1. © 2003 PeaceHealth Using Practice Teams to Improve Efficiency and Quality of Care for Older Adults Ron Stock MD MA The Gerontology Institute PeaceHealth Oregon Region rstock@peacehealth.org

2. © 2003 PeaceHealth Learning Objectives 1) Understand the key attributes of a practice team and how to develop a team in practice. 2) Describe the team-based practice changes that lead to improved efficiency and quality of care.

3. © 2003 PeaceHealth Acknowledgements PeaceHealth Oregon Region Leadership, Eugene, OR PeaceHealth Clinical & Operational Improvement Division, Bellevue, WA John A. Hartford Foundation, Geriatric Interdisciplinary Teams in Practice Initiative AHRQ Patient Safety Implementation Challenge Grant

4. © 2003 PeaceHealth

7. Care Model Influences The “Senior Health Clinic” movement Lean Thinking; “Voice of the Customer” Institute for Healthcare Improvement (IHI) Breakthrough Series on the Chronic Care Model IHI Idealized Design of Clinic Office Practice

8. Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Chronic Care Model

9. © 2003 PeaceHealth Senior Health & Wellness Center Aim: To develop a comprehensive senior healthcare practice through an interdisciplinary team approach

10. © 2003 PeaceHealth SHWC Interdisciplinary Team Geriatrician Gerontological Nurse Practitioner (GNP) Team Nursing Medical Social Worker/Care Coordinator Pharmacist Dietician Physical Therapist Chaplain Home Health Coordinator Health Information Librarian

11. © 2003 PeaceHealth Senior Health Center Care Model Geriatric expertise Prepared, proactive interdisciplinary care team Planned, coordinated, protocol-driven care Informed, activated patients Senior sensitivity trained staff Community collaboration Model description in: Stock RD, Reece D, Cesario L. Developing a Comprehensive Interdisciplinary Senior Healthcare Practice. JAGS 52:2128-2133, Dec 2004.

12. © 2003 PeaceHealth Hartford Senior Health Clinic Study “Does an interdisciplinary team (and Chronic Care Model) approach improve health/org outcomes for older adults?” 3 groups; n=1309; 30 month study Results: –Take less meds –Higher immunization rate –Fall less –Despite physical decline maintain quality of life –Depression scores improve –Pt Satisfaction unchanged –Lower Medicare costs

13. © 2003 PeaceHealth

15. Why “team” care? Changing healthcare models and environment, regulatory and training requirements Clinical outcomes better Safer, more reliable care Happier patients Happier staff

16. © 2003 PeaceHealth Challenges to Developing Effective Teams Different disciplines Not trained together Hierarchy Asynchronous care Lack of continuity Culture slow to change

17. © 2003 PeaceHealth What is a “team”? Work Group Ad hoc committee “Unit” Clinic “Practice”

18. © 2003 PeaceHealth What is a team? Multidisciplinary Interdisciplinary Interdependent

19. © 2003 PeaceHealth What is a Team? Task-oriented vs relationship-oriented Membership defined by healthcare vs. patient/family Teams develop around the core principle of “trust”

20. © 2003 PeaceHealth “…two or more individuals who have specific roles, perform interdependent tasks, are adaptable, and share a common goal. Moreover, members of teams must possess specific knowledge, skills, and attitudes (KSAs), such as the ability to exchange information, which enable individual team members to coordinate.” Baker et al. The Role of Teamwork in the Professional Education of Physicians. Jt Comm J Qual Saf 31(4): 185-202, April 2005.

21. © 2003 PeaceHealth Teamwork Model (Baker et al, 2005) Organization Team Individual

22. © 2003 PeaceHealth Team Structure 1.Core Team 2.Coordinating Team 3.Contingency Team - TeamSTEPPS

23. © 2003 PeaceHealth The Team “Bundle” Intervention Leadership Commitment –Practice/Unit level –Organization The Team Development Measure –Feedback to team with discussion –Target improvements Intra-staff communication skills training Patient/case-focused care conferences or “huddles”

24. © 2003 PeaceHealth How will you know whether you’re a team…. or not? The Team Development Measure (TDM) www.teammeasure.org 31 Items Rasch survey measurement methodology Psychometric testing: 250 teams; n=956 Mplus factor analysis= 4 factors best sol’n Cronbach’s alpha=0.90

25. The Team Development Measure (TDM) Cohesion Communication Roles Clarity Goals Clarity “…the social glue that binds the team members as a unit.” Team members…. Say what they feel and think; are truthful, respectful and positive; address conflict maturely Clearly defined roles and expectations. Accomplishments of the team are placed above individuals Clearly defined team goals and the means to reach these goals. Building PreTeam Stage 1 Fully Developed Stage 8 Stage 7 Stage 6 Stage 5 Stage 4 Stage 3 Stage 2 Established

