All Hands Meeting

1. March 22, 2012 All Hands Meeting

2. Agenda • Announcements • Carolina Access report • Introduction to the Readmission Program • Referrals • Smoking cessation efforts • Immunizations

3. Announcements • Dr. Tom Keyserling promoted to professor of medicine • UNC Health Care’s Annual Service Awards: • Marilyn Bender                 5 Yrs • Faye Johnson                    5 Yrs • Theresa Brown                10 Yrs • Maria Ford                         10 Yrs • Carla Adams                      15 Yrs • Phillis Perkins                   20 Yrs • Spring Party will be June 8.  Details to follow. • UNC Health Care is a finalist for national quality award

4. Sandi West • RN Case Manager with AccessCare • AccessCare is a Network of Community Care of North Carolina (CCNC) • Transitions patients from hospital to home including • Home visits • Medication reconciliations • Communicates with the primary care provider regarding patient goals, plans, education, and compliance issues • Assists providers in disease management education and/or follow-up • Advocates for clients and helps them navigate within the medical community • Provides information and referrals to community agencies

5. Karen Payne Carolina Access report

6. Carolina Access • Carolina ACCESS is North Carolina’s Medicaid managed care program. It provides a patient with a medical home and a primary care provider (PCP) who coordinates their medical care • Provides access to case management services • Clinic receives $5 per enrolled patient per month • 953 enrolled= $57,180 • Maximum of 2000 patients

7. CA Enrollment Protocol Carolina Access Enrollments- Arrival Procedure 1. Medicaid Patient checks in 2. Front desk validates insurance information Carolina Access Patient has an alternate Medical Home 1. Patient is asked to switch their Medical Home to UNC Internal Medicine 2. Patient signs Carolina Access Form 3. Front desk calls clinic listed on Medicaid card to obtain authorization for the visit (clinic NPI number) a. If clinic does not provide NPI number, the front desk will call the override number 4. Patient is seen at clinic appointment 5. Enrollment forms are collected each day and faxed to the appropriate DSS office Medicaid Patient does NOT have a Medical Home 1. Patient asked if they would like to have UNC IMC as their Medical Home 2. Patient can be seen without signing the CA application form

8. UNC IMC Carolina Access Enrollments

9. IMC Front Desk Challenge Goal= 350 Current= 288

10. Jamie Cavanaugh, Brooke McGuirt, and Dr. Shana Ratner Introduction to the Readmission Program

11. ReadmissionsWhat’s the big deal? Re-admission • 1 in 5 (20%) Medicare beneficiaries are readmitted to the hospital within 30 days1 • 2.6 million seniors annually2 • 13.3% preventable3 • $12 billion annual cost 1. NEJM 2009;360:1418-28 2. www.healthcare.gov 3. JAMA 2005.305:504-5

12. A near miss • 78 year old woman with newly diagnosed metastatic carcinoid syndrome, Htn, DM2 • Admitted for second time in past months for planned hepatic artery embolization • Discharged with a very low sodium level and still on HCTZ • Provider read discharge summary and was concerned about sodium level. Patient very confused but refused to come in or go to ER • Confusion resolved after stopping HCTZ

13. CMS Readmission Index Conditions Affordable Care Act of 2010 June 2007 Report to Congress: Promoting Greater Efficiency in Medicare

14. Identifying our readmission problem CCNC Medicare Data

15. Hospitals approach-SWAT Team GIM Risk allocation SWAT TEAM MEMBERS that may be contacting you • Brenda McCall • Beth McKenzie • Stephanie Stout • Low Risk= 5,023 • Moderate Risk= 6,551 • High Risk= 1,548

16. Our approach….a work in progress GIM Team Members • Jamie Cavanaugh • Steve Desper • Darren Dewalt • Brooke McGuirt • Tom Miller • Paul Njagu • Karen Payne • Shana Ratner • Betsy Shilliday

17. Steve Desper, Vickie Wheeley, Christina McMillan, Lisa White, Penny Chumley, Malinda Williams Ancillary Referral QI Project

18. Background • 56% of ancillary referrals submitted on the clinic support website were not scheduled. • Identified problem areas • Unclear procedure for processing • Undefined role of ancillary coordinator. • Loop not closed

19. Defined Steps for Processing Ancillary Referrals • Worked out step by step instructions • Created “cheat sheet” • Addressed the differences in processing an ancillary referral submitted while the patient is in the clinic and those done at another time.

20. Lab Sheet Ancillary Request Process • Physician sends an ancillary request out with the patient on the back of the lab sheet. • Make sure request is signed by the preceptor, if not take to the ordering physician to be signed. The preceptor can sign for residents • PBA who checks out the patient is responsible for scheduling and/or faxing the ancillary request to the appropriate department within 48 hours. If the request is marked URGENT the request must be scheduled by the end of the day. • The request is stamped “faxed” and initialed by the PBA that scheduled it.

