PCMH: Focus on The Care Team & Huddles

PCMH: FOCUS ON THE CARE

TEAM & HUDDLES

Session 2 July 18, 2014

Green Management Consulting Group, Inc.1

Green Management Consulting Group, Inc. 2

Quick Review of NEW 2014 PCMH Standard on Team Based Care

Quick Review PCMH: What is it?

Green Management Consulting Group, Inc.

•A care model that focuses on the primary care practitioner (PCP) directed coordination of care

•PCP coordinates a multidisciplinary team, takes responsibility for the care provided to the patient, and tracks care over time and across settings, including with other practitioners

•Organizes care around a patient’s unique needs

•Improves quality, patient experience and reduces total costs

•Focus on prevention & managing chronic conditions

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Goal of PCMH

High Quality Care

Increased Patient Satisfaction

Increased Staff Satisfaction

Eliminate gaps in care

Reduced Costs

National Recognition


PCMH 2 – Team Based Care

Element A Continuity

Element B Medical Home Responsibilities

Element C Culturally and Linguistically Appropriate Services (CLAS)

Element D The Practice Team



Element D Factor Number

Explanation Documentation

1 Defining roles for clinical & nonclinical team members.

Job roles & responsibilities emphasize a team-based approach to care & support each member of the team being trained to meet the highest level of function allowed by state law.

NCQA reviews dated descriptions of staff positions or policies & procedures describing staff roles & functions. The practice may provide an organizational chart or description of the team structure & team members.

2 Identifying the team structure & the staff who lead & sustain team based care.

The practice delineates responsibilities for sustaining team-based care, & specifies how care teams align to provide patient-centered care. Specific team units may focus on providing care coordination across & beyond the practice (factor 5). An organizational chart may be used to illustrate how a care team fits in the practice.

NCQA reviews an overview of the staffing structure for team-based care.

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Critical factor3 Holding scheduled patient care team meetings or a structured communication process focused on individual patient care.

Team meetings may be informal daily meetings or review daily schedules, with follow-up tasks. A structured communication process may include regular e-mail exchanges, tasks or messages about a patient in the medical record and how the clinician or team leader is engaged in the communication structure.

NCQA reviews the practice’s documented process for structured communication between the clinician and other care team members, which states the frequency of communication; and reviews at least three samples of meeting summaries, checklists, appointment notes or chart notes for evidence that the practice follows its process.

4 Using standing orders for services.

Standing orders (e.g., testing protocols, defined triggers for prescription orders, medication refills, vaccinations, routine preventive services) may be clinician preapproved or may be executed without prior approval of the clinician, as permitted by state law.

NCQA reviews at least one example of written standing orders.

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5 Training and assigning members of the care team to coordinate care for individual patients.

Care coordination may include obtaining test and referral results and communicating with community organizations, health plans, facilities and specialists

NCQA reviews dated descriptions of staff positions or policies and procedures describing staff roles and functions. The practice may provide an organizational chart or description of the team structure and team members.

6 Training & assigning members of the care team to support patients/families/ caregivers in self-management, self-efficacy & behavior change.

Care team members are trained in evidence-based approaches to self-management support, such as patient coaching and motivational interviewing.

Same as above

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7 Training and assigning members of the care team to manage the patient population.

Care team members are trained in managing the patient population & addressing needs of patients & families proactively. Population management assesses & manages the health needs of a patient population, such as defined groups of patients (e.g., patients with specific clinical conditions such as hypertension or diabetes, patients needing tests such as mammograms or immunizations).

NCQA reviews dated descriptions of staff positions or policies & procedures describing staff roles & functions. The practice may provide an organizational chart or description of the team structure & team members.

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8 Holding scheduled team meetings to address practice functioning.

