Patient-Centered Care

1. Patient-Centered Care VA is changing the way health care is delivered by shifting from a problem-based health care system, to one that is patient-centered and healing Key Components

2. Patient Aligned Care Team Replaces episodic care based on illness and patient complaints with coordinated care and a long term healing relationship THE PRIMARY CARE TEAM

3. Future of VA Health Care

4. The Patient’s View of Primary Care

5. Patient Aligned Care Team Access Offer same day appointments Increase shared medical appointments Increase non-appointment care • Care Management & Coordination • Focus on high-risk pts: • Identify • Manage • Coordinate • Improve care for: • Prevention • Chronic disease • Improve transitions between PCMH and: • Inpatient • Specialty • Broader Team • Practice Redesign • Redesign team: • Roles • Tasks • Enhance: • Communication • Teamwork • Improve Processes: • Visit work • Non-visit work Patient Centeredness: Mindset and Tools Improvement: Systems Redesign, VA TAMMCS Resources: Technology, Staff, Space, Community

6. Other Team Members • Clinical Pharmacy Specialist: ± 3 panels • Clinical Pharmacy anticoagulation: ± 5 panels • Social Work: ± 2 panels • Nutrition: ± 5 panels • CaseManagers • Trainees • Integrated Behavioral Health • Psychologist ± 3 panels • Social Worker ± 5 panels • Care Manager ± 5 panels • Psychiatrist ± 10 panels For each parent facility HPDP Program Manager: 1 FTE Health Behavior Coordinator: 1 FTE My HealtheVet Coordinator:1 FTE Panel size adjusted (modeled) for rooms and staffing per PCMM Handbook Monitored via Primary Care Staffing and Room Utilization Data report in VSSC *The Patient’s Primary Care Team

7. “Ways In” a practice OLD New Visits Phone e-mail Visits

8. Changes in Primary Care

9. PACT Primary Care Teamlet Veteran Health Tech or Clerk RN Care Manager Health Tech, LPN or Medical Assistant • Customer Service • Initial point of contact • Patient Advocate • Address customer service concerns & coordinating solutions. • Hand-off communication • Assists providers • Prepare paperwork requested by the Veteran and/or PCP • Specialty consult completion tracking • Coordinate information exchange for the co-managed patient • Manage telephone demand (receiving and documenting) • Manage appointment scheduling including EWL & recall. • Pre-visit patient reminder calls • Face to Face Visits • Appointment check in • Assists w/My HealtheVet registration • Performs In-Person Authentication • Assists with updating and verifying demographics and insurance information • Team Work • Daily huddle • Team Meeting • Clinic support • Identify & prepare required forms, documents/records prior to clinic session • Faxing, copying, mail mgt • Manage clinic grids • Manage office supplies & setup • Direct Patient Care • Scheduled Clinic Visits • Walk in or Urgent Visits • Group Visits • Telephone Visits • Incoming telephone demand • Triage/place orders by protocol • Pertinent Clinical Reminders • Secure Messaging • Triaged messages from patients • E-mail with consultants • Care Management • Virtual/F2F in-depth and ongoing review of patients including inpatients • Identify high risk for hospitalization. • Initiate appropriate consultations for CCHT, CM, OEF/OIF, HBPC, hospice/palliative care • Discuss care with specialty consultants • Preventive/chronic disease care needs • Triage to other team members as appropriate • Non VA records • View alerts • Follow-up calls • Team Work • Daily huddle • Team Meeting Education • New patient orientation • Mentor/precept nurse trainees • Patient health education/coaching • Direct Patient Care • Assist with triage • Assist providers with exams/procedures • Perform treatments (EKGs, V/S, blood sugar, etc) • Administer meds, wound care • Pertinent Clinical Reminders • Secure Messaging • Triage messages from patients • Care Management • Track/administer required immunizations • Triage phone calls for appointments • Coordinate group visits • Identify additional services needed by Veteran/Family • Team Work • Daily huddle • Team meetings • Education • New patient orientation • Assist with patient education • Clinic Support • Daily equipment/supply checks • Keep exam rooms stocked • Schedule appointments • As needed or requested by primary care team • Appointment check in (including correct ID) • Utilizes kiosk to check in when available (performs In-Person Authentication) • Updates insurance & demographic info • Face to Face Visits • Arrive on time • Bring medications • Required Paperwork • Health risk assessment completion (with RN) • Lab work completion • Prepare for Primary Care Visit • Discuss concerns and plan of care • Utilize My HealtheVet • Contact PC “teamlet” with any problems/concerns that arise during/after face to face encounter. • Participate • Attend committees, patient advisory groups, and task forces Provider (Physician, NP, or PA) • Direct Patient Care • Scheduled Clinic Visits • Walk in or Urgent Visits • Group Visits • Telephone Visits • Incoming telephone demand • Pertinent Clinical Reminders • Secure Messaging • Triaged messages from patients • E-mail with consultants • Care Management • Virtual review of patients including inpatients • Identify high risk for hospitalization. • Appropriate for CCHT, OEF/OIF, HBPC • Preventive care needs • Non VA records • View alerts • Diagnostic result • Discuss care with/refer to specialty consultants • Traveling veterans • Medication Reconciliation • Refer to other team members as appropriate • Team Work • Daily huddle • Team Meeting • Midlevel Collaboration Education • New patient orientation • Provider CME , Grand Rounds • Teaching trainees

10. Huddles and Team Meetings Huddles • Every Day • 10 Minutes • All Teamlet Members and Teamlet Social Worker • Identify Priorities for the Day • Communicate, Clarify, Assign • Tie Up Loose Ends from Prior Day

