PCMH 1: Enhance Access and Continuity

1. PCMH 1: Enhance Access and Continuity Caroline Currin Palmetto Pediatric and Adolescent Clinic Operations Director ccurrin@palmettopeds.net

2. Element A: Access During Office HoursMUST PASS ELEMENT • Does your practice have written process and defined standards… can you demonstrate these standards are monitored? • Providing Same-day Appointments • Providing Timely Clinical Access by Telephone During Office Hours • Providing Timely Clinical Advice by Secure Electronic Messages During Office Hours (answer may be NA if secure messages are not available) • Documenting Clinical Advice in the Medical Record

3. Providing Same Day Appointments • This is considered a critical factor and must be met for practices to receive any score for element A • A practice has the flexibility of measuring a specific type of appointment availability • The Clinical Care Committee for our practice developed a list of symptoms that require an automatic appointment… there is not a reason to speak with a nurse or determine whether or not the patient needs to be seen that day • Staff are trained annually on these symptoms and the supervisors are quizzed as well to ensure understanding and compliance • In addition, practice-wide assessment of same-day appointments versus total appointments are reviewed monthly and sent for physician and staff review in the monthly newsletter (reports are derived from EMR reports) • Data only needs to be for at least five consecutive days

4. Average Appointments Scheduled per Location Monday Tuesday Wednesday Thursday Friday Downtown 130 93 77 77 65 Harbison 106 98 72 68 61 Lexington 95 72 62 60 45 Rice Creek 60 47 38 41 28 Northeast 141 114 90 97 83 Average Same Day Appointments Scheduled Monday Tuesday Wednesday Thursday Friday Downtown 72 50 36 41 36 Harbison 53 51 34 38 35 Lexington 49 26 25 24 23 Rice Creek 32 23 14 19 18 Northeast 68 51 42 44 41

5. Timely Phone/Electronic Triage Access During Office Hours • The practice is responsible for defining a timeframe in which parents receive returned phone calls or secured electronic responses • Presently we do not utilize a secured email to respond to parents • Our rules • Our triage department is responsible for returning patient calls within 60 minutes • When a call is added to the EMR, the date and time are automatically entered • Staff are trained to change the time if the parent left a message, to that of the original call time • Staff are also trained to document the time they have spoken with a parent or attempted to reach a parent • Measuring standards • Access call times for a week, what is the average time between initial call and return call? • For the week of 6/27/11 there were 1,237 triage calls, the least amount of time between parent call and triage was one minute, the greatest amount of time 59 minutes, the average amount of time 16.28 minutes, the mode was six minutes… there were four calls without documented return call times

6. Phone Advice is documented in the patient’s chart • The practice must have standards to cover documenting medical advice in the patients chart • Three examples of medical call documentation must be provided from patient charts • Our standards • The Triage Administrative Assistant, Triage Nurse, and receptionists have standards set for documentation

7. Performance Standards Triage Nurse Triage Nurse Assistant Responsible for answering incoming calls. Responsible for adding medical calls to the Organizer and routing them to the appropriate nurse or staff member. Responsible for documenting the time of the call Responsible for understanding that only one patient should be listed in a medical call. Sibling’s names should not be included due to HIPAA. Creates a new medical call in the event that a parent asks questions regarding another child. Responsible for looking patient’s up by their date of birth and verifying the patient’s name before creating a medical call. Responsible for verifying a caller is HIPAA compliant. Responsible for obtaining at least one contact phone number from the parent or HIPAA complaint individual and verifying that the typed phone number is correct. Responsible for understanding and memorizing symptoms that require immediate nurse triage and giving the caller to the next available nurse. Responsible for understanding symptoms that authorize an automatic appointment and then offering to schedule the patient for a same day sick visit. Understands that patients should be scheduled with their primary physician when available. Responsible for understanding how to open the schedule for each office location/physician. Responsible for transferring patients who need well, consultations, ADD appointments to the office staff for scheduling. Responsible checking the prescription/immunization record/school excuse voice mail every thirty minutes and subsequently sending medicals to the nurses for completion. Responsible for contacting parents when their message is not understood. Responsible for faxing immunization records/school excuses when requested by the parent. Verifies the fax number before sending documents. Responsible for attending annual customer service training. • Responsible for returning phone calls regarding medical advice within one hour of receiving a medical call in the Organizer. • Responsible for verifying a caller (whether returning a call or answering a directly transferred call) is HIPAA compliant. • Responsible for requesting that a caller verify the child’s name and date of birth before offering medical advice. • Responsible for documenting the time for each return call and when messages are left. • Responsible for utilizing Palmetto Pediatrics approved Barton Schmitt protocol for purposes of advising parents. • Responsible for understanding that only one patient should be listed in a medical call. Sibling’s names should not be included due to HIPAA. Creates a new medical call in the event that a parent asks questions and advice is given for another child. • Responsible for scheduling sick appointments for patients when indicated. Understands that patients should be scheduled with their primary physician when available. • Responsible for understanding how to open the schedule for each office location/physician. • Responsible for transferring patients who need well, consultations, ADD appointments to the office staff for scheduling. • Responsible for completing immunization record requests within twenty four hours of parent calling. • Responsible for notifying the medical records staff if immunization history is not scanned into the patient’s chart. • Responsible for completing school excuses when requested by parents after reviewing appointment and/or phone call history. Understands that school excuses should not be written if the patient has not been seen by our office or called for advice. • Responsible for understanding and memorizing approved Standing Orders. • Responsible for sending prescriptions via eRX to the pharmacy of the patient’s choice. • Responsible for completing prior authorization requests for medications ordered when indicated by eRX or the pharmacist. • Responsible for forwarding medical calls to patient’s primary care provider when there are specific questions or when the parent demands the physician be asked. • Responsible for attending customer service training.

