Transforming Practice: Improving Healthcare thru Team Care Planning and Other Initiatives

Transforming Practice: Improving Healthcare thru Team Care Planning and Other Initiatives

Learning Objectives Upon completion of this session, the participant will be able to: Review techniques to increase patient outcomes Identify techniques to enhance patient satisfaction 2

3 Faculty Information Wendy Wright, MS, RN, APRN, FNP, FAANP Owner - Wright & Associates Family Healthcare @ Amherst, NH Owner Wright & Associates Family Healthcare @ Concord, NH Partner Partners in Healthcare Education, PLLC Speaker bureau: Vivus, Boehringer, Takeda, Merck, GSK, Sanofi

4 January 2013 Received our score card from Anthem We used this scorecard to carefully dissect our practice Looked at what we were doing well and what we needed to work on This was the push we needed to ensure that we were providing best care possible and meeting reporting requirements

5 Here is What I Sent to Our Staff Similarities: A. Both offices STINK with pediatric preventive care. WE need to run: 1. 12 18 year olds and call them for PE s. 2. 3-11 year olds and do the same B. Branded Medications Both offices are using more than standard of BRANDED nasal steroids and BRANDED SSRI s (this should not be needed as they are all generic); will encourage providers to consider generics

6 Here is What I Sent to Our Staff C. Differences: Concord Weaknesses: 1a. Med adherence/statins/ace 2a. Branded Stimulants 3a. Diabetic eye examinations 4a. SNRI branded 5a. ER visits 4 avoidable! Amherst Weaknesses: 1a. Med adherence: statin/ace 2a. Branded sleep agents 3a. Hospitalizations/ER 4 visits

We Used This As Our Starting Point! Here is what we have done so far: Run reports of all children and looked at last wellvisit Called in for well-child visits Created care planning initiative Partnered with Simmons Graduate Nurse Practitioner Students to look at our diabetes metrics Partnered with a Doctoral NP Student to work on medication adherence initiative

We Are Doing This for All Three Thousand Patients Not Just Anthem Patients

Care Planning

Pre-visit Preparation Improving clinician visit and improving patient outcomes Our model of care: Longer visits with comprehensive care What This Means: we attempt to address all preventive and acute needs at every visit, every time

Pre-visit Preparation Two days before visit: check out sheet is completed by staff member working with particular provider Focus is on HEDIS/Quality measurements Address: Mammograms Bone density Colonoscopy Immunizations Diabetes measurements A1C Foot examination Microalbumin Eye examination

Check-out/Care Planning Sheet

13 Here is what has happened Began implementing early 2013 In office services have increased significantly More vaccines are being given More A1C, microalbumin testing is being done More preventive visits/procedures are being booked Mammograms/colonoscopies procedures that were overdue are being booked Staff books these at check-out Serves two purposes: Gets accomplished Provides excellent malpractice defense

14 Here is what has happened Specifics: Amherst: Two of the past 5 months have seen the highest increase in office services in the history of our practice No new staff has been added (providers) Number of patient visits is NOT higher Means that more vaccines, A1C s, microalbumins are being done Concord: Highest increase in office services in the past five months, in three year history of practice Still with one provider Big change was implementation of care planning

15 Ultimately, Most Important Goal Good patient care Improved outcomes Happy customers

Simmons College Partnership: Graduate NP Program

17 Project Ran report of all individuals with Diabetes enrolled as patients within both sites Provided report to graduate NP students Four graduate NP students and faculty instructor came on site and reviewed each patient individually for a number of quality metrics

18 Project started June 1, 2013 Diabetes Metrics A1C < 7.0% LDL < 100 Microalbumin within 1 year Diabetic retinal examination with in 1 year Foot examination within 1 year Percent of individuals adherent with medication > 80% of days

19 Results of Project: Completed August 2013 Diabetes Metrics A1C < 7.0%: 83.95% LDL < 100: 62.34% Microalbumin within 1 year: 80.72% Diabetic retinal examination with in 1 year: 63.85% Foot examination within 1 year: 73.49% Percent of individuals adherent with medication > 80%: 83.14%

What Do We Do From Here. We have set reminders in individual charts of all at risk individuals i.e patient overdue for eye examination i.e. patient overdue for microalbumin We have sent messages to MA inbox to have MA call patients to book eye examination for them We have done NP education re: need to do foot examination at every visit and annually monofilament and reflexes

Here Is One Message MA sends patient message on patient portal MA: You are overdue for your eye examination, can I please schedule this for you? Patient: No, I am fine. Thank you My response to patient via portal: I am getting reminders from Anthem that you are overdue and we are all concerned about your eyes. Patient: Oh.I am sorry, I didn t know they were bothering you. Sure, I am on off on 9/12/2013 go ahead and book. WHATEVER IT TAKES

Staff Education We have realized as a result of this that: Lab interface does not turn LDL/Lipid profile red unless LDL > 130 Requires NP to look more closely at LDL

Doctoral NP Project

Additional Initiatives. Doctoral student: Is looking at all women 40 years of age and older for mammogram within past one year If not present, message is sent to MA to call patient to book If patients states, it has been done.we are calling local facilities to obtain report

Additional Initiative Look at potential causes of poor medication adherence Develop brochure for our patients on importance of medication adherence Deliver lecture to staff/patients on medication adherence and impact on health Project is still being defined and will continue over the next two years

Additional Initiatives at WAFHC

When Booking an Appointment or at Check-in Have had urgent medical care since your last visit? Use this as an opportunity to obtain records from ER/urgent Can use transition into care (part of meaningful use)

Prior to Clinician Visit MA to obtain vitals, spirometry, ECG, A1C, immunizations, microalbumin, lipid, INR prior to clinician entering room Train MA s to anticipate needs of clinician Care is coordinated and integrated Emphasis is on patient and prevention at every visit Allows patients to spend more face-face time with providers

Optimizing Clinician Visits Take time at outset to build templates We have 1 clinician and 1 MA responsible for templates Schedule quarterly long staff meeting, MA and NP work on building and modifying templates to meet needs of providers Must put time in up-front to create useable templates

Optimizing Clinician Visits We have 72 hour chart rule (set by guidelines/recommendations of meaningful use) If charts are nearing 72 hours, clinicians receive messages/warnings Becomes part of annual review

Optimizing Clinician Visits Offer prescription refills during visits Serves two purposes Attest to ERX requirements for CMS/medicare patients Cuts down on calls into office which increases staffing demands

Utilize Reminders Here are three examples of our reminder system to enhance patient care and improve outcomes

Utilize Reminders Diabetes: Recommended Hepatitis Series for all individuals with diabetes < 60 years of age

Utilize Reminders Hepatitis C screening

Check-out Provide summary of visit at end of visit Allows patient to review medications and correct/modify as needed Also important for meaningful use requirements Collect patient email to drive them to patient portal for questions, requesting appointments, paying bills Book specialty visits and referrals at time of check out Make sure patient is on schedule for complete PE annually and every 3 months for chronic care

Optimizing Limited Resources and Time While Providing Quality Care

Consider. Patient portal Labs can be posted Less staff time Providers publish all to portal Record of viewing Patient can pay bills and also request appointments/rx refills Part of meaningful use Stage 2

Patient Portal Can be used for important new patient information/registration information Depending upon your portal Has been used for patient surveys Office closures or important information about the practice New provider announcements

I Would Love to Learn From You What are your best practices? Thoughts for the presenters? Questions? Feel free to contact me at: WendyARNP@aol.com Visit our website at: www.wrightfhc.com