1. TCPI Project Pathway: Session 4 of 8 Identifying Patient Risk and Using Best Practices #’s 7 and 11 (#’s 8, 9, 10, 16 for primary care)

2. About the TCPI Milestones
22 Milestones for specialty practices
27 Milestones for primary care
Scores on each milestone determine Phase completion
For example, to complete Phase 1, as score of 3 is necessary on milestone 13 (setting an aim).
Other phases require various scores for other milestones.

3. Milestone Classes Review Scoring and Strategies for Meeting Them (numbers in parentheses indicate milestone numbers for primary care)
Each Milestone-Group Class will be held live 3 times:
Quality Improvement Strategies and Action –milestones 14, 15, 16 (19, 20, and 21) (already held- recording available)
Improvement Goals – milestones 1, 2, 3, 13 (1, 2, 3, 18)
Staff Engagement: Teamwork and Joy – milestones 6 and 19 (6 and 24)
Identifying Patient Risk and Using Best Practices – milestones 7, 11 (8, 9, 10, 16)
Streamlining Clinical and Office Work – milestone 22 (27)
Coordinated Care – milestones 8, 9, 10 (11, 12, 13, 14)
Person and Family-Centered Care – milestones 4, 5, 12, 17 (4, 5, 7, 15, 17and 22 for primary care)
Business Strategies – milestones 18, 20, 21 (23, 25, 26)

4. Today’s Objectives
Review scoring for risk and best practice-related milestones: 7 and 11 (8, 9, 10, 16 for primary care)
Outline strategies for meeting each of these milestones
Review relevance of milestones’ scores to phases
Open discussion

5. Identifying Patient Risk and Using Best Practices - Specialty
Milestone 7: Practice has a reliable process in place for identifying risk level of each patient and providing care appropriate to the level of risk. This may include risk includes developing a health condition not already present, exacerbation of a condition or complications, need for a higher intensity of care, including hospitalization
Milestone 11: Practice uses evidence -based protocols or care maps where appropriate to improve patient care and safety.

6. Identifying Patient Risk and Using Best Practices – Primary Care
Milestone 8: Practice uses a consistent approach to assign patients to a provider panel and confirms assignments with providers and patients. Practice reviews and updates panel assignments on a regular basis.
Milestone 9: Practice has a reliable process in place for identifying risk level of each patient and providing care appropriate to the level of risk. This may include risk includes developing a health condition not already present, exacerbation of a condition or complications, need for a higher intensity of care, including hospitalization
Milestone 10: The practice provides care management for patients at highest risk of hospitalizations and/or complications and has a standard approach to documentation.
Milestone 16: Practice uses population reports or registries to identify care gaps and acts to reduce them.

7. Milestone 7 (9 for primary care): a score of 3 is needed to complete Phase 4).

8. Your Transformation Workplan – Practice Plan Tab

9. Strategies for meeting milestone 7 (9) - a score of 3 is needed to complete Phase 4
Change Package –
Identify a risk stratification approach and use it consistently
Assign responsibility for care management
Implement a standard approach to documenting care plans
Use a consistent method to assign and adjust global risk status for all empaneled patients to allow risk stratification into actionable risk cohorts
Use on-site practice-based or shared care managers to proactively monitor and coordinate care for the highest risk cohort of patients
Use panel management and registry capabilities to support management of patients at low and intermediate risk
Engage patients at highest risk in ongoing development and refinement of their care management plan, to include integration of patient goals, values and priorities

10. An example from anesthesia*
The ASA score is a subjective assessment of a patient’s overall health that is based on five classes (I to V).
Patient is a completely healthy fit patient.
Patient has mild systemic disease.
Patient has severe systemic disease that is not incapacitating.
Patient has incapacitating disease that is a constant threat to life.
A moribund patient who is not expected to live 24 hour with or without surgery.
E. Emergency surgery, E is placed after the Roman numeral. *

11. An example for stroke risk - (https://srat.stroke.org/)

12. Strategies for meeting milestone 7 (9) - continued
Change Package –
Use the Medicare Annual Wellness Visit with Personalized Prevention Plan Services for Medicare patients
Use social determinants of health in risk-stratification models
Assess patient engagement and willingness to address care gaps
Allow for the common sense addition to high risk or rising risk factor care team – no algorithm is perfect
Identify ways to graduate patients from care management when goals are met as appropriate
Deliver care plan with patient and family
Five minute daily huddles to plan care for the day
Use risk level to identify best provider for the patient
This Photo by Unknown Author is licensed under CC BY

