Beyond the Blueprint Building the Patient Centered Medical Home

1
Beyond the Blueprint Building the Patient
Centered Medical Home

• Wisconsin Primary Care Research Quality
  Improvement Forum
• Wisconsin Dells, WI
• 11.13.09
• Christine Sinsky, MD
• Thomas Sinsky, MD
• csinsky1_at_mahealthcare.com
• Medical Associates Clinic and Health Plans
• Dubuque, Iowa

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Agenda

• Background
• The Challenges of Primary Care
• 8 strategies to transform practice
• Discussion

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Take Home Messages

• Its all about
• Planning ahead
• Sharing the load
• Enjoying the work!

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Background

• Primary Care
• NCQA Advisory Panel PCMH
• Consultant and Workshops
• All trying to solve same equation
• Different settings
• QE S quality, efficiency and satisfaction

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We will know who you are and we will be ready for
you.
Borgess Ambulatory Care, Kalamazoo, MI
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At the center of primary care are face-to-face
healing relationships.
Patient Nurse
Nurse Physician
Nurse Nurse
Patient Physician
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115 physicians, owners Health Plan 1/3 of pt
population EHR 2003
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Satisfaction
Staff Turnover lt 5 Physician Satisfaction gt
95ile AMGA PCP Productivity and Compensation
85ile MGMA
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Quality
Patient Centered Medical Home
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Snapshot of Practice

• Staffing
• Primary nurse
• Help nurse
• 1.5 nurse MD
• (no MAs)
• Space
• 3 exam rooms
• Scheduling
• 1 Receptionist 2 MDs
• Wave Scheduling

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Snapshot of Practice

• Typical Schedule
• 6-8 Annual
• 10-12 Planned Care
• 4-6 Rapid Access
• Panel Size
• 1800-2000
• Outpatient/Inpatient

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Mrs. Peters

• 65 year old annual exam
• DM2
• HTN
• Depression
• Prevention
• New c/o
• Heartburn
• Sleep disturbance
• Fatigue

of Quality measures?
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There is a lot to be done!

• 65 year old annual exam
• DM2 (9)
• HTN (17)
• Depression (10)
• Prevention (27)
• New c/o
• Heartburn (3)
• Sleep disturbance
• Fatigue

of Quality measures? 56
McGlynn EA, N Engl J Med 2003. 348262535-2645
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There is a lot to be done!

• Too much to be done by just one person
• Too important to be left to chance

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Core Team ModelPlan Ahead, Share the Load

• Right thing happens by default
• Staff work full level of ability
• Minimize work MD does that is within skill set of
  others

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• In few other sectors of the economy is the
  highest-level professional responsible for the
  majority of production, customer service, and
  clerical work.

SGIM Blue Ribbon Panel Report. Redesigning the
Practice Model for General Internal Medicine A
Proposal for Coordinated Care. J Gen Intern Med
200722400-109
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Saving (our) Office Practice A Personal Story

• Meet expectations and still have energy to
  connect?
• Guideline following automaton
• Documentation drone
• Doing tasks that neither the patient nor I valued
• To survive enjoy practice, and have time for
  other things, we would need to redesign work flow

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Episodic Care
Room pt nurse
MD
Check-in receptionist
Check-out

• Medication reconciliation
• History
• Exam
• Data Gathering
• Data entry
• Decision making
• Relationship building
• Prescription writing
• Documentation
• Paperwork
• Behavior Modification
• Results reporting
• Order entry

• Vital signs

• Insurance verification
• Collect co-pay
• Verify contact info

?
¼ MA MD
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Work Within Skill-set of Others
Room pt nurse
MD
Check-in receptionist
Check-out

• Medication reconciliation
• History/History
• Exam
• Data Gathering
• Data entry
• Decision making
• Relationship building
• Prescription writing
• Documentation
• Paperwork
• Behavior Modification
• Results reporting
• Order entry

• Vital signs

• Insurance verification
• Collect co-pay
• Verify contact info

?
¼ MA MD
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Integrated, Continuous Care
Office Visit
Nurse-MD Team
Between Visit Care
Efficiencies and care coordination
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Core Team Model Planning Ahead Sharing the
Load

• Planned Care Appt
• Order sets
• Empowered Team
• Pt. Questionnaire
• Prescription Mgmt
• Visit Summary
• Annual Exam
• Rapid Access
• Intentional Behaviors

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Planned Care Appointment

• Pre-appt lab
• Majority lab prior to appt
• Patient part of decision making
• 67 yo diabetic
• A1c 6.2
• LDL 160
• Bill P.