The practice holds scheduled team meetings routinely to improve care for all patients (factor 3 addresses care of specific patients). Meetings include clinical staff (e.g., MDs & RNPs) & nonclinical staff. The purpose of these meetings is to discuss practice & staff functions —what is working well & what may need improvement. E.g., there could be an ongoing discussion about staff roles & responsibilities, performance measurement data & related quality improvement efforts, team member training & areas for improvement. Meeting frequency can vary (e.g., monthly, bimonthly, quarterly) but are part of the practice’s routine operations.

NCQA reviews a description of team meetings, the frequency of these meetings & at least one example of meeting minutes, agendas or staff memos.

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9 Involving care team staff in the practice’s performance evaluation and quality improvement activities.

The practice has a documented process for quality improvement activities that includes a description of staff roles and involvement in the performance evaluation and improvement process. The care team receives performance measurement and patient survey data to identify areas and methods for quality improvement. The team may participate in regular quality improvement meetings or in action plan development.

NCQA reviews the practice’s documented

process for quality improvement.

10 Involving patients/families/ caregivers in quality improvement activities or on the practice’s advisory council.

The practice has a process for involving patients and their families in its quality improvement efforts. At a minimum, the process specifies how patients and families are selected, their role on the quality improvement team and the frequency of team meetings.

NCQA reviews the organization’s documented process for involving patients/families/caregivers in QI teams or on an advisory council (e.g. meeting notes, agenda, committee structure)

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VIDEOS


Cedars-Sinai proprietary DVD on PCMHhttps://www.youtube.com/watch?v=Wttxm7jAnb4

CARE TEAM ROLES


Definition of a Care Team


A care team is a small group of clinical and non-clinical staff who, together with a provider, are responsible for the health and well-being of a panel* of patients.

Who is on the care team and their specific roles will vary based on patient needs and practice organization.

* NOTE: EMPANELMENT is a precursor for teams – teams must be informed about the set of patients for whom they are responsible!

http://www.safetynetmedicalhome.org/change-concepts/continuous-team-based-healing-relationships

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Care Team Roles

Core TeamProvider/Team Leader & Medical AssistantResponsible for most care & care coordination

Other Team Members may include:LVN/RN

Care Coordinator who’s role is to oversee the medical assistants, care managers for panels of high-risk patients, performing health coaching and connecting patients with information and resources

Appointment staffReferral CoordinatorReceptionistBehavioral Health SpecialistNutritionist/ Patient EducatorPharmacist


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Basics Needed

•Standardized Protocols/Evidence Based Guidelines•Easily Accessible

•Clear Expectations•Respectful Work Place

•Staff & Patients•Time Management

•Appropriate Training to Optimize Scope of Practice

•Optimal Utilization of EHR to Enhance Patient Centered Care


Rewards

•Increased efficiency•Increased staff satisfaction -> retention•Increased patient satisfaction -> retention•Role expansion – seen as a team by the patient

•Fewer gaps in care•Receptionist/Appt staff ask about Urgent Care or ED visits and obtains records where appropriate

•Providers talk with referral specialty physicians

•Incentivize & acknowledge improvements & goal achievement


JOB DESCRIPTIONS AND SCOPE OF

PRACTICE


Unlicensed individualsPerform non-invasive routine technical support services under the supervision of a licensed physician and surgeon, podiatrist, physician assistant, nurse practitioner, or nurse midwife in a medical office or clinic settingThe supervisor must be on the premises in order for the medical assistant to perform those non-invasive technical support services

Medical Assistant


Medical Assistant, cont.

Medical assistants may obtain "certified" status through private agencies approved by the Medical Board of California

A list of "Frequently Asked Questions" addressing the appropriate training, supervision, and scope of practice issues: http://www.mbc.ca.gov/Licensees/Physicians_and_Surgeons/Medical_Assistants/


http://www.mbc.ca.gov/Licensees/Physicians_and_Surgeons/Medical_Assistants/

http://www.mbc.ca.gov/Licensees/Physicians_and_Surgeons/Medical_Assistants/

Medical Assistant Training

The California Business and Professions Code Medical Practice Act outlines laws related to medical assistance practice as well as minimum requirements for training institutions to establish accreditation and graduate students.


