By Debra Davidson, PhD, MSA, MS Luciane Tarter, RN, BSN. SBIRT grant for Behavioral Health APCP. Mo Health Net Health Home Program SBIRT

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1 By Debra Davidson, PhD, MSA, MS Luciane Tarter, RN, BSN 1 2 Team Based Care for Chronic Illness Our journey: 24 months APCP: Advanced Primary Care Practice Grant for Medicare : NCQA Level 3 by 2014 MoHealth Net Health Home Initiative: per member per month to develop team based care Learning Collaborative SBIRT grant for Behavioral Health Meaningful Use Grant SBIRT APCP Learning Collaborative Mo Health Net Health Home Program Meaningful Use Grant 3 1

2 Brief Historical Perspective Institute of Medicine (IOM) Report 1999: To Err is Human: Building a Safer Health Care System At least 44,000 people to as many as 98,000 die in hospitals as result of medical errors, that could have been prevented Variety of factors contributing to the errors, including decentralized and fragmented Health Care Delivery IOM conclusion: it is NOT acceptable for patients to be harmed by health care system that is supposed to offer healing and comfort, a system that promises to first do no harm! 4 Crossing the Quality Chasm 2001 IOM U.S. Health care delivery system does not provide consistent, high quality care to all people Many factors contribute: Rapid change in technology Growing complexity of healthcare (more to know, more to do, more to manage, more to watch) 5 Crossing the Quality Chasm Public Health care needs have changed: Americans living longer, aging population, increased incidence and prevalence of chronic conditions such as heart disease, diabetes, asthma Health Care is poorly organized to meet these challenges Today s Health Care system remains overly devoted to dealing with acute, episodic care needs! 6 2

3 Crossing the Quality Chasm: 10 Rules for Redesign 1. Care is based on continuous health relationships 2. Care is customized according to patient needs and values 3. The patient is the source of control 4. Knowledge is shared and information flows freely 5. Decision making is Evidence Based 6. Safety is a system property 7. Transparency is necessary 8. Needs are anticipated 9. Waste is decreased 10. Cooperation among clinicians is a priority 7 The Chronic Care Model by Dr. Ed Wagner MacColl Institute for Health Care Innovation (first published 1998) 8 Patient Centered Medical Home 9 3

4 PCMH Key Change Concept (Safety Net Medical Home Initiative) Engaged Leadership Quality Improvement Strategies Empanelment Continuous and Team Based Healing Relationships Organized Evidence Based Care Patient Centered Interactions Enhanced Access Care Coordination 10 National Committee of Quality Assurance NCQA Recognition NCQA Recognition required by MoHealth Net Health Home Initiative and APCP initiative for CMS Medicare Level 3 Recognition for 4 clinics: VERY ambitious 11 Journey to Team Based Care NCQA/PCMH Team: Medical Director, COO, PCMH Director, Care Coordinator, Clinic Managers, QI Director We hired team members according to MoHealth Net guidelines RN Care Managers Care Coordinator Behavioral Health Consultant PCMH Director Medical Assistant LPN Provider Patient Care Coordinator RN Care Manager BHC 12 4

5 Change Concept: Engaged Leadership Leaders facilitate transformation of care: chart the course for change Identify and allocate resources: time, dollars, staffing, equipment, technology, support to implement and sustain the changes! 13 Engaged leadership: keys for change Provide visible and sustained leadership to lead culture and change Ensure PCMH transformation has time and resources needed to be successful Ensure providers and care team members have protected time to conduct activities 14 Executive suite education Board Commitment of resources required Executive team: CEO, CFO, COO: all need to have a full understanding of comprehensive nature PCMH transformation: it is not a band aid approach See the BIG picture 15 5

6 Resources needed: Time, Money, Commitment (and plenty of pizza) QI committee met monthly before PCMH NCQA/Empanelment committee: met WEEKLY during the highest change period (just prior to all policies and processes must be in place for 90 days before NCQA application submitted), then monthly (for 2 full hours) Closed our largest clinic for 2 days to complete Care Team Training! 16 Quality Measures Monthly meeting with QI team: QI Coordinator, PCMH Director, Medical Director, COO, clinic managers, clinic i Health Home coordinator, IT nurse QI measures and PDSA change cycles are reviewed monthly in QI committee

