Define the PCMH and where residents fit in

Transcription

1 If We Build It, Will They Come? Michael J. Rosenblum, MD, FACP Orlando Torres, MD, MS Baystate Medical Center/Tufts Univ. SOM Workshop Session III 1:30 to 3:00 p.m. Wednesday, April 28, Educational Objectives Define the PCMH and where residents fit in Describe and investigate t a Team based approach to patient centered care Identify novel approaches to scheduling and how they can positively impact your residents

2 How FEW of your residents are looking for careers in outpatient medicine? 2% of medical students Why? How did we get here? Health Care that t we now have and the health care that t we could have lies not just a gap, but a chasm

3 Crossing the Quality Chasm (2001) 6 aims for Improvement: Safe Timely Equitable Efficient Effective Patient Centered Crossing the Quality Chasm: A New Health System for the 21st Century, Shaping the Future for Health, Institute of Medicine, March 2001 AHRQ 10 Rules for Redesign 1. Care is based on continuous healing relationships, 2. Care is customized according to patient needs and values. 3. The patient is the source of control. 4. Knowledge is shared and information flows freely. 5. Decision making is evidence based.

4 10 Rules for Redesign 6. Safety is a system property. 7. Transparency is necessary. 8. Needs are anticipated. 9. Waste is continuously decreased. 10. Cooperation among clinicians is a priority. What is a PCMH? a model for care Highly functional teams Strengthen physician - patient relationship with coordinated care and a long term healing relationship

5 PPC-PCMH PCMH : 10 must pass elements Access and Communication Patient Tracking and Registry Functions Organizing i Clinical i l Data Identifying Important Conditions Care Management Guidelines for Important Conditions Patient Self-Management Support & Test Tracking Referral Tracking Performance Reporting and Improvement Measures of Performance ; Reporting to Physicians ; Patient Experience Advanced Electronic Communications via an Interactive Web site & Electronic Care Management Support HSHC - An academic practice in an urban environment

6 Legend

7 Community Multicultural poverty & illiteracy Isolated communities cultural and language barriers Underserved Low health literacy Lack of insurance coverage Transportation Chronic & uncontrolled disease HSHC Patient Profile Mental illness and physical disabilities Diabetes Hypertension / Metabolic Syndrome Asthma Providers 50 resident physicians 5 NP/PA 9 clinician-educators

8 Services Provided Social Services Insurance Case Management Financial Counseling HIV Case Management Patient Driven Primary & Subspecialty Care Pharmacy Services and Indigent Pharmacy Program Diabetes Education & Nutrition Interpreter Services How do we do it?

9 How did we start Change? Identifying stakeholders Understanding roles and needs Executive Sponsorship Medical Finance Change is not EASY In Practice and Politically Multidisciplinary Team Internists Practice Nurse Medical Assistant Practice Manager Office Supervisor Scheduler Quality Consultant

10 Team Behaviors (Salas, McIntyre, et al): Shared mental model: specific roles/behaviors based on mutual goals. Mutual performance monitoring: continuous QI systems, feedback. Leadership: coordination, direction, knowledge, balance of supervision and autonomy. Backup behavior: anticipate needs and respond with resources. Adaptability: respond to internal/external changes, active management. Orientation: goals developed by team, multiple participants. Mutual trust: role performance and willingness to discuss mistakes. Closed-loop communication: confirming the message sent was what was received. Balance Academic Mission & Vision Vision: To be a national leader in team-based health care and education. Mission: To improve the lives of our patients and our community every day by providing health care in an environment that values quality, teamwork, innovation, cultural diversity, educational excellence, and mutual respect. Resident s Education (our historic focus)

11 Systems approach to "Access and Efficiency" Highly Functional Teams Balancing workload & roles Leaner processes satisfaction and quality of care should be system properties HSHC Aims for FY09 Access PCP Appointments within 4 weeks Team Urgents in 24 hours Response to calls within 24 hours 90% Continuity of care with team 50% Decrease in No-Show rate Efficiency Patient ready in room by appointment time Provider ready for patient within 15 minutes of appointment time Door to Door 2.5x appointment duration Patient Satisfaction Patient knows PCP/team Increase patient satisfaction to at least 75% -current national threshold per P.R.C. data

12 3 rd Supply and Demand Access Data: rd Next Available Appointment Team based care Pre Post Team Resident Faculty Lower is better Days START Greeting New or Established 72 hrs prior over phone? Last Update? > 90 day s or changes YES NO Registration Registration NEW Established Registration Completed Expedite Check In POD A or POD B Front to POD A Transfer Front to POD B Transfer Sit down & Waiting time for MA to Prep Pt called by MA, Prep done. Prep Completed & Pt in Exam Room Sit down & Waiting time for MA to Prep Pt called by MA, Prep done. Prep Completed & Pt in Exam Room Provider Ready for Patient Provider Ready for Patient

13 Efficiency Data: min Cycle time 20 min visit Lower is better. 100 Pre: 95 (70-120) min 80 Patients 34 % dec frequently LWT 60 At 6 months: minutes average for ALL providers minutes for ATTENDINGS 0 Pre Post Overall Attendings Redesigning Team Structure Model of a patient-centered initiative Patient Population patients per team 3-4 Providers 1 Practice Nurse 2 Medical Assistants 1 Interpreter 1 Practice Associate Rightsizing and balancing the workload

14 Redesign Pilot Teams Findings Improved outcomes Improved Quality of Care Improved staff & provider satisfaction sense of control Improved patient satisfaction Rolled out to entire practice January 2009 Quality: Dashboard Data Diabetes Mammography Cancer Screening Vaccines

