Primary Care Innovations: Stories from the Field. PCPCC Webinar Christine A Sinsky, MD Thomas A. Sinsky, MD June 29, 2012
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1 Primary Care Innovations: Stories from the Field PCPCC Webinar Christine A Sinsky, MD Thomas A. Sinsky, MD June 29, 2012
2 In Search of Joy in Practice Co-Investigators Christine Sinsky- PI Tom Bodenheimer-PI Rachel Willard Tom Sinsky Andrew Schutzbank David Margolius
3 Advisory Council
4 Places Where PC Physicians & Staff are Thriving? Where the work of primary care is do-able Enjoyable as a life s vocation
5 Group Health Olympia Joy in Practice Martin s Point- Evergreen Woods Multnomah County Health Dept Allina Fairview Rosemont Clinic Mayo Red Cedar ThedaCare Harvard Vanguard Medford Brigham and Women s Hospital Clinic Ole Sebastopol Community Health La Clinica la Raza de Univ of Utah- Redstone Clinica Family Health Services Medical Center Medical Associates Clinic Mercy Clinics Quincy, Office of the Future Cleveland Clinic- Strongsville North Shore Physicians Group Mass. General Hospital Newport News Family Practice West Los Angeles- VA South Central Foundation Site visits to 23 highperforming practices (most PCMHs) Workflow Task distribution Physical space Technology
6 Challenges Chaotic visits EHR work to MD Inadequate support Teams function poorly Time documentation
7 Challenges Innovations 1. Chaotic visits with overfull agendas Pre-visit planning Pre-appt labs Systematic Prescriptions
8 Fairview: Care Model Redesign MA pre-visit call Agenda, Med review Depression screen Advanced directive
9 Mayo-Red Cedar arranges for pre-visit lab
10 Same day pre-visit lab (15 min) ThedaCare
11 Annual Prescription Renewals Physician time 0.5 hour/day Nursing time 1 hour/day per physician 80 million PC visits/year 350,000 PCPs x 220d/yr x1 visit/d
12 Challenges Action Innovations Steps 1. Chaotic visits with overfull agendas Insurers Single co-pay lab/visit Institutions Hold future orders Staff order entry Pharmacies and Board Prescription 15 mo Resynchronize No automated faxes
13 Challenges Innovations 2. Inadequate support to meet the patient demand for care Sharing the care among the team 2:1 or 3:1 Rooming protocol Between visit Health coaching Care coordination Panel mgm t
14 Mayo Red Cedar : New Model of Nursing (2:1) Physician centric to team based model Immunizatio diabetic foot, lifestyle, HTN visits; even though 25% more visits/day, less harried; proud
15 Genesis: 3 week vacation New Model of Nursing Doctor to nurse: I was behind an hour every day. Thank God you are back! Nurse to doctor I enjoyed my time away from the daily grind that I was tempted not to return. Doctor and nurse Our practice needs to change
16 Challenges Action Innovations Steps 2. Inadequate support to meet the patient demand for care Educators MA, nurse: MI, SMS Institutions/Regulators Staffing Scope of practice Payers Fund non-md services Technology Team log-in
17 Challenges Innovations 3. Vast amounts of time spent documenting care More time doc than delivering care Scribing Assistant order entry
18 I used to be a doctor. Now I am a typist. Personal communication. Beth Kohnen, MD, internist Anchorage AL
19 The Doctor 1891 Fildes Undivided attention
20 The Doctor 2012
21 Challenges Innovations 3. Vast amounts of time spent documenting care Scribing Assistant order entry
22 Scribing: Newport News Family Practice
23 Collaborative Care Newport News n What we all hoped for n Team: 3:1 Nurse/physician
24 Collaborative Care Newport News n Four Components to Visit n Data gathering, organizing and documenting n Data analysis and exam n Decision making, creating a plan n Plan implementation, order entry, pt ed
25 Collaborative Care Newport News n Four Components to Visit n Data gathering, organizing and documenting n Data analysis and exam n Decision making, creating a plan n Plan implementation, order entry, pt ed
26 Pre-visit: Nurse with Pt (8-12 min) n Nurse gathers, records n Vitals, Med Rec., n Previous two notes n ER, Consult notes, n New lab or x-ray n Agenda, HPI n ROS guided by templates
27 Visit: Nurse, Patient and MD n Nurse gives report n M.D. n Hx, PE n M.D. n verbalizes med changes n lab, x-ray orders n diagnosis/billing codes n next followup appt. n Nurse records
28 Post-visit: Nurse with Patient n Nurse n Reviews plan n Prints and reviews visit summary n Escorts the patient to checkout n US Army
