© 2004 Institute for Healthcare Improvement Delivery System Design Cory Sevin RN, MSN, NP Nancy Gilliam Anaheim, California February 12, 2005 HDC Learning Session

© 2004 Institute for Healthcare Improvement For you all to be excited to go home and test breakthrough changes in how your care processes are designed! Goal of the Session

© 2004 Institute for Healthcare Improvement Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Functional and Clinical Outcomes Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Chronic Care Model You are here

© 2004 Institute for Healthcare Improvement Our systems are not designed to get quality outcomes in anything other than acute care. We know that many patients do not receive evidence based care and do not feel listened to We know that patients are often not active participants in their care We know that many health care providers and staff are working very hard

© 2004 Institute for Healthcare Improvement Clearly identified care teams for patients Clear roles for all team members Continuity Cleared system of chaos and waste Observation of organizations making breakthrough outcomes shows they have……

© 2004 Institute for Healthcare Improvement Patients must be prescribed and taking proven therapies Patients must be managing their illness well Patient course must be followed for changes in status and reinforcement Interactions must be productive I believe, health care workers must enjoy and get satisfaction out of what they do every day Our systems of care must be efficient and effective. To Improve Outcomes:

© 2004 Institute for Healthcare Improvement Assessment of self-management skills and confidence as well as clinical status Tailoring of clinical management by stepped protocol Collaborative goal-setting and problem-solving resulting in a shared care plan Active, sustained follow-up Informed, Activated Patient Productive Interactions Prepared Practice Team How would I recognize a productive interaction?

© 2004 Institute for Healthcare Improvement Define roles and distribute tasks amongst team members. Use planned interactions to support evidence- based care. Provide clinical case management services. Ensure regular follow-up. Give care that patients understand and that fits their culture Delivery System Design Key Leverage Points!

© 2004 Institute for Healthcare Improvement Define roles and tasks All team members have a role. Leverage Point 1

© 2004 Institute for Healthcare Improvement Team development: is there an identified team for each patient? Are all clinic staff seen as being on the team? Review process for care: who is doing what? Is this the best use of their time? Assign tasks, matching licensure and skills. Cross train staff Use protocols and standing orders Define Roles and Tasks

© 2004 Institute for Healthcare Improvement Reduce Chaos and Waste to create resources for planned care Create processes so that the patient, provider, information, room and equipment are ready at the same time. Providers do provider work and everything else gets done by others Predict and anticipate needs:know your slow and busy seasons, have plans for repeat tasks like school physicals, etc. Subtract unnecessary work Optimize rooms and equipment: standardize

© 2004 Institute for Healthcare Improvement Ensuring follow-up for depression patients Providers (both PCPs and BHCs) place red “dots” on medical record for patients they place into the collaborative Medical Records staff identifies collaborative patients based on the red “dots” and places blank PECS encounter notes on the chart when a follow-up has been scheduled Nursing staff identifies collaborative patient and checks for lapsed appointments and informs providers BHC either sees patients as a walk-in or schedules follow-up appointment while patient is in the clinic Examples: Roles and Tasks

© 2004 Institute for Healthcare Improvement Roles in Team Care RolePCPBHCNursingClericalDec Supp Identify pts for CollabXX Screen pts for DepressionXXX Provide pt careXX Produce report for patients needing follow-up X Schedule follow-up apptsX To ensure follow-up appointments are scheduled:

© 2004 Institute for Healthcare Improvement Test Roles and Tasks PDSA the MA doing LEAP exams PDSA MA’s filling out forms PDSA the nurse calling back about some lab results Other ideas? PDSA AP SD A P S D D S P A AP SD

© 2004 Institute for Healthcare Improvement Use planned interactions to support evidence-based care One-on-one, group, telephone, , outreach….the possibilities are endless Leverage Point 2

© 2004 Institute for Healthcare Improvement Set up system so the default, when possible, is to provide evidence based care, planned care.

© 2004 Institute for Healthcare Improvement Create your system to make planned interactions easy! Make sure all patients are connected to a PCP and a care team. Measure continuity Use daily huddles Systematize to reduce waste and chaos…the time can be spent actually working with patients!

© 2004 Institute for Healthcare Improvement What is a Planned Care? Planned Care is when the patient receives the right interaction at the right time by the right person. It is a system issue……. A Planned Visit is an encounter with the patient initiated by the practice to focus on aspects of care that typically are not delivered during an acute care visit.

© 2004 Institute for Healthcare Improvement What does Planned Care look like? The provider team knows the patients who need evidence based care and proactively reach out to the patient. Delivery of clinical management and patient self-management support are the key aspects of care. The care team is ready and prepared to provide evidence based care at all times. Visits occur at regular intervals as determined by provider and patient.

© 2004 Institute for Healthcare Improvement Potential Planned Care PDSA’s PDSA real time communication methods (co- location of team members, walkie talkies) PDSA how registry reports inform the care team PDSA inviting patients to a Planned Visit or a Group Visit Other ideas? PDSA’s

© 2004 Institute for Healthcare Improvement How do you do a Planned Visit? You Plan It!

