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Patient Centered Medical Home: A Team Sport

Patient Centered Medical Home: A Team Sport. 1. University of Nebraska Medical Center 2. Mount Sinai School of Medicine . Katherine J. Jones, PT, PhD 1 Jane Potter, MD 1 Andrew Vasey, MD 1 Audrey Chun, MD 2. 2011 Reynolds Grantee 9th Annual Meeting

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Patient Centered Medical Home: A Team Sport

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  1. Patient Centered Medical Home: A Team Sport • 1. University of Nebraska Medical Center • 2. Mount Sinai School of Medicine Katherine J. Jones, PT, PhD1 Jane Potter, MD1 Andrew Vasey, MD1 Audrey Chun, MD2 • 2011 Reynolds Grantee 9th Annual Meeting • Creating a Learning Community for Academic Geriatricians

  2. University of Nebraska Medical Center Objectives • Describe system redesign, culture change, and teamwork as foundational to the PCMH • Use the MOS to identify areas of culture in need of improvement to support the PCMH • Identify the key principles of teamwork taught in the TeamSTEPPS Curriculum • Describe examples of how results from the MOS have guided system redesign and implementation of teamwork to support PCMH at UNMC • Recognize universal barriers to implementing large scale organizational change such as PCMH 2

  3. University of Nebraska Medical Center PCMH Background • 1960’s: American Academy of Pediatrics • 1990’s: “Chronic Care Model” • 2000’s: • AAFP demonstration projects • Patient-Centered Primary Care Collaborative (PC-PCC) made up of AAFP, ACP, AOA, AAP • NCQA charged with development of criteria • PC-PCC: Joint statement on PCMH • What is it? • What should payment look like? 3

  4. University of Nebraska Medical Center Joint Principles • “The PCMH is an approach to providing healthcare” • “The PCMH is a setting that facilitates partnership between provider and patients” 4 http://www.ncqa.org/tabid/631/Default.aspx, last accessed May 21, 2010

  5. University of Nebraska Medical Center Joint Principles • Personal physician • Physician-directed medical practice (Team) • Whole person orientation: “All stages of life” • Care is coordinated and integrated • Quality and Safety • Enhanced Access • Payment reform 5 http://www.ncqa.org/tabid/631/Default.aspx, last accessed May 21, 2010

  6. University of Nebraska Medical Center Definition of a Medical Home • One physician serves as the main point of coordination for a patient’s health care across the continuum of care including referrals to specialist physicians, hospital care, and post-acute care. • The purpose of the medical home is to enhance the coordination of care within the interprofessional team, improve the quality of the patient/physician relationship, and decrease overall health care costs. Rosenthal, T. C. (2008). The medical home: Growing evidence to support a new approach to primary care. Journal of the American Board of Family Medicine : JABFM, 21(5), 427-440 6

  7. University of Nebraska Medical Center NCQA Certification • Principles into Process: • Practice… • …downloads material from NCQA • …documents protocols, data, procedures, etc. • …submits materials to NCQA • Practice receives a score and a “Tier” of certification 7 http://www.ncqa.org/tabid/631/Default.aspx, last accessed May 21, 2010

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  9. University of Nebraska Medical Center Geriatrics & PCMH A natural partnership Geriatrics: team-based, whole person care for older adults aligns with: • Joint principles of primary care collaborative • Potential increased reimbursements with demonstration projects, healthcare and insurance reform • Competencies/curricular redesign for residents and medical students and milestones project 9

  10. University of Nebraska Medical Center Opportunities • Improve patient care: transitions, access, education, self-management, avoid unnecessary hospitalizations, improve health and decrease overall healthcare costs. • Imbed Geriatrics QI into standard care. • Improve patient and staff satisfaction. • Reduce burnout (and encourage trainees to explore primary care as desirable option). 10

  11. University of Nebraska Medical Center Successful Implementation PCMH • Requires system redesign: • Practice organization • Health information technology • Quality measures • Consideration of the patient’s experience • Team approach to patient care • Is there a way to measure your current office culture and readiness for change? 11

  12. University of Nebraska Medical Center Developed by AHRQ to provide outpatient medical offices with a valid tool to determine whether the office culture: Emphasizes patient safety Facilitates teamwork and discussion about mistakes Engages in continuous learning & improvement Pilot tested 2007 – 2009 with 10,567 staff from 470 medical offices - preliminary comparative database Comparative database in development http://www.ahrq.gov/qual/patientsafetyculture/mosurvindex.htm Medical office survey on patient safety Culture (MOS) and The Medical Home