7 Pilot project: Cassville Clinic Functional chaos Providers were not empanelled No Care Teams established Patients saw whoever they could get in with Episodic and reactive care 19 Cassville Trial: a 45 day trial Step 1 met with Executive Committee (leadership support is vital) Step 2 met with providers (stakeholders); off site, scheduled, safe Step 3 met with support staff, front desk staff Step 4 empanel patients (started with 46,889 patients) Step 5 let providers review panels (make changes as appropriate) Step 6 move staff to teams ; practice basics (lunches, PTO, role change ) Step 7 policies, check job descriptions, review resource allocation Step 8 review/alter upcoming month of appointments, train front desk on recall appointment scheduling Step 9 set start date start monitor evaluate Step 10 change what needs changed support (staff and leaders) praise ENCOURAGE LISTEN PRAY 20 Cassville Pilot was a huge success! 21 7

8 ALL Staff Education: Patient Centered Medical Gnomes 22 Educational needs of staff RN care managers: came from acute care hospitals Care Manager: new role for RNs Role strain! Need education, support, need to feel of value to the team. Chronic Disease Education Clinical Competency Development Job Descriptions/Roles on Teams (share teams) Self Management Education Care Plans (NCQA) templates in EHR Motivational Interviewing 23 Educational Needs of the Staff Behavioral Health Consultants New Role SBIRT Chronic Disease Short visits with behavioral focus Documentation templates Coding visits SBIRT Weight Management BHC Job Description and competency list Chronic Disease Education Tobacco Cessation 24 8

9 Educational needs of the staff LPNs: Coumadin management, chronic disease benchmarks class, standing orders, MAs: chronic disease benchmarks, standing orders Clinical competencies: LPNs and MAs are checked off on competencies for foot exams, all clinical skills, performing in house labs, helping patients set self management goals 25 PCMH: Organized and Evidence Based Care Medical Director and PCMH Director researched and wrote Evidenced Based Guidelines for 8 major chronic conditions (using National Standards) Presented monthly to Medical Providers for approval Placed computers and each clinic was provided with hard copy of guidelines and supporting documentation Took an entire summer to complete the manual 26 Other Team Based Changes Morning huddles to review the day s schedule Pre visit Questionnaire Developed Standing Orders based upon the Evidence Eid Based Guidelines Improving open access using recall appointment system All patients receive a team card with name of their team, RN, LPN and MA names and how to contact Tracking logs: referrals, phone calls, diagnostic tests, Coumadin tracking logs, contacting patients who miss important visits 27 9

10 Diabetes Team Based Care: New DM Patient Night before: LPN prepares for Huddle, notes NEW DM patient to alert RN Care Manager/BHC and Provider Front desk: explains PCMH, gives brochure, and team card MA or LPN rooms the patient: all quality benchmarks are done LPN or MA schedules referrals RN care manager meets with ih patient to set up self management classes and self management care plan Patient scheduled for 5 week group class with CSI diabetes educator, and/or one on one education with RN nurse care manager RN puts patient in tracking notebook to check on, follow up with blood sugars, education, self management goals, labs etc In 3 months, patient is on recall list, front desk calls patient to schedule office visit, reminds patient to come in for any needed labs prior to office visit 28 Team Based Care for Chronically Ill Provider Front desk BHC CSI DM classes New Diabetic Patient RN CM MA LPN 29 Success Story 65 yo Hispanic male, uninsured, uncontrolled diabetes, hypertension, dyslipidemia, depression, obesity, was living in FEMA trailer Met with Care Team: provider, BHC, RN CM, LPN: assisted with application for Medicare/Medicaid, housing, employment, YMCA scholarship, dental program at community clinic Currently employed, moved to home, adherent with meds, attended diabetes education, dental plan completed A1C from 9.4 to 8.3; BMI 39 37, Microalbumin + to negative, LDL 159 to 106 and still improving! 30 10

11 Barriers Identified EMR: many, many issues Training needs Communication across system Change FATIGUE Click FATIGUE Physician/FNP buy in Reduced productivity Audits: seen as punitive Cost of care transformation Continued education 31 Team Based care works Patients like being part of the team Empanelment is a KEY change concept Huddles are key for success Supporting staff with changes is critical Maintaining the change is difficult There is NO turning back! Value Based Payment is here: QUALITY of care matters Lessons Learned 32 Making a Difference to One 33 11

12 Moving on to the next adventure as our journey continues! 34 12