PCMH: Focus on The Care Team & Huddles

1. PCMH: Focus on The Care Team & Huddles Session 2 July 18, 2014 Green Management Consulting Group, Inc.

2. Quick Review of NEW 2014 PCMH Standard on Team Based Care Green Management Consulting Group, Inc.

3. Quick Review PCMH: What is it? Green Management Consulting Group, Inc. A care model that focuses on the primary care practitioner (PCP) directed coordination of care PCP coordinates a multidisciplinary team, takes responsibility for the care provided to the patient, and tracks care over time and across settings, including with other practitioners Organizes care around a patient’s unique needs Improves quality, patient experience and reduces total costs Focus on prevention & managing chronic conditions

4. Goal of PCMH High Quality Care Increased Patient Satisfaction Increased Staff Satisfaction Eliminate gaps in care Reduced Costs National Recognition Green Management Consulting Group, Inc.

5. PCMH 2 – Team Based Care Element A Continuity Element B Medical Home Responsibilities Element C Culturally and Linguistically Appropriate Services (CLAS) Element DThe Practice Team Green Management Consulting Group, Inc.

6. Green Management Consulting Group, Inc.

7. Green Management Consulting Group, Inc.

8. Green Management Consulting Group, Inc.

9. Green Management Consulting Group, Inc.

10. Green Management Consulting Group, Inc.

11. Green Management Consulting Group, Inc.

12. Videos Cedars-Sinai proprietary DVD on PCMH https://www.youtube.com/watch?v=Wttxm7jAnb4 Green Management Consulting Group, Inc.

13. Care Team Roles Green Management Consulting Group, Inc.

14. Definition of a Care Team Green Management Consulting Group, Inc. A care team is a small group of clinical and non-clinical staff who, together with a provider, are responsible for the health and well-being of a panel* of patients. Who is on the care team and their specific roles will vary based on patient needs and practice organization. * NOTE: EMPANELMENT is a precursor for teams – teams must be informed about the set of patients for whom they are responsible! http://www.safetynetmedicalhome.org/change-concepts/continuous-team-based-healing-relationships

15. Care Team Roles Core Team Provider/Team Leader & Medical Assistant Responsible for most care & care coordination Other Team Members may include: LVN/RN Care Coordinator who’s role is to oversee the medical assistants, care managers for panels of high-risk patients, performing health coaching and connecting patients with information and resources Appointment staff Referral Coordinator Receptionist Behavioral Health Specialist Nutritionist/ Patient Educator Pharmacist Green Management Consulting Group, Inc.

16. Basics Needed • Standardized Protocols/Evidence Based Guidelines • Easily Accessible • Clear Expectations • Respectful Work Place • Staff & Patients • Time Management • Appropriate Training to Optimize Scope of Practice • Optimal Utilization of EHR to Enhance Patient Centered Care Green Management Consulting Group, Inc.

17. Rewards • Increased efficiency • Increased staff satisfaction -> retention • Increased patient satisfaction -> retention • Role expansion – seen as a team by the patient • Fewer gaps in care • Receptionist/Appt staff ask about Urgent Care or ED visits and obtains records where appropriate • Providers talk with referral specialty physicians • Incentivize & acknowledge improvements & goal achievement Green Management Consulting Group, Inc.

18. Job Descriptions and Scope of Practice Green Management Consulting Group, Inc.

19. Medical Assistant • Unlicensed individuals • Perform non-invasive routine technical support services under the supervision of a licensed physician and surgeon, podiatrist, physician assistant, nurse practitioner, or nurse midwife in a medical office or clinic setting • The supervisor must be on the premises in order for the medical assistant to perform those non-invasive technical support services Green Management Consulting Group, Inc.

20. Medical Assistant, cont. • Medical assistants may obtain "certified" status through private agencies approved by the Medical Board of California • A list of "Frequently Asked Questions" addressing the appropriate training, supervision, and scope of practice issues: http://www.mbc.ca.gov/Licensees/Physicians_and_Surgeons/Medical_Assistants/ Green Management Consulting Group, Inc.