9. Element B: After-Hours Access • Does your practice have written process and defined standards… can you demonstrate these standards are monitored? • Providing routine and urgent-care appointments outside of regular office hours • Providing Continuity of Medical Record Information for care and advice when the office is not open • Providing timely clinical advice by telephone when the office is not open • Providing timely clinical advice using a secure, interactive electronic system when the office is not open • Documenting after-hours clinical advice in the patient records

10. Extended Office Hours • What are the standards set for extended office hours? Do you offer early morning, late evening, or weekend appointments? • Small practices with limited staffing may make arrangements with other offices or other non-ER facilities • Our standards • The NE office has a physician who begins seeing patients at 7:30a (regular office hours are 8a – 5p) • We offer emergency hours for sick patients on Saturdays and Sundays beginning at 8a • Documentation • Can you produce a report to show patient utilization of extended hours? See print screen of schedule on the next page • OR -- • Do you have written materials advertizing extended hours? www.palmettopediatric.com has instructions for after hours access under Contact Us, the new patient booklet also provides these instructions

12. Continuity of the Medical Record information for care and advice after-hours • Is there a process for on-call after-hours staff and external facilities for after-hour care? • Telephone consultation with the primary clinician or a clinician with access to the records is acceptable • in addition the patient may have a personalized portable care plan, medical summary, or access to their electronic record • Our practice • All physicians have access to the EMR off-site… the use of I-Pads has made our physicians more compliant with using this option • Our after-hours triage service has access to the EMR • Patients with Special Health Care needs are given a care plan after their initial visit and after each care plan update (done at least annually) • Our Patient Portal has the option of allowing patients/parents an ability to view labs, diagnoses, medications (past/present) – we are currently not utilizing this feature • Documentation • The practice is required to provide the documented process for making records available after-hours

13. Providing Timely Clinical Advice via telephone or a secure/interactive electronic system after-hours • This is a critical factor and must be met for practices to score higher than 25% (secure e-mail may be N/A if the practice does not utilize this feature but telephone advice guidelines must exist) • The practice has a time frame for responding to phone calls or secure emails and the response is monitored against the practices statement • The advice must be interactive, meaning it is with a person not a recording and the caller has an opportunity to ask questions • Our practice • We presently do not utilize secure electronic means; however, Patient Portal does offer this capability • The standards for our after-hours service includes return calls made within one hour • Documentation Requirement • Provide the documented process and response times • Response times may be system generated or spot checks done over a one week period

14. 5. PROVIDER'S STANDARDS OF OPERATION During our Provider Hours, it is the sole responsibility of the Practice to establish a connection to the Provider Nurse Line during call coverage by way of call forwarding, answering service, or direct calls from patients. All costs and equipment associated with Practices' connection to Nurse Line is the responsibility of the Practice. When connected to the Nurse Line the patients will leave demographic information and the nature of the problem the patient is having. Provider triage nurses will return patient calls as soon as possible, typically in less than 30 minutes but can take up to 1 hour in unusually high-peak times. Call information is documented on medical call within EMR.. The Triage Nurse may notify the physician on-call for emergencies, whenever requested by parent or for any special assistance needed. Provider Triage Nurse will schedule a next day appointment for any patient in which the protocol suggests to do so, the Triage Nurse concludes that it is appropriate, or upon the patients request. The Triage Nurse will only schedule appointments for the time slots provided by the Practice. Provider will notify Practice of all appointments scheduled by 9:00AM each morning by fax or through our website at the sole discretion of Provider. The Triage Nurse is only able to call in a medication from a standing order protocol prescription form signed by the Practice. The Practice understands that Provider does not provide a medical diagnosis, but is limited to triage needs and recommendations of nursing interventions to the Practice's Patients. Practice is responsible for approving and following up with all of their patients, as Practice deems medically necessary.