29 Scribing at Cleveland Clinic Kevin Hopkins M.D.
30 Collaborative Care Cleveland Clinic: Stonebridge n Turbo practice n 2 MA: 1 MD n 2 pt/d cover cost n visits/d n 20-30% revenue n Spread to others n We re having FUN
31 The MA s are more fully engaged in patient care than they have ever been and they enjoy their work They have increased knowledge about medical care in general and about their individual patients in particular. Kevin Hopkins M.D.
32 Collaborative Care University of Utah: Redstone n 2.5 MA: 1 MD
33 I get to look at my patients and talk with them again. We re reconnecting. Our patient satisfaction numbers are up, our quality metrics have improved, our nurses are contributing more, and I am going home an hour earlier to be with my family.. Amy Haupert MD, family physician, Allina-Cambridge personal communication
34 Office Practice of the Future Quincy Family Practice Residency n 2 MA: 1 LPN: 1 MD
35 Collaborative Care Six sites Similar results Access 30% Costs covered Satisfaction Quality metrics Physician home hour earlier no work at home
36 Challenges Action Innovations Steps 3. Vast amounts of time spent documenting care Institutions Rooms: 2 computers Assistant order entry Institutions/Regulators Team log-in Technology Seamless transitions between users
37 Challenges Innovations 4. Computerized technology that pushes more work to the clinician Verbal messages In-box management
38 The task list is unbearable. I spend 1.5 hours clearing out my task list before leaving and another 1.5 hours at home after the kids go to bed. Primary Care Physician, Des Moines, IA; 2011
39 Challenges Innovations 4. Computerized technology that pushes more work to the clinician Verbal messages Inbox managment
40 Fairview: Filtering Inbox Reduce backpack 90min/d to few min Line of Sight
41 Verbal messaging at Fairview rather than getting tangled in a thicket of e- messaging.
42 Semi-circular desk, APF
43
44 Iora Health, Dartmouth-Hitchcock
45 Printer in every room University of Utah Redstone
46
47 APF, Massachusetts General Hospital
48 Challenges Action Innovations Steps 4. Computerized technology that pushes more work to the clinician Institutions message generation Nurses filter inbox Regulators Security modifications signature requirements Technology Quick log in Save a click
49 Challenges Innovations 5. Teams that function poorly and complicate rather than simplify the work Co-location Huddles Team meetings Workflow mapping Structuring the physical and personnel environment to support trust and reliance
50 Flow station at North Shore Physicians Group
51 Fairview Co-location of scheduler
52 Co-location at South Central Foundation, Alaska
53 APF, Massachusetts General Hospital
54 Pre-clinic Huddle
55 Team Meetings Do Work + Make Work Better
56 Health coach running meeting we all own practice, own meeting
57 ThedaCare: All staff trained in QI, Pulling in same direction, capacity for change
58 Clinic walls lined with data ThedaCare
59 Lean Problem solving Harvard Vanguard Medical Associates
60 Harvard Vanguard Medical Associates
61 26 Improvement Specialists South Central Foundation, Alaska
62 Challenges Action Innovations Steps 5. Teams that function poorly and complicate rather than simplify the work Institutions Co-location Line of sight Space for huddles Time for meetings Improvement specialists Aligned reporting (MA/ nursing to clinical lead)
63 Key Lessons For Burnout and Joy Share the care with team 2:1 or 3:1 staffing in stable Physician-centric to team-based care Clear communication Co-location Team meetings Systematic Planning Workflow mapping Everyone: do the work & to make work better
64 Next Steps Individual Stories Will be published on line at ABIMF p paper Video project 10 of the 23 sites Toolkits/Learning community Practical advice Campaign for envy and demand BWH
65 Discussion
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