13. Milestone 11: Practice uses evidence-based protocols or care maps where appropriate to improve patient care and safety. (a score of 3 is needed to complete Phase 4)

14. Strategies for meeting milestone 11 (a score of 3 is needed to complete Phase 4)
Change Package
Use condition-specific pathways for care of chronic conditions (e.g., hypertension, diabetes, depression, asthma and heart failure) with evidence-based protocols to guide treatment to target
Develop evidence-based protocols in house or use those externally available
Document protocols through flow sheets, process maps, care maps, swim lanes or other visual depiction
Invite visiting faculty in academic settings to learn protocols embedded in HER
Use protocols to guide communication with patients and families after a patient safety event
Embed protocols in the EMR

15. Example of an
assessment
protocol

16. Primary Care Milestone 8: Practice uses a consistent approach to assign patients to a provider panel and confirms assignments with providers and patients. Practice reviews and updates panel assignments on a regular basis.
Panel management is defined as “a set of tools and processes for population care that are applied systematically at the level of the primary care panel, with physicians directing proactive care for their patients”
(Nelson EC, Batalden PB, Homa K, Godfrey MM, Campbell C, Headrick LA, Huber TP, Mohr JJ, Wasson JH: Microsystems in health care: creating an information rich environment. Jt Comm J Qual Saf. 2003, 29: 5-15.)

17. Strategies for meeting Primary Care Milestone 8 - a score of 3 is needed to complete Phase 4
Change Package 1.3.1
Use four-cut method or another approach to develop initial panel assignments
Review and update panel assignments on a regular basis
Provide ways for patients to identify their care team without remembering names, such as color designations, posted photos of care team members, or cards with the care team identified
Determine guidelines for panel size and patient complexity per panel
Refer to care team as a team as opposed to the physician/advanced practice clinician only
Pictures of care team when patients enter exam room will help with the linkage
Divide empanelment duties among entire staff with clear protocols
Determine panel size according to patient risk and utilization

19. Four-Cut Method:

20. Primary Care Milestone 10: The practice provides care management for patients at highest risk of hospitalizations and/or complications and has a standard approach to documentation.

21. Strategies for meeting Primary Care Milestone 10 - a score of 3 is needed to complete Phase 4
Change Package – (same as for Milestone 9)
Use the Medicare Annual Wellness Visit with Personalized Prevention Plan Services for Medicare patients
Use social determinants of health in risk-stratification models
Assess patient engagement and willingness to address care gaps
Allow for the common sense addition to high risk or rising risk factor care team – no algorithm is perfect
Identify ways to graduate patients from care management when goals are met as appropriate
Deliver care plan with patient and family
Five minute daily huddles to plan care for the day
Use risk level to identify best provider for the patient

22. The Medicare Annual Wellness Visit - Resources
For clinicians:
MLN/MLNProducts/downloads/awv_chart_icn pdf
A Clinician Guide: 7cBRBwEiwAMEoXPPK3LH0_m2127b97Na74Ct_p5P3CWwxOq8qGltuKEGnplQBp4G8l_BoCAwYQAv D_BwE
For Medicare beneficiaries:

23. The tool from CMS

24. Preventing hospitalization – 5 Ways Guide - a helpful tool https://www

25. Preventing readmission of CHF patients: https://www. ncbi. nlm. nih

26. Primary Care Milestone 16: Practice uses population reports or registries to identify care gaps and acts to reduce them.

27. Strategies for meeting Primary Care Milestone 16 - a score of 3 is needed to complete Phase 4
Change Package –
Design EHR pop up reminders to appear as part of scheduling modules
Use EHR and payer care gap reports
Include medical residents’ assessments, not just faculty, for care gap reports in academic settings
Use clinical decision support aids such as “ACR Select”

28. http://www. managedhealthcareexecutive

30. This Photo by Unknown Author is licensed under CC BY-SA

31. Coming Up in the Next Class (week of September 3rd) Streamlining Clinical and Office Work: Milestone 22 (27 for primary care)
Practice uses a formal approach to understanding its work processes, eliminating waste in the processes, and increasing the value of all processing steps.