Office Redesign for Best Chronic Illness Care

1. Office Redesign for Best Chronic Illness Care Carrie Nelson, MD, MS, FAAFP The Nuts and Bolts of the Patient Centered Medical Home Conference June 25, 2010

2. Purpose The goal of this presentation is to understand how the Planned Care Model can be put into practice to improve the quality and reliability of patient care. (And make practice more fun!)

3. Learning Objectives Following this presentation, participants should be able to: • Describe the goals and key components of the Planned/Chronic Care Model. • Describe how planned care, an optimal health care team and a prepared, proactive patient come together to support a successful care delivery system. • Describe the goals of self-management support and articulate the key sources for successful health behavior change. • Describe the model for improvement.

4. Implementing Change Results Process Relationships

5. Planned Care Model We must move away from rewarding individual heroic efforts and focus on building smooth, effective processes and teamwork throughout the office. OR

6. The Media Loves a Hero…but Success Loves a Team I'm proud of the fact that my crew and I were up to the challenge with which we were confronted.

7. Planned Care Model We can consciously design our systems so that providing the best care is the default outcome even on the busiest, most chaotic of days.

8. A Typical Day at the Office

9. The AAFP Perspective PCMH Practice-based Care Team Great Outcomes Great Outcomes Health Information Technology Practice Management Practice Organization Health IT Care Management Quality Built In Patient Experience Access to Care and Information Quality and Safety Family Medicine Foundation Continuity of Care Services Practice Services *c/o AAFP

10. Developed by The MacColl Institute ®ACP-ASIM Journals & Books

11. The Essential Basis for Good Planned Care Prepared Practice Team Informed, Activated Patient Productive Interactions

12. What characterizes a “prepared” practice team? Prepared Practice Team • At the time of the visit, they have • the patient information • decision support • skills • equipment • and time • required to deliver evidence-based clinical management and self-management support.

13. What characterizes an “informed, activated” patient? Informed, Activated Patient • Understands the disease process, • Realizes his/her role as the daily self manager • Has the tools to do so effectively • With the support of family and caregivers.

14. Clinical Information Systems Registry and/or EHR? Reminder systems? Recall plans?

15. Clinical Information Systems • We know who our patients with each condition are. • We are reminded of what care they need. • We can recall patients for timely care. • We can monitor the performance of our team and system.

16. Registry References • EHR capable of reminders, recalls and reports • C-DEMS or commercial registry • California Healthcare Foundation review: http://www.chcf.org/~/media/Files/PDF/C/ChronicDiseaseRegistryReview.pdf • Build your own in Excel or Access • Paper cards

17. Lest We Think IT Will Solve Everything… There’s more to the Planned Care Model

18. Decision Support Evidence-based care? Accessible patient info? Guidelines embedded into daily practice? Staff decision rules?

19. Decision Support What is the best care and how do we make it happen every time? Don’t fall victim to the crystal ball… What kind of day will today be?

20. Delivery System Design Care team roles optimized? Proactive planned visits? Patient-centered access? Efficient flow of patients & information? Group visits?

21. Delivery System Design We know what the right care is. How do design our care processes so that right thing to do is the easy thing to do?

22. Delivery System Design • Schedule set times to plan care • Standing orders and protocols • Optimize care team roles • Huddles • Group visits

23. Group Visits • Many different structure options • A Guide to Group Visits for Chronic Conditions Affected by Overweight and Obesity: http://www.aafp.org/online/etc/medialib/aafp_org/documents/clinical/pub_health/aim/groupvisits.Par.0001.File.tmp/GroupVisitAIM.pdf • Group Visit Starter Kit

24. Self-management Support Collaborative goal-setting? Emphasis on patient’s role? Incentives & support for self-management?

25. Self-management Support • A major culture change, for patients and the health care team • It can take time and patience (less so than you might think), but is ultimately more efficient • It is rewarding

26. What’s does it take to change? • Readiness • Importance • Confidence Motivation

27. Self-management Support X Remove guilt No more “noncompliant” patients Use customized tools Discover how each patient learns best

28. New Health Partnerships www.newhealthpartnerships.org Initiative of the IHI Designed to raise awareness of self-management support Supported by more than 20 organizations, including AAFP, AAP, NCQA, NQF and RWJF

29. The Model for Improvement

30. Act Plan Study Do Model for Improvement Aim What are we trying to accomplish? How will we know thata change is an improvement? Measures What change can we make that will result in improvement? Ideas Act Plan Study Do From: Associates in Process Improvement

31. The PDSA Cycle for Learning and Improvement Act Plan • Objective • Questions and • predictions (why) • Plan to carry out the cycle • (who, what, where, when) • Plan for data collection • What changes • are to be made? • Next cycle? Study Do • Complete the • analysis of the data • Compare data to • predictions • Summarize • what was • learned • Carry out the plan • Document problems • and unexpected • observations • Begin analysis • of the data From: Associates in Process Improvement

32. Repeated Use of the PDSA Cycle Model for Improvement What are we trying to accomplish? How will we know thata change is an improvement? What change can we make that will result in improvement? A P S D D S P A A P S D A P S D Changes That Result in Improvement Evidence & Data Implementation of Change Test new conditions Learning and Improvement Follow-up Tests Hunches Theories Ideas Small Scale Testing From: Associates in Process Improvement

33. Multiple PDSA Cycle Ramps P P P P A A A A D D D D S S S S S S S S D D D D A A A A P P P P A A A A P P P P S S S S D D D D P P P P A A A A D D D D S S S S Testing and adaptation Group visits Adopt guideline Non-MD roles in visit flow Registry Change Concepts From Associates in Process Improvement

34. CME: www.YHPlus.com New and Improved IT Platform • How to Conduct a Quality Improvement Program in Primary Care Practice • Managing Childhood Asthma in Primary Care: A Quality Improvement Program • Managing Adult Depression in Primary Care: A Quality Improvement Program • Managing COPD in Primary Care: A Quality Improvement Program • Managing Heart Failure in Primary Care: A Quality Improvement Program • Managing Diabetes in Primary Care: A Quality Improvement Program • Managing Substance-Use Disorders in Primary Care: A Quality Improvement Program

35. Supplement Volume 8 2010: Review of the AAFP National Demonstration Project • Both facilitated and self-directed NDP practices made substantial progress toward implementing the predominantly technological components of the NDP model • Roles and identities need to change if a practice is to get beyond incremental change and actually transform • Such change may require personal transformation

36. Home Sweet Home

37. Thank You Carrie Nelson, MD, MS,FAAFP Medical Director, Your Healthcare Plus McKesson Health Solutions 224-542-8071 Carrie.nelson@mckesson.com