San Mateo Medical Center Innovative Care Clinic

San Mateo Medical Center Innovative Care Clinic

2 2009 CAPH/SNI Quality Leaders Awards NARRATIVE DESCRIPTION OF PROGRAM Please respond to the following questions. Please give detailed, but succinct answers per question. Remember that scoring is based on: Challenge, Solution, and Creativity (defined on Page 2 above). 1) Please describe your program/project in 200 words or less. Please include the start date (and end date if this was a pilot program). In 2007, the Primary Care Clinic at San Mateo Medical Center (SMMC) initiated a comprehensive clinic redesign. The goals of the redesign were: (1) improve quality of care, (2) reduce cost of care, and (3) improve patient and staff satisfaction. The impetus for the redesign was our belief that a higher level of quality could not occur by stressing the existing system. Rather than tying to work harder in a flawed system, our redesign focused on developing a new system of primary care. SMMC established a multidisciplinary workgroup to develop a vision, strategy, and work plan based on input from clinic staff, administration, and patients regarding how an ideal primary care clinic would function. The resulting model includes: 1. Team Based Care 2. Flexible/Expanded Staff Roles 3. Implementation of the Chronic Care Model 4. Advanced Access 5. Performance and Outcomes Measurement 6. Effective Use of Information Technology 7. Coordination of Care with Support Staff 8. Focus on Health Promotion and Education Additional workgroups were established to focus on implementation including space renovation, four clinic improvement collaboratives, and the hiring of new staff. Our Grand Opening ceremony was held in January 2009 to officially open the Innovative Care Clinic. 2) What is the problem that the program was designed to address? And/or: What is the opportunity the effort was designed to maximize? The Innovative Care Clinic (ICC) was established to address numerous challenges faced by the staff and patients in our Primary Care Clinic. In our previous model, care was often delivered in a fragmented manner, driven by the acute complaints of the patients. Patients often were seen by different providers and care was organized around the physicians needs. There was minimal coordination of care and providers, nurses, and clerical staff often worked in silos with little communication. The clinic operated in a paper-based system with minimal data collection and reporting. The patients often were left with the responsibility of coordinating their own care without the appropriate involvement of the clinic staff. Access to care was an issue at several levels and patients reported difficulty getting appointments and often turned our emergency room for non-urgent matters. Patients also experienced difficulty navigating the phone lines and were unable to reach appropriate clinic staff in a timely manner. Additionally, there were challenges in accessing medications due to problems with changes in coverage, co-pays, refills, and prior authorizations. All of these inter-connected challenges needed to be addressed in a comprehensive manner to improve quality of care, and patient safety and satisfaction.