Administer Injections 10 hours Training

IM, SQ, ID 10 demonstrations of each, dose checked by Provider

Perform Venipuncture 10 hours training & 10 demonstrations

Administer Inhalation Therapy 10 hours training & 10 demonstrations

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Training Topics


•Anatomy & Physiology related to Procedure

•Proper Sterile Technique

•Hazards & Complications

•Patient Care following test/procedure

•Awareness of emergency procedures

•Capacity to choose appropriate equipment

General MA Job Description

Perform administrative and certain clinical duties under the direction of physician/Health Care Provider.

Administrative duties may include•scheduling appointments,•maintaining medical records, •billing, and coding for insurance purposes.


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Summary of Clinical Duties• Obtaining patient history and vital signs such as blood pressure, pulse, height and weight

• Preparing & maintaining examination and treatment areas

•Preparing patients for examination• Assisting with procedures and treatments• Preparing and administering medications and immunizations

•Recognizing and responding to emergencies •Screening and following up on patient test results •Collecting and processing specimens for diagnostic tests


Care Manager Job Description

LVN Care Manager : Ensuring the accurate documentation of patient care activity, maintaining a quality standard of care, anticipating daily workload, prioritizing activities, and coordinating the workload of other employees. Provides patient care to patients ranging in age from infancy to geriatric

Assists physicians with examinations and diagnostic testing

Maintains appropriately stocked work areas

Completes special projects or other duties as assigned

Registered Nurse Case Manager participates in all phases of the Case Management Program (CMP) and ensure that the CMP meets established case management (CM) standards of care. Assist in coordinating a multidisciplinary team to meet the health care needs, including medical and/or psychosocial management, of specified patients.


Care Manager Job Description, cont.

•Serve as consultant to all disciplines regarding CM issues. Provide nursing expertise about the CM process, including assessment, planning, implementation, coordination, and monitoring. Identify opportunities for CM and identify and integrate local CM processes.

•Develop and implement local strategies using inpatient, outpatient, onsite and telephonic CM; develop and implement policies and protocols for home health assessments and outcome measures.

•Develop and implement tools to support case management, such as those used for patient identification and patient assessment, clinical practice guidelines, algorithms, CM software, databases for community resources, etc.

•Integrate CM and utilization management (UM) and integrate nursing case management with social work case management. Prepare routine reports and conduct analyses.



•Assist in establishing and maintaining liaison with appropriate community agencies and organizations.

•Maintain adherence to JCAHO, URAC, CMSA and other regulatory requirements. Apply medical care criteria (e.g., InterQual).

•Ensure accurate collection and input of patient care data and ensure basic CM budgetary management.

•Provide input on hospital's CM resources and make recommendations to the Command as to how those resources can best be utilized.



•Collaborate with the multidisciplinary team members to set patient-specific goals. Develop treatment plans including preventive, therapeutic, rehabilitative, psychosocial, and clinical interventions to ensure continuity of care toward the goal of optimal wellness.

•Establish and implement mechanisms to ensure proper implementation of patient treatment plan and follow-up post discharge in ambulatory and community health care settings.

•Provide nursing advice and consultation in person and via telephone.

•Ensure appropriate health care instruction to patient and/or caregivers based on identified learning needs.



•Alert physicians to significant changes or abnormalities in patients and provide information concerning their relevant condition, medical history and specialized treatment plan or protocol.

•Facilitate multidisciplinary discharge planning and other professional staff meetings as indicated for complex patient cases and develop a database and knowledge of local community resources.

•Develop and implement mechanisms to evaluate the patient, family and provider satisfaction and use of resources and services in a quality-conscious, cost-effective manner.

•Implement strategies to ensure smooth transition and continued health care treatment for patients. Develop a policy for, and assist with, relocation/change of health plan.



