Session 8: ACP Featured Speaker: Beyond the Medical Home: Building the Medical Neighborhood Learning Objectives

Transcription

1 Session 8: ACP Featured Speaker: Beyond the Medical Home: Building the Medical Neighborhood Learning Objectives Put the medical

2 Session 8 ACP Featured Speaker: Beyond the Medical Home: Building the Medical Neighborhood Faculty Sue S. Bornstein, MD, FACP Executive Director, Texas Medical Home Initiative Governor-Elect, American College of Physicians, Texas Northern Dallas, Texas Sue Bornstein, MD, FACP, is currently serving as executive director of the Texas Medical Home Initiative (TMHI), a multi-stakeholder, physician-led organization dedicated to implementing the patient-centered medical home concept in Texas. Dr Bornstein has served in this capacity since June Prior to being selected to lead the TMHI, Sue worked as a senior physician consultant for the Bard Group, a consulting firm in Boston that specializes in physician-hospital relations. Sue served as lead consultant for several medical staff reorganization and hospital-medical staff integration engagements during her tenure as a consultant. Sue practiced internal medicine at Baylor University Medical Center in Dallas from , first in private practice and then as a palliative care and clinical ethics consultant. While at Baylor, she was elected president of the medical staff in 2005 and served as chairman of the Medical Executive Committee in Throughout her time at Baylor, Dr Bornstein was active in the resident teaching program, including serving as medicine clinic attending and medicine ward attending. Dr Bornstein is governor -elect of the Texas Northern Chapter of the American College of Physicians. She serves as the Texas American College of Physicians representative to the Texas Medical Association (TMA) Interspecialty Society and as a Dallas County Medical Society delegate to the TMA. She has served on the Dallas County Medical Society Executive Committee as secretary/treasurer and was previously chair of the Board of Censors. Sue is a graduate of the University of Texas at Austin and earned her medical degree at Texas Tech Health Sciences Center where she was the recipient of the Gold Headed Cane award. She completed her internal medicine residency at Baylor University Medical Center in Dallas. In her spare time, Sue is an avid fly-fisherman and participates in Master s swimming programs. Faculty Financial Disclosure Statement The presenting faculty reports the following: Dr Bornstein has no financial relationships to disclose.

3 Faculty Disclosures Session 8: 10:15 AM - 11:15 AM Dr Bornstein has no financial relationships to disclose. ACP Featured Speaker: Beyond the Medical Home: Building the Medical Neighborhood Sue S. Bornstein, MD, FACP Learning Objectives The Primary Care Practice of the Future: Are You Ready? Sue S. Bornstein, MD, FACP Pri-Med Access with ACP Houston November 17, 2012 After attending this lecture, you should be able to: Make the case for the medical home. Put the medical home in the larger context of health reform. Outline Why we need a new model of primary care Are you ready for a new model? 8 questions to test your readiness Practical tools for practice transformation Resources Discussion/questions Why we need a new model of primary care Significant growth of population Increased longevity of population Increased prevalence of chronic disease Chronic shortage of primary care physicians Unsustainable growth in health care costs Current model based on acute care needs Payment based on discrete episodes of care 1

4 Epidemiologic Transition Omran A. The Epidemiologic Transition: A theory of the epidemiology of a population change. Milbank Q. 1971:49: Top 10 Causes of Death: 1900 vs Non-Communicable Disease Mortality Rates Infectious Disease Epidemiologic Transition Top 10 Causes of Death: 1900 vs Jones DS et al. N Engl J Med 2012;366: Data are from the Centers for Disease Control and Prevention. The Value of Primary Care Strong primary care systems are associated with decreased mortality rates overall and lower levels of premature deaths from a variety of important preventable and/or treatable conditions. These conditions include asthma, diabetes, heart and cerebrovascular diseases, and pneumonia. Question: Is your practice ready to incorporate a share of the 31 million newly insured people who will be seeking medical care beginning in 2014? 2

5 Is your practice ready for the future? 1. Patients in my practice have excellent access through same-day appointments, e-visits, and phone visits. 2. Appointment slots are tailored to different patient needs: acute, preventive, and chronic care visits. 3. I can compile lists of my patients with diabetes and other chronic conditions to see their individual and overall levels of control. 4. People in this practice operate as a team. Is your practice ready for the future? 5. The team meets regularly to plan the day s work and make adjustments in the schedule as needed. 6. My office has processes in place to ensure that tracking is done on tests, referrals, and follow-up testing. 7. My practice embraces the importance of continuous quality improvement. 8. My practice s patients receive self-management support to help them achieve health goals. Enhanced access through QuickSick visits Consider the QuickSick visit 5-minute visit Rules: no new patients; URI complaints only; ages 3 months to 65 years 3-4 visits folded into the schedule over the noon hour and at the end of the day Create an EMR template that the nurse fills out with HPI and vitals You follow behind with physical exam and assessment and plan Enhanced access through QuickSick visits Goal is to get patient in and out of the office in 30 minutes (possibly over their lunch break) Can help keep your patients out of the ED Keeps them in their medical home where their medical record exists Personal communication Amy Mullins, MD, November 5, 2012 Enhanced access through e-visits At Trinity Clinic Whitehouse, they began in 2006 offering 12 different types of visits online After a year, they realized that three types of visits made up 95% of the e-visit traffic They are upper respiratory infection, hypertension, and depression So they consolidated their resources and focused on these visits Enhanced access through e-visits Rules for e-visits: Must be established patient Only for three types of visits set up online Ages 2 65 If physician finds history too complicated or full of red flags, patient asked to come in with no charge for e-visit Personal communication Amy Mullins, MD, November 5,

