WelcomeThe National Cooperative Agreement on

Advancing Team-Based Care

WEBINAR 5: A Team Approach to Prevention and Chronic Illness Management

April 21st, 2016

Presented by the the Community Health Center, Inc. & the MacColl Center for Health Care

Innovation

SpeakersFrom MacColl Center for Health Care Innovation, Group Health Research Institute:Ed Wagner, MD, MPH, Director Emeritus Brian Austin, Deputy DirectorKatie Coleman, MSPH, Research Associate

From Community Health Center, Inc.:Margaret Flinter, APRN, PhD, Senior Vice President & Clinical Director Kerry Bamrick, MBA, Senior Program ManagerMary Blankson, DNP, APRN, FNP-C, Chief Nursing Officer

From Cambridge Health Alliance:Kirsten Meisinger, MD, Regional Medical Director

Community Health Center, Inc.

Foundational Pillars1. Clinical Excellence- fully Integrated teams,

fully integrated EMR, PCMH Level 3

2. Research & Development- CHC’s Weitzman Institute is the home of formal research, quality improvement, and R&D 3. Training the Next Generation: Postgraduate training programs for nurse practitioners and postdoctoral clinical psychologists as well as training for all health professions students

CHC Profile:•Founding Year - 1972•200+ delivery sites•130k patients

The Community Health Center, Inc. and its Weitzman Institute will provide education, information, and training

to interested health centers in: Transforming Teams• National Webinars on advancing team based care• Invited participation in Learning Collaboratives to advance team

based care at your health center

Training the Next Generation• Two National Webinar series on developing Nurse Practitioner

and Clinical Psychology residency programs and successfully hosting health professions students within health centers

• Invited participation in Learning Collaboratives to implement these programs at your health center

Email your contact information to nca@chc1.com and visit www.chc1.com/NCA.

Learning Objectives:1. Participants will understand how the core team can share

responsibilities to reliably deliver population health, planned care and self-management support.

2. Participants will be able to describe two ways practices build trust by developing shared competency and training protocols.

3. Participants will be able to identify two innovative practices used to train and retain high-quality staff by creating career-ladders.

Get the Most Out of Your Zoom Experience• Send your questions using Q&A function in Zoom• Look for our polling questions• Live tweet us at @CHCworkforceNCA and #primarycareteams and

#HRSAnca • Recording and slides are available after the presentation on our

website within one week• CME approved activity; requires survey completion • Upcoming webinars: Register at www.chc1.com/nca

A Team Approach to Prevention and Chronic Illness Management

Learning from Effective Ambulatory Practices

MacColl Center for Health Care InnovationGroup Health Research Institute

April 21, 2016

Ed Wagner, Director Emeritus Katie Coleman, Research Associate | Brian Austin, Deputy Director

How Do Teams Enable Practices To AchieveBenchmark Preventive Care?

By using their teams to effectively perform key primary care functions.

The Key Functions Of Excellent Primary Care

Providing planned, evidence-based care

to patients presenting for care—

PLANNED CARE

Need to access care gap data by

individual patients (e.g., tomorrow’s appointments)

Searching for and reaching out to patients needing

care—POPULATION MANAGEMENT

Need to access care gap data by population (e.g.,

patients with type 2 diabetes).

What leads to benchmark clinical performance?

What is a Care Gap?A care gap is a health problem or service need that requires attention from the practice team:• An uncontrolled chronic condition --e.g., type 2 diabetes

with HbA1c >9% without a recent visit.• An overdue evidence-based service –e.g., mammogram,

diabetic foot exam, flu shot• An abnormal lab result• A failed referral—e.g., appointment not made, consultant

note not returned• A high risk situation—e.g., multiple ER user, opioid abuse,

Population Management/Planned Care Key Changes

Link each patient to a specific team and provider

Decide which patient populations and which data elements to track

Create consensus to follow selected evidence based guidelines

Develop criteria that specify who/when/how to take action

Enable EMR to provide actionable care gap data on individual patients and populations

Select and train population management staff

Use data to plan visits and reach out to patients needing care

Create Consensus on Evidence Based Guidelines to Use

Must make guidelines actionable by

embedding them in team work flows for

population and panel management

Selecting & developing consensus on the

guidelines is responsibility of

clinicians

Population Management There are four overarching key principles for population management

1. Population-Based Care: Focus on caring for the whole population you are serving, not just the individuals actively seeking care.