• Planned Care Appt
• Order sets
• Empowered Team
• Pt. Questionnaire
• Prescription Mgmt
• Visit Summary
• Annual Exam
• Rapid Access
• Intentional Behaviors

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Planned Care Appointment

• Efficiency
• Just in time info processing
• Close the loop during that appt
• Results reporting
• 4 hr clinic ? 2 hr post-appt
• Safety
• Missing or overlooked inform
• Pt family part of safety net

• Planned Care Appt
• Order sets
• Empowered Team
• Pt. Questionnaire
• Prescription Mgmt
• Visit Summary
• Annual Exam
• Rapid Access
• Intentional Behaviors

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Lab Summary
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Post-Appointment Order Sets

• Planned Care Appt
• Order sets
• Empowered Team
• Pt. Questionnaire
• Prescription Mgmt
• Visit Summary
• Annual Exam
• Rapid Access
• Intentional Behaviors

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Acute Symptom Evaluation
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Planned Care Appt
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Annual Comprehensive Care Visit
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Upcoming appts/lab
Last PE
Place Todays Care in Continuum of Time
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Post-Appointment Order Sets

• 73 yo est. pt Rapid w/ fever, cough

• Planned Care Appt
• Order sets
• Empowered Team
• Pt. Questionnaire
• Prescription Mgmt
• Visit Summary
• Annual Exam
• Rapid Access
• Intentional Behaviors

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Post-Appointment Order Sets

• 64 yo DM 2, hypothyroidism, atrial fibrillation,
  CRI

• Planned Care Appt
• Order sets
• Empowered Team
• Pt. Questionnaire
• Prescription Mgmt
• Visit Summary
• Annual Exam
• Rapid Access
• Intentional Behaviors

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Post-Appointment Order Sets

• The next appointment starts today
• A plan, a promise to continue the relationship
• We want to see you again, and we will plan ahead
  to make that most meaningful.

• Planned Care Appt
• Order sets
• Empowered Team
• Pt. Questionnaire
• Prescription Mgmt
• Visit Summary
• Annual Exam
• Rapid Access
• Intentional Behaviors

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Appointment doesnt start when the patient checks
in
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Empowered Teamwork

• Nursing staff full partners

• Planned Care Appt
• Order sets
• Empowered Team
• Pt. Questionnaire
• Prescription Mgmt
• Visit Summary
• Annual Exam
• Rapid Access
• Intentional Behaviors

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• Nexus of organization of our practice
• Filter
• Between Visit
• Extension of me when dealing with patients
  patients recognize this.
• Coordinates transitions (hospital, NH, Hospice)
• Manages returns most phone calls
• Does prescriptions

• Updates EHR
• Completes all paperwork
• Visit
• Med. Reconcil.
• Initial review of lab
• Pt education
• Immunizations
• Colonoscopy
• Sx driven tests (PFT, EKG)
• Diabetic foot exam/eye exam
• Present patient
• (? info drop-off)

The Boss
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Mini-huddle

• Staff deeply engaged
• Mentor nurses
• Physician better prepared
• Stronger handoff

• Planned Care Appt
• Order sets
• Empowered Team
• Pt. Questionnaire
• Prescription Mgmt
• Visit Summary
• Annual Exam
• Rapid Access
• Intentional Behaviors

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Mini-huddle

• 47 yo Rapid Access new patient
• CC dysphagia
• Nurse Mini-huddle
• She seems depressed
• Is anyone hurting you?
• Physician better prepared

• Planned Care Appt
• Order sets
• Empowered Team
• Pt. Questionnaire
• Prescription Mgmt
• Visit Summary
• Annual Exam
• Rapid Access
• Intentional Behaviors

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Hand-back

• Planned Care Appt
• Order sets
• Empowered Team
• Pt. Questionnaire
• Prescription Mgmt
• Visit Summary
• Annual Exam
• Rapid Access
• Intentional Behaviors

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Introduction to Partnership

• Planned Care Appt
• Order sets
• Empowered Team
• Pt. Questionnaire
• Prescription Mgmt
• Visit Summary
• Annual Exam
• Rapid Access
• Intentional Behaviors

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Pre-appointment Questionnaire

• Identifies the patients agenda
• MD plan visit before entering
• Systems approach
• Update PFSH
• Complete ROS
• Behavior issues exercise, smoking, alcohol
  webmeeting.nih.gov/intro
• Future
• Kiosk in waiting area
• Web portal from home

• Planned Care Appt
• Order sets
• Empowered Team
• Pt. Questionnaire
• Prescription Mgmt
• Visit Summary
• Annual Exam
• Rapid Access
• Intentional Behaviors

