1. Beyond the Blueprint Building the Patient Centered Medical Home Wisconsin Primary Care Research & Quality Improvement Forum Wisconsin Dells, WI 11.13.09 Christine Sinsky, MD Thomas Sinsky, MD csinsky1@mahealthcare.com Medical Associates Clinic and Health Plans Dubuque, Iowa

2. Agenda Background Background The Challenges of Primary Care The Challenges of Primary Care 8 strategies to transform practice 8 strategies to transform practice Discussion Discussion

3. Take Home Messages It’s all about It’s all about Planning ahead Planning ahead Sharing the load Sharing the load Enjoying the work! Enjoying the work!

4. Background Primary Care Primary Care NCQA Advisory Panel: PCMH NCQA Advisory Panel: PCMH Consultant and Workshops Consultant and Workshops All trying to solve same equation All trying to solve same equation Different settings Different settings QE & S: quality, efficiency and satisfaction QE & S: quality, efficiency and satisfaction

5. We will know who you are and we will be ready for you. Borgess Ambulatory Care, Kalamazoo, MI

6. At the center of primary care are face-to-face healing relationships. Patient: Nurse Nurse: Physician Nurse: Nurse Patient: Physician

9. 115 physicians, owners Health Plan: 1/3 of pt population EHR: 2003

10. Staff Turnover: < 5% Physician Satisfaction : > 95%’ile AMGA PCP Productivity and Compensation: 85%’ile MGMA Satisfaction

11. Patient Centered Medical Home Quality

12. Snapshot of Practice Staffing Staffing Primary nurse Primary nurse Help nurse Help nurse 1.5 nurse: MD 1.5 nurse: MD (no MAs) (no MAs) Space Space 3 exam rooms 3 exam rooms Scheduling Scheduling 1 Receptionist: 2 MDs 1 Receptionist: 2 MDs Wave Scheduling Wave Scheduling

13. Snapshot of Practice Typical Schedule Typical Schedule 6-8 Annual 6-8 Annual 10-12 Planned Care 10-12 Planned Care 4-6 Rapid Access 4-6 Rapid Access Panel Size Panel Size 1800-2000 1800-2000 Outpatient/Inpatient Outpatient/Inpatient

14. Mrs. Peters 65 year old annual exam 65 year old annual exam DM2 DM2 HTN HTN Depression Depression Prevention Prevention New c/o New c/o Heartburn Heartburn Sleep disturbance Sleep disturbance Fatigue Fatigue # of Quality measures?

15. There is a lot to be done! 65 year old annual exam DM2 (9) HTN (17) Depression (10) Prevention (27) New c/o Heartburn (3) Sleep disturbance Fatigue # of Quality measures? 56 *McGlynn EA, N Engl J Med 2003. 348;26:2535-2645

16. There is a lot to be done! Too much to be done by just one person Too important to be left to chance

17. Core Team Model: Plan Ahead, Share the Load Right thing happens by default Right thing happens by default Staff work full level of ability Staff work full level of ability Minimize work MD does that is within skill set of others Minimize work MD does that is within skill set of others

18. “In few other sectors of the economy is the highest-level professional responsible for the majority of production, customer service, and clerical work.” SGIM Blue Ribbon Panel Report. Redesigning the Practice Model for General Internal Medicine: A Proposal for Coordinated Care. J Gen Intern Med 2007;22:400-109

19. Saving (our) Office Practice — A Personal Story Meet expectations and still have energy to connect? Meet expectations and still have energy to connect? Guideline following automaton Guideline following automaton Documentation drone Documentation drone Doing tasks that neither the patient nor I valued Doing tasks that neither the patient nor I valued To survive & enjoy practice, and have time for other things, we would need to redesign work flow To survive & enjoy practice, and have time for other things, we would need to redesign work flow

20. Episodic Care Check-in receptionist Room pt nurse MD MD Check- out Vital signs Vital signs Medication reconciliation Medication reconciliation History History Exam Exam Data Gathering Data Gathering Data entry Data entry Decision making Decision making Relationship building Relationship building Prescription writing Prescription writing Documentation Documentation Paperwork Paperwork Behavior Modification Behavior Modification Results reporting Results reporting Order entry Order entry Insurance verification Insurance verification Collect co-pay Collect co-pay Verify contact info Verify contact info ¼ MA: MD ?