2. Data-Driven Care: Utilize data and analytics in order to make informed decisions to serve those in your population who most need care.

3. Evidence-Based Care: Make use of the best available evidence to guide treatment decisions and delivery of care.

4. Care Management: Engage in actionable care management for the population you serve.

Select and train population management staff

• In most LEAP practices, population management is shared among staff; Front desk or panel managers review care gaps

requiring appointments to be made Team RN reviews chronically ill out of control

patients. RN care managers review recent hospital

discharges

Steps for planned care

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Assign the delivery of key services to specific staff and train them.

Use protocols and standing orders to allow staff to act independently.

Efficiently generate patient-specific care gap data on patients to be seen.

HUDDLE the core team and organize visits to close care gaps.

Cambridge Health Alliance

Integrating Population Health into every day care

Kirsten Meisinger, MD Rachelle Jean Amberly Ticotsky , RN

Central Concepts• Every interaction with a patient represents an

opportunity to help that patient come closer to health

• Outreach – go looking for trouble– Registries are the key tool

• In-reach - every patient, every time, no excuses– Lists are the key tool

MA and LPN roles on the team• Flow, warm handoffs to RN, pharmacy and psych

especially important• Labs, vaccines• Patient education and reinforcement of team

messages• Coordination of care – make appts, direct pt to

referral coordinator etc.• Pharmacy calls and clarifications• Outreach for selected population health categories

Redesigning Care Delivery:Care is no longer based primarily on visits

Previsit

The time of recognized need or risk by system

or time of patient contact to check-in

Care team plans for the encounter

Visit

Time of check-in to departure from health

center

Patient’s encounter with clinician and

care team

Post-visit

Departure to completion of visit

plans/actions

Between visit

Completion of visit plans/actions to

previsit

Care management

The Clinical Encounter – Pre-visit work• LPN reviews all appointments for the week on and starts the

documentation, specifically with any immunizations due• Format is:

– Provider:– MA:– LPN:– RN:– timestamp

• MA and MD and RN all do the same (usually the night before)

• Any team member who sees it is not done yet will start the process – especially for same day appointments

The Clinical Encounter - Huddle• 2-3 minutes with MA and provider present as a

minimum, co-location means that more often than not, the RN is also present

• Teams use the “rolling huddle” approach – frequent check ins with each other to see how things are going

• RNs focus on tel. management of pts who do not need an appointment and those who are post-hospitalization, rising risk etc.

• LPN does ER follow up letters, calls and appointments and sends to the team

The Clinical Encounter – Post visit• Patient chart is in a folder with a routing slip that serves as the

guide to all post provider stops (lab, referrals, imaging)• All screening papers arrive in the folder but stay with the

team (if leave in the folder get caught at check out)• Pt goes to check out and is tracked through labs, referrals etc

by check out on lists (safety concerns addressed and better flow)

• Advanced Access means usually no follow up appointment booked– pt put on a list specifying need for follow up (either for

chronic disease or a recall list)

Outreach• PCM Objective: provide care at a panel level• Meetings are meant to review a panel of patients, not 1-2 patients• Coordinated development of action plans by care teams for targeted patient

cohorts; some actions include:– Send a staff message to remind a team member to schedule a visit with PCP, PA,

RN, BH, Pharmacy, LPN, etc.– Phone call to update PHQ-9, care plan, ADHD check-in– Perform a change in medications– Update HM, problem list, etc.– Perform a referral to CCM, Specialty, community resources, etc.– Other…

• Recommended PCMs typically occur weekly and last 30 mins.

