1. Tracy Hofeditz, MD Belmar Family Medicine, Lakewood, Colorado Chet Seward, MA Colorado Medical Society, Denver, Colorado Deb Barnett RN, MS, FNP-C HealthTeamWorks, Lakewood, Colorado Colorado Medical Society/Specialty Society Systems of Care/Patient-centered Medical Home Initiative

2. Upon completion of the program the participants should be able to:  Describe how “test tracking” is linked to effective care management and the PCMH.  Use basic quality improvement skills to produce a mapping of their practice’s current test tracking process.  Identify an initial test of change based on completed process mapping to try once back at home in own clinic environment.

5. Health Information Technology/Exchange Infrastructure Quality Improvement Approach Evidence Based Medicine & Population Management Efficiency, Quality & Safety Patient Centered Care

6.  Where do you fit in this new reality?  Can you make the necessary transformations?  Will you survive? Will you thrive?  It’s not easy but it can be done. Today is about “M&Ms”—Movement and Maturation.  Notes from the field – Tracy Hofeditz, MD

7.  In a medical home, family physicians practice closer to the ideals of their training, where they focus on the needs and experience of the patient, lead a team with communicated common purpose, use information technology to achieve higher quality and improve safety, enhance access of the patient to the care they need, and continuously measure themselves to guide improvement.

8. CURRENT RULE NEW RULE Care based primarily on visits Care is based on continuous healing relationships Professional autonomy drives variability Care is customized according to pt needs/values Professional controls care Patient controls care Information is a record Knowledge is shared and information flows freely Decision making based on training and experience Decision making is evidence based Do no harm is an individual responsibility Safety is a system property Secrecy is necessary Transparency is necessary System reacts to needs Needs are anticipated Cost reduction is sought Waste is continuously decreased Preference given to professional roles Clinician cooperation is prioritized Excellence is assumedExcellence is pursued

9.  An adaptation of the rapid-cycle improvement strategy  Initially structured as a “TRIA” in a Lunch-and-Learn format  Overall goals consistent thread as new versions developed:  Improvement in patient outcomes—originally by embedding EBGs into clinical practice  Improvement in office efficiency  Improvement in healthcare team and patient satisfaction

10.  Test tracking – How is it working in your practice?  Gateway to patient-centeredness (PC) and strategic waste management (SWM)  Describing the ideal - Your picture of a clinic with effective, efficient test tracking abilities  NCQA definition – “Must Pass” Standard 6A  Let’s go swimming!

12.  Divide into teams, equal representation of departments  Use Post-Its in your SWiM lanes  Identify roles: facilitator, sequencer and reporter  Write out steps—1 step/Post-It  Sequence workflow  2 minute report on “ahas,” advice and test of change proposals

13.  SW i M away  “M&M” Movement & Maturation

14.  M&M  “Ahas” and advice  Addressing “Four Test of Change” questions  What are you trying to change  What did we learn from already trying?  How to test it, try it tomorrow  How to know if it worked

16. ATTRIBUTE ATTRIBUTE DESCRIPTION DESCRIPTION A deep understanding of the whole person Considers all influences on health helping to integrate rather than fragment. A generative impact on patients’ lives Continuous, comprehensive care fostering personal growth and behavior change. A talent to humanize health care Ability to connect in human ways with patients considering patient culture and values. A natural command of complexity Tolerance of uncertainty, complexity while considering all the factors contributing to health and well-being. A commitment to multi dimensional accessibility Physically accessible to patients but also maintain communication with all involved in the care process. “A commitment to continuous improvement and the pursuit of excellence while adapting to the changing needs of patients.” – Tracy Hofeditz, MD

17.  Applications to other issues  “See” your team  M ovement & M aturation  Re-examine  Resource list : http://www.cms.org/strategic- priorities/practice-viability/systems-of- carepatient-centered-medical-home-initiative/http://www.cms.org/strategic- priorities/practice-viability/systems-of- carepatient-centered-medical-home-initiative/