Care Coordination and Interoperable Health IT Systems

1. Care Coordination and Interoperable Health IT Systems Unit 2: Team-based Approach to Patient Care Lecture b – Transformation Planning This material (Comp 22 Unit 2) was developed by The University of Texas Health Science Center at Houston, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0006. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.

2. Team-based Approach to Patient CareLearning Objectives • Objective 1: Identify best-practice types of team-based interventions (Lecture a) • Objective 2: Describe key elements for transforming to team-based care (Lecture a) • Objective 3: Plan for transformation to team-based care (Lecture b) • Objective 4: Identify evidence-based clinical practice guidelines resources (Lecture c)

3. Transformation Plan: Five Key Elements of Team Building • Clear goals with measurable outcomes • Clinical and administrative systems • Divisions of labor • Training • Communication

4. Transformation to Team-based Care • Integrate the patient-centered medical home recognition standards checklists • Implement the elements from the Patient-Centered Medical Home (PCMH) standards and criteria • Adapt processes that work best for the transforming team

5. Transforming to Team-based Care (Cont’d – 1) • National Demonstration Project (NDP) proved three foundational elements of team-based care: • Leadership • Communication • Teamwork • Using behavior change theory and proven change management, transformation to team-based care delivery models can be successful

6. Requirements for Change • Traditional, top-down, autocratic approach exhausts leadership and fails to engage all team members • All members must be active • Prioritize sufficient time and effort to ensure successful transformation

7. Transforming the Culture • Coordination and integration of every functional area of the practice including the patient • Remember key elements: communication, leadership, informatics, and teamwork • Nourish a rewarding, adaptive practice culture • Teamwork thrives in learning system culture • Refer to Component 18, Unit 10 for more information on Change Management

8. Remember in Team-based Care… • Patient is included as part of the high-functioning team • Team members are enabled with health information technology systems

9. Designating Roles • Designate workload by skill • Redistribution of the workload gains efficiencies and work experience satisfaction • Team members work at the top of licensure • E.g., Physicians delegate to other team members the tasks and functions that do not require medical training • Employ systems engineering principles

10. Going from Reactive to Proactive Care • Proactive care: • Population health management processes • Implementing planned care • Collaboratively accomplished with the patient and family when appropriate • Data analytics support: • Care decisions • Wellness promotions • Disease prevention • Early detection • Chronic disease management

11. Population Health Management • Proactive care for the whole person over time • Efficient use of health information technology • Robust registries • Screening and prevention measures • Best practices for patient engagement • Collaborative self-management support • Refer to Component 21 for more information on Population Health

12. Team-based Intervention Rollout Strategy • A rollout strategy needs: • Road map or plan • Designate phases for baseline assessment and reassessment milestones • Gap analyses • Identify precisely where the transformation leadership may need to redirect communication and teamwork • Informatics • Track and meet transformational goals

13. Supporting Team-based Care Transformation • Professional consultation organizations can assist transformations • Assigning practice facilitation coaches is essential • Advances teams through a standardized approach • Incorporates behavior change theory, organizational development methods, and best practices in curriculum

14. Developing Team-based Care • The Department of Health and Human Services (HHS) has funded research and resources through Agency for Healthcare Research and Quality (AHRQ) and other organizations • National Committee for Quality Assurance (NCQA), the Joint Commission, Utilization Review Accreditation Commission (URAC), and others publish standards and criteria

15. Team-based Care Non-Clinical Guidelines • The non-clinical guidelines list is designed to ensure patients and families / partners are empowered and respected as essential members centric in the health care team • Share all decision-making • Respect the patient’s choice and preferences • Include family members/partners to provide • Comfort and support • Patient information during care transitions • Refer to Component 25 for more information on Patient Centered Care

16. Unit 2: Team-based Approach to Patient CareSummary – Lecture b – Transformation Planning • Three foundational elements of successful transformation to team-based care are: leadership, communication, and teamwork • Requirements for creating culture change • Going from reactive to proactive care • Creating a team-based rollout strategy for intervention

17. Unit 2: Team-based Approach to Patient Care References – Lecture b References Accreditation, Health Care, Certification | Joint Commission. (n.d.). Retrieved March 9, 2016, from http://www.jointcommission.org/ Agency for Healthcare Research & Quality. (n.d.). Retrieved March 9, 2016, from http://www.ahrq.gov/ Crabtree, B. F., Nutting, P. A., Miller, W. L., Stange, K. C., Stewart, E. E., & Jaén, C. R. (2010). Summary of the National Demonstration Project and recommendations for the patient-centered medical home. The Annals of Family Medicine, 8(Suppl 1), S80-S90. Health Care Accreditation, Health Plan Accreditation Organization - NCQA. (n.d.). Retrieved March 9, 2016, from http://www.ncqa.org/ PCMH Resource Center. (n.d.). Retrieved March 9, 2016, from https://pcmh.ahrq.gov/ Homepage. (n.d.). Retrieved March 9, 2016, from https://www.urac.org/

18. Unit 2: Team-based Approach to Care Coordination Lecture b – Transformation Planning This material was developed by The University of Texas Health Science Center at Houston, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0006.