1. Following the Yellow Brick Road to the Emerald City of Patient Care Coordination On a Budget Cortney McDuff, RN Cindy McHenry, RN BSN

2. Disclosures ACTIVITY DISCLAIMER The material presented at this activity is being made available by the Society of Teachers of Family Medicine (STFM) for educational purposes only. This material is not intended to represent the only, nor necessarily best, method or procedure appropriate for the medical situations discussed but, rather, is intended to present an approach, view, statement or opinion of the faculty that may be helpful to others who face similar situations. The STFM disclaims any and all liability for injury or other damages resulting to any individual attending this program and for all claims that may arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Every effort has been made to ensure the accuracy of the data presented at these activities. Physicians may care to check specific details such as drug doses and contraindications, etc. in standard sources prior to clinical application. These materials have been produced. solely for the education of attendees. Any use of content or the name of the speaker or STFM is prohibited without written consent of the STFM. FACULTY DISCLOSURE The STFM has selected all faculty appearing in this program. It is the policy of the STFM that all CME planning committees, faculty, authors, editors, and staff disclose relationships with commercial entities upon nomination or invitation of participation. Disclosure documents are reviewed for potential conflicts of interest and, if identified, they are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity.

3. Goppert-Trinity Family Care Family Medicine Residency Program 20 Faculty Physicians 32 Resident Physicians 50 Clinic Staff –Divided into three teams (Red, Yellow, Blue) 2 RN’s 1 LPN 1 MA Diverse Population

4. NCQA Certification First Certification under 2009 Standards Re-Certification under 2011 Standards –PCMH Clinically Important Population Hypertension Diabetes Smoking –High Risk Population Depression Hospital follow-up (Transition of Care)

5. Team Nursing Staff RN –Pre-Visit Planning –Hospital to Home (Transition of Care) LPN –Keep the flow of clinic moving MA –In charge of daily huddles and rooming patients

6. Pre-Visit Planning Evolves NCQA Re-Certification –Process developed during our NCQA Recertification August 2015 –RN on each team selected to help develop the process

7. Trial and Error Down the Yellow Brick Road –Meeting Every Friday –Developed Forms to help plan each patient visit –Developed Order Sets Ordered Labs Select Patient Education Care Plans

8. First Form Developed DIABETES Date of Last Visit________________________ HgbA1c (every 6 months)________________________ Microalbumin/Creatinine ratio, random urine (annual)________________________ CMP (annual)________________________ Lipid Panel (annual)________________________ Retinal Exam (annual)________________________ Diabetic Education (annual)________________________ Foot exam with monofilament (annual)________________________ Foot exam visual (every visit)________________________ Flu Vaccine (annual)________________________ Pneumonia Vaccine________________________ Hep B Vaccine (determined by provider)________________________ HYPERTENSION Date of Last Visit________________________ BMP or CMP (annual)________________________ Microalbumin/Creatinine ratio, random urine (annual)________________________ Lipid Panel (annual on meds; every 2 years not on meds)________________________ Diabetes Screen (every 3 years: HgbA1c)________________________ EKG (once within 2 years of diagnosis)________________________

9. Current Form

10. Staff Education How to use order sets How to do diabetic foot exams Improved Nurse Physician Communication Nurse helps with Discharge Process Patient Education

11. Getting the Staff Motivated Glenda the Good Witch –Weekly meetings with all staff

12. The Wizard of Oz 1 st NCQA Certification –Audits done manually –No system to pull reports –Data not in structured fields NCQA Re-Certification –IT Created CareVantage Prepare Manage

13. CareVantage & Pre-Visit Planning Prepare

14. Finally We Reached the Emerald City We get a Care Coordinator Focus on Diabetic and Hypertensive patients – Schedule – Educate – Hospital to Home – Use CareVantage to sort the patients

15. CareVantage and Care Coordination Manage

16. Work in Progress CareVantage updates Building patient relationships Ordering labs in advance Chronic Care Management ICD-10

17. Barriers The Monkeys It is not my job I can’t do one more thing I don’t like feet I don’t get it How is this helping the patient?

18. Positives Allowed physicians to spend more face to face time with patients Clinic efficiency Patient education at every visit Improved communication between nurses and physicians Consistent care Patients are focusing on goals

19. Questions

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