Care Initiatives, Panel Management, and Quality Improvement The Health Center “Health Care The Way It Ought To Be” Care Initiatives, Panel Management, and Quality Improvement Don Grabowski Laura Carleu, RN, MS, MPH PCMH Coordinator Practice Facilitator, VT Blueprint for Health

The Patient Centered Medical Home… … provides high quality, comprehensive, holistic health care focusing on wellness, medical needs and personal health goals. Patients can expect: Coordination of care and improved access Coordination with specialists, the hospital and community resources Convenient appointments available 24/7 provider access Evidence-based care with IT support Health maintenance and preventive service reminders Wellness support Wrap-around services: education, self-management, health coaching, social work Shift to working toward patient goals in addition to adhering to clinical guidelines

Empanelment… …the process for ensuring that every patient has an assigned Primary Care Provider (PCP)

Defining a Panel… Increases Patient Satisfaction Balances the workload Choice of provider Better access to provider Development of the health care relationship Balances the workload Define by providers’ skills, interests and/or specialty Ensures each provider carries “fair share” of patients Predicts patient demand Pre-visit planning (clinical and non-clinical) Revenue and staffing projections Improves understanding of provider performance Individual and practice-wide evaluations Increases commitment to continuity Improvement in clinical measures Reduced costs and enhanced revenue per visit AAFP, 2007

Panel Management A systematic approach to identify and address patients’ unmet chronic and preventive care needs Population-based, data-driven approach Multidisciplinary team Technology driven by patient “registries” Identify care opportunities Facilitate communication with patients Includes patients who HAVE NOT been seen In-reach and out-reach

Active In-reach Pre-visit planning “Pink” reminder The care team is provided with easily accessible information about preventive and chronic care services which are due. “Pink” reminder Well care flow sheet Diabetes flow sheet Hypertension flow sheet

PDSA: A Continuous Quality Improvement Approach FAHC Jeffords Institute for Clinical and Operational Effectiveness

In-reach: Brief Foot Exam PDSA model Goal: increase percentage of brief foot exams in the diabetic population by 10% in 6 months Actions: Training of all nursing staff Creation of “cheat sheet” Chart sticker in diabetic patient chart prior to visit

RESULTS: Findings included corns that needed attention, lots of red areas, jagged nails that needed attention (funny story)

The Less Measureable Outcomes Team Based Care Patient Engagement Self Management Building the Medical Neighborhood Central Vermont Home Health Foot Care Clinics The Vermont Chronic Care Initiative Medicaid Care Management Support SASH Program Support in Congregate Housing Hospitals and Nursing Homes Discharge Planning Coordination Post Emergency Room follow-up

Active Outreach Building registries Identifying opportunities for care Calls and letters to patients about health maintenance, care due and appointments Offering classes and groups to specific patient populations

MMR Panel Panel: Goal: Children 18-36 months of age No documented MMR immunization Goal: Increase documented MMR immunizations by 20% in this patient population

MMR Panel PLAN: DO: STUDY: ACT: Identify patient panel Ensure “clean” data Send patient letter DO: Carry out immunization plan and documentation Identify interventions: Share data at staff meeting Staff education (documenting refusals) Consistent use of encounter form to schedule Well Child Check STUDY: Run comparison report in November ACT: Examine data Plan further changes

Ongoing Patient Panels Adults with HTN with no visit in 12 months Children ages 18-36 months with no documented lead screen Adults with Diabetes and no A1C in 12 months Adults with diabetes and no documented eye exam in 2 years NOTE: These panels offer a “place to start”. The goal is for all patient care to meet evidence based guidelines.

Panel: Addressing Patient Education Panel: Adults with Diabetes and Hypertension Intervention: Series of classes that address the guidelines of care, self-management, and wellness of people with that co-diagnosis

Diabetes and High Blood Pressure Workshop for people who have both Diabetes and High Blood Pressure The combined diagnosis of both diabetes and high blood pressure (hypertension) requires a little different management than if a person has only one or the other. We are offering a workshop to help better understand and manage this combination of diagnoses. This workshop will provide information to better manage both diabetes and high blood pressure. Lauri Snetsinger, a Registered Nurse, will provide information about how diabetes and hypertension interact with each other, and the medical concerns of having both at the same time. Janice Waterman, a Registered Dietician and Certified Diabetes Educator, will discuss ways to help best manage diabetes and high blood pressure.   There will be time to ask questions.    We look forward to seeing you there!

Staff Education Sharing QI Data with providers and staff Identifies populations that would benefit from additional support Generates more ideas for interventions Routinely measures performance against goals Highlights educational needs of staff and patients

Intervention: Post-Discharge Support In-patient and ER RN Wellness Coach contacts patients shortly after discharge Medication reconciliation and review Follow-up appointment confirmed/scheduled Discharge plan reviewed Barriers assessed Referrals to other services

Health Coach Contact Form Discharge Follow Up Patient: DOB: Phone number: Admission date: Discharge date: Provider: Reason for admission: Place of Admission: Discharge DX: Next THC apt: Patient or guardian report of present status: Follow up appointments scheduled: Review discharge plan with patient: Y/N Patient reports understanding: Y/N Medication Reconciliation: /New prescriptions: Y/ N /Picked up: Y/N / Begun: Y/N Review all prescriptions and any changes:

Health Coach Contact Form (continued) Patient reports understanding of these medications: Y/N Remind patient to bring ALL prescriptions to their next THC appointment: Y/N Assess for any barriers the patient might have to meet their day to day needs: Review when to call THC or use ER, remind patient of Saturday morning THC hours and MD on call 24 hours: Y/N PLAN: Coordination: Comments: Signature:______________________________________Date:

What Has Worked Well… “Hot hand-offs” Regular Care Team Meetings Support at the point of care Wrap-around services of a Medical Home Regular Care Team Meetings Case reviews Share “success stories” and best practices QI Workgroups Include providers, nurses, office staff, and Blueprint Facilitator Make QI a practice-wide, every-day priority Staff and provider “Champions” assist with “buy-in” at all levels The Vermont Chronic Care Initiative Support for high-risk and high-cost Medicaid patients In-house 2 times a week and as needed

What to Monitor Data integrity Process changes and Defined workloads Ensure it is current, accurate, and includes the parameters you want Process changes and Defined workloads Make sure everyone is working to the optimum of their capability and licensure Work smarter, not harder Referrals Ask yourself if the referral is truly appropriate for the patient Refer patients who are ready to make changes Focus interventions on patient needs - not data purposes or staff convenience

Provider Feedback “I am practicing better medicine…” Point of care assistance using co-visits and “hot hand-offs” Care plan support with Medical Home wrap-around services Better educated patients Improved overall outcomes and performance measures

Staff Feedback “I feel like I have more options for my patients.” Nurses and other clinical staff work to maximum of their skill and licensure level Health maintenance and other patient needs identified prior, or at time of, a visit Extra patient support services available in-house and can be utilized by any staff member

Patient Feedback “This place just gets better and better. I’m glad I’m a patient.” High level of patient satisfaction with convenient office hours and on-call availability Attendees of diabetes education asked for monthly “drop-in” group

“Health Care The Way It Ought To Be” Intended Outcomes Reduced re-admission to hospital Reduced ER visits Improved clinical outcomes Improved continuity of care Improved patient satisfaction Improved staff satisfaction “Health Care The Way It Ought To Be”

For More Information …. Don Grabowski, PCMH Coordinator, The Health Center dgrabowski@the-health-center.org (802) 322-6600 Heather Caldera, RN Wellness Coach, hcaldera@the-health-center.org (802) 454-8336