Delivery System Design

1. Delivery System Design Cory Sevin RN, MSN, NP Nancy Gilliam Anaheim, California February 12, 2005 HDC Learning Session 1 2005

2. Goal of the Session For you all to be excited to go home and test breakthrough changes in how your care processes are designed!

3. Chronic Care Model You are here Community Health System Resources and Policies Health Care Organization Self-Management Support DeliverySystem Design ClinicalInformationSystems Decision Support Informed, Activated Patient Prepared, Proactive Practice Team Productive Interactions Functional and Clinical Outcomes

4. Our systems are not designed to get quality outcomes in anything other than acute care. • We know that many patients do not receive evidence based care and do not feel listened to • We know that patients are often not active participants in their care • We know that many health care providers and staff are working very hard

5. Observation of organizations making breakthrough outcomes shows they have…… • Clearly identified care teams for patients • Clear roles for all team members • Continuity • Cleared system of chaos and waste

6. To Improve Outcomes: • Patients must be prescribed and taking proven therapies • Patients must be managing their illness well • Patient course must be followed for changes in status and reinforcement • Interactions must be productive • I believe, health care workers must enjoy and get satisfaction out of what they do every day • Our systems of care must be efficient and effective.

7. How would I recognize a productive interaction? Prepared Practice Team Informed, Activated Patient Productive Interactions • Assessment of self-management skills and confidence as well as clinical status • Tailoring of clinical management by stepped protocol • Collaborative goal-setting and problem-solving resulting in a shared care plan • Active, sustained follow-up

8. Delivery System Design Key Leverage Points! • Define roles and distribute tasks amongst team members. • Use planned interactions to support evidence-based care. • Provide clinical case management services. • Ensure regular follow-up. • Give care that patients understand and that fits their culture

9. Define roles and tasks All team members have a role. Leverage Point 1

10. Define Roles and Tasks • Team development: is there an identified team for each patient? • Are all clinic staff seen as being on the team? • Review process for care: who is doing what? • Is this the best use of their time? • Assign tasks, matching licensure and skills. • Cross train staff • Use protocols and standing orders

11. Reduce Chaos and Waste to create resources for planned care • Create processes so that the patient, provider, information, room and equipment are ready at the same time. • Providers do provider work and everything else gets done by others • Predict and anticipate needs:know your slow and busy seasons, have plans for repeat tasks like school physicals, etc. • Subtract unnecessary work • Optimize rooms and equipment: standardize

12. Examples: Roles and Tasks Ensuring follow-up for depression patients • Providers (both PCPs and BHCs) place red “dots” on medical record for patients they place into the collaborative • Medical Records staff identifies collaborative patients based on the red “dots” and places blank PECS encounter notes on the chart when a follow-up has been scheduled • Nursing staff identifies collaborative patient and checks for lapsed appointments and informs providers • BHC either sees patients as a walk-in or schedules follow-up appointment while patient is in the clinic

13. Roles in Team Care To ensure follow-up appointments are scheduled:

14. PDSA the MA doing LEAP exams PDSA MA’s filling out forms PDSA the nurse calling back about some lab results Other ideas? PDSA A P S D D S P A A P S D A P S D Test Roles and Tasks

15. Use planned interactions to support evidence-based care One-on-one, group, telephone, email, outreach….the possibilities are endless Leverage Point 2

16. Set up system so the default, when possible, is to provide evidence based care, planned care.

17. Create your system to make planned interactions easy! • Make sure all patients are connected to a PCP and a care team. • Measure continuity • Use daily huddles • Systematize to reduce waste and chaos…the time can be spent actually working with patients!

18. What is a Planned Care? • Planned Care is when the patient receives the right interaction at the right time by the right person. It is a system issue……. • A Planned Visit is an encounter with the patient initiated by the practice to focus on aspects of care that typically are not delivered during an acute care visit.

19. What does Planned Care look like? • The provider team knows the patients who need evidence based care and proactively reach out to the patient. • Delivery of clinical management and patient self-management support are the key aspects of care. • The care team is ready and prepared to provide evidence based care at all times. • Visits occur at regular intervals as determined by provider and patient.

