Primary Care Model - A Quick Primer

Transcription

1 Reform and Transform: Ensuring the Right Skill Mix for Primary Care Margaret Flinter Vice President & Clinical Director CHC Inc. February 8, /8/2010 1

2 Federally Qualified Health Centers Serves as health care home for 17 million people in over 6,000 communities Largest primary healthcare system in the nation When 47 million people become newly insured who will care for them? 2/8/2010 2

3 CHC Inc. and the State of CT Connecticut pop: 3,000,000 Publicly Insured: 450,000 Uninsured: est ,000 State employees: 60,000 FQHC Patients: 242,034 CHC Inc. Patients 53,000 A state of contrasts: CT is the wealthiest state in the country but with urban areas equivalent to 3 rd world poverty & Health status 2/8/2010 3

4 Transformational Care 1. Clinical Excellence 2. Research & Development 3. Training the Next Generation 2/8/2010 4

5 Profile Of Patients 2/8/2010 5

6 Definition of Primary Care The provisional definition of primary care adopted by the IOM Committee on the Future of Primary Care follows: Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. or as defined by Barbara Starfield (1992) care that is characterized by first contact, accessibility, longitudinality and comprehensiveness. 2/8/2010 6

7 What Does Primary Care Look Like In FQHC? 2/8/2010 7

8 CHC Model of Care Eliminate waits, waste and delays: advanced access scheduling Improve clinical outcomes: team based, planned care and chronic care model: Make the automatic, automatic checklists, protocols, standing orders Incorporate prevention and health promotion into every visit, every time EMR, Patient Portal and Health Information Exchange 2/8/2010 8

9 Creating the Primary Care Team Primary Care Provider (MD or APRN) 1: 1500 Primary Care RN (1 RN:2 PCPs) Medical Assistants (1:1 PCP) Clinical Receptionists (1:1 PCP) Behavioralist (1:3 PCPs) * 2/8/2010 9

10 Supporting Primary Care Teams In House Psychiatry Podiatry Nutrition HIV/AIDS Specialist OB/Gyn Dentists, Hygienists Pharmacist Specialty RNs (CDE, HIV, Care Coordinator) 2/8/

11 External Support for Primary Care Hospitalists Specialists Lab and Pharmacy econsults access to specialists 2/8/

12 Building Healthy Communities CHC s AmeriCorps Team Launches Stamford Outreach Vinnie s Jump & Jive Mobile Dental Family Resource Center 2/8/

13 What the eye sees New Britain Site NB New Building Frontal Facade Meriden Site NB Reception Area Clinton Site Waiting Area 2/8/

14 Skill Sets in Primary Care Panel Management of complex patients Expert use of information technology (EMR, HIE, econsults, virtual encounters) Ability to apply all elements of planned care/chronic care model Self management goal setting/management Patient coaching and engagement Care Coordination and Transition management 2/8/

15 Primary Care Provider Owns the panel, continuous relationship Coordinator of complex care Delegates and support care within a team Medical decision maker And expert in managing the complex problems of substance abuse, mental illness, pain management Supports new primary care providers 2/8/

16 Provider Panel PCP Panel Weighted panel all visits Visits w PCP Continuity Rate Avg Visits per patient (all visits) 12 months Blankson APRN, Mary FP , % 3.65 Borgonos MD, Ovanes FP , % 3.83 Channamsetty MD, Veena FP , % 3.62 Decker APRN, Patricia FP , % 4.11 Doerwaldt MD, Hartmut FP , % 3.35 Dudley MD, Robert PD , % 3.11 Eddinger APRN, Ann FP , % 3.62 Farb MD, Alan PD , % 2.82 Gollnick APRN, Rachel FP , % 3.51 Huddleston MD, Matthew FP , % 3.95 Kirby MD, Jacqueline PD , % 3.83 Kucharchik MD, Thomas FP , % 3.16 Lecce MD, Carl FP , % 3.20 Long APRN, Sarah FP , % 3.39 Monroe, Jr. MD, John FP , % 3.79 Olayiwola MD, Nwando FP % 3.17 Pathman MD, Anandhi IM PD , % 2.87 Thomas APRN, Bernadette FP , % 4.17 Vitale MD, Marie FP , % 4.18 Wilensky MD, Dan FP , % /8/