21. Medical Assistant Training The California Business and Professions Code Medical Practice Act outlines laws related to medical assistance practice as well as minimum requirements for training institutions to establish accreditation and graduate students. Green Management Consulting Group, Inc.

22. Training Topics • Anatomy & Physiology related to Procedure • Proper Sterile Technique • Hazards & Complications • Patient Care following test/procedure • Awareness of emergency procedures • Capacity to choose appropriate equipment Green Management Consulting Group, Inc.

23. General MA Job Description Perform administrative and certain clinical duties under the direction of physician/Health Care Provider. Administrative duties may include • scheduling appointments, • maintaining medical records, • billing, and coding for insurance purposes. Green Management Consulting Group, Inc.

24. Summary of Clinical Duties • Obtaining patient history and vital signs such as blood pressure, pulse, height and weight • Preparing & maintaining examination and treatment areas • Preparing patients for examination • Assisting with procedures and treatments • Preparing and administering medications and immunizations • Recognizing and responding to emergencies • Screening and following up on patient test results • Collecting and processing specimens for diagnostic tests Green Management Consulting Group, Inc.

25. Care Manager Job Description LVN Care Manager : Ensuring the accurate documentation of patient care activity, maintaining a quality standard of care, anticipating daily workload, prioritizing activities, and coordinating the workload of other employees. Provides patient care to patients ranging in age from infancy to geriatric Assists physicians with examinations and diagnostic testing Maintains appropriately stocked work areas Completes special projects or other duties as assigned Registered Nurse Case Manager participates in all phases of the Case Management Program (CMP) and ensure that the CMP meets established case management (CM) standards of care. Assist in coordinating a multidisciplinary team to meet the health care needs, including medical and/or psychosocial management, of specified patients. Green Management Consulting Group, Inc.

26. Care Manager Job Description, cont. • Serve as consultant to all disciplines regarding CM issues. Provide nursing expertise about the CM process, including assessment, planning, implementation, coordination, and monitoring. Identify opportunities for CM and identify and integrate local CM processes. • Develop and implement local strategies using inpatient, outpatient, onsite and telephonic CM; develop and implement policies and protocols for home health assessments and outcome measures. • Develop and implement tools to support case management, such as those used for patient identification and patient assessment, clinical practice guidelines, algorithms, CM software, databases for community resources, etc. • Integrate CM and utilization management (UM) and integrate nursing case management with social work case management. Prepare routine reports and conduct analyses. Green Management Consulting Group, Inc.

27. Care Manager Job Description, cont. • Assist in establishing and maintaining liaison with appropriate community agencies and organizations. • Maintain adherence to JCAHO, URAC, CMSA and other regulatory requirements. Apply medical care criteria (e.g., InterQual). • Ensure accurate collection and input of patient care data and ensure basic CM budgetary management. • Provide input on hospital's CM resources and make recommendations to the Command as to how those resources can best be utilized. Green Management Consulting Group, Inc.

28. Care Manager Job Description, cont. • Collaborate with the multidisciplinary team members to set patient-specific goals. Develop treatment plans including preventive, therapeutic, rehabilitative, psychosocial, and clinical interventions to ensure continuity of care toward the goal of optimal wellness. • Establish and implement mechanisms to ensure proper implementation of patient treatment plan and follow-up post discharge in ambulatory and community health care settings. • Provide nursing advice and consultation in person and via telephone. • Ensure appropriate health care instruction to patient and/or caregivers based on identified learning needs. Green Management Consulting Group, Inc.