21. Work Within Skill-set of Others Check-in receptionist Room pt nurse MD MD Check- out Vital signs Vital signs Medication reconciliation Medication reconciliation History/History History/History Exam Exam Data Gathering Data Gathering Data entry Data entry Decision making Decision making Relationship building Relationship building Prescription writing Prescription writing Documentation Documentation Paperwork Paperwork Behavior Modification Behavior Modification Results reporting Results reporting Order entry Order entry Insurance verification Insurance verification Collect co-pay Collect co-pay Verify contact info Verify contact info ¼ MA: MD ?

22. Integrated, Continuous Care Office Visit Between Visit Care Efficiencies and care coordination Nurse-MD Team Build-in rather than Carve-out Pre-appt lab

23. Core Team Model: Planning Ahead & Sharing the Load Planned Care Appt Planned Care Appt Order sets Order sets Empowered Team Empowered Team Pt. Questionnaire Pt. Questionnaire Prescription Mgm’t Prescription Mgm’t Visit Summary Visit Summary Annual Exam Annual Exam Rapid Access Rapid Access Intentional Behaviors Intentional Behaviors

25. Planned Care Appointment Pre-appt lab Majority lab prior to appt Patient part of decision making 67 yo diabetic A1c 6.2 LDL 160 Bill P. Planned Care Appt Planned Care Appt Order sets Order sets Empowered Team Empowered Team Pt. Questionnaire Pt. Questionnaire Prescription Mgm’t Prescription Mgm’t Visit Summary Visit Summary Annual Exam Annual Exam Rapid Access Rapid Access Intentional Behaviors Intentional Behaviors

26. Planned Care Appointment Efficiency “Just in time” info processing Close the loop during that appt Results reporting 4 hr clinic → 2 hr post-appt Safety Missing or overlooked inform Pt & family part of safety net Planned Care Appt Planned Care Appt Order sets Order sets Empowered Team Empowered Team Pt. Questionnaire Pt. Questionnaire Prescription Mgm’t Prescription Mgm’t Visit Summary Visit Summary Annual Exam Annual Exam Rapid Access Rapid Access Intentional Behaviors Intentional Behaviors

27. Lab Summary

28. Post-Appointment Order Sets Planned Care Appt Planned Care Appt Order sets Order sets Empowered Team Empowered Team Pt. Questionnaire Pt. Questionnaire Prescription Mgm’t Prescription Mgm’t Visit Summary Visit Summary Annual Exam Annual Exam Rapid Access Rapid Access Intentional Behaviors Intentional Behaviors

29. Acute Symptom Evaluation

30. Planned Care Appt

31. Annual Comprehensive Care Visit

32. Place Today’s Care in Continuum of Time Last PE Upcoming appts/lab

33. Post-Appointment Order Sets 73 yo est. pt Rapid w/ fever, cough Planned Care Appt Planned Care Appt Order sets Order sets Empowered Team Empowered Team Pt. Questionnaire Pt. Questionnaire Prescription Mgm’t Prescription Mgm’t Visit Summary Visit Summary Annual Exam Annual Exam Rapid Access Rapid Access Intentional Behaviors Intentional Behaviors

35. Post-Appointment Order Sets 64 yo DM 2, hypothyroidism, atrial fibrillation, CRI Planned Care Appt Planned Care Appt Order sets Order sets Empowered Team Empowered Team Pt. Questionnaire Pt. Questionnaire Prescription Mgm’t Prescription Mgm’t Visit Summary Visit Summary Annual Exam Annual Exam Rapid Access Rapid Access Intentional Behaviors Intentional Behaviors

37. Post-Appointment Order Sets “The next appointment starts today” A plan, a promise to continue the relationship “We want to see you again, and we will plan ahead to make that most meaningful.” Planned Care Appt Planned Care Appt Order sets Order sets Empowered Team Empowered Team Pt. Questionnaire Pt. Questionnaire Prescription Mgm’t Prescription Mgm’t Visit Summary Visit Summary Annual Exam Annual Exam Rapid Access Rapid Access Intentional Behaviors Intentional Behaviors

38. Appointment doesn’t start when the patient checks in

40. Empowered Teamwork Nursing staff full partners Planned Care Appt Planned Care Appt Order sets Order sets Empowered Team Empowered Team Pt. Questionnaire Pt. Questionnaire Prescription Mgm’t Prescription Mgm’t Visit Summary Visit Summary Annual Exam Annual Exam Rapid Access Rapid Access Intentional Behaviors Intentional Behaviors

