One Best Practice Change

1. One Best Practice Change First Up: Bala Cynwyd Medical Associates

2. “The One Best Practice Change” Bala Cynwyd Medical Associates • Attitude towards patients • Patient as team member • Medicine is a team sport. Until the collaborative I never viewed the patient as a member of the team. Now I realize the patient is the most important member of our team • Resulting Positive Impact/Outcomes • Retention of patients who were thinking of leaving the practice • Better outcomes • Better staff satisfaction

3. “The One Best Practice Change” Project Salud Major change Change of diabetes self-management tool and consistent use of the tool Self-management tool had been in English and could not be applied to the majority of our population New self-management tool includes multiple pictures so that patients with low literacy level can understand the tool Resulting Positive Impact/Outcomes Patients begin thinking about an area they would like to improve on and can discuss with the provider prior to the provider entering the room Patients get to take the self management tool home with them to have visual reinforcement of self-management goals

4. “The One Best Practice Change” Crozer Medical Associates Major change Pre-Visit Planning 30 Day Appointment List with Deficiencies Contact patient to arrange blood tests prior to visit Resulting Positive Impact/Outcomes Patients arrive at appointments with up to date labs Providers have necessary data to make decisions In the initial stages of rolling out to network practices

5. “The One Best Practice Change” Medical Group at Marple Commons Major change We use a disease registry For the first time, the doctors and MA’s can track individual diabetic patients and our entire population. MA’s are more involved in patient care Resulting Positive Impact/Outcomes Patients are more involved in their care More individual self-management support. We have overcome clinical inertia for a number of measures. Improvement in almost all tracked measures

6. Children’s Health Center of VNA Community Services • Major change • Utilization of an Asthma Visit Form • An Asthma Visit Form was developed which included data fields, components of disease management and the NAEPP guidelines. • Resulting Positive Impact/Outcomes • The visit ran smoother. • All data fields were completed ensuring key components in asthma care were addressed. • NAEPP guidelines were followed. • Asthma visit forms are utilized on all asthma patients regardless of the reason for the visit.

7. “The One Best Practice Change” Buckingham Family Medicine Major change Implementation of EMR We now do all of our charting on an electronic medical record. All labs, letters and reports are imported or scanned into the system. Health maintenance rules allow us to track vaccines, cancer screening and disease specific testing needed. Resulting Positive Impact/Outcomes Tracking needed tests/visits Prescription management Access to medical record when off site Searchable database

8. “The One Best Practice Change”Abbottsford/Falls Major change Initiated Diabetic Group Visits with use of “Conversation Maps” Gather 6-10 patients to share and exchange information Discuss “action before motivation” Patient’s help motivate each other to help control BS’s Resulting Positive Impact/Outcomes Decline in A1C’s Patients are taking BS’s and recording them more consistently One patient started her own support group in her apartment complex. Greater patient empowerment and confidence in their ability to manage a chronic illness. Greater compliance with medication regimen More family involvement as a support system to patient.

9. “The One Best Practice Change” Crozer Keystone Center for Family Health Major change Developed “Diabetic Report Card” Created a letter to communicate results and interpretation of diabetic testing to patients that is written at a 6th grade reading level that is populated with data from our EMR Resulting Positive Impact/Outcomes Positive patient feedback Now printed prior to visits to help guide MA’s and providers determine services that need to be provided to patients Prompts providers to address diabetes even when that is not the primary purpose for the visit DM report card has been shared with and adopted by several practices in the Collaborative

10. “The One Best Practice Change” PHMC Health Connection Major change Social Worker will track referrals to increase attendance at specialist appointments Make appointment Call to remind of appointment Check if appointment kept If appointment is missed, call and reschedule - repeat, as above Resulting Positive Impact/Outcomes More appointments kept More reports received

11. The One Best Practice ChangeJefferson Family Medical Associates • Expanding the role of our medical assistants to fill out diabetes flow-sheets and perform monofilament exams • Resulting Positive Impact/Outcomes • Involving medical assistants in patient care has been enjoyable for the medical assistants and for patients • Reviewing flow-sheets allows patients to be more involved in their care • Flow-sheets have helped PCP’s to identify goals of care, deficiencies in care, and overcome clinical inertia

12. “The One Best Practice Change” Rising Sun Health Center Major change Replicating immunization follow-up for Diabetes At time of visit - file in tickler file for one week before the next clinic visit An addressed postcard reminder If appointment is missed call and reschedule Resulting Positive Impact/Outcomes More appointments kept for follow-up

13. “The One Best Practice Change” Kids First High Point • Major change • Patient Panel review with PCP and RN prior to start of office hours • Takes < 5 minutes • Significantly includes the nurse in patient care and decisions • Prepares for Asthma planned visit • Resulting Positive Impact/Outcomes • Have improved daily schedule: • Allot enough time per visit • Have all pertinent records available prior to pt arrival • Better compliance completing ACT and Asthma Intake Hx • More comprehensive visit -- Feels Good!

