1. Creating Clinical Change through Teams: Lessons Learned in a Community Based Program Pamela Webber (MD), Kate Rutledge (MD), Mimi Choate (MD)

2. Outline Introduction PCMH Clinic change – Huddles – Call Center – OB Care coordinator Logic Model as tool Discussion

3. Objectives Describe the keep steps in multidisciplinary team formation and function involving staff and residents Understand potential challenges in making clinic change in a Residency clinic Contrast three different team based strategies to implement clinic changes Understand how the logic model can be used to focus team goals and activities

4. Residency Program/ PCMH Teams Overview

5. Fort Collins Family Medicine Residency Program A community based 6/6/6 program 30,000 patient visits, 150 continuity deliveries/year 14 faculty members, 8 physicians The only residency program in Fort Collins An attractive city with urban amenities and wilderness nearby

6. PCMH Resident and staff lead Steering committee as clearing house for clinic improvement projects Members – Mimi Choate (R3) co-chair – Bonnie Campos (Lab) co-chair – Kristen Bene and David Marchant (Faculty) – Janet Rehor, Maddy Wawro and Mandi Baxter (Front Desk) – Cheryl French and Vicki Lemhagen (Nurses) – Leslie Ayres-Reichert (Social Work) – Michelle Hillaire (Pharmacist faculty)

7. Timeline December 2008 funding through Colorado Trust – Colorado Family Medicine Residency PCMH Project February 2009 steering committee forms and meets with facilitator – Resident Champion identified – Physician faculty not included on steering committee Clinic Wide identification of areas of emphasis – Team building, and pods work on projects Diabetes, Depression, Hypertension

8. October 2010 upgrade of EHR (chaos) Reorganization of steering committee – Begins work on Huddles (NP champion identified) – Begins work on call center (began April 2011) – Begins work on diabetes registry December 2010 OB PCMH group formed – Registry for OB patients Jan 2010 – OB Care Coordinator designated Jan 2012

9. PCMH Steering Committee PCMH Steering Committee

10. Huddles Proposed by steering committee Found NP who was champion Advertisement of process and continued education Generally well accepted and part of culture at clinic as process before clinic between nurse and provider

11. Bad Bad Huddles Good Good Bad Good

12. Call Center Steering Committee Identified problem Call volume and procedure mapped Changes proposed Job interviews for internal reception staff for call center Continued monitoring and education about process

13. Call Center Call Center

14. Call Center Statistics

18. OB PCMH Team Multi disciplinary team from throughout clinic working on OB issues Members – Cheryl French (now OB Care coordinator) co-chair – Kate Rutledge (resident OB-peds chief) co-chair – Diane Duvall, Cheryl Gansen-Tobias, Elaine Ferguson, Laura Roberts -- nursing – Mandi Baxter – reception – Leslie Ayres-Reichert, Andrea Holt – Behaviorists – Bonnie Campos – Lab (steering committee) – Pam Webber -- faculty

19. OB PCMH projects Excel registry of all patients Centralized registration and making of new OB appointments with one receptionist Pilot project for initial ob intake before visit with provider Develop job description for OB Care Coordinator Work on group visits – Focus groups – 24- 28 week group visits

20. OB Care Coordinator/Team OB Care Coordinator/Team Before After Before AfterBeforeAfterBeforeAfter

21. Challenges to OB project Starting out with group model project and not having buy in from faculty/clinic administration Time lags in getting things done, approval by executive committee, HR job description Struggling to maintain focus

22. Logic Model Used by OB PCMH committee to gain consensus about direction Used to guide goals for year Communication tool with faculty and executive committee about the projects of the group – OB Care Coordinator – Group Visits

23. Resources 1. FMC staff 2. Community resources 3. OB PCMH committee 4. PCMH steering committee 5. High risk OB committee Resources 1. FMC staff 2. Community resources 3. OB PCMH committee 4. PCMH steering committee 5. High risk OB committee Assumptions 1. We can do a better job in care of OB patients 2. Team based care is a good model 3. Consistent patient education is good 4. We have a responsibility to offer thorough, culturally sensitive OB care Assumptions 1. We can do a better job in care of OB patients 2. Team based care is a good model 3. Consistent patient education is good 4. We have a responsibility to offer thorough, culturally sensitive OB care Activities 1. Complete spread sheet 2. OB PCMH meeting 3. GDM project 4. Pilot project with Leslie and Mandi Activities 1. Complete spread sheet 2. OB PCMH meeting 3. GDM project 4. Pilot project with Leslie and Mandi Output 1. Initial OB visit before 11 weeks 2. Initial visit with nurse who provides education, referrals, completes paperwork before OB intake 3. Designated contact person 4. Consistent OB charts Output 1. Initial OB visit before 11 weeks 2. Initial visit with nurse who provides education, referrals, completes paperwork before OB intake 3. Designated contact person 4. Consistent OB charts Outcomes 1. Healthy moms and babies 2. Consistent education and referral 3. Group visit opportunities 4. Consistent OB education for residents 5. More time during OB visits for questions and education since paperwork is completed ahead of time. Outcomes 1. Healthy moms and babies 2. Consistent education and referral 3. Group visit opportunities 4. Consistent OB education for residents 5. More time during OB visits for questions and education since paperwork is completed ahead of time. External Factors 1, Patients with different cultural beliefs about OB care, 2. Need to implement with current FTE’s,3. Potential change back to electronic medical record. Problem/ Situation OB Care at FMC Inconsistent OB care at FMC resulting in patient, provider and staff frustration, Desire to provide greater continuity and consistency in Obstetric Care for FMC patients, so that all patients have the same education and access to community and clinic resources. Goals 1. Improve OB patient Care 2. Improve OB education for residents 3 Improve provider, staff and patient satisfaction

24. Themes Project champions are essential Consistent co-leadership with staff member helps with continuity Having the input of a faculty person who understand the complicated residency system helps facilitate projects moving forward Use of the multidisciplinary team can identify processes and changes that may be missed from a top/down approach Recognize the power differential between staff and physicians Change can eventually occur, persistence is important

25. Thanks to our Multidisciplinary team and Education team, Carrie Williams and Denise Daley for assistance with preparation of this presentation

26. Discussion/Questions Contact information Pam Webber webbpa@pvhs.org