41. Nexus of organization of our practice Filter Between Visit Extension of me when dealing with patients; patients recognize this. Coordinates transitions (hospital, NH, Hospice) Manages & returns most phone calls Does prescriptions Updates EHR Completes all paperwork Visit Med. Reconcil. Initial review of lab Pt education Immunizations Colonoscopy Sx driven tests (PFT, EKG) Diabetic foot exam/eye exam Present patient (↓ info drop-off) The Boss

42. Mini-huddle Staff deeply engaged Mentor nurses Physician better prepared Stronger handoff Planned Care Appt Planned Care Appt Order sets Order sets Empowered Team Empowered Team Pt. Questionnaire Pt. Questionnaire Prescription Mgm’t Prescription Mgm’t Visit Summary Visit Summary Annual Exam Annual Exam Rapid Access Rapid Access Intentional Behaviors Intentional Behaviors

43. Mini-huddle 47 yo “Rapid Access” new patient CC: dysphagia Nurse Mini-huddle “She seems depressed” “Is anyone hurting you?” Physician better prepared Planned Care Appt Planned Care Appt Order sets Order sets Empowered Team Empowered Team Pt. Questionnaire Pt. Questionnaire Prescription Mgm’t Prescription Mgm’t Visit Summary Visit Summary Annual Exam Annual Exam Rapid Access Rapid Access Intentional Behaviors Intentional Behaviors

44. Hand-back Planned Care Appt Planned Care Appt Order sets Order sets Empowered Team Empowered Team Pt. Questionnaire Pt. Questionnaire Prescription Mgm’t Prescription Mgm’t Visit Summary Visit Summary Annual Exam Annual Exam Rapid Access Rapid Access Intentional Behaviors Intentional Behaviors

45. Introduction to Partnership Planned Care Appt Planned Care Appt Order sets Order sets Empowered Team Empowered Team Pt. Questionnaire Pt. Questionnaire Prescription Mgm’t Prescription Mgm’t Visit Summary Visit Summary Annual Exam Annual Exam Rapid Access Rapid Access Intentional Behaviors Intentional Behaviors

46. Pre-appointment Questionnaire Identifies the patients agenda MD plan visit before entering Systems approach Update PFSH Complete ROS Behavior issues : exercise, smoking, alcohol webmeeting.nih.gov/intro Future Kiosk in waiting area Web portal from home Planned Care Appt Planned Care Appt Order sets Order sets Empowered Team Empowered Team Pt. Questionnaire Pt. Questionnaire Prescription Mgm’t Prescription Mgm’t Visit Summary Visit Summary Annual Exam Annual Exam Rapid Access Rapid Access Intentional Behaviors Intentional Behaviors

50. Prescriptions are killing us… my nurse is spending so much time on refills that we can’t seem to get anything done. Minnesota Family Physician 2007

51. Prescription Management Survey: majority calls for scripts Systems: all scripts 1 yr at annual Efficiency: ↓ phone calls by 50% Synchronized, Bundled Renewals Planned Care Appt Planned Care Appt Order sets Order sets Empowered Team Empowered Team Pt. Questionnaire Pt. Questionnaire Prescription Mgm’t Prescription Mgm’t Visit Summary Visit Summary Annual Exam Annual Exam Rapid Access Rapid Access Intentional Behaviors Intentional Behaviors

52. Prescription Management We don’t use scripts as hook Planned care appts (not expired script) trigger disease monitoring Avoid loading interval visits with unnecessary, redundant work Before: six calls or faxes/year After: zero Maggie Planned Care Appt Planned Care Appt Order sets Order sets Empowered Team Empowered Team Pt. Questionnaire Pt. Questionnaire Prescription Mgm’t Prescription Mgm’t Visit Summary Visit Summary Annual Exam Annual Exam Rapid Access Rapid Access Intentional Behaviors Intentional Behaviors

53. Annual Comprehensive Care Visit Cornerstone of care Dedicated appt prevention/ annual review of chronic dz Customized not one-size-fits-all Planned Care Appt Planned Care Appt Order sets Order sets Empowered Team Empowered Team Pt. Questionnaire Pt. Questionnaire Prescription Mgm’t Prescription Mgm’t Visit Summary Visit Summary Annual Exam Annual Exam Rapid Access Rapid Access Intentional Behaviors Intentional Behaviors

54. Annual Comprehensive Care Visit Prevention built-in Not dependent on random acute visits Not overload interval visits Planned Care Appt Planned Care Appt Order sets Order sets Empowered Team Empowered Team Pt. Questionnaire Pt. Questionnaire Prescription Mgm’t Prescription Mgm’t Visit Summary Visit Summary Annual Exam Annual Exam Rapid Access Rapid Access Intentional Behaviors Intentional Behaviors