© 2004 Institute for Healthcare Improvement Patients with higher suicide risk Step 1 Identify patients with higher suicidal risk based on a score greater than 0 on question 9 of the PHQ For Decision Support, generate a list of patients meeting the criteria PCPs and BHCs are provided the list and can ensure appropriate follow-up is conducted based on the treatment guidelines

© 2004 Institute for Healthcare Improvement Step Two: Patient Outreach for Depression Receptionist/Patient Account Rep identifies last visit by the patient and if a follow-up has been scheduled (in the appropriate time frame) If no follow-up has been scheduled the PAR works with the patient to schedule an appointment Patient is offered the opportunity to talk to the BHC at that time if things aren’t going well The appointment is scheduled with the phrase Depression Follow-up in the reason code

© 2004 Institute for Healthcare Improvement Medical Records sees that the patient is a collaborative patient and attaches the blank PECS encounter note Both the nursing staff and the providers see that the reason for the visit is a follow-up for Depression so they can ensure that the patient receives a depression screen Step Three: Preparing for the Depression Follow-up Visit

© 2004 Institute for Healthcare Improvement Review how the patient is doing/feeling Adjust remaining medications as needed Review the self-management goals Problem solve barriers to treatment Adjust self-management goals Schedule follow-up with the BHC and/or the PCP Step Four: The Depression Visit

© 2004 Institute for Healthcare Improvement Follow-ups are generally scheduled with the BHC Phone follow-ups by the BHC are conducted within 1-2 weeks of initial visit Patients that are unwilling to see the BHC are scheduled a depression follow-up with the PCP Lapsed appointments are tracked and patients that haven’t had a follow-up in 4-6 weeks are contacted to schedule an appointment. Step 5: Depression Follow-up

© 2004 Institute for Healthcare Improvement Group Visits Patients brought in by clinically relevant groups Patients can receive: Specialty service as needed/available One-on-one with medical provider Medication counseling Self-management support training Social support Multiple Models for Group Visits

© 2004 Institute for Healthcare Improvement Group Visits: Success Weekly depression groups are conducted. Patients attend and the success stories from the groups are impressive. Patients that couldn’t get out of bed are now able to successfully hold down a job. The patients are supportive of one another. Keys to success: –Involve the providers in the referral process –Utilize open group format –Develop curriculum that empowers patients –Utilize community resources

© 2004 Institute for Healthcare Improvement Provide clinical case management services for complex patients. Knowing who needs more support and finding a way to deliver it. Leverage Point 3

© 2004 Institute for Healthcare Improvement Many different things to different people Resource coordination Utilization management Follow-up Patient education Clinical management Casemanagement

© 2004 Institute for Healthcare Improvement Develop patient selection criteria: who needs what kinds of services? Who can provide casemanagement? Review team roles and tasks and fill in gaps. Assure that patients receive CM services. Link into community resources Key Changes for Casemanagement

© 2004 Institute for Healthcare Improvement Regularly assess disease control, adherence, and self-management status Either adjust treatment or communicate need to physician immediately Provide self-management support Provide more intense follow-up Assist with navigation through the health care process Features of effective Casemanagement

© 2004 Institute for Healthcare Improvement Evidence suggests that non-professionals can be trained to perform follow-up and assessment. That alone when linked to a physician or nurse case manager has improved outcomes in depression and arthritis Automatic Voice Response telephone systems can perform this function. Who can be a casemanager?

© 2004 Institute for Healthcare Improvement Use combination of resources. For example: For Decision Support, produce reports that show patients needing follow-up Clerical Staff can review schedules and contact patients that need appointments BHC contacts patients needing early follow-up, interventions or referrals Casemanagement

© 2004 Institute for Healthcare Improvement Casemanagers: examples Trained lay health professionals provide: Follow-up Patient education Registry management Self-management support Facilitate group visits Liaison to community resources Can be an important link to cultural issues affecting outcomes.

© 2004 Institute for Healthcare Improvement PDSA’s for casemanagement PDSA front desk staff to use registry to identify and call patients who need follow-up appointments PDSA a lay health professional to help patients develop self-management goals Other ideas?

© 2004 Institute for Healthcare Improvement Ensure regular follow-up by the primary care team The alternative to lost to follow- up…there is strong evidence that it makes a big difference in chronic illness. Leverage Point 4

© 2004 Institute for Healthcare Improvement Develop process for follow-up Tailor follow-up to patient and provider needs Eliminate unnecessary follow-ups Schedule follow-up. Monitor for missed follow-up. Reach out to those not attending follow- ups. Make Follow-Up Work for You

© 2004 Institute for Healthcare Improvement Face-to-face Clinical case manager Outreach worker In groups Phone Think out of the box….

© 2004 Institute for Healthcare Improvement Improved identification of depression patients Improved teamwork between providers Improved self-management goal setting (11% to 91%) Improved scheduling of follow-ups, implementing early phone follow-ups Standardized use of tools City of Austin Depression Results

© 2004 Institute for Healthcare Improvement Example: Patients with higher suicide risk Step 1 Identify patients with higher suicidal risk based on a score greater than 0 on question 9 of the PHQ For Decision Support generate a list of patients meeting the criteria PCPs and BHCs are provided the list and can ensure appropriate follow-up is conducted based on the treatment guidelines

© 2004 Institute for Healthcare Improvement Leverage Point 5 Give care patients understand and fits their culture Connect patients to a care team who will get to know them and they trust It is more than just translating…..

© 2004 Institute for Healthcare Improvement For you all to be excited to go home and test breakthrough changes in how your care processes are designed! Goal of the Session