TCPI Project Pathway: Session 7 of 8 Person and Family Centered Care Milestone #’s 4, 5, 12, 17 (specialty) 4, 5, 7, 15, 17and 22 (primary care)

About the TCPI Milestones 22 Milestones for specialty practices 27 Milestones for primary care Scores on each milestone determine Phase completion For example, to complete Phase 1, as score of 3 is necessary on milestone 13 (setting an aim). Other phases require various scores for other milestones.

Milestone Classes Review Scoring and Strategies for Meeting Them (numbers in parentheses indicate milestone numbers for primary care) Each Milestone-Group Class will be held live 3 times: Quality Improvement Strategies and Action –milestones 14, 15, 16 (19, 20, and 21) (already held- recording available) Improvement Goals – milestones 1, 2, 3, 13 (1, 2, 3, 18) Staff Engagement: Teamwork and Joy – milestones 6 and 19 (6 and 24) Identifying Patient Risk and Using Best Practices – milestones 7, 11 (8, 9, 10, 16) Streamlining Clinical and Office Work – milestone 22 (27) Coordinated Care – milestones 8, 9, 10 (11, 12, 13, 14) Person and Family-Centered Care – milestones 4, 5, 12, 17 (4, 5, 7, 15, 17and 22 for primary care) Business Strategies – milestones 18, 20, 21 (23, 25, 26)

Today’s Objectives Review scoring for person and family centered care- related milestones: 4, 5, 12, 17 (specialty) 4, 5, 7, 15, 17and 22 (primary care) Outline strategies for meeting each of these milestones Review relevance of milestones’ scores to phases Open discussion

Person and Family-Centered Care Specialty milestones 4, 5, 12, 17 Primary care milestones 4, 5, 7, 15, 17, 22

Your Transformation Workplan – Practice Plan Tab

Milestone 4 (#4 for primary care): a score of 3 is needed to complete Phase 4

Strategies for Meeting Milestone 4 (# 4 for primary care) Change Package – 1.1.3 Train staff in motivational interviewing approaches Create a shared care plan for every patient Use evidence-based decision aids to provide information about risks and benefits of care options in preference-sensitive conditions Routinely share test results, along with appropriate education about the implications of those results, with patients Engage patients, family and caregivers in developing a plan of care and prioritizing their goals for action, documented in the Electronic Health Record (EHR) Incorporate evidence-based techniques to promote self- management into usual care, using techniques such as goal setting with structured follow-up, Teach Back, action planning or motivational interviewing Use tools to assist patients in assessing their need for support for self- management (e.g., the Patient Activation Measure or How’s My Health)

Strategies for Meeting Milestone 4 –continued Change Package – 1.1.3 Provide a pre-visit development of a shared visit agenda with the patient Provide coaching between visits with follow-up on care plan and goals Provide peer-led support for self-management Provide group visits for common chronic conditions (e.g., diabetes) Provide condition-specific chronic disease self-management support programs or coaching or link patients to those programs in the community Train staff in self-management goal setting Standardized action planning and plan follow-up process so entire team can participate Educate patients and families on health care transformation so they can be active, informed change agents. Use appropriate language, simple language, and pictures Ensure patient leaves office with plan of care in hand

https://www.healthit.gov/sites/default/files/nlc_shared_decision_making_fact_sheet.pdf

Additional resources about Shared Decision Making Shared Decision Making — The Pinnacle of Patient-Centered Care (Michael J. Barry, M.D, and Susan Edgman-Levitan, P.A.) https://www.nejm.org/doi/full/10.1056/nejmp1109283 3 Best Practices for Shared Decision-Making in Healthcare https://patientengagementhit.com/news/3-best-practices-for-shared-decision- making-in-healthcare Center for Shared Decision Making https://med.dartmouth-hitchcock.org/csdm_toolkits.html Strategy 6I: Shared Decision making https://www.ahrq.gov/cahps/quality-improvement/improvement-guide/6- strategies-for-improving/communication/strategy6i-shared-decisionmaking.html

Motivational Interviewing “Motivational Interviewing is a collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.” Miller and Rollnick (2012) https://www.ausmed.com/articles/motivational-interviewing/ Prochaska model for change Four Basic Principles of Motivational Interviewing: R – resist the urge to change the individual’s course of action through didactic means U – understand it’s the individual’s reasons for change, not those of the practitioner, that will elicit a change in behaviour L – listening is important; the solutions lie within the individual, not the practitioner E – empower the individual to understand that they have the ability to change their behaviour

https://www.communitycarenc.org/media/files/mi-guide.pdf

Milestone 5 (#5 for primary care): a score of 3 is needed to complete Phase 4

Strategies for Meeting Milestone 5 (#5 for primary care) Change Package – 1.1.2 Include a patient on the organization’s board Implement a patient and family advisory group Regularly survey patients and families Invite patients to operational meetings Include patients and families in all quality improvement (QI) initiatives Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms

http://planetree.org/wp-content/uploads/2017/09/Patient-Engagement-in-Research-A-Toolkit-for-PFACs.pdf

Additional Resources related to PFACs Link to webinar VCSQI offered on this topic https://youtu.be/kSwZ4hYp560 Forming a Patient and Family Advisory Council/Steps Forward https://www.stepsforward.org/modules/pfac PFAC Toolkit – Ohio Hospital Association https://www.ohiohospitals.org/OHA/media/Images/Patient%20Safety%20and %20Quality/Documents/PFE/OHA_PFAC-Toolkit_FINAL.pdf Patient and Family Advisory Council – Getting Started Toolkit https://cdn.ymaws.com/www.theberylinstitute.org/resource/resmgr/webinar _pdf/pfac_toolkit_shared_version.pdf PFAC Toolkit and Trainers’ Guide http://www.hret-hiin.org/resources/display/pfac-toolkit-and-trainers-guide