3 2009 CAPH/SNI Quality Leaders Awards 3) How does the program solve the problem or maximize the opportunity? Developed with DHS Health Care Coverage Initiative funding, the features of our ICC model were designed to address the challenges described above. Following is a typical clinic experience for a diabetic patient in our new model: Scheduling/Check-In: The patient has scheduled an appointment to address her chronic conditions. Two days prior to her scheduled appointment, an ICC Team Clerk contacts the patient to confirm the appointment, review her demographics, and remind her to bring all medications to the visit. When the patient arrives, she is met by an ICC Greeter who directs her to her the Team Clerk who had confirmed her appointment. The patient is checked in using our Electronic Medical Record and the team Medical Assistant (MA) is contacted by walkie-talkie, alerting her that the patient is ready to be escorted to the exam room. Exam Prep/Patient Education: The MA has prepared and reviewed the Diabetes Registry Flowchart. The patient is given a Pneumonia vaccine (standing order if not done) and this is recorded in the Bay Area Regional Registry. The MA discusses a Self Management Goal with the patient and asks her to remove her shoes for the pending footcheck. The MA also determines if the patient will need a retinal camera picture after her visit (if not done in the last year). All the patient s medications are placed on the desk in the exam room and reviewed in the EMR. The Provider is notified by walkie-talkie that the patient is ready to be seen. Provider Visit/Follow-Up: The provider examines the patient, reviews the registry note, enters order in EMR, sends prescriptions via e-prescribing, and schedules follow-up with the clerk by walkie-talkie. If there is a problem with medications, social issues, diet, blood glucose control, or mental health, the patient is escorted to the clinic pharmacist, social worker, nutritionist, diabetes educator, or psychologist for a real-time connection. The Patient leaves the clinic with a printout of all follow-up appointments, instructions, and medications. For urgent matters, the same patient contacts the clinic by phone. A redesigned phone triage system connects her to a phone greeter who answers the phone calls in real time and connects the patient to her care team or the appropriate support staff or hospital department. If needed, she is given a same-day appointment with her primary care physician using an available advanced access appointment slot. Overall, our new redesigned workflow focuses on teamwork, advanced preparation, evidence-based chronic disease management, utilization of technology, improved access, and integration of support staff. 4) What is the target population, if any, of the program? The Innovative Care Clinic serves all adult primary care patients seen at San Mateo Medical Center s main campus. During fiscal year 2009/2010, the primary care clinic served 21,398 patients. This was 492 or 2.4% more than we had budgeted to see. Volumes are expected to rise with the new model due to improved access.

4 2009 CAPH/SNI Quality Leaders Awards 5) What activities take place through the program? (i.e. What services are offered? What work is done?) In addition to redesigning the general clinic workflow (as described above), we implemented these new features in our clinic model: 1. A new ICC Pharmacist Medication Management Program to improve medication safety and adherence. This feature allows us to 1) provide a liaison between pharmacies and providers to assist with medication discrepancies, medication refills, and prior authorization requests; 2) manage a panel of patients to address barriers to compliance and providing educational materials/tools; 3) work with electronic prescribing systems managers to discuss potential errors; 4) provide drug information and formulary updates to providers to improve drug usage and therapeutic outcomes; and 5) manage a panel of Lipid Clinic patients for medication initiation, adjustment, and monitoring and to track lipid outcomes. 2. Group Visits for diabetic patients utilizing a Chronic Disease Management toolkit. These two-hour visits are led by a Diabetes Educator, a Physician, and a Medical Assistant. 3. Low-cost Retinopathy Screenings for underserved diabetic patients. These screenings are done on a Diabetes Retinal Camera provided through a California HealthCare Foundation collaborative. 4. Multiple modalities of technology including full implementation of Electronic Medical Record (in April 2009), Electronic Prescribing, Chronic Disease Electronic Medical Registry, Bay Area Regional Vaccination Registry, Health Care Interpreter Network Video (video interpreters), and clinic-wide usage of walkie-talkies. 5. A new category of nursing appointments for low acuity visits that require only brief consultation with the physician in order to free up the physician schedule for more complicated patients. 6) How is the program staffed? The ICC operates in a model of team-based care. The clinic staff are divided into three teams or pods. Each pod is identified by color blue, green, or yellow to signify that all members of the team are of equal importance. Each pod consists of two Physicians, two Medical Assistants, one Registered Nurse, and one Patient Services Assistant. Each pod is responsible for providing care for a designated panel of patients, and the care is determined by a proactive plan set by the pod. Data is collected and reviewed for a variety of measures, on a monthly basis, for each pod. The three pods also are assisted by a group of clinic support staff including a Certified Diabetic Educator, Nutritionist, Pharmacist, Social Worker, Psychologist, interns, volunteers, and information technology staff. In our previous model, physicians spent a significant proportion of their clinic time problem-solving issues with patients such as how to set a food plan, how to enter a shelter, or how to cope with the loss of a family member, in a manner that was rushed, incomplete, and not in the physician s area of expertise. With a group of specialized, clinic-based support staff, we are able to help our patients manage such significant barriers to good health in a timely manner. 7) Where is the program being implemented? The Innovative Care Clinic is located at the main campus of San Mateo Medical Center s hospital and clinic system. Certain features of the ICC model have been implemented in other SMMC outpatient clinics including team-based care, group visits for diabetic patients, retinopathy screenings and the ambulatory electronic medical record. Once fully tested, we plan to roll out the ICC model in full throughout our ambulatory care system.