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Week 1 Week 2 Week 3 Week 4

Cancer Screening & Follow Up

Diabetes & Hypertension

Depression Complex Care

Team meetings• PCP panel is the unit of work• 30 minutes once a week, everyone present• Division of work with increasing panels now

spread across multiple team members, not just the core team of MD/MA/RN/Receptionist

• PA and MD cover each other when the other is away, ensuring the work gets addressed seamlessly

Operational Strategy: Deploy & monitor

planned care actions

Operational Strategy: Agree on care actions for

patients in need

1 2 3PCM Sample Workflow: Hypertension

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At PCM After PCMBefore PCM• MAs identify/review

patients who need a BP test

• RNs identify/review patients with high BP

• Care team meets to review HTN patients

• Team agrees on patients who require outreach for tests, BP follow ups, or other

• Snapshot, HM, etc. updated as needed

• Team reviews quality dashboard

• Teams deploy actions agreed during PCMo Schedule a visito Phone encounter to

update a care plan, PHQ-9, etc.

o Change medicationso Process referralso Etc.

• PCC monitors and supports team

Epic Report Used: My Loc Pts w/ Hypertension

www.improvingprimarycare.org

Resource Spotlight #1

Resource Spotlight #2

How Do Teams Enable Practices To AchieveBenchmark Chronic Care?

By using their teams to effectively perform key primary care functions.

The Key Functions Of Excellent Primary Care

What do Patients with Chronic Illness Need to Optimize Outcomes

• Drug therapy and medication management that gets them safely to therapeutic goals.

• Effective self-management support so that they can manage their illness competently.

• Preventive interventions at recommended times.• Evidence-based monitoring and self-monitoring to detect

exacerbations and complications early.• Follow-up tailored to severity, and more intensive

management for those at high risk. • Timely, well-coordinated services from medical specialists and

other community resources.

Skilled and Well-organized Care Teams

• Team involvement in the care of chronically ill folks is the single most powerful intervention.

• Involvement of non-physician care team members in care has been associated with a 0.75% reduction in HbA1c and a 13 mmHg reduction in BP.

How do effective practices implement self-management support

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• linkages with self-management programs in the community.Forge

• team members to provide basic self-management support.Organize & train

• self-management support into every interaction.Build

• self-management goals and their attainment in the patient’s record.Document

How do effective practices manage medications?

• Protocol-based prescribing and monitoring of adherence and outcomes is routine.

• Medication reconciliation is viewed as a critical intervention for both patient and practice. MAs collect important information on drug use.

• Pharmacists and RNs play important roles in complex med. rec., titrating medications, and addressing non-adherence and other drug problems.

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How do effective practices deliver planned follow-up and Care Management (outside of visits)

• Follow-up can range in intensity from periodic status checks by telephone or e-mail (MA) to active care management (RN).

• LEAP practices have tended to move routine chronic illness follow-up care to team RNS.

• Follow-up/care management are core functions of the practice team.

• Higher risk patients (poor disease control, frailty, etc.) receive regular follow-up (monitoring) AND active care management by RN care managers.

Relationship between care coordination, follow-up & care management activities

39

Care Management

Logistical

Logistical

Logistical Clinical Monitoring

Care Coordination

Clinical Follow-up

Medication managementSelf-management Support

Clinical Monitoring

Administrativestaff

Medical Assistant

RegisteredNurse (team)

LEAP Innovations in Chronic Care

• Use of trained MA or lay health coaches to provide routine self-management support.

• Independent or conjoint RN visits for routine chronic care follow-up.

• RN titration of anti-hypertensive, hypoglycemic, anti-cholesterol drugs using delegated order sets.

Cambridge Health Alliance

Implementing Chronic Illness Care into everyday practice

CHA Chronic Illness StrategyRN role transformed into the team member primarily responsible for patients with chronic diseases who are not at goal

Education, empathy and patient centeredness are hallmarks of excellent nursing education – use them!