•Plan for professional growth and development as related to the case manager position and maintenance of CM certification.

•Establish cost containment/cost avoidance strategies for case management and develop mechanisms to measure its cost effectiveness.

•Assist with the Electronic Health Record and interface or other database designed to support CM.

•Participate in video teleconferences and other meetings as required.


Other Team Members

•Appointment Staff: Training on pt. centered care, appt. preps, checking on UC or ED visits, appointment reminders, language services, using EHR to communicate

•Receptionists: Training on pt. centered care, optimizing flow, checking on Urgent Care or ED appointments, & appointment prep (blood draw? See Social Worker first?)

•Social Worker/Nutritionists/ Referral Coordinator: Part of team, Recommendations, Communication!


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Scope of Practice

•Primarily an issue for the MA•Most MAs won’t know their scope of practice

•Want to please, want to help•Experience in private offices, on-the-job skills

•Need to ensure are trained and comfortable with procedures•Return demonstrations•Orientation period for new employees


Scope of Practice

Check FAQs on California Medical Association website •Can only give medications after verification by a physician, podiatrist or another appropriate licensed person.

•http://www.mbc.ca.gov/Licensees/Physicians_and_Surgeons/Medical_Assistants/Medical_Assistants_FAQ.aspx#2


http://www.mbc.ca.gov/Licensees/Physicians_and_Surgeons/Medical_Assistants/Medical_Assistants_FAQ.aspx

http://www.mbc.ca.gov/Licensees/Physicians_and_Surgeons/Medical_Assistants/Medical_Assistants_FAQ.aspx

Can medical assistants be supervised by a nurse practitioner, nurse midwife, or physicians assistant in the absence of a physician and surgeon?

Per Business and Professions Code section 2069 (a)(1), a supervising physician and surgeon at a "community clinic" licensed under Health and Safety Code section 1204(a) may, at his or her discretion, in consultation with the nurse practitioner, nurse midwife, or physician assistant provide written instructions to be followed by a medical assistant in the performance of tasks or supportive services. The written instructions may provide that the supervisory function for the medical assistant in performing these tasks or supportive services may be delegated to the nurse practitioner, nurse midwife, or physician assistant and that those tasks may be performed when the supervising physician and surgeon is not on site.http://www.mbc.ca.gov/Licensees/Physicians_and_Surgeons/Medical_Assistants/

Medical_Assistants_FAQ.aspx#2


What isn’t within the MA Scope?

•Invasive Procedures•Cannot insert urinary catheters

•Assessments/Triage•Check pupillary response•Cannot read, interpret or diagnose symptoms or test results

•No phone triage

•Cannot apply splints, casts, or other external devices, but can remove them if trained

•Cannot interpret skin test results•But can measure and describe the test reaction and make a record in the patient's chart

•Cannot call in new prescriptions or prescription changes


LVN Scope of Practice•The licensure and practice of vocational nurses is authorized by the California Business and Professions Code and regulated by the Board of Vocational Nurse and Psychiatric Technicians (BVNPT).

•The LVN must practice under the direction of a licensed physician or Registered Nurse (RN) at all times. Such direction may be provided verbally, telephonically, or by written order.

•The LVN may assist in the collection of data during the assessment process. VALIDATION of assessment data, however, must be done by the RN.

•The LVN may perform that part of the triage process that includes interview, observation, the collection of subjective and objective data, and the recognition of problems or abnormal conditions specific to the patient

•Perform lifesaving nursing procedures. Such procedures include basic CPR and management of assaultive behavior

http://www.cphcs.ca.gov/docs/imspp/imspp-v05-ch05.pdf


http://www.cphcs.ca.gov/docs/imspp/imspp-v05-ch05.pdf

What Can’t the LVN Do?•May not independently determine or initiate a course of clinical action.

