Promoting Team Based
Care
DC Primary Care AssociationOctober 27, 2015
Mary Blankson DNP, APRN, FNP-C Chief Nursing Officer
Our Vision: Since 1972, Community Health Center, Inc. has been building a world-class primary health care system committed to caring for underserved and uninsured populations and focused on improving health outcomes, as well as building healthy communities. CHC Inc. Profile:•Founding Year - 1972•Primary Care Hubs – 13 ; 218 sites•Organization Staff – 650; active patients: 130k•Disciplines: Medical, Behavioral Health, Dental•Specialties: CDE, Nutritionist, Podiatry, Chiropractic Care•Specialty access by eConsultsTop Chronic Diseases
Cardiovascular Disease Obesity/Overweight
Diabetes Chronic Pain
Asthma Depression
Three Foundational Pillars Clinical Excellence
Research & Development Training the Next Generation
Elements of Model
• Integrated primary care teams/pods• Integrated medical, dental, BH EMR• PCMH Level 3• TJC Patient Home• School Based Health Centers across CT• “Wherever You Are” HCH program
Innovations• Postgraduate Training Programs • Weitzman Institute • Project ECHO –CT (pain, opioid addiction, QI)
• Specialty access by eConsults
CHC’s Educational, Technical & Innovation Projects
Facilities and Physical Model
• Interdisciplinary Pods that Promote Team-Based Care• Open office structure• Collaboration throughout the workday
6
• Exam rooms and therapy rooms
• Reducing stigma of seeing other disciplines
• Seamless transition between Disciplines
05/14/2014
Facilities: One Corridor Care
What does an Integrated Record Look Like?
800/00/00
Data Driven: the Right Data at the Right Time
EHR
ETL Process
Data WarehouseStructured Data Pulls
Dashboards
Scorecards
Additional on-site specialties
Nutrition Diabetes
education Chiropractic Podiatry Retinal screening
Care that is Comprehensive: IPCP Team
PATIENT
Medical
BH
Nursing
Pharmacy
Prenatal
Dental
4 Clinical Chief positions: Chief Medical Officer Chief Nursing Officer Chief of Behavioral Health Chief Dental Officer
Leadership Support Executive Mentoring Interdisciplinary Chief Meetings Leadership Meetings
Collaboration/Integration among departments QI Projects/Microsystem work Clinical Initiatives/Policies
MU2/PCMH/UDS
Interdisciplinary Leadership
Onsite Clinical Directors OSMD Nursing Managers OSBHD OSDD
Collaboration/Integration among departments Integrated Microsystems Integrated Care Meetings Clinical/Pod “Huddles”
Leadership Support Leadership Skills Training Leadership Meetings
Interdisciplinary Leading
Interdisciplinary Care“Every CHC Patient has Team!”
Initiative BH Medical
Nursing
Dental
Integrated Care Meetings r r r
Recalls r r r r
BH Groups r r
Shared Medical Visits r r r
Warm Hand-Offs r r r
Prenatal-Dental Project r r r
Shared Care Plans r r r
Complex Care Management
r r r
Trauma Screening & TFCBT
r r
Standing Orders r r
Fluoride Varnish r r r
SBIRT r r r
BH Dashboard r r r r
Appointment Allocation r r r r
00/00/00
Interdisciplinary Care Initiatives
Figure 1. Diabetes Dashboard by Provider
Team-Based Care: Tele-Ophthalmology
• Rooms Patient• Collects Vitals• Captures Images
MA
• Diabetes Education• Self-Management
Goal Setting
Nurse
• Reviews Results• Creates a Referral
when needed
PCP
Collaboration/Integration among departments Training/Competencies Program Oversight Developing Standing Orders Chair of the Pharmacy & Therapeutics Committee MU2 Implementation PCMH, UDS Reporting & TJC MA/RN recruitment Nursing Informatics Promotion of Research & Translation Mentor/Coach to the Nurse Managers Relationships with Professional Schools
Leadership for RNs and MAs: The Role of the CNO in Team-Based Care
POD design 2 Medical Providers 1 Registered Nurse 2 Medical Assistants 1 Behavioral Health Clinician Additional members: podiatrist, dietician, Pharm-D,
chiropractor, CDE Student/Trainees
The Interdisciplinary Team
Essential member of the primary care team and interprofessional activities
(1) RN supports (2) primary care providers/panelsKey functional activities:
Patient education and treatment within provider visits Independent Nurse Visits under standing orders Delegated provider follow up visits using order sets Self management goal setting and care management Complex Care Management; coordination and planning Telephonic Advice and Triage via dedicated triage line Quality improvement leaders, coaches, and participants Leaders and participants in research Clinical mentoring of RN students; Supervision and mentoring of Medical Assistants
Domains of RN Nursing Practice at CHC, Inc.
Uncomplicated UTI Vulvovaginal candidiasis Comprehensive diabetes visit with retinal screening Pupil dilation Titration of basal insulin Pedi & adult vaccines TB DOT Bronchodilator testing in spirometry Tobacco cessation Emergency contraception Pregnancy testing Orders for emergency situations
Nursing Standing Orders
Independent Nursing Visits
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000 12,870
4,2285,444
736 1,4222,952
766
Total Visits: 20,717, Total Services Delivered: 28,418
Total Visits: 20,717, Total Services Delivered: 28,418
Hypertension; 41.9%
Diabetes Man-agement; 25.3%
BH; 10.6%
Asthma/COPD; 7.9%
HCV/HIV; 2.2%
Obesity; 1.6%CAD; 1.0% Hyperlipidemia;
0.7%
Other; 8.8%Chronic Illness Care
National Advisory Council on Nurse Education and Practice
Competency Fairs Leadership Conferences Facilitation Training Comprehensive didactics for Complex Care Management
• Transition Care• Medication Reconciliation• CHF• DM• Asthma• COPD• Psych• MI/SMG
Training
4-day comprehensive didactics for Care Coordination Transition Care, Medication Reconciliation, CHF, DM,
Pediatric Asthma, COPD, Psych, Motivational Interviewing, Self Management Goal Setting
Supervision Case Reviews via videoconference EHR Templates
Structured Intakes/Follow up Nursing Informatics/Outcome Measures Dashboards (Population Management)
Community Engagement Open House Data Sharing
RN Complex Care Management
Reason for Complex Care Management
Consider Possible Data Sources
Customizing the Sort
Additional Actionable Data
29
Complex Care Management Scorecard
00/00/00
30
Complex Care Management Scorecard
00/00/00
Planned Care Delegated Ordering Panel Management Scanning/Faxing/handling of incoming faxes Retinal Camera Operation QI/Microsystem Participants
Role of the Medical Assistant
Planned Care Dashboard
33
11/1/2014
36.5%
2/1/2015
41.5%
00/00/00
PCD—Birth Cohort HCV Screening
Added to the PCD
Baseline Screening
Rates
Final Data Collection Completed
New Screening
Rate
As initiatives/responsibilities are added, redefining ratios
Refining workflows with EHR limitations
Recruiting RNs with ambulatory care experience
Training to our model of care
Working toward full MA certification
Challenges
Additional standing orders
Improve data driven performance appraisals for MA/RN teams
Improve structured data entry for team members (Informatics) to better document the impact of various care team members
Increasing the use of automated workflows
Continue to enhance front-line involvement and leading in initiatives
Future Directions
Contact Information
National Advisory Council on Nurse Education and Practice
Mary Blankson, DNP, APRN, FNP-C Chief Nursing Officer(860) 852-0851 office(860) 227-5432 cell
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