Circles of Care: A Transition to Patient Care Teams Story

1. Circles of Care: A Transition to Patient Care Teams Story

2. Presenters • Laurel Domanski Diaz, MNO, Director of Business Operations • Dan Gauntner, CNP, Director of Clinical Operations • Marianella Napolitano, RN, MBA, Clinical Quality Coordinator

3. Objectives • Participants will understand how safety net practices can implement a systematic approach to caring for their communities • Participants will learn how to organize a practice to allow staff members to work at the top of their licenses. • Participants will become familiar with how implementing care teams can improve the quality of care.

4. NFP Background • A Federally Qualified Community Health Center founded in 1980 • Last year served 13,400 patients on the near west side of Cleveland • 17 Providers on staff--8 Family Practice MDs, 6 Family Practice CNPs, 3 Certified Nurse Midwives • Focus on the medically underserved • Serve a large Hispanic population

5. Partnering with the community for everyone’s best health • NFP has always believed that partnering with a patient is the best way to achieve healthy outcomes. • NFP sees that the services provided to patients are each just one stop in a constant continuum of care that envelopes every patient into their own medical home. • NFP developed a model, Circles of Care, to transform our Community Health Center into a Care Team and EMR driven practice focused on Patient Centered Care.

6. Redesign Activities • Care Teams • EMR • Optimization • Continuous Improvement Processes

7. Why Care Teams? • Working from NFP’s 2009-2011 Strategic Plan, NFP identified the following areas to be addressed: • Improvement of patient’s health and safety • Improvement in NFP’s financial performance • Increased provider, staff and patient satisfaction • Becoming an NCQA Patient Centered Medical Home

8. Care Teams • A Care Team has been defined as: A panel of patients who usually see or choose a particular group of providers for their care AND the group of staff who generally work together for the care of that panel of patients.

9. Providers & Behavioral Health NFP Circles of Care NFP IT Staff & Medical Records Community Agencies Front Office Management & Executive Leadership Information Technology Administrative Clinical Billing & PBS Nurses, MAs, Patient Advocates OCHIN/ Epic Contract IT Staff Patient

10. Care Team Composition • Three Providers—combination of Family MDs, Family CNPs, (one team’s providers consists of 3 Certified Nurse Midwives) • One to two RNs • One to two Patient Advocates • Medical Assistant for each Provider • Front Office representative at each team meeting

11. Care Teams • Developing new procedures around scheduling, registering patients & directing phone calls to teams • Conducting training activities to facilitate team communication, structure and creating ongoing team meetings • Redesigning of nursing staff structure to provide individual nurses to care teams. • Organizing providers and support staff into integrated care teams. • Adding a Patient Advocate to each team

12. Team Training • Promoting the idea of team across the organization • Team formation activities prior to implementation • Team trainings help decrease hierarchical systems (TEAMSTEPPS, Practice Coaching) • Practice Coaching and facilitation

13. Team Meetings • Goal: Improve communication and increase efficiency across all disciplines • Commitment from the leadership • Financial investment • More frequently initially • Outside facilitator present at the beginning • Internal staff facilitates meetings

14. Team Huddles • Daily meetings at the beginning of the morning, may include the entire team, Provider and MA • Approximately 10 minutes • Provides MA with clear path of what needs to be done to prepare for the Providers entrance in the exam room

15. Patient Service Representative Role • Accurate team scheduling • Directing of patient inquiries (phone and in-person) to the appropriate team • Reinforcing PCMH message: scheduling with PCP, we do not operate as an urgent care • Serves as a member of the Care Team for Team meetings

16. Patient Advocates • Initially grant funded • Started with a focus on specific populations • Our Patient Advocates range from recent college grads to members of our community who have a background in activism or social work • Use of standing orders and protocols allow PAs to unload the provider and nursing workload • Each PA has a specialized area—Hispanic patients, women’s health, refugees, computer expertise • Increase patient’s access to the Care Teams by helping with patient communication and correspondence

20. Ancillary Support Services • Available In-Office Support includes: • On-site Behavioral Health • On-site Clinical Pharmacist • RNs provided by insurance companies • Wellness Coordinator • Medication Assistance Program • Diabetes Educational Sessions provided by local Diabetic Assoc.

21. Optimization • Enabling Providers to practice at highest scope • Professionals will work at the top of their licenses if: • They have people they can delegate to. At NFP this was done by increasing the skill set of: • Medical Assistants • Patient Advocates • There are effective communication methods • In-basket messages within the EMR to make clinical communication efficient • Team meetings for peer and cross professional feedback

22. Optimization (cont.) • Patient Advocates • Use evidence based protocols to address health disparities • Use registries to identify gaps in healthcare • Identify high risk patients for case management by nurses • Tracking and monitoring goals of the Health Center • Operational • Clinical • Developing policies and procedures for EMR system and Care Teams at NFP

23. Outcomes of the Circles of Care Project • NFP achieved Level 3 NCQA PCMH Accreditation with a score of 99% • In a Medicare Pilot Program on PCMH, NFP was the top scoring FQHC in the country. • Improved communication • Increased coordination • Improved quality of care for our patients

24. Patient Satisfaction – Decreasing wait time

25. Continued Wait Time Improvement

26. Financial Performance Improvement

27. HbA1c less than 8 • Increased from 48% to 62%

28. BP control in DM patients • Increased from 72% to 79%

29. DM patients who had a Foot Exam • Challenges tracking this information • Increase coordination and communication with all team members

30. Questions?