•May not administer intravenous medications•May not dispense medications

•Dispensing medication is defined as the interpretation of a physician’s order for a drug and the proper selection, measuring, packaging, labeling, or in any way filling a prescription for a patient. This includes counting stock medications, placing them in a container with the patient name and issuing the medication to the patient.

•May not perform that part of the triage process that includes independent evaluation, interpretation of data, and determination of treatment priorities and levels of care.


BREAK!


Huddle/Patient Care Team Meeting P&P Review•Policy: Team Huddle•Purpose•Procedure


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Overall High Level Workflow

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Huddle • Provider direction / decisions• List of follow- up items• List of intake orders, tags, activities

Intake• Intake Activities• Post Tags as needed• Pend orders• Notes on Rooming Sheet• Shred Chart Prep Sheet

Physician Visit• Review pended orders• Review tagged items• Usual care processes• Ensure AVS information

Chart Prep• Chart Review• List of Huddle discussion items• List of follow- up items

Patient makes appointment

Patient receives reminder call (auto)

Patient receives call for X

Patient arrives Patient leaves

Follow-up as needed• Reschedule / call patient• Ensure equipment, supplies, forms• Other f/u activities

Discharge• Check and process orders • Complete documentation• AVS

Patient

Patient Service Representative

Medical Assistant /LVN

Physician

Registration• Consents• Forms

Out Processing• Appointments• Referrals

Pre-Visit Visit

XxxxXxxXxxXxxXxxxxx

Order:XxxXxxTag:XxxOther:xx

XxxxXxxXxxXxxXxxxxx

Chart Prep and Huddle Worksheet

RoomingSheet

RoomingSheetxxxxxx

Order:XxxXxxTag:XxxOther:xx

XxxxXxxXxxXxxXxxxxx


Chart Prep Grid Example – General Preparation for all patients scheduled to see a physician

Activity / Purpose

Workstep / Criteria

Next Step / Huddle ActivityIntake (as needed)

Schedule Check

• Compare schedule to reason for visit and notes to ensure patient on correct schedule

• If a mismatch, discuss in huddle so PSR can change if patient not on correct schedule (Physician or Clinical Support)

Reason for Visit

• Review the Visit Type Area on the Schedule

• Review the PCP’s Last Progress Note if needed

• Plan to prepare Exam Room based upon the Reason for Visit

• Pre-op (note or appointment type)• Access orders during huddle• If order includes EKG, Chest X-ray , labs, note what is

due based on specific orders• During huddle, MD determines which pre-op tasks are

needed• If EKG ordered, make sure there is paper in machine,

gel, patches available• Physical – ask which labs will probably be needed• Follow-up from recent Urgent Care, ED Visit or

Hospitalization – note date of discharge and reason. Check for report In huddle, notify MD of discharge or visit .

• Clear for work, DMV or other visit where a form is needed (notes). Ask PSR to fill out demographics, MA/LVN to fill out as appropriate, attach to Huddle list for MD signature

• Pap (notes) – ensure supplies / equipment available and plan for set-up

• Complete EKG• Pend orders

*Tag visit report

• Attach form to Rooming Sheet for signature


Name: __________________________________MRN: _______________DOB: _______________Gender: Male Female Age: ____________

Chart Preparation-Huddle-Task Form for MAAppointment Date and Time: ____________________

Date of last physical exam: _______________

CHART REVIEW HUDDLE INTAKE TASKS

Schedule checkReason for visit: _____________ Need for schedule change? Syncope history

Any outstanding: (since last visit)Procedures Yes No Labs Yes No Pathology Yes No Imaging Yes NoCardiology Yes NoReferrals Yes NoFuture/standing orders Yes No

What is outstanding? (Procedures, labs, pathology, imaging, cardiology, other orders, referrals, future or standing orders)

What would you like to order?Labs/Imaging: CBC CMP TSH Vit DLipid Panel EKG Xray

Others: _____________________

Referrals:

Diabetes Yes* NoHgb A1C __________, __________ (Date/result)

