1. Care Initiatives, Panel Management, and Quality Improvement
The Health Center “Health Care The Way It Ought To Be”
Care Initiatives, Panel Management, and Quality Improvement
Don Grabowski Laura Carleu, RN, MS, MPH
PCMH Coordinator Practice Facilitator, VT Blueprint for Health

2. The Patient Centered Medical Home…
… provides high quality, comprehensive, holistic health care
focusing on wellness, medical needs and personal health goals.
Patients can expect:
Coordination of care and improved access
Coordination with specialists, the hospital and community resources
Convenient appointments available
24/7 provider access
Evidence-based care with IT support
Health maintenance and preventive service reminders
Wellness support
Wrap-around services: education, self-management, health coaching, social work
Shift to working toward patient goals in addition to adhering to clinical guidelines

3. Empanelment…
…the process for ensuring that every patient has an assigned Primary Care Provider (PCP)

4. Defining a Panel… Increases Patient Satisfaction Balances the workload
Choice of provider
Better access to provider
Development of the health care relationship
Balances the workload
Define by providers’ skills, interests and/or specialty
Ensures each provider carries “fair share” of patients
Predicts patient demand
Pre-visit planning (clinical and non-clinical)
Revenue and staffing projections
Improves understanding of provider performance
Individual and practice-wide evaluations
Increases commitment to continuity
Improvement in clinical measures
Reduced costs and enhanced revenue per visit
AAFP, 2007

5. Panel Management A systematic approach to identify and address
patients’ unmet chronic and preventive care needs
Population-based, data-driven approach
Multidisciplinary team
Technology driven by patient “registries”
Identify care opportunities
Facilitate communication with patients
Includes patients who HAVE NOT been seen
In-reach and out-reach

6. Active In-reach Pre-visit planning “Pink” reminder
The care team is provided with easily accessible information about preventive and chronic care services which are due.
“Pink” reminder
Well care flow sheet
Diabetes flow sheet
Hypertension flow sheet

9. PDSA: A Continuous Quality Improvement Approach
FAHC Jeffords Institute for Clinical and Operational Effectiveness

10. In-reach: Brief Foot Exam
PDSA model
Goal: increase percentage of brief foot exams in the diabetic population by 10% in 6 months
Actions:
Training of all nursing staff
Creation of “cheat sheet”
Chart sticker in diabetic patient chart prior to visit

11. RESULTS:
Findings included corns that needed attention, lots of red areas, jagged nails that needed attention (funny story)

12. The Less Measureable Outcomes
Team Based Care
Patient Engagement Self Management
Building the Medical Neighborhood
Central Vermont Home Health
Foot Care Clinics
The Vermont Chronic Care Initiative
Medicaid Care Management Support
SASH Program
Support in Congregate Housing
Hospitals and Nursing Homes
Discharge Planning Coordination
Post Emergency Room follow-up

13. Active Outreach Building registries Identifying opportunities for care
Calls and letters to patients about health maintenance, care due and appointments
Offering classes and groups to specific patient populations

14. MMR Panel Panel: Goal: Children 18-36 months of age
No documented MMR immunization
Goal:
Increase documented MMR immunizations by 20% in this patient population

15. MMR Panel PLAN: DO: STUDY: ACT: Identify patient panel
Ensure “clean” data
Send patient letter
DO:
Carry out immunization plan and documentation
Identify interventions:
Share data at staff meeting
Staff education (documenting refusals)
Consistent use of encounter form to schedule Well Child Check
STUDY:
Run comparison report in November
ACT:
Examine data
Plan further changes

16. Ongoing Patient Panels
Adults with HTN with no visit in 12 months
Children ages months with no documented lead screen
Adults with Diabetes and no A1C in 12 months
Adults with diabetes and no documented eye exam in 2 years
NOTE:
These panels offer a “place to start”. The goal is for
all patient care to meet evidence based guidelines.