15 Intrinsic Factors Redesign Challenges Physical plant Supply: demand d mismatch i.e. Interpreters Academic Practice Part time providers (66% of volume) Residency rotation: two week blocks Inpatient >> outpatient Recruitment & retention Dt Data mining ii and business itlli intelligence Extrinsic Factors Inconsistent show rates Complex patients Conclusion Redesign has no deadline. Continued Process Improvement Healthcare delivery should be organized by physicians Leadership roles Understand the business environment and political challenges Understand the bottom line

16 Where we wanted to go: Full AM/PM team days Consistent support staff Designated team space Work at highest level of licensure Nurse: education and medication reconciliation (the Glue) NP/PA: for urgent team care Medical assistant: DM foot exam, screening HCM Practice associate: Form completion Provider: Medicine How do we build teams July meet and greet with team and patients Specific roles and expectations Huddle: needs of patients Friendly competitions for best team

17 Continuous Healing Relationship Index (CHRI) Ongoing research (N=1067 patients) 98% of visits it with faculty as PCP are own patients. t 76% for residents as PCP. Relationship between Patient satisfaction and resident satisfaction. Theory: when patient and provider experience satisfaction, metrics will improve. Resident satisfaction WAAAAAAAY BETTER! Not left to battle it alone Relationship with team Efficiency Patients are in the room on time Know who to go to for help I get help Attending knows my patients I know my team s patients and they know my patients Faculty satisfaction -not working solo

18 Correcting Continuity Panel Size to Promote a Continuous Healing Relationship Section III: Innovative Scheduling 14 day alternating Mini-blocks Evening clinic: work/life balance

19 Does this sound familiar? I find that 4 weeks of wards are extremely exhausting bt but rewarding my mind id is constantly tl on my sick inpatients. I still keep getting pages about inpatients and it is hard to concentrate on outpt stuff. I find myself late to continuity clinic, rushed to get done, finish my box, so that I can check back in on my hospitalized pts. Medicine-pediatrics resident Background/History Wards: month long blocks Competing inpatient and outpatient Fatigue = normal Education, efficiency and satisfaction suffer Patients frustrated by poor access to part-time providers

20 Hypotheses 14 day Mini-Blocks will improve resident satisfaction, fatigue, teamwork and receptivity it to learning Patient satisfaction will advance with improved access and opportunities for care coordination 14 Day Alternating Mini-Blocks 14 Traditional Day Alternating and New Mini Models -Blocks OLD Block 1 (28D) Manager (M) 2 Ambulatory (A) 3 CCU (28D) NEW 1A 1B 2A 2B 3 (14D) M A M A CCU

21 Methodology Manager year ( PGY-2 ): three ambulatory and three ward blocks Separated inpatient/outpatient responsibilities 3 sessions/week during ambulatory Shorter call blocks Questions (abridged): N=10 (max) Selected Comments Which type of schedule do you prefer? 90% Miniblocks Better focus on wards and clinic, better time management. Improves learning and overall satisfaction. How easy/difficult are inpatient handoffs? 75% same as full-month 25% easier Would say easier, except patients are more complicated so for that reason, I find the handover about equal. Opportunity for follow up? 80% prefer Mini-blocks I can see my patient in the clinic, give 3-4 weeks appointment, do 2 weeks of manager and then see the patient again in the clinic. I like that. Effect on learning? equivalent I have learned more ambulatory medicine, I feel better prepared for out pt medicine now.

22 What effect has the new schedule had on your fatigue level? 60% less fatigue 40% same level 0% more You don t get fatigue, you can think about your hospital pt w/o thinking or worrying about your outpatient it improves outside hospital life with your family/so/loved ones How satisfied are you with the new scheduling model and its impact on your ambulatory training? 90% more satisfied I enjoy having more primary care patient panels when I'm at clinic. I find it less stressful than squeezing in clinic during inpatient. Overall, how satisfied are you with your ambulatory care experience? 1-5 Scale Average= 3.5 Overall this has been a GREAT change in the program. It has increased the ability to focus on care, not get exhausted and learn more. Key Themes Near universal preference Less fatigue Improved ambulatory learning Improved access/coordination of care Increased satisfaction with both inpatient and ambulatory experience

23 Lessons Learned Discordant percentages of inpatient versus ambulatory experience makes further rollout complex Difficult to measure impact on patient satisfaction Innovative scheduling has positively impacted multiple facets of the resident experience Future Directions Match-pair residents to improve availability Great potential for unit months Roll-out for all residents/rotations in ?

24 Evening Clinic The way it was! Ambulatory block experience Monday-Friday Residents reported great difficulty in scheduling appointments Low satisfaction with work-life balance Patients frustrated by limited hours most health centers offer

25 Hypotheses An evening continuity session that creates a free half-day will improve resident work-life balance Patient satisfaction will advance as a result of improved access. Methodology Consistent weekly evening session during amb blocks Compensatory AM or PM session off Maximum three residents/preceptor An anonymous pre-intervention survey (5 point Likert-Scale and yes/no questions) was utilized during the summer of 2009 (N= twenty-six R2/R3 s) A post-intervention survey of all three years was completed winter (N=33)

26 Pre-Intervention results 77% had neglected their health and wellness 33% felt it was impossible to take care of a DDS or MD appointment 88% welcomed an opportunity to have an evening continuity clinic

27 Themes Opportunities for resident healthcare and other needs have markedly improved Overall satisfaction with patient care, education and efficiency for residents is uniformly high. Numerous patients who struggle with daytime appointments have expressed great satisfaction

28 Conclusions Better work-life balance and improved access for patients. New opportunity to schedule appointments t and take care of personal/familial l issues. Efficient evening sessions require creative scheduling for faculty, residents, and complimentary resources. The financial impact of extended hours (utilities, security and staff) must be balanced by productivity at this time. The opportunity for M-F evenings and weekend hours are being considered.