Multidisciplinary Physician-Led Teams for Quality Improvement, Communication and Continuity in an Academic Patient Centered-Medical Home Karen Fitzpatrick, M.D., PCMH CCE West Virginia University Department of Family Medicine L19

Academic Family Medicine clinic within tertiary care center residency, Sports Med Fellowship (soon a PCMH Fellowship!) 15 faculty physicians, 5 mid-level providers 10 Medical assistants, 6 LPNs, 4 RNs, 2 RN case managers 35,000 visits per year/ 14,000 unique patients Epic 2012 EHR across an integrated health system (hospital and multispecialty group)

For PCMH Transformation we needed : CULTURE of TEAM Resident Training in working with TEAMs Team members trained in Population Management Team involvement in PRACTICE and QUALITY IMPROVEMENT

ACGME emphasis on Resident participation in Quality Improvement Residents are expected to develop skills and habits to be able to systematically analyze practice using quality improvement methods, and implement changes with the goal of practice improvement IV.A.5.c).(4) Quality improvement skills may be obtained by active participation on a QI committee (planning; implementation; analysis of an intervention on a practice outcome; incorporation into practice if improvement has occurred; initiation of a new PDSA cycle if improvement has not occurred).

Challenges to Team-building Separate work areas for providers and staff Separate meetings for faculty, residents, nursing, registration Large meeting rooms not easily available

How to build TEAMS??? Providers Variable Resident clinic schedules Fixed Faculty preceptor schedules “Herding cats” Support Staff Nurses didn’t “own” the patients Nurses not assigned to same providers Provider expectations inconsistent or unclear Front office staff disconnected Change fatigue

Care Improvement Team Concept 2-3 Faculty Nursing 3 MA/LPNs 1 RN 1 Mid- Level 1 Front Office Team Coordinator Residents PGY Team Patients A practice “microcosm” Small team representing ALL the clinical roles Connect team more closely to THEIR patients Ongoing forum for care improvement work

Planning for the Teams Team manual for each team Orientation materials Forms for meeting agenda, minutes, PDSA records Orientation to Teams and Quality Improvement training Quality Report

Epic “Reporting Workbench” “My Reports” Clinical Reports  “Find patients by Generic Criteria” Searched by “Current PCP” and “Encounter Department” in a 2 year time frame Created a report for all team patients Created a report for Diabetes (“Problem List Grouper”) Copied reports into “Patient Lists” for each Team and each provider Shared the “Patient Lists” with the team in Epic Added columns to show key parameters Sorted columns to calculate for summary quality report

Patient Panel Lists Team List and Individual Provider Lists Interactive with real time info Providers can add patients Residents can view and evaluate their panels Enable quick chart review (double click into record) Key parameters Name, age, sex, BMI Last BP, LDL, A1c, Microalb/cr with dates Last visit, next visit Require periodic updates by trained staff (rerun reports) to add or remove patients based on PCP change

Communication Care Improvement Continuity Forum to discuss: Team roles Inbasket messaging Visit efficiency Preplanning Huddles Nurse rounding Acute care Triage Identifying high risk Communicating within the visit Nurse In-basket messages limited to TEAM patients Nurse-provider assignments based on TEAM TEAM access to panel list in EHR Structured handoff of patients within the team at end of residency Quality improvement projects Faculty supervised, Resident-led, with input from entire team Quality reports for the team’s patient panel Forum to develop and test QI ideas on a smaller scale Care Gap outreach

Culture Change Improved resident understanding of process of care and roles of the support staff Clinical support staff were empowered for greater participation in practice improvement Teams agreed on best practices that could often be disseminated to the larger practice

Finding Solutions: Implementing Huddles for Resident Clinics PROBLEM Huddles had been encouraged but weren’t happening for resident clinics Medical assistants often covered more than 1 resident and were often rooming patients at the start of clinic Nursing staff and providers were both preplanning but not communicating SOLUTION Group huddle with preceptor(s), all residents, nurse leader (and available medical assistants) at start of clinic session Nurse leader would take notes on daily schedule and update medical assistants Residents learned they could put reminders on the posted daily schedule, also

Resident-Led Quality Improvement Projects Diabetic Foot Exam Weight Management referrals for obese patients Tobacco cessation counseling Nephropathy screening Patient and provider hand-washing (scholarly roundtable tomorrow!)

Diabetes Nephropathy Screening: Urine Microalbumin/Creatinine Ratio PROBLEM Noted high percentage missing this measure Many patients had orders but not released by lab registration Support staff did not understand the test or how to explain to patients Patients did not understand the test and declined it SOLUTION Fast Facts memo for clinic staff New Protocol order Reminder signs posted Epic Best Practice Alert

Team Continuity Nurse-Patient Continuity nurses to work more closely with team providers’ patients Inbasket messages handled by team nurses Reassign PGY2 Reassign PGY1 Reassign New INTERN Graduating PGY3 Senior residents “click and drag” patient names from their panel list to Junior Resident Reassign Lists PCP is changed by Front Office Team member

Care Gap Outreach Report identified 152 diabetes patients not seen in 8 months Each team was given list of their patients (18-40 each) Team support staff did letter/telephone outreach (6-10 each) Recorded results on printed spreadsheet PCP changed by front office staff Teams made large-scale outreach more feasible. Case managers are using teams to delegate some follow-up tasks.

Optimizing the Team CHALLENGES Finding meeting space Schedule conflicts Resident attendance Arranging coverage for staff Agreeing on simple QI ideas with measurable outcomes QI Learning Curve FUTURE POSSIBILTIES Improve strategic quality measures Telephone follow-up for complex patients Care Managers training team staff to assume more case management tasks Self-directed Care Gap Outreach

What we learned? Care Improvement Teams are an effective alternative to clinical pods. Practice culture improved by involving the entire clinical staff in practice improvement. Small Teams provide opportunities for residents to develop leadership and team skills. Teams can facilitate the development and testing of numerous small interventions. Population management work is more feasible when divided among the teams.

Group Discussion Other examples of team configuration? How do your practices manage population management? Other ideas for resident involvement in quality improvement? How do your practices transfer patients from graduating residents to other providers? How are your practices promoting a team culture?

West Virginia University Family Medicine is recruiting for our Academic PCMH Fellowship For more information: Website