15. Documenting After-hours Clinical Advice in Patient Records • After-hours advice, whether by phone call or e-mail, must be recorded in the medical record • Our practice • Our after-hours service has access to our EMR • They are required to document calls in the EMR as they speak with patients • Presently these calls are monitored on a monthly basis • During the week of 6/27/11, there were 60 calls after-hours, the quickest return call was four minutes, the greatest amount of time 31 minutes, and average time was 11 minutes.

16. Element C: Electronic Access • Does your practice have written process and defined standards… can you demonstrate these standards are monitored? • More than 50% of patients who request an electronic copy of their health information receive it within three business days • At Least 10% of patients have electronic access to their current health information within four business days of when the information is available to the practice • Clinical summaries are provided to patients for more than 50% of office visits within three business days • Two-way communication between patients/families and the practice • Request for appointments or prescription refills • Request for referrals or test results

17. This sections is our greatest weakness • Due to the most recent upgrade (7/7/11) our EMR has the capability to allow us to meet the standards for Factor 1, 2, 3, and 4 • With training and acceptance, we should be able to meet these standards soon • Unfortunately there is a fear of what patients/parents will do with this information so this transition will most likely be slow

18. Element D: Continuity • Does your practice have written process and defined standards… can you demonstrate these standards are monitored? • Expect patients/families to select a personal clinician • Document the patient/family choice of clinician • Monitor the percentage of patient visits with the selected clinician or team

19. Expecting Patients/Families to select a personal clinician & the PCP is documented in the record • The practice is responsible for requiring patients to select a PCP and explain the importance • The PCP must be documented in the record or the practice must have a written process explaining the importance of a PCP

21. Doctor of Record is a required field in the EMR New patients cannot be saved without a doctor of record being recorded

22. Monitoring the percentage of patient visits with a selected clinician or team • A team = the support staff working with a clinican • Documentation requirements • Report at least one week worth of data showing the proportion of patient encounter that occurred with the selected PCP or team • For the week of 6/20/11, Dr Greenhouse saw 90 patients… 64 of these patients had her listed as the PCP (she was listed as the PCP for 71% of the patients seen)

23. Element E: Medical Home Responsibilities • Does your practice have written process and defined standards… can you demonstrate these standards are monitored? • The practice is responsible for coordinating patient care across multiple settings • Instructions on obtaining care and clinical advice during office hours and when the office is closed • The practice functions most effectively as a medical home if patients/families provide a complete medical history and information about care obtained outside the practice • The care team gives the patient/family access to evidence-based care and self-management support

24. The practice coordinates patient care across multiple settings • How can the practice show they care about the “whole person” and take responsibility for coordinating care? • Documentation applies for all factors in this section • The practice has a documented process for giving patient information and materials about the obligations of a medical home • Can be in the form of a patient brochure, written statement for the patient and family, link to online video, web site, patient compact

25. Instructions on Obtaining Care and Clinical Advice during office hours and when the office is closed • Information is provided to patients regarding where to seek after-hours care, how to communicate with the clinician or team, and how to request clinical advice

28. The practice functions most effectively as a medical home if patients/families provide a complete medical history and information about care obtained outside the practice • When you rely on patients to be responsible for divulging information, there is a risk in not obtaining pertinent points • This factor involves the PCP receiving/requesting a comprehensive medication list, progress notes from specialists, medical history, health status, recent test results, self-care information, recent hospitalizations, and ER information

29. Element F: Culturally and Linguistically Appropriate Services • Does your practice have written process and defined standards… can you demonstrate these standards are monitored? • Assesses the racial and ethnic diversity of its population • Assesses the language needs of its population • Provides interpretation or bilingual services to meet the language needs of its population • Provides printed materials in the languages of its population

30. Assesses the racial, ethnic, and language diversity of its population • Information may be collected directly from the patient or by using information available regarding the county it serves • The practice has a report showing these aspects are collected and measured