21. Lab Sheet Ancillary Request Process continued • A phone message is put in WEBCIS stating the ancillary was scheduled. (see instructions below) • Copy of completed request is filed in centralized location at each desk. • Ancillary request is sent to medical records.

22. Online In ClinicAncillary Request Process • Physician prints and signs ancillary order and sends it to the front desk with the patient. • Make sure request is signed by the physician, if not take to the ordering physician to be signed. The preceptor can sign for residents. • PBA who checks out the patient is responsible for scheduling and/or faxing the ancillary request to the appropriate department within 48 hours. If the request is marked URGENT the request must be scheduled by the end of the day.

23. Online In ClinicAncillary Request Process continued • The request is to be stamped “faxed” and initialed by the PBA that scheduled it. • A phone message is put in WEBCIS stating the ancillary was scheduled (see instructions below). • PBA emails the Ancillary Coordinator letting them know that the request was taken care of. • Copy of completed request is filed in centralized location at each desk. • Ancillary request is sent to medical records.

24. Online Not in ClinicAncillary Request Process • Ancillary Coordinator handles these requests • Ancillary Coordinator monitors outlook express for all ancillaries that are submitted online. • Takes requests to preceptor to sign. • Prints out all ancillary requests and confirms that the requests have been completed within 48 hours. • Schedules any ancillary requests that were not completed at the time of patient check-out following protocols

25. Ancillary Coordinators Desk #1: Vickie Wheeley Back-up: Christina McMillan and Rob Hartman Desk #2: Jamie Walker Back-up: Wanda Brigman

26. Closing the loop with a WebCIS phone message • Message Titles: Referral*CT Referral*PV Referral*MAMMO Referral*GI Referral*US Referral*H&V Referral*MRI Referral*CP Referral*MRA Referral*NP Referral*MBS Referral*QDR Referral*PT/OT Referral*PF • Examples: • referral*H&V faxed request to heart and vascular for exercise stress test on 12/5/11 • referral*QDR bone density scheduled for 12/20/11 faxed order on 12/5/11 • referral*PF Spirometry Single scheduled for 01/12/11, faxed order on 12/6/11

27. Initial Data Collected

28. Data Collected After New Protocols

29. Weekly Monitoring-online referrals

30. Weekly Monitoring-lab sheet referrals

31. Joshua Hash, Jan Williams, Jo Williams, Natalie Phillips, Karen Payne, Dr. Asher Wolf, Dr. Doug Friedman, Dr. Shana Ratner, and Brooke McGuirt Smoking Cessation

32. January Smoking Data • Percentage of Current Smokers that Plan to Quit Smoking • December= 46/337= 13.65% • February= 91/362= 25.14% • Advise to Quit • December= 333/337= 98.81% • February= 276/362= 76.24%

33. Public Relations Campaign

34. Quitline

35. Quitline Referrals Intervention

36. Dr. Eldesia Granger, and the Nursing Staff Improving Immunizations in Our Clinic

37. QI Project Overview Project Goals: • Determine what percentage of continuity clinic patients have received Tdap, HPV, Zoster, Tetanus, and Pneumococcal vaccination if eligible? • Determine what clinic systems are in place for immunization? • Determine systemic barriers to immunization. • Improve vaccination coverage through process revision.

38. Immunization Rates at Baseline: IMC vs. USAReview of 250 Charts 23%

39. AIM Statement Improve Tdap vaccination coverage (percentage) in eligible continuity clinic patients by 10% within 1 week by using a standardized immunization pathway, vaccine promotional materials, and standing orders.

40. Interventions that Increase Use of Adult Immunization *Compared to usual care or control group, adjusted for all remaining interventions Stone E. Ann Intern Med 136:641-51, 2002

41. Process • Focus on Tdap with gradual rollout of additional vaccines over time. • Standing orders for Tdap • Vaccine Supplies: Vaccine Preparation Stations • Patient Knowledge: Immunization Promotional Materials. • Patient Refusal: Vaccine for Adults Info Sheet for patient refusal.

42. Process Map Patient Arrives for Continuity Clinic Appointment Review Immunizations Tab to Determine Tdap Need Patient Notified of Need for Tdap Provide Patient with “Vaccines for Adults” Tdap Document in Webcis Proceed to Standing Orders Document Refusal in Webcis

43. 36% 23% 23%

44. The Future • Tdap Data Review in 1 month. • Strategies to Improve other recommended vaccines. “Every Defect is a Treasure”

45. ACC Nursing Staff

46. R&D: Barriers to Adult Immunization Patients Providers • Belief that they are healthy and vaccination is not necessary. • Vaccination Shortages. • Concern for adverse effects. • Shot is not effective or causes the disease. • Vaccine not recommended by the provider. • Healthcare system mistrust. • Patients with a low show rate for well visits. • Urgent concerns dominate visit. • Vaccination Shortages. • No reminder system. • Belief that most patients will refuse the vaccine. • Reimbursement