17 Training for Primary Care Clinical Receptionist Receptionist Competency Checklist Competency Operational definition Measurement method Verbalizes/ Demonstrates Correct Behavior- Date Make announcement on overhead page system Uses correct code/"[name], please call ext. xxxx" Simulated skill demo Answer telephone promptly Within 30 sec. Service level in ACD by individual Verbally interact with patients per CHC scripts Follows dental, medical and behavioral health script. Phone monitoring and direct observation Use the language line Follows written instructions. Correct language identified and translator on line. Transfer telephone calls Successful transfer. Skill demo Record telephone encounters with pertinent information in ECW and on paper as appropriate. Hub update pharmacy. Route messages to triage nurse or providers Uses written English adequate to clearly communicate content of message; brevity; lack of ambiguity; timely transmission, list pharmacy; record name of person calling and tel. number where they can be reached. Spell checks. Appropriate content. Check with Shanti. Review of five appts on five different days. Timeliness of routing. Follows appt allocation guidelines. Follows guidelines for paging Review of messages. nurse. Update patient pharmacy information in ECW Complete and accurate info. Feedback from pts Initials of Reviewee Initials of Reviewer Use appointment allocation guidelines correctly Appointment Allocation Guidelines. Feedback from nurses, providers and supervisor Apply advanced access guidelines to schedule appointments Appropriate mix of appts. Smart scheduling process. Balanced schedule for providers. Visual check based on color codes of one day's schedule. Acceptable/Unacceptable rating. Schedule, cancel and reschedule appointments Apts are correctly entered and documented in Centricity: appropriate appt type Review of five appts on five selected, note in appt as to appt reason, apt scheduled with appropriate provider, recall different days. is attached, pt demographic info verified, authorization for Beh. Health attached. Process check-in and no show patient appointments Correct in notation in system. Ensure correct demographic, pharmacy and insurance Info.Record no shows in encounter for provider if appropriate. Direct observation of a patient check-in. Respond appropriately to walk-in appointments Register patient in Centricity, fully populating required fields Says, "We discourage walk-in appts. Our preference is to schedule an appt for the provider you want to see. " or "If you would like to establish care here, we will set you up with an ATC appt who can register you for care here." Name, address, DOB, sex, SS #, insurance, tel #, guarantor info if under 18 yo, release of info, HIPAA form, current sliding fee scale. Obtains address or populates field with none or refused." Anecdotal review and skill practice Pull five pt records Respond appropriately to angry or agitated patients Obtain medical release as needed Obtain and scan required documents into ECW Fax info from ECW (medical receptionist/medical records clerk only) Update patient information in Centricity 2/8/2010 Treats angry or agitated patients with respect, and refers patient to senior receptionist Observation/Patient feedback or supervisor if needed. Correctly completes medical release in terms of date, person providing info, what info is All reqd info is included and needed, to whom request is going, reason for request, statement that pt is transferring correct out, patient signature, length of time for release, witness. Proof of income, insurance cards, profile and HIPAA. Scanned to correct pt record and Direct pt record audit -- frequency assigned to appropriate person. based on perf. Record of employee Uses FAX prompt in ECW. FAX completion records in ECW Name, address, DOB, sex, SS #, insurance, tel #, guarantor info if under 18 yo, release of info, HIPAA form, current sliding fee scale. Obtains address or populates field with none or refused." Feedback from pts, Pt Accounts and nurses Confirm appointments with patients Pts called day before appt. and message left if person not reached. Pull five pt records 17

18 FQHC Based Residency Training for Nurse Practitioners Provide new nurse practitioners with a depth, breadth, volume, and intensity of clinical training necessary to serve as primary care providers in the complex setting of the country s FQHCs. Train new nurse practitioners to a model of primary care consistent with the IOM principles of health care and the needs of vulnerable populations Create a nationally replicable model of FQHC based Residency training for primary care nurse practitioners Prepare new NPs for practice in any FQHC setting rural, urban, large or small 2/8/

19 Measure and Improve Customer/Patient Service Utilization vs. Capacity Clinical Outcomes Process Outcome 2/8/

20 Measure and Improve Week of Jan 11th ACD queue name ACD contacts offered ACD contacts handled Appts Scheduled Provider only Slots Availabl e 104% Filled Slot NB MEDICAL NL MEDICAL ENGLISH MR MEDICAL MT MEDICAL ENGLISH CL MEDICAL GROTON MEDICAL ENFIELD DANBURY Agency Capacity Additional Provider time needed using slots available Service level % Answe r % All PCP Appts for Week No Shows PCP % of No Shows % % % % % % % % Stamford Medical (0.05) % Total % 2/8/