LDL __________, __________ (Date/result)Microalb/Crea Ratio __________, _________ (Date/result)

Retinal Exam _________ (Date)

Monofilament foot exam __________ (Date)

Due: Hgb A1C (Lab5626 or POC4)Lipid Panel (Lab18)Microalbumin/Creatinine Ratio (289438)Ophthalmology Referral (Ref57)Monofilament Foot Exam (HM7)


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Chart Prep Form (side 2)Health Maintenance Colonoscopy _______________ (Date) Bone Density (Dexa) _______________ (Date) Mammogram _______________ (Date) LDL Direct/Lipid Panel __________, __________ (Date/result) Persistent Medications Potassium _________, _______ (Date/result) BUN _________, _______ (Date/result) Creatinine ______ ___, _______ (Date/result) PSA _______________, ________ (Date/result) PAP _______________ (Date) GC/Chlamydia _______________ (Date)

Needs: Referral(s): Colonoscopy (REF5023) Bone Density —Dexa (IMG1153) Mammogram (IMG1965 or IMG1283) Screening Diagnostic LDL Direct (Lab102) Lipid Panel (Lab18) Persistent Medications Potassium (Lab114) BMP (Lab15) BUN (Lab140) CMP (Lab17) Creatinine (Lab66) PSA PAP GC/Chlamydia

Immunizations Flu _______________ (Date) TDaP _______________ (Date) Pneumovax _______________ (Date) Zoster _______________ (Date) Gardasil _______________ (Date)

Flu TDaP Pneumovax Zoster Gard asil

Revised 03.23.2011 WS


Successful Huddles/Patient Care Team Meetings• Huddle (Patient Care Team Meetings) standing Agenda Items

1. MA: Specific items/ questions from chart prep 2. Receptionist (R): Appointment related discussion items – i.e. changing

appointments, fasting for physicals3. MA, R: Outstanding patient calls/messages4. MA: Any referral question5. R: Any opportunities for double booking/ working in walk-in’s6. Care Manager: Outstanding patient issues / questions

• Ask for clear direction and specific orders, confirm understanding

• Summarize after each patient

• Receptionist may have some follow-up such as changing appointment type or calling patients

• Consider having a team weekly debrief when starting huddles to discuss what works, what doesn’t, and refine process


Documenting Huddles/Pt. Care Team Meetings

•Policy and Procedure•Save prep sheets examples•Document in EHR (pt discussed in huddle - to have lab work prior to appt.)

•Keep copies of huddle schedule•Keep minutes of meetings where operation of huddles is discussed and refined


NCQA reviews the practice’s documented process for structured communication between the clinician and other care team members, which states the frequency of communication; and reviews at least three samples of meeting summaries, checklists, appointment notes or chart notes for evidence that the practice follows its process.


Documenting Huddles/Pt. Care Team Meetings

Huddle Schedule Example

Monday Tuesday Wednesday Thursday Friday 15 minutes prior

to start of AM clinic- Win

9:45 Ho 11:45 Ho 11:45 Ruiz 12:30/12:45 Smith, MD

12:30/12:45 Smith, MD

12:30/12:45 Smith, MD

12:30/12:45 Smith, MD

12:30 Ong, RNP 12:30 Ong 12:30 Ong 12:30 Ong 12:30 Mawashiri. PA(for Wed pts.)

12:30 Mawashiri (for Thurs. pts.)

12:30 Mawashiri (for Mon. pts)

15 min. prior to start of PM clinic Win

15 minutes prior to start of PM clinic- Win

4:30 (for Wed) Ruiz

End of Day (for Thurs) Ruiz

4:30 Ruiz

4:30 Ho 4:45 J ames 4:45 J ames 4:45 J ames 4:45 J ames

Green Management Consulting Group, Inc


Q & A

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Thank you!


Susan Chen: [email protected] Green: [email protected]

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PCMH: Focus on The Care Team & Huddles

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