Strategies for Meeting Milestone 5 (#5 for primary care) Change Package – 1.1.2 Communicate to patients the changes being implemented by the practice. Educate patients and community on what they should expect and look for in a physician. Currently, it is very difficult to know who the excellent providers are. Transparency in data, (quality, complications, readmissions, etc. should be publicly available) Run focus groups to obtain patient and family feedback Include patients and families in staff feedback education events Use patient stories to start each meeting Use real-time electronic systems for capturing patient feedback

Milestone #12 (specialty care) and #17 (primary care): a score of 3 is needed to complete Phase 3

Strategies for Meeting Milestone 12 (17) Change package – 1.7.1 Create a centralized call center operation to more efficiently manage patient calls Maintain a patient portal and encourage its use by patients and families Set up a secure messaging system or use Direct Secure Messaging Provide 24/7 access to provider or care team for advice about urgent and emergent care Provide care team with access to medical record after hours Ensure providers who are cross-covering have access to medical record Protocol-driven nurse line with access to medical record

Strategies for Meeting Milestone 12 (17) -continued Change package – 1.7.1 Expanded hours in evenings and weekends with access to the patient medical record (e.g., coordinate small practices to provide alternate hours’ office visits and urgent care). Use alternatives to increase access to care-team and provider, such as e-visits, phone visits, group visits, home visits and alternate locations (e.g., senior centers and assisted living centers). Provide same-day or next-day access to a consistent provider or care team when needed for urgent care or transition management Provide a patient portal for patient-controlled access to health information Use warm hand offs for cross coverage Implement a 24-hour nurse call line that is algorithm-driven

Milestone 17 (Specialty) and #22 (Primary Care): A score of 3 is needed to complete Phase 3

Strategies for Meeting Milestone 17 (22) Change Package – 2.4.1 Use secure email visits Use telemedicine visits for patients in rural areas or for specialty consultations Use home tele-monitoring options Instruct on receiving payment for e-visits and e-consults Use text prompts to look at portal messages Use text appointment reminders with permission Home International Normalized Ratio (INR) monitoring Protocols for monitoring urinary tract infection or upper respiratory infection with phone call

Strategies for Meeting Milestone 17 (22) - continued Change Package – 2.4.1 Use portal or texting to provide electronic reminders Use patient portals to avoid unnecessary visits to provider and answer questions by appropriate care team member Use apps – everyone has a cellphone (almost) Have portal messages go to the team, not just provider Implement a system for ongoing review of workflows and train on updates Assess access in rural areas and consider alternative web access approaches Use web-based video technology (e.g., Skype) for homebound patients

The next 2 milestones are just for Primary Care practices: #7 and #15.

Milestone 7 (primary care): a score of 3 is needed to complete Phase 3 Continuity of Care (COC) measures the extent to which an individual patient sees a given provider over a specified period of time. So here we are talking about continuity of care within the practice. This will help patients have the same caregivers over time whenever possible.

Strategies for Meeting Milestone 7 (primary care) Change Package – 1.2.3 Measure and monitor continuity between patient and care team regularly Develop a script to assist schedulers in providing appointment options with the care team to which a patient is assigned as well as to assign new patients to an appropriate team Provide medical record access to provider/ care team members caring for patients after hours Provide direct secure messages or web-based access to and from emergency departments (EDs) patients may frequent Electronically share information with care providers outside the practice so that information or tests are not duplicated

Strategies for Meeting Milestone 7 (primary care)-continued Change Package – 1.2.3 In specialty care, assign accountability for each patient to a care team and ensure coordination with the primary care team to which the patient is empaneled Measure continuity between patient and provider and/or care team Use scheduling strategies that optimize continuity while accounting for needs for urgent access Use a shared care plan to ensure continuity of management between within the practice and with consultants (for high risk patients) Ensure that all providers within the practice and all members of the care team have access to the same patient information to guide care. Develop contingency plans for when continuity is not possible Create primary care provider identification cards that patients can carry with them throughout the health neighborhood

Milestone 15 (primary care): a score of 3 is needed to complete Phase 4

Strategies for Meeting Milestone 15 (primary care) Change Package – 1.6.1 Develop formal referral relationships with mental health and substance abuse services in the community Ensure primary care providers and other clinical staff has been trained in principles of behavioral health care and are able to handle routine behavioral health care needs Include use of non-clinical staff to provide screening and assessment of behavioral health care needs Ensure regular communication and coordinated workflows between primary care and behavioral health providers Conduct regular case reviews for at-risk or unstable patients and those who are not responding to treatment

Strategies for Meeting Milestone 15 (primary care) - continued Change Package – 1.6.1 Use the registry function of the EHR or a shared registry to support active care management and outreach to patients in treatment Ensure that advance directives are included in discussions with patient and family and documented; Use web-based documentation support systems where available Integrate behavioral health and medical care plans and facilitate integration through co-location of services when feasible Integrate oral health services into primary care and specialty settings

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Coming Next Week – Class 8 Business Strategies Specialty milestones 18, 20, 21 Primary care milestones 23, 25, 26