20. PDSA real time communication methods (co-location of team members, walkie talkies) PDSA how registry reports inform the care team PDSA inviting patients to a Planned Visit or a Group Visit Other ideas? Potential Planned Care PDSA’s PDSA’s

21. How do you do a Planned Visit? You Plan It!

22. Patients with higher suicide risk Step 1 • Identify patients with higher suicidal risk based on a score greater than 0 on question 9 of the PHQ • For Decision Support, generate a list of patients meeting the criteria • PCPs and BHCs are provided the list and can ensure appropriate follow-up is conducted based on the treatment guidelines

23. Step Two: Patient Outreach for Depression • Receptionist/Patient Account Rep identifies last visit by the patient and if a follow-up has been scheduled (in the appropriate time frame) • If no follow-up has been scheduled the PAR works with the patient to schedule an appointment • Patient is offered the opportunity to talk to the BHC at that time if things aren’t going well • The appointment is scheduled with the phrase Depression Follow-up in the reason code

24. Step Three: Preparing for the Depression Follow-up Visit • Medical Records sees that the patient is a collaborative patient and attaches the blank PECS encounter note • Both the nursing staff and the providers see that the reason for the visit is a follow-up for Depression so they can ensure that the patient receives a depression screen

25. Step Four: The Depression Visit • Review how the patient is doing/feeling • Adjust remaining medications as needed • Review the self-management goals • Problem solve barriers to treatment • Adjust self-management goals • Schedule follow-up with the BHC and/or the PCP

26. Step 5: Depression Follow-up • Follow-ups are generally scheduled with the BHC • Phone follow-ups by the BHC are conducted within 1-2 weeks of initial visit • Patients that are unwilling to see the BHC are scheduled a depression follow-up with the PCP • Lapsed appointments are tracked and patients that haven’t had a follow-up in 4-6 weeks are contacted to schedule an appointment.

27. Group Visits • Patients brought in by clinically relevant groups • Patients can receive: • Specialty service as needed/available • One-on-one with medical provider • Medication counseling • Self-management support training • Social support • Multiple Models for Group Visits

28. Group Visits: Success • Weekly depression groups are conducted. Patients attend and the success stories from the groups are impressive. Patients that couldn’t get out of bed are now able to successfully hold down a job. The patients are supportive of one another. • Keys to success: • Involve the providers in the referral process • Utilize open group format • Develop curriculum that empowers patients • Utilize community resources

29. Provide clinical case management services for complex patients. Knowing who needs more support and finding a way to deliver it. Leverage Point 3

30. Casemanagement Many different things to different people • Resource coordination • Utilization management • Follow-up • Patient education • Clinical management

31. Key Changes for Casemanagement • Develop patient selection criteria: who needs what kinds of services? • Who can provide casemanagement? • Review team roles and tasks and fill in gaps. • Assure that patients receive CM services. • Link into community resources

32. Features of effective Casemanagement • Regularly assess disease control, adherence, and self-management status • Either adjust treatment or communicate need to physician immediately • Provide self-management support • Provide more intense follow-up • Assist with navigation through the health care process

33. Who can be a casemanager? • Evidence suggests that non-professionals can be trained to perform follow-up and assessment. • That alone when linked to a physician or nurse case manager has improved outcomes in depression and arthritis • Automatic Voice Response telephone systems can perform this function.

34. Casemanagement Use combination of resources. For example: • For Decision Support, produce reports that show patients needing follow-up • Clerical Staff can review schedules and contact patients that need appointments • BHC contacts patients needing early follow-up, interventions or referrals

35. Casemanagers: examples • Trained lay health professionals provide: • Follow-up • Patient education • Registry management • Self-management support • Facilitate group visits • Liaison to community resources • Can be an important link to cultural issues affecting outcomes.

36. PDSA’s for casemanagement • PDSA front desk staff to use registry to identify and call patients who need follow-up appointments • PDSA a lay health professional to help patients develop self-management goals • Other ideas?

37. Ensure regular follow-up by the primary care team The alternative to lost to follow-up…there is strong evidence that it makes a big difference in chronic illness. Leverage Point 4

38. Make Follow-Up Work for You • Develop process for follow-up • Tailor follow-up to patient and provider needs • Eliminate unnecessary follow-ups • Schedule follow-up. • Monitor for missed follow-up. • Reach out to those not attending follow-ups.

39. Think out of the box…. • Face-to-face • Clinical case manager • Outreach worker • In groups • Phone • E-mail

40. City of Austin Depression Results • Improved identification of depression patients • Improved teamwork between providers • Improved self-management goal setting (11% to 91%) • Improved scheduling of follow-ups, implementing early phone follow-ups • Standardized use of tools

41. Example: Patients with higher suicide risk Step 1 • Identify patients with higher suicidal risk based on a score greater than 0 on question 9 of the PHQ • For Decision Support generate a list of patients meeting the criteria • PCPs and BHCs are provided the list and can ensure appropriate follow-up is conducted based on the treatment guidelines

42. Leverage Point 5 • Give care patients understand and fits their culture • Connect patients to a care team who will get to know them and they trust • It is more than just translating…..

43. Goal of the Session For you all to be excited to go home and test breakthrough changes in how your care processes are designed!