  13. University of Nebraska Medical Center Becoming a PCMH • Differences from practice to practice • Different accreditation organizations • NCQA • URAC • Joint Commission • AAAHC 13

  14. University of Nebraska Medical Center Becoming a PCMH • NCQA and MOS • Access/communication • Patient tracking/registries • Care management • Patient self management support • Test tracking • Electric prescribing • Referral tracking • Performance reporting and improvement • Advanced electronic communication 14

  15. University of Nebraska Medical Center Definition of Safety Culture • Enduring, shared, LEARNED1 beliefs and behaviors that reflect an organization’s willingness to learn from errors2 • Beliefs consistent with goals of PCMH3 • We use teamwork to coordinate care for patients • We communicate effectively • We close the loop…test results, preventive care, monitoring • We use standard processes to work efficiently and share information with patients, families, other providers • We report and learn from mistakes Schein, E. Organizational Culture and Leadership. 4th ed. San Francisco, CA: John Wiley & Sons; 2010. 2. Wiegmann. A synthesis of safety culture and safety climate research; 2002. http://www.humanfactors.uiuc.edu/Reports&PapersPDFs/TechReport/02-03.pdf 3. Rosenthal, 2008; Bodenheimer, Wagner, & Grumbach, 2002; American Academy of Family Practice http://www.aafp.org/online/en/home/membership/initiatives/pcmh.html 15

  16. University of Nebraska Medical Center MOS – 52 Items in 12 Dimensions • Communication about Error • Communication Openness • Information Exchange with Other Settings • Office Processes and Standardization • Organizational Learning • Overall Perceptions of Patient Safety and Quality • Owner/Managing Partner/Leadership Support for Patient Safety • Patient Care Tracking/Followup • Patient Safety and Quality Issues • Staff Training • Teamwork • Work Pressure and Pace 16

  17. University of Nebraska Medical Center “…in many organizations, values reflect desired behavior but are not reflected in observed behavior.”Schein, E.H. Organizational Leadership and Culture 4th ed. San Francisco: John Wiley & Sons; 2010, p.24, 27. http://search.dilbert.com/search?w=values&view=list&filter=type%3Acomic&x=44&y=19

  18. University of Nebraska Medical Center The MOS (Cont.) • Two overall rating questions • Health care quality (effective, patient-centered, timely, efficient, equitable) • Patient safety • Ten items to assess TeamSTEPPS at Baseline (Modification of the MOS by UNMC to assess impact of TeamSTEPPS program on culture) • Team Training experience • Knowledge of TeamSTEPPS Tools (alpha=0.71) • Adoption of Team Behaviors (alpha=0.79) 18

  19. University of Nebraska Medical Center MOS Methodology • Feb. – March 2011 Baseline assessment • Personalized paper surveys using Dillman 4-contact method • Population Surveyed • Geriatric clinic (n=18) • Resident-run Mid-Town clinic (n=54) • Response Rates • 18/25 = (72%) • 54/74 = (73%) • Scanned and entered in database

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  21. University of Nebraska Medical Center Implementing Key Elements of Medical Home Require Teamwork • Sustained relationships • Manage complexity of chronic conditions • Focus on patient/caregiver self-management • Maintain complete record of care 21

  22. University of Nebraska Medical Center Team Strategies & Tools to Enhance Performance & Patient Safety “Initiative based on evidence derived from team performance…leveraging more than 25 years of research in military, aviation, nuclear power, business and industry…to acquire team competencies” http://teamstepps.ahrq.gov/ 22

  23. University of Nebraska Medical Center Outcomes of Team Competencies • Knowledge • Shared Mental Model • Attitudes • Mutual Trust • Team Orientation • Performance • Adaptability • Accuracy • Productivity • Efficiency • Safety http://teamstepps.ahrq.gov/ 23

  24. University of Nebraska Medical Center Fundamentals Course April 30, 2011 • Module 1—Introduction • Module 2—Team Structure • Module 3—Leadership • Module 4—Situation Monitoring • Module 5—Mutual Support • Module 6—Communication • Module 7—Summary—Pulling It All Together http://teamstepps.ahrq.gov/ 24

  25. University of Nebraska Medical Center *p= .678 *p < .001 25

  26. University of Nebraska Medical Center 26

  27. Midtown Clinic Selected areas needing improvement from Medical Office Survey and steps taken to achieve change 27

  28. University of Nebraska Medical Center Midtown Clinic • Site for resident continuity clinic • 4 residents per staff MD • Resident Board of Directors • Onsite Social worker and mental health provider • Pharmacy residents • Nurse coordinator, RNs, LPNs, MAs, Radiology technician • More than 10,000 patient visits annually 28