6 Enhanced access through e-visits Charge is $25 Insurance typically doesn t pay Can charge to credit card Cost is similar to many co-pays Now getting paid for services they d been offering for free! Open access scheduling Get the Process Started Work with your project team to agree on a set date to stop prescheduling visits. Have scheduling staff start offering same-day appointments to all patients who call to schedule a visit. During the transition period, you will see same-day scheduled patients as well as patients who had already been pre-scheduled. It might take 2 to 3 months to work down your backlog. Standardize Appointments Consider standardizing appointment lengths. Standard appointment lengths make scheduling simpler for staff and allows greater flexibility for patients, who can then pick any appointment slots. Open access scheduling Educate Patients Educate patients about your practice s new system. Let them know that they can call and make an appointment for the same day when they are ready to see the doctor. Most will probably welcome this change. If a patient calls and is not ready to make an appointment for that same day, go ahead and pre-schedule the appointment. Telling patients to call back on the day they want an appointment will only increase your phone traffic. Instead, inform the patient about the practice s new system. Open access scheduling Prepare for Capacity Challenges Open access won t work if the supply and demand of appointments are mismatched. Prepare by measuring demand, supply, panel size variation, and current delays before putting the system into practice. Develop a contingency plan to address occasional mismatches, such as those caused by illness, vacations, or seasonal influences. Patient registries Registries supplement rather than replace medical records They are different from an EMR in that they manage only selected patient information related to specific conditions rather than providing a set of comprehensive information Registries enable providers to manage both practice patients (i.e., population) and individual patients Level 1 Functionality Point of care: Integration of clinical guideline-based prompts Inform care team on gaps in patient care Alerts and reminders Tools for establishing care team roles and responsibilities 4

7 Level 2 Functionality Care management with outreach to patient Tracking patients between visits Level 3 Functionality Population management for performance improvement Aggregated information on care management of practice patients Feedback to physicians and practice about conditionspecific status of practice patients Aggregated data is basis for performance monitoring for quality and patient safety HealthTeamWorks, Why we need high-functioning health care teams Creating effective teams It is no longer feasible for primary care physicians to take sole responsibility for the acute care, chronic disease management, and preventive services for all their patients. It would take almost 18 hours a day to provide all evidencebased chronic and preventive care to the average U.S. panel of 2,300 patients. Without a population-wide panel size reduction, physicians can no longer enjoy trusting relationships with all their patients. Just as tasks must be shared among the primary care team, the joy of personal interaction must also be shared. To promote a patient-centered focus, it is necessary to change the roles and the work of individuals in practices and the organizations in which they operate Factors identified with better performance include good leadership, a clear division of labor, training of team members in their personal roles and in team functioning. Teams require investment in training, the creation of protocols that define tasks, adoption of team rules including decision making and communication, and protected non-patient care time for team meetings. Huddles: Increased efficiency in minutes a day! Huddles why they work Super Bowl Sunday and the score is tied, two minutes left in the game. The offensive players walk on the field. What is the first thing they do? THEY HUDDLE! Monday morning at the Health Family Medicine Clinic, and the phones are ringing frantically. Staff knows the day will be busy, so what s the first thing they do? THEY START SEEING PATIENTS! Huddles work because they demand rapid team formation and preparation at the practice level. They allow practices to plan for any changes in the daily work flow, manage crises before they arise, and make adjustments in ways that improve access to patients and quality of life for staff Huddles work because they elicit a pattern of practice-level thinking that is often not intuitive to each individual staff member but ultimately beneficial to the entire practice: staff begins to think like a team. 5

8 Keys to effective huddles Suggested huddle agendas Limit huddles to 7 minutes or less Hold the huddle in a central location STAND rather than sit! Choose a consistent time on a daily basis Experiment with different times of day and attendance Whether the physician physically attends or not, his or her buy-in and support of daily huddles is critical to their success In the beginning, huddles will need designated leaders and a structured agenda At first, they will require daily discipline and a champion TransforMED, Check for patients on the schedule that may require more time/assistance due to age, disability, etc. Who can help? Check for back-to-back lengthy appointments, such as physicals. How can they be worked around to prevent backlog? Are there openings that can be filled? Chronic no-shows? Check provider and staff schedule. Does anyone need to leave early or break for a phone call or meeting? TransforMED, Tracking and follow up of test results Model for Improvement The model for improvement is a time-tested method for quality improvement that is simple, highly effective, and supports a bottom-up approach to change. The Model for Improvement reduces risk by starting small. At its most basic, it has 2 parts: Three fundamental questions and the PDSA cycle 1. What are we trying to accomplish? 2. How will we know that a change is improvement? 3. What changes can we make that will result in improvement? Northern Physicians Association, Traverse City, Michigan,

9 Aim statement The aim statement should: State the aim clearly; Use numerical goals; State the timeframe and site of work Improvement through PDSA cycles PDSA cycle is shorthand for testing a change by developing a plan to test the change (Plan), carrying out the test (Do), observing and learning from the consequences (Study), and determining what modifications should be made to the test (Act). Institute for Healthcare Improvement Patient education and self-management support Traditional patient education emphasizes knowledge acquisition and didactic counseling While such interventions increase knowledge, they are frequently unsuccessful in changing behavior or improving disease control and other outcomes We must shift our thinking from a framework of patient education to include patient selfmanagement Patient Education Begins with the provider s determination of need Information and technical skills are taught Usually disease-specific Assumes that knowledge leads to behavior change (FALSE!) Goal is compliance Teachers are always professionals Self-Management Support Begins with the patient s self-identified problems Problem-solving skills are taught Skills are generalizable Assumes self-efficacy leads to change (TRUE!) Goal is more self-efficacy Teachers can be professionals or peers 7

10 Resources PatientCenteredMedicalHomePCMH.asp delivery_and_payment_models/pcmh/ Slide courtesy of the Institute for Healthcare Improvement (IHI) Questions? 8