21 Measure and Improve Quality Care Indicators/Health Outcomes and Disparities CHC Baseline UDS DATA CY /8/

22 Measure and Improve Immunizations (Over 65) Current Pull Sept 2009 Last Pull (June 2009) Influenza OrgName Denom Num % of patients % of patients % of patients CHC of Clinton % 48% 49% CHC of Danbury % 15% 25% CHC of Enfield % 28% 36% CHC of Groton % 35% 32% CHC of Meriden % 57% 58% CHC of Middletown % 47% 54% CHC of New Britain % 40% 52% CHC of New London % 39% 35% Agency % 43% 45% All patients with medical visit in last 18 months over the age of 65 with Flu vaccine during most recent flu season (september February) Pneumonia Current Pull Sept 2009 Last Pull (June 2009) OrgName Denom Num % of patients % of patients % of patients CHC of Clinton % 71% 64% CHC of Danbury % 21% 17% CHC of Enfield % 44% 46% CHC of Groton % 24% 21% CHC of Meriden % 83% 77% CHC of Middletown % 80% 72% CHC of New Britain % 79% 75% CHC of New London % 60% 50% Agency % 65% 59% All patients with medical visit in last 18 months over the age of 65 with pneumonia vaccine in lifetime 2/8/

23 Data Unites Us Anecdotes Divide Us Colorectal Cancer Screening Current Pull Sept 2009 Pull (June 2009) OrgName Denom Num % of patients % of patients % of patients CHC of Clinton % 63% 60% CHC of Danbury % 35% 25% CHC of Enfield % 27% 33% CHC of Groton % 32% 25% CHC of Meriden % 62% 64% CHC of Middletown % 60% 56% CHC of New Britain % 62% 57% CHC of New London % 60% 59% Agency % 56% 54% CHC patients with Medical visit in last 18 months age colonoscopy <=10 years or FOBT <=1 year Mammogram Screening Current Pull Sept 2009 Last Pull (June 2009) OrgName Denom Num % of patients % of patients % of patients CHC of Clinton % 75% 70% CHC of Danbury % 44% 33% CHC of Enfield % 46% 50% CHC of Groton % 59% 56% CHC of Meriden % 82% 83% CHC of Middletown % 87% 83% CHC of New Britain % 83% 82% CHC of New London % 76% 75% Agency % 76% 75% Women age with Medical visit in last 18 months with Mammogram in last 2years 2/8/

24 Improving Chronic Disease Care Health Outcomes and Disparities CHC Baseline UDS DATA CY /8/

25 Improving Chronic Disease Care Health Outcomes and Disparities CHC Baseline UDS DATA CY /8/

26 It is not easy The Community Health Center, Inc. (CHC) implemented a system wide (12 sites, 70,000 patients) tobacco cessation intervention based on the U.S. Department of Health and Human Services Treating Tobacco Use and Dependence: 2008 Update Clinical Practice Guideline # of women Screened for smoking and advised to quit 8,190 Received intensive counseling as part of provider visit 1,920 Received intensive counseling and qualified for program 1,238 Enrolled in Program 520 Completed Program 155 Available for follow up 72 Study Results 31% of the women in the study had quit smoking. The study also found that while there was no significant difference between the amount of cigarettes smoked by pregnant women and non pregnant women at program initiation, at program completion, there were statistically significant differences between smoking rates of pregnant and nonpregnant women, with pregnant women showing a decrease in numbers of cigarettes smoked. The final finding of the study was that there were no disparities in smoking cessation rates across racial and socio economic groups. 2/8/

27 Infrastructure Human Resources Facilities Practice Management Information Technology Leadership Clinical leadership Executive leadership 2/8/

28 Health Reform in CT Based on the work and recommendations of many groups, Connecticut created Sustinet 1.Will rationalize payment for publicly insured and privately insured 2.Will bake in requirements for patient centered medical home 3.Will make medical home services available to small practices on a utility or community based model 4.Provides support and coaching to practices for implementing IT and medical home 5.Creates common outcome reporting and benchmarks 6.Integrates public health priorities (tobacco/obesity) into private insurance plans 7.Combines all publicly funded healthcare, including state employees into one plan 2/8/

29 2/8/

30 Comments or Questions? Please Contact: Margaret Flinter, APRN, MSN, FAANP Vice President and Clinical Director & Director, Weitzman Center for Innovation Community Health Center, Inc ext /8/