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Complex Care Coordination: Development of A New Role

Complex Care Coordination: Development of A New Role. Paige Hatcher, MD - Diplomate , ABFM - Preventive Medicine Resident, OHSU - MPH Candidate, PSU - Health Policy Fellow, OHA. Capacity. Average panel size as the population ages is estimated to increase to 2300 per PCP 1 .

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Complex Care Coordination: Development of A New Role

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  1. Complex Care Coordination: Development of A New Role Paige Hatcher, MD - Diplomate, ABFM - Preventive Medicine Resident, OHSU - MPH Candidate, PSU - Health Policy Fellow, OHA

  2. Capacity • Average panel size as the population ages is estimated to increase to 2300 per PCP1. • This would require 7.4 hours a day to provide all their needed preventive care2 and 10.6 hours a day to manage their chronic conditions3. • 15 minute FFS model

  3. Share the CareTM • Thomas Bodenhemier, UCSF and California HealthCare Foundation • Based on model for caregiver support • Shift from lone doctor with helpers • Physician has responsibility to make all the decisions and delegates tasks • Delegating tasks from doctor to team implies less work for doctor and more work for others • “We” paradigm means relocating responsibility. The panel is cared for by the team. Ghoroh, A., & Bodenheimer, T. (2012). Share the Care: Building Teams in Primary Care Practices. Journal of the American Board of Family Medicine, 25(2), 143-145.

  4. Share the CareTM • Co-location • Team Goals • Mapping Team Workflow • Team Training, Meetings, and Expectations • Standing Orders

  5. Key Elements of Team Building • Defined Goals and specific, measurable operational objectives • Clinical and Administrative systems • Division of labor • Training and Cross-training • Communication Structures and Processes Grumbach, K. (2004). Can Health Care Teams Improve Primary Care Practice? JAMA: The Journal of the American Medical Association, 291(10), 1246-1251. doi: 10.1001/jama.291.10.1246

  6. Team Size and Composition • Optimal size 6-12 members to prevent increasing complexity and number of handoffs • Protected time required for all team members • Redefinition of existing roles, or creation of new ones, is critical • Stability of membership important • Culture Changes/hierarchy

  7. Low-Hanging Fruit Procedures for providing prescription refills Escobedo, J. (2002). Rethinking Refills. Family Practice Management, 9(9), 55-56.

  8. Low-Hanging Fruit Pre-visit scrub for preventive care

  9. Low-Hanging Fruit Visual Measures The Power of a Green Dot!

  10. Huddles General Rules • Meet prior to each session in a central location • Limit the time to several minutes • Cover the same agenda every time Stewart, E. E., & Johnson, B. C. (2007). Huddles: Improve Office Efficiency in Mere Minutes. Family Practice Management, 14(6), 27-29.

  11. Huddles • What is needed for the day? Equipment, staff, extra time, etc. • Are there any obvious changes that need to be made to the schedule? (errors, rooming particular patients early or late, etc.) • Schedule issues for the day (meetings, breaks, other providers) • Records or lab results that are needed • Identify schedule “bottlenecks”

  12. Low-hanging Fruit • Procedures for informing patients of laboratory results • Team meetings led by non-physicians • Conflict ResolutionTraining

  13. Economic Impact • Cost per visit hasn’t decreased so far, but satisfaction and turnover have improved tremendously. • Physicians estimate that 50% of their time is spent on activities that could be performed by caregivers with far less training • Services provided outside the visit, and by non-physicians are harder to bill. • May increase volume and access and decrease costs to system at-large. Bodenheimer, T. (2007, July). Building Teams in Primary Care: Lessons Learned (Rep. No. ISBN 1-933795-30-1).

  14. Teamlet • Previsit • Huddle • Agenda Setting • Medication Reconciliation • Ordering Routing Services • History Taking • Visit • Postvisit • Soliciting Patient Concerns • Closing the Loop • Goal Setting • Navigating the System Bodenheimer, T., & Laing, B. Y. (2007). The Teamlet Model of Primary Care. The Annals of Family Medicine, 5(5), 457-461. doi: 10.1370/afm.731

  15. Additional References 1. Alexander, G.C., J. Kurlander, M.K. Wynia. “Physicians in retainer (“concierge”) practice. A national survey of physician, patient, and practice characteristics.” Journal of General Internal Medicine 2005; 20:1079–83. 2. Yarnall, K.S., K.I. Pollak, T. Ostbye, K.M. Krause, J.L. Michener. “Primary care: is there enough time for prevention?” American Journal of Public Health 2003; 93:635–41. 3. Ostbye, T., K.S. Yarnal, K.M. Krause, K.I. Pollak, M. Gradison, J.L. Michener. “Is there time for management of patients with chronic diseases in primary care?” Annals of Family Medicine 2005; 3:209–14.

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