11. Huddles and Team Meetings Team Meetings • Once a Week • One Hour • Teamlet, Social Worker and Others as Related to Agenda • Agenda • Microsystem improvement • Care decisions with interdisciplinary team regarding complex Veterans

12. Access: Traditional • Saturated schedules • Triage and rework often with high intensity resource • Multiple appointment types • Needs for “urgent”, “routine” and intermediate not met • Capacity: Overbook and “over there” • Continuity: Fine if you wait

13. Open Access PACT Continuity: Every patient sees their own provider/team member Capacity: Future schedule is truly open • Backlog has been eliminated • Increase non-appointment care • Increase shared medical appointments • Right team member engaged with right patient’s needs • Right needs addressed by right tool (phone)

14. Creating Schedule Space • Work Harder = add capacity temporarily • Work Smarter = reduce provider demand • Improve continuity • Reduce NS rate • Extend RVI • Schedule phone visit • Delegate tasks to others • Use group visits • Increase self care

15. Contingency Plans • Predict and respond to variation in demand between days • Seasons • Plan for variation in supply between days • Short Term • Long Term • Plan for variation of demand and supply WITHIN the day

16. Shared Medical Appointments • One-on-one care with observers • 15-20 patients in 90 – 120 min. • Patients learn from staff and from each other • Appeals to about ½ of those offered option • Requires substantial planning & help

17. When to Schedule an Appointment? • Is a physical exam needed? • Is this a “relationship” visit? • Is there a need for a critical conversation? The harder the problem, the more valuable the appointment strategy.

18. Delivering Telephone Care in PACT • 30% patient care can be done by telephone • Telephone Care by all team members needs to be legitimized, formalized and accepted. • Scheduled time on appointment grids & unscheduled visits • Documentation of Telephone Care via telephone stop codes, telephone clinics, coding/encounters and progress notes supports VERA allocation & workload.

20. POSTER

21. Why Secure Messaging? • 62% of Veteran population has access to the Internet • Veterans are requesting timely access to their health information • Veterans want to play an active role in partnering with primary care providers to manage their healthcare

22. Goals of Secure Messaging • Improved Quality: patient-provider partnership promoting health, wellness, and informed decision-making. • Improved Veteran Satisfaction: patients’ desire this type of automated service for enhanced efficiency, convenience, and satisfaction. • Improved Access: reduction in unnecessary office visits, expansion of case management and ease of access to services. • Improved Patient Growth: new generation of veterans are highly acclimated to the electronic environment

23. Increase Supply • Look inside of the appointment • What is the work? • Who is doing it now? • Who could be doing it? • What is the provider doing that someone else could do?

24. Future PACT Access

25. PACT Access Opportunities

26. Source: 2009 Voice of the Veteran Survey

27. PCMH Provider TimeSample Weekly Schedule

28. Care Management • Prevention and Health Promotion • Chronic Disease Management • Transitions • Inpatient Outpatient • Primary Care Specialist • VA Community

29. The Global Burden of Chronic Diseases • Chronic diseases are the largest cause of death in the world. • In 2002, the leading chronic diseases—cardiovascular disease, cancer, chronic respiratory disease, and diabetes—caused 29 million deaths worldwide • Global response to the problem remains inadequate • elevating chronic diseases on the health agenda of key policymakers • persuading them of the need for health systems change. Yach et al. JAMA, June 2, 2004—Vol 291, No. 21

30. Chronic Disease in the United States Affects more than 180 million Americans Accounts for more than 75 cents of every dollar spent and nearly 2/3 of the total healthcare expense By 2030: Anticipated increase in healthcare costs tied to chronic disease, 25% to 54% 45% of the American population have at least one chronic condition

32. Care Management Making sure the right things get done at the right time by the right person in the right place

33. Coordination Emergency Department Diagnostic Tests PCMH Teamlet Specialty Care Patient Family In-Patient Care Home Care

34. Tools of Care Coordination

35. Developing DMP’s CCHT uses Evidenced Based Disease Management Protocols (DMP) Existing DMP’s Diabetes CHF COPD HTN Major Depression Substance Use Disorder Weight Management TBI Palliative Care Dementia PTSD SCI Katherine Corrigan, MD

36. Bridging Primary and Specialty Care (Any Discipline)

37. Outpatient and Inpatient Care Coordination: How To Do It

38. VA and Non-VA Care Coordination: How To Do It

39. The Journey for a Patient with Diabetes new complications Non diabetes admissions heart disease 85% life events stroke PREVENTION treatment change eg insulin ED EVENTS Initial Management Diagnosis Continuing Care Pregnancy Severe hypos Institutional care ketoacidosis Foot issues protenuria Eye problems

40. PRIMARY CARE TEAM Case Manager Social Worker PC Provider Clinical Associate TEAMLET HOSPITALISTS NON-VA CARE Behaviorist RN Care Manager Administrative Clerk PATIENT Mental Health Pharmacist Dietitian Nursing SPECIALISTS Family

41. Practice Redesign Principles

42. Synchronizing to the Appointment Time How do we get the provider, the patient, the equipment, the information to an available room-on time, every time?

43. Supply: The Link Between Access and Practice Redesign

44. VHA Preventive Care Program

45. How will we know? • Readmission rates • Ambulatory care sensitive admissions • ED monthly rates • Prevention (package) rates • Outcome data by chronic disease • Patient satisfaction • Staff satisfaction • Provider satisfaction

46. PACT Implementation at a Glance

47. High Performing PACTs: Outcome Measures 43% 47% Better Performance Better Performance

48. 6% decrease (8% FY11) 6% decrease (4% FY11)

49. ACP Medical Home Builder VHA Average Oct-09 69% Jul-11 80%

50. High Performing PACTs: Access Measures 6 days 6% Better Performance Better Performance