26. © 2003 PeaceHealth Typical 1 st Assessment Results

27. © 2003 PeaceHealth Same Team 4 Months Later

28. © 2003 PeaceHealth What have we learned about teams? Teams don’t just happen, formalized training is necessary Requires ongoing maintenance Use the Team Measure to inform and improve Weekly Care Conference/huddle helps the team “practice” Teams are a prerequisite for sustainable quality improvement Clinical outcomes are better Organizational health improves

29. © 2003 PeaceHealth Team Practice Interventions That Make a Difference Practice re-design Protocol-Driven Standardized Processes Care Management Services Managing “Transitions” Engagement of Patients and Families

30. © 2003 PeaceHealth Practice Re-Design One-stop shop Nursing care teams Advance Practice Nurses

31. © 2003 PeaceHealth Protocol-Driven Standardized Processes Very Important Papers (VIP) process Immunizations Medication Management Disease-specific management

32. © 2003 PeaceHealth Immunization Pearls Agree on immunization protocol Educate all staff Provide standing orders Assign the role of immunization management to a staff nurse and provide appropriate training and resources Measure and have a process for follow-up

33. © 2003 PeaceHealth  Pneumovax and influenza vaccination rates are significantly higher in the Intervention Group, the Senior Health & Wellness Center (SHWC) model.

34. © 2003 PeaceHealth Medication Management Pearls Agree and educate on “bad” drugs Screen for patients on >4 meds Referral to geriatric pharmacist for med review if on >4 drugs (standing order) Standardize process components of med reconciliation in ambulatory setting

35. © 2003 PeaceHealth Medications  SHWC participants (intervention group) were prescribed significantly less medications and use did not increase over time.

36. © 2003 PeaceHealth Care Management Services Primary care-based RN/MSW High intensity/low volume Care Management Plus

37. © 2003 PeaceHealth Managing Care Transitions Develop services that address care across the care continuum Leverage EMR capabilities www.caretransitions.org

38. © 2003 PeaceHealth Patient & Family Engagement Self-management support (Group visits; Chronic Disease Self-Management Program) Office practice volunteers New patient and family orientation Quality Improvement project participation Patient Advisory Council

39. © 2003 PeaceHealth What have we learned? This model of care has features that produce better outcomes; Implement a “bundle” of improvement changes Interdisciplinary, Interdependent team approach Planned, coordinated care Protocol-driven processes (standardization) Continually involve patients and caregivers; Patients and families need to be “partners”, not just “consumers”

40. © 2003 PeaceHealth References www.teammeasure.org GITT program (www.gitt.org)www.gitt.org TeamSTEPPS http://www.ahrq.gov/qual/teamsteppshttp://www.ahrq.gov/qual/teamstepps Drinka T and Clark PG. Health Care Teamwork: Interdisciplinary Practice and Teaching. Westport, CT: Auburn House, 2000. Grumbach K and Bodenheimer T. Can Health Care Teams Improve Primary Care Practice? JAMA 2004;291(10):1246-1251. Baker et al. The Role of Teamwork in the Professional Education of Physicians. Jt Comm J Qual Saf 31(4): 185-202, April 2005. Pronovost P, Berenholtz S, et al. Improving communication in the ICU using daily goals. J Crit Care. June 2003; 18(2):71-75.

41. © 2003 PeaceHealth References Singh H, et al. Medical errors involving trainees. Arch Intern Med Oct 2007; 167(19):2030-2036. Baker et al. The Role of Teamwork in the Professional Education of Physicians. Jt Comm J Qual Saf 31(4): 185-202, April 2005. Cohen, S.G. and Bailey, D.E What makes teams work: Group effectiveness research from the shop floor to the executive suite. Journal of Management, 23, 1997, 239-290. Gaba et al. Simulation-based training in anesthesia crisis resource management (ACRM): A decade of experience. Simulation Gaming 2001; 32:175-193. Pizzi L, Goldfarb N, and Nash D. Chapter 44. Crew Resource Management and its Application in Medicine. http://www.ahrq.gov/clinic/ptsafety/chap44.htm

42. © 2003 PeaceHealth The Team Development Initiative Development of a comprehensive senior healthcare practice using the Chronic Care Model and IDT principles Funded by the Hartford Foundation Geriatric Interdisciplinary Teams in Practice (GIT-P) Initiative and subsequent 3-year Dissemination Project Spread: PeaceHealth; Group Health; Providence-Oregon; preliminary discussions with Kaiser