The Planned Care Model : A Framework for Improving Care for Your Patients

1. The Planned Care Model:A Framework for Improving Care for Your Patients Donna Levi • Steve DiGiovanni, MD MaineHealth May 8, 2008

2. Objectives • Describe model for improving chronic illness care and prevention that is… • Patient-centered • Interdisciplinary • Evidence-based • Demonstrate how the model can provide an effective framework for practices to improve care

3. Rx for Improvement

4. Planned Care – Key Concepts • A high functioning team • Informed, motivated, prepared patients • Proactive care plans • Clinical information systems to support patient & care team • Supportive leadership

5. “Systems are perfectly designed to get the results they achieve”-Paul Batalden

6. Current “Systems”

7. Time for a Different Approach? In the past: • Emphasis for change was on physician, not system • No clear model for components of successful, evidence-based interventions • Common interventions to improve outcomes across chronic conditions not well supported

8. Essential Elements of Good Care Informed, Activated Patient Prepared Practice Team Productive Interactions Improved Outcomes

9. Planned Care Model Health System Community Health Care Organization Resources and Policies ClinicalInformationSystems DeliverySystem Design Self-Management Support Decision Support Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Improved Outcomes

10. The Flu Shot: It is not a lost cause • Ordering supply • Database: CIR • Multi-faceted approach • Educate families through out the year • Letters sent to families • Any visit (Acute of HCM) • Flu clinics • Phone calls to the slackers • Use the CIR to track outcomes

11. Self-Management Support • Support patient’s ability to manage their own condition • Identify what’s important to your patient • Use effective behavior change methods • Make the patient a partner in care – can require a culture shift!

12. Self-management Support • Patient education materials • Self-care tools • Self-management education and training

13. Think differently! Focus on collaborative goal setting Support behavior change with body language and words Moving beyond “compliance”… “Non-compliant patient”

14. How important is the change to the patient? How confident are they that they can make the change? Collaborative Goal-Setting 1 2 3 4 5 6 7 8 9 10 • What barriers are likely to get in the way?

15. Create supportive practice team Doc can’t do it alone Everyone has a role Delivery System Design

16. A Prepared Practice Team • has… • patient information • decision support • people, equipment, and time • …to deliver evidence-based clinical management and self-management support

17. Redesigning the Care Team • Use “planned care” visits; not acute care visits • - Prepared patient (bring meds, devices) • - Use visit templates, flow sheets, standing orders • Provide follow-up care according to guideline recommendations • Consider alternative care models – group visits, follow-up phone calls

18. Asthma Education Fax Referral • Initially needed to be provider initiated • Automatic Referral Protocol

19. Get tools into practice to help providers make the right decision – every time! Translate guidelines into practice! Clinical Decision Support

20. Clinical Decision Support • Embed guidelines into practice with tools, algorithms • Encourage case-based learning and alternative models for provider education • Integrate specialist expertise when needed

21. Use data to track care & outcomes Measure improvement to stay on track Use data to improve individuals and populations health Clinical Information Systems

22. Clinical Information Systems • Any system will do – EMR, registry, paper • Use clinical information systems to… • Summarize key issues at point of care • Create provider, practice reports to monitor performance and provide data feedback • Identify high-risk pt subgroups needing proactive care

23. Using the Data • Train a leader in the office to use the data. Centralize the data. • Share the data with the team and key stakeholders.

24. Your practice exists within a larger community – do you know your community? Form partnerships with local community resources Strengthen connections with local Comprehensive Community Health Coalitions Raise public awareness through community education Community Resources

25. 8 Public Health Districts with Comprehensive Community Health Coalitions (CCHC’s)

26. THE MANTRA • Make your patient’s life better • Educate • Empower • Make your staff’s life better • Educate • Empower

27. Break it down • Patient enters the office • Patient leaves the office • Patient in the community

28. Lessons learned • Create a small leadership team • Get buy in from the entire staff • Set specific objectives • Start small but set high goals • The physician is a minor player • Change is good, be happy • Measure the program • Grow the program

29. Planned Care Model Health System Community Health Care Organization Resources and Policies ClinicalInformationSystems DeliverySystem Design Self-Management Support Decision Support Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Improved Outcomes

30. How can YOU Make the Care Model “Real”? • Support patients to understand, manage their own condition(s) • Build on evidence-based guidelines • Use the tools – for patients & providers • Get support for change: MH Learning Community • Educational sessions - Learn from peers • Tools - Coaching • Use “rapid cycle” framework for change (PDSA)

31. For more info: • Planned Care Model references • www.improvingchroniccare.org • www.mainehealth.org Adapted from presentation by Ed Wagner M.D, MPH, Macoll Institute, Group Health Puget Sound