29. Care Manager Job Description, cont. • Alert physicians to significant changes or abnormalities in patients and provide information concerning their relevant condition, medical history and specialized treatment plan or protocol. • Facilitate multidisciplinary discharge planning and other professional staff meetings as indicated for complex patient cases and develop a database and knowledge of local community resources. • Develop and implement mechanisms to evaluate the patient, family and provider satisfaction and use of resources and services in a quality-conscious, cost-effective manner. • Implement strategies to ensure smooth transition and continued health care treatment for patients. Develop a policy for, and assist with, relocation/change of health plan. Green Management Consulting Group, Inc.

30. Care Manager Job Description, cont. • Plan for professional growth and development as related to the case manager position and maintenance of CM certification. • Establish cost containment/cost avoidance strategies for case management and develop mechanisms to measure its cost effectiveness. • Assist with the Electronic Health Record and interface or other database designed to support CM. • Participate in video teleconferences and other meetings as required. Green Management Consulting Group, Inc.

31. Other Team Members • Appointment Staff: Training on pt. centered care, appt. preps, checking on UC or ED visits, appointment reminders, language services, using EHR to communicate • Receptionists: Training on pt. centered care, optimizing flow, checking on Urgent Care or ED appointments, & appointment prep (blood draw? See Social Worker first?) • Social Worker/Nutritionists/ Referral Coordinator: Part of team, Recommendations, Communication! Green Management Consulting Group, Inc.

32. Scope of Practice • Primarily an issue for the MA • Most MAs won’t know their scope of practice • Want to please, want to help • Experience in private offices, on-the-job skills • Need to ensure are trained and comfortable with procedures • Return demonstrations • Orientation period for new employees Green Management Consulting Group, Inc.

33. Scope of Practice Check FAQs on California Medical Association website • Can only give medications after verification by a physician, podiatrist or another appropriate licensed person. • http://www.mbc.ca.gov/Licensees/Physicians_and_Surgeons/Medical_Assistants/Medical_Assistants_FAQ.aspx#2 Green Management Consulting Group, Inc.

34. Can medical assistants be supervised by a nurse practitioner, nurse midwife, or physicians assistant in the absence of a physician and surgeon? Per Business and Professions Code section 2069 (a)(1), a supervising physician and surgeon at a "community clinic" licensed under Health and Safety Code section 1204(a) may, at his or her discretion, in consultation with the nurse practitioner, nurse midwife, or physician assistant provide written instructions to be followed by a medical assistant in the performance of tasks or supportive services. The written instructions may provide that the supervisory function for the medical assistant in performing these tasks or supportive services may be delegated to the nurse practitioner, nurse midwife, or physician assistant and that those tasks may be performed when the supervising physician and surgeon is not on site. http://www.mbc.ca.gov/Licensees/Physicians_and_Surgeons/Medical_Assistants/Medical_Assistants_FAQ.aspx#2 Green Management Consulting Group, Inc.

35. What isn’t within the MA Scope? • Invasive Procedures • Cannot insert urinary catheters • Assessments/Triage • Check pupillary response • Cannot read, interpret or diagnose symptoms or test results • No phone triage • Cannot apply splints, casts, or other external devices, but can remove them if trained • Cannot interpret skin test results • But can measure and describe the test reaction and make a record in the patient's chart • Cannot call in new prescriptions or prescription changes Green Management Consulting Group, Inc.

36. LVN Scope of Practice • The licensure and practice of vocational nurses is authorized by the California Business and Professions Code and regulated by the Board of Vocational Nurse and Psychiatric Technicians (BVNPT). • The LVN must practice under the direction of a licensed physician or Registered Nurse (RN) at all times. Such direction may be provided verbally, telephonically, or by written order. • The LVN may assist in the collection of data during the assessment process. VALIDATION of assessment data, however, must be done by the RN. • The LVN may perform that part of the triage process that includes interview, observation, the collection of subjective and objective data, and the recognition of problems or abnormal conditions specific to the patient • Perform lifesaving nursing procedures. Such procedures include basic CPR and management of assaultive behavior http://www.cphcs.ca.gov/docs/imspp/imspp-v05-ch05.pdf Green Management Consulting Group, Inc.

