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Kirsten Meisinger, MDDeb Scannell, RN
Nitzali Rivera, LPNPatricia Alves, MA
Cambridge Health Alliance
Change Concepts for Practice Transformation
Wagner EH, Coleman K, Reid RJ, Phillips K, Abrams MK, Sugarman JR. The Changes Involved in Patient-Centered Medical Home Transformation. Primary Care: Clinics in Office Practice. 2012; 39:241-259.
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What work are you doing?
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The World Health Organization (WHO) estimates that…
At least 80% of all heart disease, stroke, and type 2 diabetes, and
More than 40% of cancer
would be prevented if only Americans were to do three things:
Stop smoking Start eating healthy Get in shape
The vast majority of cases of chronic disease could be better prevented or managed.
http://www.fightchronicdisease.org/
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Next: Who is going to do the work?
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Do this:Parallel Work Flow Redesign
Why teams?
Places patient at the center – MD not the center of staff attention
Entire staff know and own the care of the patient
Work is distributed according to level of staff training (e.g. RNs free to do RN level tasks)
Improves quality and efficiency of care
Makes primary care possible and ENJOYABLE!
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There are many roads
Form follows Function: who is around to help with the work?
Teams need leadership direction and support but can grow organically (especially important when there are economic constraints)
Functions and roles of teams members change over time based on staffing and need
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How Teams Structure The Work‐Maintaining the Change
The work of the team is organized around four processes: pre‐visit, visit, post‐visit and between visits
All MA‐MD pairs “huddle” prior to and after each patient care session. Significantly improved the flow and productivity (#s of pts seen, what was done for each patient) of each session.
Meet regularly as a whole team to manage “between visit” work – weekly meetings of whole team Celebrate successes , discuss patients who are struggling, review quality goals, plan outreach, assign tasks
Redesigning Care Delivery:Care is no longer based primarily on visits
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Voice of the Team
Starting the visit: Medical Receptionists
Pre‐visit work and Visit planning: Medical Assistant and LPN
Patricia Alves/Nitzali Rivera
What is the difference between a Team “Meeting” and a “Huddle”?
“HUDDLES”
Goal: before each session (AM & PM) )
Minimum: once a day
Ideal: In addition, post‐session quick huddle for f/u tasks
Average 10 minutes or less!
* Who’s coming in today: what do they need?
* Who was in the hospital/ED and what is the plan for f/u?
A provider and the MA who are working together to see the patient that day.
The receptionist joins the team if at all possible to assist with scheduling of appointments.
The team RN connects with this team either during the huddle or sometime during the day to review the hospital/ED f/us.
Planning for care of the patients scheduled to receive care during the session/day by the provider.
Includes planning for flow of the session (i.e. provider informs RN that this patient on the schedule will be a quick follow up and an add on can be double booked in this slot)
Includes planning for patient’s:
Health Maintenance issues
Chronic Care issues
Urgent Care issues (i.e.provider informs MA that this patient will need an EKG, this one a throat culture, etc.)
TEAM MEETINGS
Goal: weeklyMinimum: biweekly
30‐60 minutes depending on weekly/biweekly
This meeting time should occur during a time when team members CAN ATTEND and coverage for their work is available. Team meetings are part of administrative time for providers.
All assigned members of the Planned Care TeamRequired participants: Provider, Nurse, Medical Assistant,
Medical Receptionist, Planned Care Coordinator, and Complex Care Managers (for high risk case discussions)
Support team participants: Clinical Pharmacist, Nutrition, Mental/Behavioral Health, Social Work, Patient Navigators, Community Resource Specialists
Planning for care of a panel/population of patients. This includes patients who touch
the health care system regularly (during appointments and phone contacts) and those who do not touch the health care system regularly.
Includes planning for patient’s:Health Maintenance issues
Chronic Care issuesSocial and Resource issues
High risk patients
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Workshop activity
Design a huddle for your clinical site(s) using the worksheet:
Who needs to be present?
Where will they meet?
What work will get done?
Do you have the tools they need or do you have to develop more?
Or, without data, we are nothing!
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What happens when the patient is not at the clinic?
Population Health (MA, MR, panel manager)
Care Management (team for everyone, RNs for the high risk, CCM for the highest risk)
Responsible for the patient even when they are interacting with other components of the Health Care System (everyone at the site)
Planned Care Team Meetings/Prevention GroupsClinic: Union Square Family HealthDate/Time of Monthly ALL STAFF meeting: 4th Wednesday of Every MonthPlanned Care Coordinator (PCC) Name: Vanessa DolyresGroup Visits: Wheeler DM (2nd Wed – Monthly 4:15-6:30pm); Demasi 6 weeks Tues evesPrenatal group Monday eves (Vogel); Baby Group 1st Wednesday of the month (Meisinger)Paula Coutinho (SW) and Joan Byrne (RN), CCM teamPharmacist: Joeseph Falinski, PharmD
Care Team Name
Date/Time of Team Meetings
Mtg Place
Provider RN(s) MA(s) Front Desk Staff
PA
Thackrey Friday 1:00-1:30pm
USFH Dr. Michael Thackrey
Monica Tague
Veronica Miranda
Judith Roc
Juliane
Cohen Tuesday 1:30-2 USFH Dr. Bonnie Cohen
Susan Gesing
Veronica Miranda
Judith Roc
Janice
Demasi Thursday 1-1.30PM
USFH Dr. Monica Demasi
Autumn Roy
Patricia Alves Eli Barbosa
Amy
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Cycle of Team Meetings
Week 1: Diabetes
Week 2: “Watch List”/Depression
Week 3: Complex Care Management
Week 4: Abnormal Pap/Abnormal Mammo/PSA/Pulmonary Nodules
Week 5: Well Child/Prenatals
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Voice of the Team
Panel Management:
Leadership perspective – Deb Scannell
On the ground: Nitzali Rivera, LPN
and
Patricia Alves, MA
Team Orientation and Training
First, who will do what? Define the Roles
Clear hiring strategy to identify candidates who will succeed in this model
Every new staff member spends time shadowing different team members
Concept of patient care teams and their expected role is a focal point of new staff orientation
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Workshop Activity Design your Quality structure for your clinical site(s) using the worksheet:
planned care meetings (weekly recommended)
Workflow team or Performance Improvement Team
Reporting process – where do you get your data?
For each of these that you deem appropriate to your site(s), specify what roles will be required to attend and what function they will perform during the meeting
Measures of Success – Work Environment
Provider and staff satisfaction
Extremely low rate of avoidable turnover despite very challenging financial hurdles as an organization
Professional development of staff
Easy to recruit new staff members to the site
Staff‐led visioning and initiatives
Providers identified this as a best practice site in organization‐wide survey
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Traps
Important for people to own the work ‐ clear communication, role definition, empowerment
Important to preserve a sense of teamwork across care teams – vacations, sick days, etc
Appropriate prospective staffing and scheduling really matters
Personality management – help each person to succeed
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“Teams can work if your whole team loves the patient as much as you do.”
Lucy Candib
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