Better Patient Care Through Strong Clinical Support. Theresa Knowles, FNP-C

Transcription

1 Better Patient Care Through Strong Clinical Support Theresa Knowles, FNP-C

2 Why Need for Change Increasing provider/staff burnout Patients are sicker, less time to provide the necessary care Providers can t do it all High levels of receptionist, medical assistant (MA), and provider turnover Staff doesn t always feel like a meaningful part of the care team Growing administrative and compliance demands Shift to value-based delivery of care More patients to see, less providers available to see them

3 USE OF STANDING ORDERS TO IMPROVE PATIENT CARE

4 Standing Orders/Protocols Allow care to be shared among non-clinician members of the team (MA s, nurses, receptionists and referral staff) Often based on clinical guidelines Practices may customize based on their own patient population or environment Authorizes staff to carry out an order without a provider's examination or prior approval All patients who meet the criteria for the order receive the same treatment Standing orders can be written for: Immunizations, medications, or procedures Preventive care or chronic disease management Referrals, scheduling or answering phones

5 How Can They Be Useful? Enable all members of the team to function to their fullest capacity Support staff are easily trained to carry them out Improves efficiency Improves access to care Improves interdisciplinary integration of care Improves quality of care Reduces unintentional oversight of services due Encourages a sense of empowerment for staff Removes some of the burden from the provider providers can t do it all

6 Selecting Standing Orders 1. Do the orders reflect current best practice? 2. Do orders consider use of other team members? 3. Would 100% of providers agree with them?

7 Do s and Don ts of Selection Don t allow for some providers to opt in and others to abstain Creates chaos! Do select those that are considered low-risk if inappropriately implemented Don t select controversial orders or those that are divisive For example, mammograms yearly at 40 or every other year at age 50

8 Categories of Standing Orders Consults: Case management, wound care nurse, nutritionist, pharmacist, care management Vaccinations: Orders to vaccinate as appropriate, use of ACIP guidelines Therapy: Physical therapy, speech therapy (continuation visits), licensed clinical social worker Audiology: Re-evaluate/evaluate for premature babies Developmental Screening: Autistic children needing re-evaluation every three years for school Laboratory: Routine blood work, medication monitoring, Strep test for sore throat, confirmatory culture for all pediatric Strep negatives

9 Examples of Good Standing Orders MA s/rn refills Supplies Incontinence pads Diapers/formula for children CPAP machine and supplies Medications: Albuterol Vitamin B12 Docusate Senna Criteria for Selection Do the orders reflect current best practice? Do orders consider use of other disciplines? Would 100% of providers would agree?

10 Medications Our intent is to streamline, standardize and reduce wait times for refills of medications The medications are listed by generic and trade names Document time that the patient must have office visit for automatic refill If the patient not seen during time frame One-month supply given Office visit is scheduled before any additional refills. Any lab work needed for the ongoing monitoring of the medication is identified/ordered at the time of the refill

11 Medication Standing Orders

12 Referrals to the Care Team The Medical Assistant will create a referral to CCT in the EMR if a patient meets ANY of the following and is willing to receive services: Hospital Admissions 3 or more admissions in the past 6 months or 5 or more admissions in the past 12 months Recent hospitalizations and/or recent skilled nursing facility stay (Identified as being high-risk for readmission due to high medical and/or social need) ER Utilization 3 or more ER visits in the past 6 months or 5 or more ER visits in the past 12 months The Medical Assistant will create a referral to social work services in the EMR if the patient has ANY of the following needs and is willing to receive these services: Obtaining transportation Insurance (MaineCare, Medicare, Health Care Exchange, ACP needs) Financial assistance (General assistance, TANF, ASPIRE, local pantries & churches) Heating & electric resources (LIHEAP, facilitating medical emergency forms for electricity providers with PCP, etc.) Food resources (Food stamps, food pantries, Meals for Me, etc.)

13 Controlled Substance Compliance Standing Orders If the patient is receiving any controlled substance for more than a three month period, the MA will perform the following on a yearly basis and flow sheet the results in the EMR for the provider to review and address: Random pill count (at least 2 3 weeks after the prescription has been filled) Random urine drug screen Updated opioid contract/patient agreement A prescription monitoring report will be completed quarterly for all patients on controlled substances

14 Preventative Care Standing Orders The MA will order a screening lipid panel on men 35 and over and women 45 and over (if they have not already had at least one lipid panel result in their record) if they are at increased risk of heart disease (obese, hypertension, family history of heart disease, cigarette smoker, diabetes). The MA will screen patients age for HIV once (unless done previously). The MA will screen all sexually active young women 24 and under for gonorrhea/chlamydia. The MA will screen all patients 65 years or older for risk of falls. If the patient has had a fall in the past year or is at high risk for falls, the MA will place a physical therapy order if the patient is willing to receive these services. The MA can also refer the patient to Eastern Agency on Aging for a free in-home fall risk assessment and participation in the Matter of Balance program The MA will offer the shingles vaccine to all patients 60 and over. The MA will order an A1c and an LDL (lipid) yearly for all patients taking an antipsychotic.