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Prescriptions are killing usmy nurse is
spending so much time on refills that we cant
seem to get anything done. Minnesota Family
Physician 2007
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Prescription Management

• Survey majority calls for scripts
• Systems all scripts 1 yr at annual
• Efficiency ? phone calls by 50
• Synchronized, Bundled Renewals

• Planned Care Appt
• Order sets
• Empowered Team
• Pt. Questionnaire
• Prescription Mgmt
• Visit Summary
• Annual Exam
• Rapid Access
• Intentional Behaviors

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Prescription Management

• We dont use scripts as hook
• Planned care appts (not expired script) trigger
  disease monitoring
• Avoid loading interval visits with unnecessary,
  redundant work
• Before six calls or faxes/year
• After zero
• Maggie

• Planned Care Appt
• Order sets
• Empowered Team
• Pt. Questionnaire
• Prescription Mgmt
• Visit Summary
• Annual Exam
• Rapid Access
• Intentional Behaviors

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Annual Comprehensive Care Visit

• Cornerstone of care
• Dedicated appt
• prevention/ annual review of chronic dz
• Customized
• not one-size-fits-all

• Planned Care Appt
• Order sets
• Empowered Team
• Pt. Questionnaire
• Prescription Mgmt
• Visit Summary
• Annual Exam
• Rapid Access
• Intentional Behaviors

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Annual Comprehensive Care Visit

• Prevention built-in
• Not dependent on random acute visits
• Not overload interval visits

• Planned Care Appt
• Order sets
• Empowered Team
• Pt. Questionnaire
• Prescription Mgmt
• Visit Summary
• Annual Exam
• Rapid Access
• Intentional Behaviors

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I spend several minutes with each appointment
rifling through the chart looking for the last
mammogram and colonoscopy. And then I spend less
time on the patients main concern. Family
physician, WI 5.06
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Annual Comprehensive Care Visit

• CC DM 2, HTN, ?chol, new depr.
• Prevention
• Mammo ahead
• Ca, BMI, immunization (nurse)
• Chronic Care
• Diabetes, HTN lab done ahead
• Foot and eye exam (nurse)
• Acute
• Energy to address depression

• Planned Care Appt
• Order sets
• Empowered Team
• Pt. Questionnaire
• Prescription Mgmt
• Visit Summary
• Annual Exam
• Rapid Access
• Intentional Behaviors

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Rapid Access

• Scheduling for same day access
• Today not Triage
• Triage takes time
• 30 sec yes, 5 min no later
• One staff touch vs 5
• Pts dont have to plead case

• Planned Care Appt
• Order sets
• Empowered Team
• Pt. Questionnaire
• Prescription Mgmt
• Visit Summary
• Annual Exam
• Rapid Access
• Intentional Behaviors

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Rapid Access Electronic Scheduling Tool
Internal medicine nurse on call
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Integrated, Continuous Care
Lab Mammo
Mammo
Sept
Planned Care
S C R I P T S
HTN ? Chol ? Glucose Osteoporosis Depression
L A B
O R D E R S
LDL 75, A1c 6.2
Efficiencies and care coordination
Same Day Surgery Appt
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Integrated, Continuous care
Architecture Of Care
INR
CHF Education/ Clinic
Home Care
L A B
O R D E R S
Diabetic Education
Family
A1c 6.8 LDL 145
INR
CXR
INR
Jun
FBS, A1c Lipids
INR
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Intentional Behaviors

• Eye contact/physical touch
• Key phrases
• What else do I need to know?
• Did we cover everything you wanted?
• How are you handling this?

• Planned Care Appt
• Order sets
• Empowered Nursing
• Pt. Questionnaire
• Prescription Mgmt
• Visit Summary
• Annual Exam
• Rapid Access
• Intentional Behaviors

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Intentional Behaviors

• More Key phrases
• What do you do for fun?
• Could you bring me a picture of .at your next
  appointment
• Social notes at end of dictation

• Planned Care Appt
• Order sets
• Empowered Nursing
• Pt. Questionnaire
• Prescription Mgmt
• Visit Summary
• Annual Exam
• Rapid Access
• Intentional Behaviors

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Sister Mary Owen, what have you been up to
lately?
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Sister Mary Owen, what have you been up to
lately?
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Sr. Mary Owen, what have you been up to lately?
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At the center of primary care are face-to-face
healing relationships.
Patient Nurse
Nurse Physician
Nurse Nurse
Patient Physician
68
We will know who you are and we will be ready for
you.
Borgess Ambulatory Care, Kalamazoo, MI
69
Discussion