SETTING THE COURSE FOR CHANGE

PATIENT CENTERED MEDICAL HOME

4.17 .2012

Leadership Symposium

Objectives

• Recognize how creating the Medical Home through Care Model Redesign supports the IHS strategic vision

• Identify the guiding principles of a team-based care model

• Understand the components of the care model and implementation strategies

• Describe how care packages based on evidence-based medicine improve the quality of patient care

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Medical Home

Redesign care to create the ideal Iowa Health System experience that focuses on the “Best Outcome for Every Patient Every Time”

Iowa Health System

“The road to the future is constantly under construction.” ~ A Wise Man

Changes to the Future of Healthcare

Payment ModelInnovative Quality SystemsPopulation ManagementClinical IntegrationElectronic Heath Record / CPOEMeaningful Use MeasuresStructure of the Health Care Delivery System

Iowa Health SystemCommitment to the Future

Physician Alignment (NewGroup)Clinical IntegrationPCMH (Patient Centered Medical Home)Integrated Health ManagementAdvanced Medical TeamHospice / Palliative CareACO/ICO DevelopmentPhysician Leadership Academy

Iowa Health System

“For tomorrow belongs to the people who prepare for it today.” ~ African Proverb

Value-Based Strategy

Physician Alignment

Delivering Value

Demonstrating Value

Value-Based Contracting

4

Prototype Clinics

Grimes Family Physicians• Dr. Dennis Bussey• Carin Bejarno, ARNP• Janell Schlosser, MHA Clinic Administrator• Cora Duncan, RN• Donna Starck, CDE• Kate LaFollette, RN Project Coordinator

Prototype Clinics

Lakeview Internal Medicine• Dr Heather Roberts• Dr Tyler Casey• Dr Dan Allen• Dr Ailey Brehmer• Dr Katie Burns• Heath Hill, MHA Clinic Administrator• Renea Seagren RN• Carrie Leiran RD, LD• Carrie Koenigsfeld, PharmD• Kate LaFollette, RN Project Coordinator

Care Model Redesign / Care Packaging

• Redesign care and align incentives to produce quality care with a reduction in total cost of care based on defined metrics

• Improve clinical quality outcomes aligned with evidence based guidelines

• Improve employee, physician, and patient / family satisfaction with care provided through the new model

• Implement a team based care model

• Identify, prioritize and sequence five Care Packages that provide enhanced quality with effective cost efficiencies at the identified prototype clinics

Team Based Care Models The fundamental structure or the “track” in which quality

care will run

Care PackagesQuality Care will be

designed through the use of Care Packages or “cars”

that will run on the track

Care Model Redesign & Care Packaging

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Team Based Care ModelGuiding Principles

Multidisciplinary teams working at the top of their licenses

Daily team communication for effective team workComplete planning prior to day of visitEffective communication to patients and families Creating health literate educational handoutsCreate and implement a standard rooming process Create and implement a standard room set-up Institute standard medication reconciliation processCreate and implement standardized BP ProtocolPractice effective EMR task management processesPDSA (Plan, Do, Study/Check, Act)

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Implementing the Care Model

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Team Based Care

A Multi-Disciplinary Team – Top of Licensure Physicians Mid-Level Providers RNs RDs CDEs Pharm D CMAs Schedulers

Team Model

Goal: Multidisciplinary team working at top of license

Nursing staff, providers, scheduler, RN, pharmacist

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Care Model Basics

Co-location Huddles Task management

Phone tree First call resolution

Standardization Standardized Room Set Up Standardized Rooming Process / Family Team Care BP protocol Medication conciliation

Change management PDSA

Health literacy Made materials health literate Teach back

Co-Location

Co-Location

Team Huddles

Daily communication among entire clinicIncludes entire teamPDSA Office FlowReview Quality Measures and Difficult Patients

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Phone Tree

Goal: 1st Call Resolution

Reduced call abandonment rate: -11%

Overall task reduction: -31%

Reduction in tasks assigned to providers: -15%

Room Standardization

Room Set Up Standardized Rooming ProcessBP ProtocolMedication Reconciliation

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Care Model Basics

Pre Visit Calls Goal: Complete planning prior to day of visit My Nurse / RN

Part of multidisciplinary team Extension of the clinic Pre visit calls and proactive outreach Chart Updates (Medical / Surgical / Family/ Social

History) Screenings Updated or Scheduled

• Breast / Colon / Prostate / Cervical Screening• Immunizations• Vision / Hearing Screenings

