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PresentersLaurel Domanski Diaz, MNO, Director of
Business OperationsDan Gauntner, CNP, Director of Clinical
OperationsMarianella Napolitano, RN, MBA, Clinical
Quality Coordinator
ObjectivesParticipants will understand how safety
net practices can implement a systematic approach to caring for their communities
Participants will learn how to organize a practice to allow staff members to work at the top of their licenses.
Participants will become familiar with how implementing care teams can improve the quality of care.
NFP BackgroundA Federally Qualified Community Health
Center founded in 1980Last year served 13,400 patients on the near
west side of Cleveland17 Providers on staff--8 Family Practice MDs,
6 Family Practice CNPs, 3 Certified Nurse Midwives
Focus on the medically underservedServe a large Hispanic population
Partnering with the community for everyone’s best healthNFP has always believed that partnering with a
patient is the best way to achieve healthy outcomes.
NFP sees that the services provided to patients are each just one stop in a constant continuum of care that envelopes every patient into their own medical home.
NFP developed a model, Circles of Care, to transform our Community Health Center into a Care Team and EMR driven practice focused on Patient Centered Care.
Why Care Teams?Working from NFP’s 2009-2011 Strategic Plan,
NFP identified the following areas to be addressed:Improvement of patient’s health and safetyImprovement in NFP’s financial performanceIncreased provider, staff and patient satisfactionBecoming an NCQA Patient Centered Medical Home
Care TeamsA Care Team has been defined as: A panel of
patients who usually see or choose a particular group of providers for their care AND the group of staff who generally work together for the care of that panel of patients.
NFP Circles of Care
Patient
Contract IT Staff
OCHIN/ Epic
Information
Technology
NFP IT Staff & Medical Records
Nurses, MAs, Patient Advocates
Clinical
Providers & Behavioral Health
Community Agencies
Front Office
Billing & PBS
Administrative
Management & Executive Leadership
Care Team CompositionThree Providers—combination of Family MDs,
Family CNPs, (one team’s providers consists of 3 Certified Nurse Midwives)
One to two RNsOne to two Patient AdvocatesMedical Assistant for each ProviderFront Office representative at each team
meeting
Care TeamsDeveloping new procedures around scheduling,
registering patients & directing phone calls to teams
Conducting training activities to facilitate team communication, structure and creating ongoing team meetings
Redesigning of nursing staff structure to provide individual nurses to care teams.
Organizing providers and support staff into integrated care teams.
Adding a Patient Advocate to each team
Team TrainingPromoting the idea of team across the
organizationTeam formation activities prior to implementationTeam trainings help decrease hierarchical
systems (TEAMSTEPPS, Practice Coaching)Practice Coaching and facilitation
Team MeetingsGoal: Improve communication and increase
efficiency across all disciplinesCommitment from the leadershipFinancial investmentMore frequently initiallyOutside facilitator present at the beginningInternal staff facilitates meetings
Team HuddlesDaily meetings at the beginning of the
morning, may include the entire team, Provider and MA
Approximately 10 minutesProvides MA with clear path of what needs to
be done to prepare for the Providers entrance in the exam room
Patient Service Representative RoleAccurate team schedulingDirecting of patient inquiries (phone and in-
person) to the appropriate team Reinforcing PCMH message: scheduling with
PCP, we do not operate as an urgent careServes as a member of the Care Team for
Team meetings
Patient AdvocatesInitially grant fundedStarted with a focus on specific populationsOur Patient Advocates range from recent college
grads to members of our community who have a background in activism or social work
Use of standing orders and protocols allow PAs to unload the provider and nursing workload
Each PA has a specialized area—Hispanic patients, women’s health, refugees, computer expertise
Increase patient’s access to the Care Teams by helping with patient communication and correspondence
Patient Advocate Role
Paperwork• Processing requests for disability, physical forms, utilities,
faxing, copying, mailing forms, letter processing.
Population Management• DM,HTN,WCC, Hospital follow up, Hunt groups 2005,
2000 coverage, Nurse messages
Case Management• Meeting with patients at provider request, community
resource coordination, making appointments for urgent referrals, Huddle participation, No-Show follow up coordination
Referrals• X-rays, ultrasounds, specialists and DME, some urgent—
nothing requiring prior authorization
Other Responsibilities• Interpreting, Coordination of Centering, Coordination of
Refugee Clinic, grant funded responsibilities, PDSA activities
Order Entry• DX--DM, HTN, Adult Physical, Hypothyroidism,
Hyperlipidemia, heart issues. Entering standard orders routine labs, immunizations, referrals.
Nurse Role
Care Team Support• Preparing forms for provider signature, calling in Rx,
calling patients with lab or test results
Patient Triage• Speaking with patients on the phone about their
symptoms and concerns, triaging patients in the waiting room that may need to be seen immediately or may need to be overbooked.
Patient Visits• Seeing patients in the health center for
immunizations, INR, something that is not a new concern.
Patient Education• Educating patients with diabetes and hypertension,
answering questions about medications, done on the phone or in person.
Medical Assistant Role
Rooming Patients• Taking Vitals, entering in chart: medications, chief
complaint, review allergies, PHQ scores, complete tobacco, substance, sexual abuse history, enter diagnosis, check for Pharmacy, goal sheets.
Maintain Provider Rooms• Keep rooms stocked with appropriate supplies, tests, do
inventory every 2 weeks
Back Office Labs• Order and Result back office labs--UA, Strep, INR,
Glucose, Hemoglobin, HbA1c, icon
Immunizations• Complete immunization consent forms, Review past
immunizations given, Print out IMPACT sheet to review what is needed , Review old chart, Order and pend immunizations needed- provider to review and sign, Enter into IMPACT, Historical immunizations must be entered into EPIC Order Entry & Release
• Female Physicals—order mammogram, Fit Test—women and men over 50, WCC—lead and HGb for 1 to 6 YO, DM—foot exam, last eye exam, enter referral, HTN—do EKG, Others--PAP, Urine culture, Chlamydia/ Gonorrhea
Ancillary Support ServicesAvailable In-Office Support includes:
On-site Behavioral Health On-site Clinical PharmacistRNs provided by insurance companiesWellness CoordinatorMedication Assistance ProgramDiabetes Educational Sessions
provided by local Diabetic Assoc.
OptimizationEnabling Providers to practice at highest scopeProfessionals will work at the top of their
licenses if:They have people they can delegate to. At NFP
this was done by increasing the skill set of: Medical Assistants Patient Advocates
There are effective communication methods In-basket messages within the EMR to make clinical
communication efficient Team meetings for peer and cross professional
feedback
Optimization (cont.)Patient Advocates
Use evidence based protocols to address health disparities
Use registries to identify gaps in healthcare Identify high risk patients for case management by
nursesTracking and monitoring goals of the Health
CenterOperational Clinical
Developing policies and procedures for EMR system and Care Teams at NFP
Outcomes of the Circles of Care ProjectNFP achieved Level 3 NCQA PCMH
Accreditation with a score of 99%In a Medicare Pilot Program on PCMH, NFP
was the top scoring FQHC in the country. Improved communicationIncreased coordinationImproved quality of care for our patients
DM patients who had a Foot ExamChallenges tracking this information Increase coordination and communication with all team members
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