17. Panel: Addressing Patient Education
Panel: Adults with Diabetes and Hypertension
Intervention: Series of classes that address the guidelines of care, self-management, and wellness of people with that co-diagnosis

18. Diabetes and High Blood Pressure
Workshop for people who have both
Diabetes and High Blood Pressure
The combined diagnosis of both diabetes and high blood pressure (hypertension) requires a little different management than if a person has only one or the other.
We are offering a workshop to help better understand and manage this combination of diagnoses.
This workshop will provide information to better manage both diabetes and high blood pressure.
Lauri Snetsinger, a Registered Nurse, will provide information about how diabetes and hypertension interact with each other, and the medical concerns of having both at the same time.
Janice Waterman, a Registered Dietician and Certified Diabetes Educator, will discuss ways to help best manage diabetes and high blood pressure.
There will be time to ask questions.   
We look forward to seeing you there!

19. Staff Education Sharing QI Data with providers and staff
Identifies populations that would benefit from additional support
Generates more ideas for interventions
Routinely measures performance against goals
Highlights educational needs of staff and patients

20. Intervention: Post-Discharge Support In-patient and ER
RN Wellness Coach contacts patients shortly after discharge
Medication reconciliation and review
Follow-up appointment confirmed/scheduled
Discharge plan reviewed
Barriers assessed
Referrals to other services

21. Health Coach Contact Form
Discharge Follow Up Patient: DOB: Phone number: Admission date: Discharge date: Provider: Reason for admission: Place of Admission: Discharge DX: Next THC apt: Patient or guardian report of present status: Follow up appointments scheduled: Review discharge plan with patient: Y/N Patient reports understanding: Y/N Medication Reconciliation: /New prescriptions: Y/ N /Picked up: Y/N / Begun: Y/N Review all prescriptions and any changes:

22. Health Coach Contact Form (continued)
Patient reports understanding of these medications: Y/N Remind patient to bring ALL prescriptions to their next THC appointment: Y/N Assess for any barriers the patient might have to meet their day to day needs: Review when to call THC or use ER, remind patient of Saturday morning THC hours and MD on call 24 hours: Y/N PLAN: Coordination: Comments: Signature:______________________________________Date:

23. What Has Worked Well… “Hot hand-offs” Regular Care Team Meetings
Support at the point of care
Wrap-around services of a Medical Home
Regular Care Team Meetings
Case reviews
Share “success stories” and best practices
QI Workgroups
Include providers, nurses, office staff, and Blueprint Facilitator
Make QI a practice-wide, every-day priority
Staff and provider “Champions” assist with “buy-in” at all levels
The Vermont Chronic Care Initiative
Support for high-risk and high-cost Medicaid patients
In-house 2 times a week and as needed

24. What to Monitor Data integrity Process changes and Defined workloads
Ensure it is current, accurate, and includes the parameters you want
Process changes and Defined workloads
Make sure everyone is working to the optimum of their capability and licensure
Work smarter, not harder
Referrals
Ask yourself if the referral is truly appropriate for the patient
Refer patients who are ready to make changes
Focus interventions on patient needs - not data purposes or staff convenience

25. Provider Feedback “I am practicing better medicine…”
Point of care assistance using co-visits and “hot hand-offs”
Care plan support with Medical Home wrap-around services
Better educated patients
Improved overall outcomes and performance measures

26. Staff Feedback “I feel like I have more options for my patients.”
Nurses and other clinical staff work to maximum of their skill and licensure level
Health maintenance and other patient needs identified prior, or at time of, a visit
Extra patient support services available in-house and can be utilized by any staff member

27. Patient Feedback
“This place just gets better and better. I’m glad I’m a patient.”
High level of patient satisfaction with convenient office hours and on-call availability
Attendees of diabetes education asked for monthly “drop-in” group

28. “Health Care The Way It Ought To Be”
Intended Outcomes
Reduced re-admission to hospital
Reduced ER visits
Improved clinical outcomes
Improved continuity of care
Improved patient satisfaction
Improved staff satisfaction
“Health Care The Way It Ought To Be”

29. For More Information ….
Don Grabowski, PCMH Coordinator, The Health Center (802) Heather Caldera, RN Wellness Coach, (802)