Palmetto Health/University of South Carolina PACER Team - Our Journey Nicole Bookstaver, Scott Carney, Renee Connolly, Christopher Goodman, Jocelyn Harmon, Mark Humphrey, Matthew Orr, Jennifer Porth, Donna Ray, Kathryn Stephenson, Gregg Talente, & Cynthia Winston Our Mission: The Palmetto Health/University of South Carolina (PH/USC) PACER Team will work to improve resident training & delivery of care in our three PH/USC PACER sites Family Medicine, Internal Medicine & Pediatric (Children’s Hospital Outpatient) Clinics – to be increasingly patient oriented and integrated in our care delivery. Our Vision: To be a learning lab for patient centered medical care Educational Transformation Recognizing that the “Clinic is the curriculum” Interpersonal Medicine – Accelerating Patient Activation & Practitioner Wellbeing Inter-professional faculty development sessions in motivational interviewing (MI) completed to include our PACER team members, Pediatrics and Family Medicine faculty and 60% of our general Internal Medicine faculty Residents from all 3 residency programs are completing initial MI training which also included pharmacy residents Certified medical assistants (CMA’s) joining PH/USC Medical Group now have MI training as part of their on-boarding, 12 have completed. Care managers at PH also are being trained in motivational interviewing Assessments post training include follow up at multiple intervals and direct observation tools have been modified to verify utilization and coach for MI Quotes from Resident’s change plans for implementation of motivational interviewing: “ I want to develop my listening skills when working with patients’ families to understand what they are saying.“ “…consistently reflecting on what my patients tell me.” “ When taking a patient history, I am going to ask more open-ended questions.” Culinary Medicine Curriculum from Tulane – will be implemented as part of our SC FoodShare clinical collaboration project Joint PH/USC PACER Grand Rounds October 2016 PACER – an overview of the national program & local efforts January 2017 Improving Care through Patient Empowerment (Session delivered with our Coach Steve Crane) Future - Optimizing Partnerships with Pharmacists, and more… Pilot of PCMH Criteria Workshop (Family Medicine) as part of practice management series “QuEST” IPE Pilot – medical & pharmacy students recruited through USC IHI Open School Chapter in an elective experience doing quality improvement work at Palmetto Health; faculty represents multiple professions Clinical Transformation Family Medicine Center Recertified as NCQA – PCMH Readmission/Emergency Department Utilization Project Re-established Patient Council Pediatric Clinic - CHOC QTIP National Collaborative USC School of Law Medicolegal partnership Carolina Collaborative In SC/NC for SDOH Pediatrics Internal Medicine Family Medicine I3 Value Collaborative (Regional) Quadruple Aim focus of metrics Diabetes Mellitus care Smoking cessation screening & counseling NQF # Measure Descriptor Domain Population: Active patients with at least 2 visits in previous 24 months CLINICAL QUALITY RECOMMENDED 0059 Comprehensive Diabetes Care The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) whose most recent HbA1c level during the measurement year was greater than 9.0% (poor control) or was missing a result, or if an HbA1c test was not done during the measurement year Clinical Quality 0028 Preventive Care Screening: Tobacco Use: Screening and Cessation The percentage of patients aged 18 years of age and older who were screened for tobacco use at least once during the two year measurement period AND who received cessation counseling intervention if identified as a tobacco user PATIENT EXPERIENCE N/A TNA (Access) Average number of days to third next available appointment for an office visit Patient Experience Usual Primary Care (UPC) Continuity of care measure Average UPC for all active patients PHYSICIAN & STAFF EXPERIENCE RECOMMENDED – COMING SOON MA/staff turnover The percentage of medical assistant staff who left their position in the previous 12 months Provider & Staff Experience Clinical Team Satisfaction Faces scale UTILIZATION/COST 1789 Hospital Readmissions Total # of 30-day readmissions for active patients during the measurement year Utilization ED Visits Total # of ED visits by active patients during the measurement year Patient Engagement Project Collaboration with USC Education department, graduate class for customized survey process Internal Medicine Clinic Clinic Improvement Team reinvigorated Weekly Case management Conference Team-based special population care Joint Clinical Initiatives (across all three clinical sites) Resident Incentive Program, Optional Goal – Quality Improvement Projects Sponsored by Palmetto Health Graduate Medical Education 6 residency programs completed for added incentive payments in 2017 New cycle in progress, PH/USC PACER team provides peer review & coaching Interpersonal Medicine – Accelerating Patient Activation & Practitioner Well-Being These “process groups” are detailed further under educational transformation; We are integrating motivational interviewing into the clinical training for multiple professions and exploring potential for team training with simulation in the future. SC FoodShare Collaboration – Building on pilot work in Pediatrics, all three clinics will screen for food insecurity using FDA 2-question screen, share resources with patients and families and enroll appropriate patients/families in FoodShare study (measure health impacts); Grant application under review. Clinic walk-through visits for patient-centered care using a tool developed from Palmetto Health (PH) Patient Centered Medical Home handbook, the Patient Centered Environmental Audit Tool, the Interprofessional Education Collaborative (IPEC) and the Institute for Family Centered Care, as well as the PACER PCMH Monitor Survey. Early stage of collaboration with Palmetto Health “Patient Experience” leadership and the PH Patient & Family Advisory Council (PFAC) to align Clinic PFACs with overall system initiatives. A Few Challenges: Change of team member for Pediatrics, but warm hand-off to help onboard new member EMR upgrade anticipated 2016 was delayed significantly, affected data retrieval for QI Scheduling joint resident education has been challenging; requiring more “parallel play” Next Steps: Dissemination – continued efforts to spread to other residencies within the system and to rural programs near us & connected through Palmetto Health or USC School of Medicine Collaborative efforts - Eastern Virginia Medical School & I3 for regional growth of patient-centered care and interprofessional education and care delivery Continue to gather data for assessment of our learners and overall program evaluation Adolescent to Adult transitions of care for all 3 clinics Expand group visit model, including follow up for newborn care for participants who had been involved in group visit models during pregnancy Continue to promote PACER concepts and invite others to join in transformational efforts Explore funding mechanisms to support ongoing change efforts locally and regionally Our sincere thanks to the Oregon Health & Science University for leading the charge and to the sponsors.