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  30. University of Nebraska Medical Center % Positive = Most of time/Always % Neutral = Sometimes % Negative = Never/Rarely Midtown Clinic (n=54) 30

  31. University of Nebraska Medical Center % Positive = Most of time/Always % Neutral = Sometimes % Negative = Never/Rarely Midtown Clinic (n=54) 31

  32. University of Nebraska Medical Center % Positive = Most of time/Always % Neutral = Sometimes % Negative = Never/Rarely Midtown Clinic (n=54)

  33. University of Nebraska Medical Center % Positive = Most of time/Always % Neutral = Sometimes % Negative = Never/Rarely Midtown Clinic (n=54)

  34. University of Nebraska Medical Center Action Plan for the Midtown Clinic • Major Concerns: • Patient Care Tracking and Follow-Up • Action Plan: • Sent out reminders for annual check-up to patients around time of birthday. • Participated in call back trend analysis: calls received by the triage nurses from patients were tracked and categorized by topic of the call (such as medication information, appointment reminders, test result information, etc.) and the patient’s resident, in order to give the resident a better idea of ways to improve patient care and follow-up. 34

  35. University of Nebraska Medical Center Scale = Strongly Disagree – Strongly Agree Midtown Clinic (n=54) 35

  36. University of Nebraska Medical Center Action Plan for the Midtown Clinic • Major Concerns: • Office Processes and Standardization • Action Plan: • New resident orientation to the Mid-Town Clinic 36

  37. University of Nebraska Medical Center Small group exercise • Break into 4 groups • assume a role during the discussion: • Attending (2), resident/fellow (4), APRN (2), medical assistant (2), clinic nurse (2), receptionist/scheduler (2). • Example 37

  38. Geriatrics Clinic How the MOS identified problems and set us on a course for improvement using newly enhanced team skills 39

  39. University of Nebraska Medical Center Overall MOS results(graphic)

  40. University of Nebraska Medical Center Team STEPPS Team Training • Gave us the tools for improvement • Provided a common language and expectations • Made safety, quality and satisfaction (for patients and staff) a common goal 41

  41. University of Nebraska Medical Center Change Team • Who: Social Work, RN, NP, Front Desk, MD, Admin Support • How: weekly, now 2-3x/month meetings • What: address issues identified by the MOS; review what worked (or not); continue the process 42

  42. University of Nebraska Medical Center Scale %(+) = 0-2x past 12 mos.; %(N) = Monthly, SevXs/yr; %( -)= dly/wkly Work Pressure and Pace Geriatrics Clinic (n=18) 43

  43. University of Nebraska Medical Center How do we work with our patients more effectively and efficiently and feel less stressed in clinic? • Implement: briefs, huddles, debriefs, situation monitoring, task assistance • Briefs: we know who you (the patient) are and why you are here; we know where schedule will be hectic (anticipate task assistance). • Huddles: when things aren’t going well, fix it immediately (need for huddles reduced with situation monitoring and offers of task assistance) • Debriefs: what worked, what didn’t, what are anticipated patient follow up needs 44

  44. University of Nebraska Medical Center Scale = Strongly Disagree – Strongly Agree Office Processes and Standardization Geriatrics Clinic (n=18) 45

  45. University of Nebraska Medical Center How do we improve workflow in this office and make sure work is done correctly? • Reorganize into care teams for groups of patients • Nurse, NP, MD (SW and Pharmacy available) • All inter-visit communications is with a primary nurse who knows the patient • Team members communicate face-to-face at least once weekly and all other communication is through the electronic record 46

  46. University of Nebraska Medical Center Summary PCMH is an innovation “Getting a new idea adopted, even when it has obvious advantages, is difficult…a common problem for many individuals and organizations is how to speed up the rate of diffusion of an innovation.” Rogers EM. (2003). Diffusion of Innovations (5th ed.). New York, NY: Free Press, p. 1.

  47. University of Nebraska Medical Center Challenges to Large Scale Change • No sense of urgency • Change is not presented as a clear advantage • Change is overly complex • No plan for role modeling and rewarding new behaviors • Lack of management support • No champion(s) • No evidence the change is a priority (flavor of month) • Lack of resources (time, $, people, equipment) • Change not hard-wired into policies/procedures, job desc. • Change is not evaluated 48

  48. University of Nebraska Medical Center Helfrich CD, Weiner BJ, McKinney MM, Minasian L. (2007). Determinants of implementation effectiveness: Adapting a framework for complex innovations. Medical Care Research and Review;64(3):279-303. 49

  49. University of Nebraska Medical Center University of Nebraska Medical Center Questions?

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