37. What Can’t the LVN Do? • May not independently determine or initiate a course of clinical action. • May not administer intravenous medications • May not dispense medications • Dispensing medication is defined as the interpretation of a physician’s order for a drug and the proper selection, measuring, packaging, labeling, or in any way filling a prescription for a patient. This includes counting stock medications, placing them in a container with the patient name and issuing the medication to the patient. • May not perform that part of the triage process that includes independent evaluation, interpretation of data, and determination of treatment priorities and levels of care. Green Management Consulting Group, Inc.

38. BREAK! Green Management Consulting Group, Inc.

39. Huddle/Patient Care Team Meeting P&P Review • Policy: Team Huddle • Purpose • Procedure Green Management Consulting Group, Inc.

40. Overall High Level Workflow Pre-Visit Visit Patient makes appointment Patient receives reminder call (auto) Patient receives call for X Patient arrives Patient leaves • Registration • Consents • Forms • Out Processing • Appointments • Referrals Rooming Sheet xxx xxx Rooming Sheet • Chart Prep • Chart Review • List of Huddle • discussion • items • List of follow- • up items • Huddle • Provider • direction / • decisions • List of follow- • up items • List of intake • orders, tags, • activities • Follow-up as needed • Reschedule / call • patient • Ensure equipment, • supplies, forms • Other f/u activities • Intake • Intake Activities • Post Tags as needed • Pend orders • Notes on Rooming Sheet • Shred Chart Prep Sheet Chart Prep and Huddle Worksheet Xxxx Xxx Xxx Xxx Xxx xxx • Physician Visit • Review pended orders • Review tagged items • Usual care processes • Ensure AVS information Xxxx Xxx Xxx Xxx Xxx xxx Xxxx Xxx Xxx Xxx Xxx xxx Order: Xxx Xxx Tag: Xxx Other: xx Order: Xxx Xxx Tag: Xxx Other: xx Patient Patient Service Representative Medical Assistant /LVN Physician • Discharge • Check and process orders • Complete documentation • AVS Green Management Consulting Group, Inc.

41. Chart Prep Grid Example – General Preparation for all patients scheduled to see a physician Green Management Consulting Group, Inc.

42. Green Management Consulting Group, Inc.

43. Chart Prep Form (side 2) Green Management Consulting Group, Inc.

44. Successful Huddles/Patient Care Team Meetings • Huddle (Patient Care Team Meetings) standing Agenda Items • MA: Specific items/ questions from chart prep • Receptionist (R): Appointment related discussion items – i.e. changing appointments, fasting for physicals • MA, R: Outstanding patient calls/messages • MA: Any referral question • R: Any opportunities for double booking/ working in walk-in’s • Care Manager: Outstanding patient issues / questions • Ask for clear direction and specific orders, confirm understanding • Summarize after each patient • Receptionist may have some follow-up such as changing appointment type or calling patients • Consider having a team weekly debrief when starting huddles to discuss what works, what doesn’t, and refine process Green Management Consulting Group, Inc.

45. Documenting Huddles/Pt. Care Team Meetings • Policy and Procedure • Save prep sheets examples • Document in EHR (pt discussed in huddle - to have lab work prior to appt.) • Keep copies of huddle schedule • Keep minutes of meetings where operation of huddles is discussed and refined Green Management Consulting Group, Inc.

46. Documenting Huddles/Pt. Care Team Meetings NCQA reviews the practice’s documented process for structured communication between the clinician and other care team members, which states the frequency of communication; and reviews at least three samples of meeting summaries, checklists, appointment notes or chart notes for evidence that the practice follows its process. Green Management Consulting Group, Inc.

47. Huddle Schedule Example Green Management Consulting Group, Inc

48. Q & A Green Management Consulting Group, Inc.

49. Thank you! Susan Chen: schen@greenconsultinggroup.net Susan Green: sgreen@greenconsultinggroup.net Green Management Consulting Group, Inc.