14. “The One Practice Change” Health Annex • Major change --Dedicated 2 new staff members to work exclusively with diabetic patients. --RN and CDE dietitian conduct one on one education and intensive case management total 106 visits over 3 months. Positive Impact/Outcomes -- More glucometer use and testing -- 56 Podiatry visits were scheduled by RN -- Patients are seeing behavioral health therapist at time of visit. -- Building trust, confidence and empowerment

15. “The One Best Practice Change” Mt. Airy Family Practice A paradigm shift from “I tell the patients and it is up to them to follow my advice.” to “How can I empower patients to manage their diabetes?” Causes of this changed attitude: NCQA certification process/ Medical Home SEPA CCC educational process and program RMD Registry Impact for patients and the practice: Higher level of accountability on both sides Improved satisfaction and outcomes of care

16. “The One Best Practice Change” Holland Medical Associates Major change Institution of Case Management CRNP and RN Focused Case Management Resulting Positive Impact/Outcomes Patient Empowerment Lower A1c’s Increase in Compliance

17. “The One Best Practice Change” North Willow Grove Pediatrics, PC Major Change Implemented new asthma visit template that incorporates evidence based guidelines. All providers involved in Asthma Chronic Care Model. Documentation now matches care of patients! Resulting Positive Impact/Outcomes Efficiency!! Implementing our new asthma template has increased our goal percentages. Each provider can follow previous provider’s plan of care. Has spread to other chronic diseases/diagnoses; now have templates for ADHD, injuries, newborn weight checks.

18. “The One Best Practice Change” Greenhouse Internists Major change Implementing SMS New staff/staff roles Enhanced educational resources Patient outreach and follow up Planned visits Resulting Positive Impact/Outcomes Appreciative patients Empowered and accountable patients Healthy behavior changes Engaged staff

19. “The One Best Practice Change” Lower Bucks Pediatrics, P.C. Major change Asthma Nurse Educator Case Management Action Plan Triage Medication Management Resulting Positive Impact/Outcomes Better Understanding of Disease Self Management Fewer ER visits, hospitalization

20. “The One Best Practice Change” Mary Howard Health Center • Major change • Starting of open access last calendar year. • Resulting Positive Impact/Outcomes Patients are seen same day. Patient’s are aware of process, so no one is turned away No more long lines of patients waiting to be seen.

21. “The One Best Practice Change” Founders Medical Practice Institution of Self-management Education for all DM patients Stratification of DM pts Staff initiates SM education for all DM pts High and medium risk patients referred for direct SM education by CRNP Staff provided additional education Resulting Positive Impact/Outcomes Improvement in SM goals for all DM Pts Improved referrals for podiatry, eye exams Closer to goals for HgA1c results

22. “The One Best Practice Change”Ninth Street Internal Medicine Major Change Adoption of the PDSA Process as a Change Agent -Impetus/focus for weekly meetings - Smooth transitions to new protocols - Gave “permission” to take chances and try new things Resulting Positive Impact/Outcomes Development and Use of Innovative tools Implemented Pre-Visit Planning Improved Preventive Care Increased Accuracy of Medication Lists Standardized Data Increased Patient Involvement in Self- Management Strengthened Team Concept

23. “The One Best Practice Change” Kids First Chestnut Hill Major change Blending of PNP’s into the CCI project within our site Descriptor Initially attempted to utilize traditional management and clinical support staff; conclusion was that initial development and implementation required a higher level of clinical and operational training and experience Currently have 32/hrs per week of PNP carved out and funded “time” allocated to the collaborative project, who are higher level clinicians in terms of training and experience Develop, implement and support CCI goals throughout entire three year program on a daily and consistent basis Provide leadership, education and resource roles to all staff Resource to newly named team champions and care coordinator Resulting Positive Impact/Outcomes Incorporated evidence based practices within all clinical decisions Developed an infrastructure that imbeds clinical goals into workflow and is sustainable Developed workflows that are efficient and fiscally sound Professional development of all staff members Generalization (Halo Effect) to other processes within the office Best Practice Model for other sites in our network

24. “The One Best Practice Change” 11t Street Family Health Services Ophthalmology Clinic Developed Access to on site retinal exams Planned visits – pts called from registry “Captured” patients seen by PCP and LCSW also Positive Outcomes We overcame our fear of planned visits damaging OPEN ACCESS appt scheduling We obtained care for the uninsured, underinsured and non compliant patient reducing barriers From this we modeled our Friday AM “Intense” focus group visits – targeting lowering BP first!