55. I spend several minutes with each appointment rifling through the chart looking for the last mammogram and colonoscopy. And then I spend less time on the patient’s main concern. Family physician, WI 5.06

56. Annual Comprehensive Care Visit CC: DM 2, HTN, ↑chol, new depr. Prevention Mammo ahead Ca, BMI, immunization (nurse) Chronic Care Diabetes, HTN lab done ahead Foot and eye exam (nurse) Acute Energy to address depression Planned Care Appt Planned Care Appt Order sets Order sets Empowered Team Empowered Team Pt. Questionnaire Pt. Questionnaire Prescription Mgm’t Prescription Mgm’t Visit Summary Visit Summary Annual Exam Annual Exam Rapid Access Rapid Access Intentional Behaviors Intentional Behaviors

58. Rapid Access Scheduling for same day access Today not Triage Triage takes time 30 sec “yes”, 5 min “no” “later” One staff touch vs 5 Pt’s don’t have to plead case Planned Care Appt Planned Care Appt Order sets Order sets Empowered Team Empowered Team Pt. Questionnaire Pt. Questionnaire Prescription Mgm’t Prescription Mgm’t Visit Summary Visit Summary Annual Exam Annual Exam Rapid Access Rapid Access Intentional Behaviors Intentional Behaviors

59. RAPID ACCESS Multi-port scheduling tool Central Scheduling Patient call-ins Health Plan sales rep Outside referrals Acute Care Receptionists Walk-ins Other depart. Receptionists In house ref. 24 hour Help Nurse Patient triage After hours referrals ER Nursing homes Home health Student health Parish nursing Primary Care Nurses Schedule patients Open “hidden rapids” Close rapids Mini-maintenance Internal medicine nurse on call Rapid Access Electronic Scheduling Tool

60. Nurse-MD Team HTN  Chol  Glucose OsteoporosisDepressionLABORDERS Planned Care Same Day Surgery Appt Integrated, Continuous Care LDL 75, A1c 6.2 LabMammo Sept Prevention HTN  Chol  Glucose OsteoporosisDepressionLipids,FBS Cr, K, Mam LABORDERS ComprehensiveMar Efficiencies and care coordination Mammo SCRIPTS

61. Nurse-MD Team LAB ORDERS Jun HTN DM 2 DepressionLABORDERS Planned Care FBS, A1c Lipids Integrated, Continuous care HTN DM 2 Depression Planned Care Mar RapidAccessLBPAprRapidAccessPneumoniaAug A1c 6.8 LDL 145 Efficiencies and care coordination HTN DM 2 Depression Planned Care Sept FBS, A1c LAB ORDERS CXR CHFEducation/Clinic DiabeticEducation Home Care Family INR INR INR INRINR INR INR INR INR INR INR INR HospitalCHFNov Prevention HTN DM 2 DepressionLABORDERS Comprehensive FBS, A1c, lipids, alb, mammoDecSCRIPTS ArchitectureOfCare

62. Intentional Behaviors Eye contact/physical touch Key phrases What else do I need to know? Did we cover everything you wanted? How are you handling this? Planned Care Appt Planned Care Appt Order sets Order sets Empowered Nursing Empowered Nursing Pt. Questionnaire Pt. Questionnaire Prescription Mgm’t Prescription Mgm’t Visit Summary Visit Summary Annual Exam Annual Exam Rapid Access Rapid Access Intentional Behaviors Intentional Behaviors

63. Intentional Behaviors More Key phrases What do you do for fun? Could you bring me a picture of ….at your next appointment Social notes at end of dictation Planned Care Appt Planned Care Appt Order sets Order sets Empowered Nursing Empowered Nursing Pt. Questionnaire Pt. Questionnaire Prescription Mgm’t Prescription Mgm’t Visit Summary Visit Summary Annual Exam Annual Exam Rapid Access Rapid Access Intentional Behaviors Intentional Behaviors

64. Sister Mary Owen, what have you been up to lately?

66. Sr. Mary Owen, what have you been up to lately?

67. At the center of primary care are face-to-face healing relationships. Patient: Nurse Nurse: Physician Nurse: Nurse Patient: Physician

68. We will know who you are and we will be ready for you. Borgess Ambulatory Care, Kalamazoo, MI

69. Discussion Discussion