Site based or regional resources (the Extended Team)

• Pharmacist – 40% time (direct pt visits for DM, HTN, Anti-coagulation; not staffing a pharmacy)

• Referral Coordinator• Nutrition• Psychiatry/ On site behaviorist (integrated

therapist)/On site care partner (non-licensed BH)• Social Work • LPN (immunizations, ED follow up, managing the

floor)• Complex Care team• Family Planning Counselor

RN Role on the team: what we do when we come to work every day

• RNs co-manage multiple chronic diseases: depression, diabetes, HTN, anxiety, abnormal cancer screening

• Monthly review of Rising Risk, depression, diabetes, abnormal cancer screen lists at weekly team meetings

• Self structured review of lists in between to outreach to patients

• Care coordination: are the glue for the patients with chronic illness – they guide which team member will see the patient next

RN Training• CDE based training using our larger system and

specialty RN (endocrinology)• Multi-disciplinary case conferences (pharmacy,

CDE, PCP, SW) at first; now they have their feet wet and feel more independent

• Co-management and co-location with the Providers and team engenders continual learning in both directions

• Motivational Interviewing training• Diabetes, HTN, CHF clinical updates

RN Visits• Dedicated time for RN visits• LPN hired to get them off the floor (shots, limited

triage, supplies and stocking, faxing!)• Two RNs seeing visits all sessions, evenings busy with

floor and some visits• Chronic Care visits 30/60 min and urgent care 15/30

min• Dedicated time for outreach for depression patients

and the home bound

Typical ScheduleRN PCP

Role of the extended Team

Patient story• New patient with new diabetes from Nepal, little English• Presents with 6th nerve palsy from TB!• Seen first day by MD who started medications for diabetes,

RN by warm hand off for teaching and labs and PHQ9 screening done by protocol by MA

• Pt screened positive for depression – unable to complete school work due to double vision and afraid will lose his visa

• Nurse visit 5 days later – care plan completed, pt had not picked up or started meds, did not understand them, very depressed– Pt declined depression meds but accepted counseling from team

Patient story (con’t)• Telephone call 2 weeks later with RN, pt depressed and overwhelmed,

counseled by RN• PCP visit soon after, sl better mood, added medicine for glucose control• RN visit 2d later to confirm the plan• Patient no shows to all appointments 3 months later• Telephone call 2 weeks later – confused about medicines and not taking

them correctly, unable to make nutrition appt and not sure what to eat– Same day nutrition appt made, patient seen

• Patient no shows to all appointments 3 months later– Outreach by team MA results in patient coming back to care, agrees to appt with RN

RN appointment kept and detailed care plan done again, pt with much improved depression and glycemic control

Did it work?• A1c: originally (5/4/2013) 9.0; PHQ9 was 12

• Went to 6.1 by 7/31/2015; PHQ9 was 7

• Now (12/4/2015) 6.5; PHQ9 is now 6

Team Dynamic• PCP saw patient for initial visit and largely prescribes

medications• RN had next visit with patient to focus on chronic diseases of

diabetes and nutrition – is the center of the patient’s journey into managing their new chronic disease

• RN developed the primary relationship with this patient through longer appointments, motivational interviewing, and follow up phone calls

• Population management was essential to keeping him on track – if he had been allowed to no show, he would not have gotten to goal!

Outcomes – the right away

• RNs have taken on direct patient education for high risk patients, esp. diabetics

Hgba1c Avg

7.7

7.8

7.9

8

8.1

8.2

8.3

8.4

8.5

8.6

2011 2012

Hgba1c Avg

LDL Avg

96

98

100

102

104

106

108

110

2011 2012

LDL Avg

Diabetes “Perfect Care”Outcomes – the long term

0

10

20

30

40

50

60

70

2008 2009 2010 2011 2012 2013 2014 2015

Perfect care

Union Square Staff

www.improvingprimarycare.org

Resource Spotlight #3

www.improvingprimarycare.org

Open Space for Discussion

RemindersSign up for our next webinar in this series:

Complex Care Management in Primary CareThursday May 5th, 3–4 p.m. EST

Complete our survey!

Sign up at www.chc1.com/NCA