31. Provides interpretation or bilingual services to meet the language needs of its population • The interpreter may be a staff member or a third party interpretation service • The interpreter may not be a friend or family member • Documentation • The practice may provide an invoice or agreement with a third party • If there is an interpreter on staff, a copy of the policy may be provided • The policy must explain the procedures it takes when a family speaks a language the bilingual staff are unable to interpret

33. Provides printed materials in the languages of its population • Practices need to identify languages spoken by at least 5% of their patient population • If the practice can prove that less than 5% of their population speaks another language, N/A would be used for this factor • Printed materials should be available to these families in their spoken language • This includes forms the parent/patient is expected to sign for the administrative and clinical staff • Documentation • The forms may be sent for review • A link to online materials • Website in other languages

34. Element G: The Practice Team • Does your practice have written process and defined standards… can you demonstrate these standards are monitored? • Defining roles for clinical and nonclinical team members • Having regular team meetings and communication processes • Using standing orders for services • Training and assigning care teams to coordinate care for individual patients • Training and assigning care teams to support patients and families in self-management, self-efficacy, and behavior change • Training and assigning care teams for patient population management • Training and designating care team members in communication skills • Involving care team staff in the practice’s performance evaluation and quality improvement activities

35. Defining roles for clinical and nonclinical staff • Performance standards should be completed for all staff members • Documentation • Provide a written job description/performance standards • Emphasis should be placed on a team based approach to care • Our practice • Descriptions are reviewed annually and are available for all staff

36. Regular team meetings and communication processes • This factor is critical and must be passed in order to score higher than 25% on element G • The meeting may be a huddle where the regularity is defined by the practice • Communication may include email, tasks, or messages within a patients record • The practice should be able to provide meeting notes, email correspondence, meeting notes, memo’s to staff

37. Our practice • The QTIP blog is an excellent source of notating changes, processes, and progress • Monthly newsletters are emailed to all staff • Physicians use flags/medical calls to communicate patient needs with our staff • In the past, we had an annual “State of the Union” meeting… last year we reinstated this process • Quarterly meetings to review processes and communicate upcoming changes are done with each department

39. Standing Orders • Standing orders may be preapproved by clinicians • Includes testing protocols, vaccination schedules, prescription refills • Our practice examples • Testing Protocols: if a rapid strep is negative send a throat culture • Prescription Protocols: Ciprodex (4gtts BID/day for 7 days) may be called in for patients with draining tubes

40. Train and assign care teams to coordinate care for individual patients • Coordinate care for your patients… obtain lab results, specialists reports, communicate with community organizations and health plans • Written training documents should be available or a process that describes training • Our practice • We have Kim • Kim does training with our staff to review community resources available to patients • Our referral department also assists in care coordination on communication with specialists/insurance companies

41. Training and assigning care teams to support patients and families in self-management, self-efficacy and behavior changes • Care team members are trained on evidence based approaches to self-management support, such as patient coaching and motivational interviewing • Our triage staff has limited training on customer service to include behavior changes and coaching • Kim attends many training opportunities to assist in self-management, efficacy and behavioral changes

42. Training and assigning care teams for patient population management • Population Management = assessing and managing the health needs of a patient population such as defined groups of patients • The practice must provide a description of it’s training process to include the training schedule or materials to show how staff are trained • Our practice • We presently monitor ADD/ADHD patients • Training includes scheduling follow up appointments • Asking specific questions during phone follow ups to ensure the patient is doing well with their medication • Soon we will also have a process in place for children with suspected Autism

43. Training and designating care team members in communication skills • Care team members are trained to communicate effectively with patients, especially those who are vulnerable • Vulnerable populations = vulnerability lies in the patients financial status, living situation, health, age, personal characteristics, functional or developmental status, ability to effectively communicate, and presence of chronic illness or disability • Evidence based approaches should be used to determine and assist in communication needs: • Ask Me 3, Rapid Estimate of Adult Literacy in Medicine (REALM-R), Wide Range Achievement Test-Revised (WRAT-R) • Our practice • There is room for improvement in this area

44. Involving care team staff in the practice’s performance evaluation and quality improvement activities • The care team receives performance measurement and patient survey data • Areas where there is room for improvement are identified and the group uses this to develop quality improvement initiatives • Documentation • A description of staff roles in the QI or minutes from meetings • Our practice • QTIP QI • Clinical Care Committee works with physicians and nurses to improve care and create standards