15 Referral Standing Orders If a provider has ordered an abdominal ultrasound and the radiologist feels as if the test should be a more focused (limited) ultrasound (renal, gallbladder, etc.) the referral specialist can remove the previous order from the EMR and select the appropriate order per the radiologist The referral specialist will use the same diagnoses as selected for the original order and will copy and paste the comments of the original order in the new order If a provider has ordered an ultrasound for the diagnosis of a hernia and the radiologist requires the location of the ultrasound to be changed, for example ultrasound of the Pelvis will need to be changed to an ultrasound of the abdomen, the referral specialist can remove or adjust the previous order from the EMR to the appropriate order per the radiologist If a provider has ordered a CT scan for the diagnosis of a hernia and the radiologist requires the location of the CT to be changed, for example CT of the pelvis will need to be changed to a CT of the abdomen/pelvis, the referral specialist can remove or adjust the previous order from the EMR to the appropriate order per the radiologist. If a specialist calls and requests an annual order from the primary care provider for a speech evaluation, the referral specialist will place the order with the appropriate diagnosis. The referral specialist will go to the orders section of the EMR, select the appropriate referral, change the name of the ordering provider and enter the appropriate provider

16 Standing Orders for Scheduling 15 Minute Appointment Types Acute pain (other than chest or abdominal pain) Cast removal Chronic pain visits (established) Ear pain Fever Follow-up ER visits (not hospital discharge) General follow-up for one of the following conditions: Hypertension GERD COPD Asthma Hypercholesterolemia

17 Standing Orders for Scheduling (Cont.) 30 Minute Appointment Types Abdominal pain Annual Physical/CPE Bus driver/dot/firefighter physical Chest pain Chronic disease in which patient has not been seen for 9 months or more Depression/anxiety Diabetes Dizziness Headaches (initial visit or worsening) Hospital discharge visit (not ED visit) Manipulation visit (OMT) Provider specific

18 Group Work Each person identify one standing order that they would recommend to be implemented in their practice upon returning from this conference (2 minutes) Form a group of five people and present to the group your recommendation for the standing order with your rationale (5 minutes) The group must select one standing order that they will recommend to the full group using the criteria mentioned to justify your selection (3 minutes) These will be compiled by Maine Quality Counts and drafted as a standing order set to be shared with participants

19 How to Implement Select protocols and create the document Are instructions complete, unambiguous, and clear? Does the document outline who is able to carry out the standing orders? Present to clinical leadership/medical director for approval Train medical assistants/nurses/receptionists on protocols selected and when to activate Train staff on why the selected care is important for the patient Train providers on protocols selected and when they will be activated Other staff should also learn about the standing orders, so that they can support the new roles

20 Common Pitfalls Not getting buy-in from clinical leadership Trying to implement too many standing orders at once Selecting measures that are divisive Not training staff well enough before implementing Not trying a pilot site/few providers to champion first Trying to create a comprehensive standing order Assuming that no mistakes will be made

21 Challenges with Implementation Not wanting to delegate Perception of liability issues Providers not always trained to work in teams Knowing where to start/gaining buy-in Distrust in the data used by staff to implement the standing orders

22 ADVANCED USE OF STANDING ORDERS

23 How to Pre-Visit Plan Identify gaps in care for preventive care and chronic disease care Order care through standing orders Document in appropriate discrete field if care rendered Obtain any missing documents and have them imported into EMR Vital sign form (check for smoking status, depression screen and emergency contact) Update medications Update problems Review orders and complete as appropriate Check ER/Hospital section for use since last visit Check to see if anything ordered/suggested Check care management folder for frequent ER use or hospital admissions/readmissions (refer as appropriate) Check provider s last note (impression and plan)

24 Provider Desktop Management Twice daily Prioritize labs and tests Update previous medical/social/surgical history from consults, ER/hospital reports Obtain results of additional testing from hospitals or specialists Entering data in discrete fields Ensure follow-up if appropriate (cancellations and no-shows) Order additional testing (INR in 2 days, repeat BMP or potassium etc.)

25 RESULTS OF ADVANCED DELEGATION

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29 QUESTIONS?