Facilitating Primary Care Practice Transformation Nursing Research Symposium November 12, 2011

1. Facilitating Primary Care Practice Transformation Nursing Research Symposium November 12, 2011 Sandra M. Robinson, MS, RN, Practice Facilitator Nancy H. Abernathey, MSW, LICSW, Practice Facilitator Laura Carleu, RN, MS, MPH, Practice Facilitator Theresa Fortner, RN, Practice Facilitator Elise McKenna, RN, MPH, MSEd., Practice Facilitator Miriam Sheehey, RN, Practice Facilitator

2. Facilitating Primary Care Practice Transformation • Blueprint Expansion • Legislative mandate (Act 128) • Vermont Act 128 of 2010 requires Commissioner of Vermont Health Access to expand the Blueprint for Health to at least two primary care practices in very hospital service area no later than July 1, 2011 and no later than October 1, 2013 to primary care practices statewide whose owners wish to participate(Multi-payer Advanced Primary Care Practice Demonstration Project application, 8/11/2010)

3. Facilitating Primary Care Practice Transformation • Blueprint Expansion • 545 physicians and 239 APRNs, CNMs and PA-Cs in 220 primary care practices in Vermont • 12 practice facilitators deployed throughout state with “caseload” of 4-10 practices each; work with practice 6-12 months • 46 practices scored in last 12 months since facilitators began work in 11/10. • Adding approximately 6 practices per month to those recognized as patient-centered medical homes; another 90 practices are scheduled to be scored/recognized in 2012. (Multi-payer Advanced Primary Care Practice Demonstration Project application, 8/11/2010)

4. Facilitating Primary Care Practice Transformation • Blueprint Assumptions/Principles • Advanced Model of Primary Care can result in better health outcomes and reduced expenses for costly ED and hospital visits • Foundation of primary care is a long-term relationship with one provider (for continuity and consistency) • Team-based approach to primary care utilizes all team members in a patient-centered approach, engaging patient to participate and/or direct his/her care (self-management)

5. Facilitating Primary Care Practice Transformation • Blueprint Assumptions/Principles • Managing a panel or population of patients is an organized, systematic approach to primary care that measures success: • Process measures (eg Asthma panel: # patients who do not have an asthma action plan) • Outcomes measures (eg Asthma panel: # patients who had ED visit in a defined time period) • “Care gaps” are addressed by improving processes for care

6. Facilitating Primary Care Practice Transformation CHANGE “It is not the strongest of the species that survives, nor the most intelligent that survives, it is the one that is the most adaptable to change.” Charles Darwin

7. Facilitating Primary Care Practice Transformation Characteristicsof effective changechampions • Responsive to data • Encourage open exchange of ideas • Not always the “expert” – ask for help • Organized • Available/visible • Action-oriented • Approachable • Reliable • Source: HealthTeamWorks

8. Facilitating Primary Care Practice Transformation • Statewide revolution of grass-roots, local process improvement work • Small businesses • Small staff • Small/No budget • Big ambition • Huge commitment • Spectacular results

9. Facilitating Primary Care Practice Transformation • Facilitator role is an opportunity to be part of this “moment in time,”“grand experiment” • Challenge/opportunity requires: • Commitment to making primary care better for all Vermonters • High tolerance for ambiguity • Confidence and humility (insight to know when to show which) • Generosity and team spirit (share everything you know and do with everyone!) • Sense of humor

10. Facilitating Primary Care Practice Transformation • What do we do? • Assess the practice • Clinical microsystems – how does the system work? • Visit cycle time • Through the Eyes of Patients • Patient Satisfaction • Staff Satisfaction • Core process assessment

11. Facilitating Primary Care Practice Transformation • Assess the practice • NCQA Standards • Access and Continuity • Panel Management • Focus on chronic conditions important to practice • Evidenced-based guidelines • Self-management • Test/referral tracking and follow-up • Coordination of care/transitions • Performance Improvement/measurement

12. Facilitating Primary Care Practice Transformation • What do we do? • Identify gaps

13. Facilitating Primary Care Practice Transformation • What do we do? • Plan improvements • Access • Data integrity • Care coordination • Panel/population management • Self-management

14. Facilitating Primary Care Practice Transformation • What do we do? • Examples of improvements • Evidence-based guidelines in EHR visit templates – improved adherence to guidelines • Panel management improvements: • Mammograms • Hgb A1Cs for patients with diabetes • Installation of kiosk for registration to free up time staff time for telephones

15. Facilitating Primary Care Practice Transformation • What do we do? • Measure success

16. Waterbury Medical Associates • Goal: to increase the % of diabetic patients with documented data on 4 core variables to 85% during the pilot period • The Intervention: • Decision to measure heights on all patients at non-acute visits • Review documentation rules (where each measure should be documented in the EMR) • Patient “flow sheet” printed out for all patients with a dx of diabetes the evening before the visit for the provider to review. The flow sheet contains longitudinal data from the last 5 visits

17. Waterbury Medical AssociatesResults Provider 1: Phase I (n=10) Provider 2: Phase II (n=15)

18. St. Albans Primary CareKiosk check-in Improvement Plan • AIM: Free up one front desk person to focus on timely answering of phones so as to put patients/callers on hold less. Kiosk installed for patients to use to check in independently so that one less person is needed to at front desk.

19. St. Albans Primary CareKiosk check-in Improvement Plan Results

20. St. Albans Primary CareKiosk check-in Improvement Plan Results

21. Facilitating Primary Care Practice Transformation • Where do we work? • Hospital-owned practices

22. Facilitating Primary Care Practice Transformation • Where do we work? • Small, independent practices

23. Facilitating Primary Care Practice Transformation • Where do we work? • Federally-qualified health centers

24. Facilitating Primary Care Practice Transformation • Where do we work? • Multi-practice corporations with sites throughout state

25. Facilitating Primary Care Practice Transformation • Nursing skills required: • Knowledge of evidenced-based guidelines • Understanding of IT and how EHRs work • Data management • Creativity/ingenuity • Are practice facilitators making a difference? • Sustainability – building capacity in practices • What is the future role for facilitators? • Consultant to primary care practices for ongoing process improvement support • Support future Blueprint Expansion

26. Thank you!