cultivating a robust primary care home team. team-based care 1.who we are, early steps and successes...
TRANSCRIPT
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Cultivating a Robust Primary Care Home Team
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Team-Based Care
1. Who We Are, Early Steps and Successes2. Developing Staff Buy-In3. Work Streams and Barrier Analysis4. Roles Definition Process5. Our Team-Based Care Model and Roles6. Next Steps
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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!).
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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 high-quality, comprehensive, culturally competent primary care services, regardless of age, healthcare insurance coverage,
language of origin or any other demographic characteristic.
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Care: From volume driven to value driven
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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
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PCMH PilotOur 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
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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”
PCMH Pilot Successes
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Developing Staff Buy-In
• Initial PCPCH Meetings• Monthly Site Meetings• New Employee Orientation• Huddle Boards• Next Steps: Increasing Provider Participation
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Clinical Improvement Teams
Teams: Clinical Team – MA Focus
Clinical Team – RN Focus
Epic Workflows
Team Members:
2 Providers1 Clinic Medical Director1-2 Medical Assistants1 RN 1 Team Care AssistantPCPCH Specialist
2 Providers1 Clinic Medical Director1 MA1-2 RN Care Coordinators1 Team Care AssistantCHW & Referrals PRNPCPCH Specialist
2 Providers1 Clinic Medical DirectorEpic Site SpecialistsBilling ManagerIT DirectorClinic ManagersNursing SupervisorPCPCH Specialist
Tentative Topics:
Huddles, Chart Scrubbing, Registries, Advanced Directives, After Visit Summary
Transitions of Care, Care Plans, Referral Tracking, Pt Room Resources, Patient Self-Management
Health Information Exchange, Test and Referral Tracking, MyChart, Implementing new facets of EPIC, Systematizing decisions made by other clinical groups
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Barrier Analysis
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Work Stream Analysis
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Challenges Along the Way
• Leadership transition• Remote locations• Balancing patient care and meeting time• Epic limitations
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Defining Our Teams: Basic Model• All team members
operating at the top of their scope.
• Care Services, Education & Support also available to multiple teams.
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Roles DefinitionTeam-Based Planning Worksheet
Full document available through Safety Net Medical Home Initiative Elevating the Role of the MA Training Materials
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Who Does What?Providers Registered Nurses Clinical Support Staff
- Assess, diagnose and treat patients
- Prescribe, manage and reconcile medications
- 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
- Clinical advice expert
- Triage
- Interpret reports and plan for population management
- Planned care and group visit organizer and participant
- Care management, care coordination, patient education and self management support for high risk and complex patients
- Train and supervise team
- Assist with policies, guidelines, standing order development
- Mentor, leader, role model
- Patient flow
- Collect information and populate records
- Cue up orders, referrals
- Clinical list changes, RX refill requests
- Populate registry
- Planned care and group visit participant
- Care coordination
- Patient education and self-management support for less complex patients
- Use guidelines and standing orders to support evidence based care
Source: Safety Net Medical Home Initiative Elevating the Role of the MA Training Materials
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Scheduler Operator• Schedules patient
appointments• Screens symptom-
based calls for urgency
• Routes to appropriate department
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Education & Support• Billing• Front Desk• Interpreting• Health IT• Patient Navigator• Community Health
Worker• Referral Coordinator• Medication
Assistance Program
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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.
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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.
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Care Services• Lab/phlebotomist• RN Triage• RN Lead• Pharmacist (soon to
come)• Behavioral Health• Mental Health
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Mental Health Specialist• 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.
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Longitudinal Care Plan Management
•RN Care Coordinator
•Team Care Assistant
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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.
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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.
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Visit-Level Care• Provider• Medical Assistant
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Medical Assistant• 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.
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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
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Team-Based Care Feedback From the Staff • My Diabetic patients HgA1Cs are quickly improving • I am enjoying participating and being part of a team that is making a difference
each day‖ • Although we are not 100% Patient-Centered – but once we have our teams 100%
in place; we will be an amazing clinic.‖ • I feel important; my ideas about care and treatment plans can be shared with the
provider and nurses.‖ • I go home on time feeling effective and fulfilled, having had the time to do a good
job with each patient.‖ From the Patients • I love knowing the face of the nurse always helping me.‖ • None of my friends have their own health advocates---I have a lot of fighters‘ for
me.‖ • I am treated as an individual at Mosaic Medical.‖ • I don‘t just get medical care at Mosaic Medical—I get life care.‖