Using a team-based care approach to achieve Care Coordination
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1 Using a team-based care approach to achieve Care Coordination June 2015 Dawn Welling RN MSN Director of PCMH Care Initiatives Kimberly Wente RN BSN, Senior Care Coordinator Jen Kirstein RN BSN, Care Coordinator Family Medicine-East Des Moines Team based care is a necessary approach to achieving best outcome for every patient every time. UnityPoint Clinic is utilizing the RN s skillset in a new way through the Patient Centered Medical Home. 2 1
2 Objectives Understand the role of a Care Coordinator RN in a PCMH Primary Care Clinic Setting. Learn how team based care works and why it is important to patient, provider and staff satisfaction. Learn how team based care can impact patient outcomes, as well as Triple Aim goals. 3 What does a Care Coordinator do? New Work Care Coordination Support patient through transitions in care Patient education and coaching related to chronic disease self- management Focus on rising risk patient population Support patient and provider in goal attainment/identifying barriers Identify rising risk patients and proactively intervening with the guidance of the provider Promoting general population health Provide information regarding internal and external resources, including community resources 5/26/
3 5/26/ National Committee for Quality Assurance (NCQA) NCQA provides a very useful roadmap for clinics to operationalize the following PCMH features: Patient Centered Access Team Based Care Population Health Care Management Care Transitions Performance Improvement 6 3
4 Patient-Centered Medical Home Primary Care Team-Based Access and Communication Care Coordinator Data and Metrics Care Protocols 7 Population Health Management High Risk Rising Risk 5% of patients Complex chronic conditions, comorbidities Care navigators Chronic care coordination Wraparound services 15%-35% of patients May have conditions not under control Patient-Centered Medical Home Care coordinators Low Risk 60%-80% of patients Minor conditions, easily managed Low-acuity access, education E-health 8 4
5 Team-Based Care A cooperatively functioning group that works with the patient and family toward ideal patient care Patient and family, Providers, Care Coordinator, Clinical Staff, Patient Service Representatives, Clinic Administrator All are Leaders (no hierarchy), Not competitive, Communication, no frontback office separation 5/26/ Co-location People with different job roles working in the same common workspace Why it works Communication! Same day access Care Coordination Ideal patient care 5/26/
6 Huddles Once/Twice a day 15 min Everyone attends Start/end on time Things to talk about Patient issues Successes/challenges Quality Scheduling patients and staff Process Improvement Meaningful Use 5/26/ Culture shift to team-based care Trust Time Understanding of new roles & relationship building Patient and family education 12 6
7 Change is Hard! 5/26/ Care Coordination Integrated Approach Link patients with community resources Track and support patients Follow up with patients within few days of discharge from emergency room or hospital Patient Centered Care Plans 5/26/
8 Top of licensure and skill set The approach and skill set of a Care Coordinator RN includes Education, RN includes assessment, triage, and critical thinking Motivational Interviewing Teach Back Self-Management Support SMART goal setting Action plans Follow-up 15 Hemoglobin A1c < % 90.0% 80.0% % Patients w/ Hemoglobin A1c <8 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% CI: FM-East Des Moines CR: FM-Mt Vernon QC: IM-Moline WL: FM-United Medical Park Jan % 61.8% 62.3% 78.3% Dec % 70.0% 77.4% 87.6% Target 70% 70% 70% 70% 16 8
9 Decrease in readmissions with TCM code 17 Comments from Providers & Staff I began to see this patient in August. She initially was depressed and feeling hopeless about her diabetes. As of December 31st, her A1c has dropped to 7, she is checking and recording her blood glucose regularly (and taking insulin appropriately) and is now exercising [the patient] really feels that I have helped her to coordinate care between her doctors, address other medical concerns as they come up, and now she feels confident about taking care of herself. Care Coordinator, Cedar Rapids Region It really promotes teamwork; everyone gets a say. RN, CI Region 5/26/
10 Comments from Providers and Staff We had a gentleman with an A1c of 9.1 in May of His most recent A1c was 6.8. Just having [our care coordinator] meet with [him] 2 times...[the provider s comment was] she never thought she would see this patient start being compliant with his diabetes. Clinic Administrator, Waterloo Region Traditional Family Practice was primarily a siloed type of delivery care system whereas medical home has integrated our system as a function of a team, providing all the services that should surround the patient. Physician, CI Region 5/26/ Comments from Patients in a PCMH My care coordinator is a professional friend who cares about my health and works hard to be supportive, encouraging and helpful. My daughter is helping herself on food choices that are best for her. It is amazing for her to want to eat healthy and to now understand why it is so important. She has spent a lot of time making individual recommendations for snacks and meals. She has helped her with social difficulties too. This experience is affecting a healthier eating style for our entire family which I can't even explain enough how amazing this is. I wish more kids could receive this much needed help. Quote from Parent 5/26/
11 Comments from Patients in a PCMH I trust my medical home team and they are willing to work with me. I have comfort in knowing that I will be taken care of today by my care team. Having [the Care Coordinator here], I can t thank UnityPoint enough, if they didn t have her, I wouldn t be sitting here today as a success story I would be sitting here as a negative statistic she s changed my life. There is a visible difference in my health care since my clinic became a medical home. I would never want to go back. 5/26/ Patient Testimonials 22 11
12 Patient Stories Kimberly Wente RN, BSN-Senior Care Coordinator (previously Pediatrics- Lakeview Care Coordinator) Jen Kirstein RN, BSN-Family Medicine- East Des Moines Care Coordinator 23 Team based care-next steps Expand team within clinic setting where appropriate Continue to develop connections with teams outside clinic setting, Community based services 24 12
13 References Businessballs.com website. (n.d.) John Fisher's personal transition curve website. Retrieved on June 1, 2013 from Cohen, d. (2005). The heart of change field guide. Boston, MA: Harvard Business School Press. Hiatt, J. (2006). ADKAR; A model for change in business, government, and our community. Loveland, CO: Prosci learning Center Publications. Institute for Healthcare Improvement (IHI) Triple Aim website. (2013). Retrieved June 24, 2013 from 5/26/ References Kansas PCMH Initiative website. (n.d.) Retrieved on June 1, 2013 from Kenagy, J. (2011). Choosing to thrive in 21 st century healthcare: The adaptive M2S2. Retrieved June 24, 2013 from Kotter, J. (1996). Leading change. Boston, MA: Harvard Business School Press. NCQA website. (n.d.). Retrieved June 24, 2013 from es_ pdf. 5/26/
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