5 2009 CAPH/SNI Quality Leaders Awards 8) What are the results from this effort? How do you know the program is working? Please include the quantitative measures and outcomes data demonstrating the success of your efforts. If this is not possible, please give anecdotal or qualitative data to demonstrate the program s impact. We have created an ICC Dashboard to measure data in five key categories: Chronic Disease Management, Health Care Maintenance, Access, Satisfaction, and Finance. The data is collected monthly from a variety of sources including the Hospital Network, Chronic Disease Registry, manual counts, and internal surveys. There are measurable improvements in several categories: Chronic Disease Management More than 1,400 diabetic patients have been entered and are tracked in our CDEMS registry. This will enable us to track population process and outcome goals for a significant population. Pneumonia vaccination rates are up 5% Aspirin usage is up 10% Health Care Maintenance Development of Self Management Goals are up 8% Clinic Access Patient Panels developed for all providers; monthly monitoring of patient volumes for each provider; improved ability to match appointment availability and activity level. Ten percent decrease in clinic no show rates. Ten percent increase in digital retinopathy exam rates (more than 500 patients in total). Patient Satisfaction Clinic cycle times have been at goal of less then 60 minutes for the past year. We have been able to sustain these cycle times across our system, improving from waits as high as 120 minutes several years ago. San Mateo Medical Center has contracted with the Urban Institute for a more expansive evaluation of the Innovative Care Clinic in the context of all county efforts under the Coverage Initiative Grant. 9) How has this program affected patient/staff satisfaction and/or impacted the quality of care at your site? We have implemented a new Patient Satisfaction Survey which we administer on a quarterly basis. Although our scores have fluctuated during the implementation phase of our redesign, we have consistently received positive written feedback from patients. Examples of patient comments include: The new system the clinic has gotten very efficient! Excellent service! Fast, and staff very kind. This clinic is the Beverly Hills Hospital. The staff is the best! Our redesigned model has had an overall positive impact on staff satisfaction. All clinic staff were engaged in the planning process and most were assigned to specific workgroups. Despite the initial unease expected with any new process, staff comments reflect the successes of the redesign: It appears to be working well for the patients.

6 2009 CAPH/SNI Quality Leaders Awards 10) Is there anything else you would like to report? The ICC is not only the flagship clinic for our system, but it has been recognized statewide. The California Healthcare Foundation recently invited San Mateo County to testify at a State hearing about the Coverage Initiative. The State s Secretary for Health and Human Services, Kim Belshe, and the State s Director of the Department of Health Care Services, David Maxwell-Jolly, recently visited SMMC to learn more about our innovations in chronic disease care, and specifically the ICC. We are extremely proud of our accomplishments, and look forward to spreading the model further throughout our system as we document its benefits further. 11) Attachments: Photos 1. SMMC-ICC-GreenPod The Innovative Care Clinic operates in a model of team-based care. Here are a few of the members of one of three pods/teams: a Physician, a Medical Assistant, and a Team Clerk 2. SMMC-ICC-Greeters.jpg The Team Clerks welcome the patients and check them in using the Electronic Medical Record system. 3. SMMC-ICC-WalkieTalkie.jpg Following a chart review, and discussing the patient s Self Management Goal, the Medical Assistant notifies the physician by walkie-talkie that the patient is ready to be seen. 4. SMMC-ICC-EyeScreening.jpg An ICC team member conducts a retinopathy screening on a diabetes patient. 5. SMMC-ICC-Pharmacist.jpg Following his visit with his physician, a patient discusses his medications with the clinic s Pharmacist in the clinic setting.