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Previsit Call Text Template

Care Package Goals

Functional and Risk Status Improve functional status and sense of well being Reduce and manage co-morbidities

Satisfaction and Perceived Health Benefits Improve overall service satisfaction – staff / patients

Cost Reduce overall cost Reduce office visits / Increase phone calls and RN

visits Reduce Pharmacy / Indirect cost Reduce redundant lab costs

It is when care is redesigned and incentives are aligned to produce quality care with a reduction in total cost of care

Adult

Preventive

Hypertensio

n

DiabetesWell

ChildHyperlipidemi

a

Care Packaging

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Adult Preventive

Adult Preventive

20-25 Components addressed for All Adult PhysicalsAge and Gender SpecificPre-Visit Planning – RN / My Nurse

Review / UpdatePast Medical, Social, Family, Surgical History

Lipid / DM ScreeningCancer Screening

Breast / Cervical / Colon / ProstateDepression Screening

PHQ-2 / PHQ-9Immunizations

Flu / Tetanus / Pneumonia / ZosterCounseling

Tobacco / Alcohol / ASA / Folic Acid21

Hypertension

Hypertension GoalsRN Care Package BP protocol/competenciesPatient education and teach backStanding orders

Hypertension Goals

Goal MetricAccurate Measurement of blood pressure 100% of the time

Educate patients regarding lifestyle modification and self management of HTN

Educate HTN patients in each visit

Hypertensive patients reach/maintain goal:

140/90 All patients (except for diabetes, CKD, patients that require an individual goal based on their specific condition)OR130/80  Diabetes and Chronic Kidney Disease

Increase control

Reduce cost None at this time

Hypertension

Accurate BP Measurements at all visits Staff / Provider Competencies Completed

Net Learning / Skill competenciesEducate HTN Patients at every office visit

Teach Back Education Methodology Health Literate Education Materials

EHR order set / Web Based tools HTN Patients reach / maintain goal

130/80 – DM / CKD 140/90 – All other patients

Reduce Cost RN HTN Care Program

RN Hypertension Care Program

Provider Referral for entry into the ProgramRN Schedules / EHR Note TypesVerification of EKG / Labs being UTDEducation

Diagnosis / Management Lifestyle Modifications

Standing Orders Medication titration / Lab monitoring

Office / Phone follow ups

Hyperlipidemia

HyperlipidemiaEHR changes/flow sheet

Hyperlipidemia Goals

Evaluate/Classify New Patients with Hyperlipidemia Framingham Score (CoQ Measure)

Assess Lifestyle Risk / Other Risk FactorsLab Evaluation to R/O Secondary Hyperlipidemia

FBS / TSH / Cr / LFTs / UAInitiate Lifestyle Modifications

RN Care Program Diet / Weight Management / Exercise / Smoking / EtOH

Initiate Lipid Lowering Rx per guidelines ATP III Classification / Treatment Goals

Monitoring of Lipids / LFTs while on Therapy

Hyperlipidemia Flow Sheet

Diabetes Care Package

Changed/added to EHR templates Documentation of all elements in one place Changed text templates

Interdisciplinary team approach See RN, dietician/DE, or pharmacists in addition to

physicianSupporting diabetic patients

Bringing diabetic education to the clinic Personalized care, tailored to their needs

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Well Child

Multiple screenings needed in first five years Lead, TB screening Social and developmental screenings Autism screening

Using Ages and Stages Questionnaire on-line Parents complete questions on line before Well Child

appointment Returned and scored electronically Results available at visit, referrals made as needed Software can run reports, reminders, provide

education

Data

CoQ – year end for LVIM and GrimesQuality Metrics for beginning 2012Employee satisfaction survey Patient satisfaction

Year End CoQ Data - LVIM

Employee Satisfaction Survey

Huddles med rec co-location Room standarization pre-visit calls0

10

20

30

40

50

60

70

80

90

Strongly disagreedisagreeagreestrongly agree

The following changes have improved my ability to care for patients

Patient Satisfaction

Q4 09 Q4 10 Q4 1191

91.5

92

92.5

93

93.5

94

94.5

95

GrimesLVIM

Overall likelihood to recommend practice

Next Steps

Improving care coordination Communication across settings Coordinating care across settings

Interdisciplinary Team Adding mental health counselor (Grimes) Increased coordinator role for RN (LVIM)

Deployment plan

Stories

PatientsStaff perspectivePhysician perspective

Contact Information

Kate LaFollettelafollcs@ihs.org515-471-9292