter into IMPACT, Historical immunizations must be entered into EPIC
Order Entry & Release
• Female Physicals—order mammogram, Fit Test—women and men over 50, WCC—lead and HGb for 1 to 6
YO, DM—foot exam, last eye exam, enter referral, HTN—do EKG, Others--PAP, Urine culture, Chlamydia/
Gonorrhea
Ancillary Support Services
 Available In-Office Support includes:
 On-site Behavioral Health
 On-site Clinical Pharmacist
 RNs provided by insurance companies
 Wellness Coordinator
 Medication Assistance Program
 Diabetes Educational Sessions
provided by local Diabetic Assoc.
Optimization
 Enabling Providers to practice at highest scope
 Professionals will work at the top of their licenses if:
 They have people they can delegate to. At NFP this was
done by increasing the skill set of:
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Medical Assistants
Patient Advocates
 There are effective communication methods
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In-basket messages within the EMR to make clinical
communication efficient
Team meetings for peer and cross professional feedback
Optimization (cont.)
 Patient Advocates
 Use evidence based protocols to address health disparities
 Use registries to identify gaps in healthcare
 Identify high risk patients for case management by nurses
 Tracking and monitoring goals of the Health Center
 Operational
 Clinical
 Developing policies and procedures for EMR system and
Care Teams at NFP
Outcomes of the Circles of Care
Project
 NFP achieved Level 3 NCQA PCMH Accreditation
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with a score of 99%
In a Medicare Pilot Program on PCMH, NFP was the
top scoring FQHC in the country.
Improved communication
Increased coordination
Improved quality of care for our patients
Patient Satisfaction –
Decreasing wait time
Continued Wait Time Improvement
Financial Performance
Improvement
HbA1c less than 8
• Increased from 48% to 62%
BP control in DM patients
 Increased from 72% to 79%
DM patients who had a Foot Exam
 Challenges tracking this information
 Increase coordination and communication with all team members
Questions?