MiCMRC/MiPCT Care Manager Educational Webinar 2015 Summit Best Practice Award Presentations February 24, 2016
MiCMRC/MiPCT Care Manager Educational Webinar Presenters: Dr. Gerald Lee, Alpine Internal Medicine & Pediatrics, Spectrum Health Medical Group Dee Dailey, Integrated Health Partners PO Leader, Representing Cereal City Pediatrics and Moazami Pediatrics Chelsea Hauschild, New Day Family Medicine Practice Coach Deepa Nandamudi LMSW/ACSW, Complex Care Manager, CHC Fort Gratiot
Objectives Describe best practices learned from some of the 2015 Summit Best Practice Award winners. Discuss how some of these best practices may be applied to your practice.
Chelsea Hauschild, New Day Family Medicine Practice Coach
Winning Category: Most Improved-Diabetes Practice Name: New Day WHAT MADE A DIFFERENCE: A Flexible and Eager to Adopt New Things Culture -- The team takes care to make sure that everyone has bought in to a proposed change Whole Practice Team (coach, CM, physician, front desk lead) meets twice a month to go over their performance on measures, discuss gaps in care, etc.) and uses IHP online registry Sustaining the Gains of the IHP Diabetes Collaboratives Integrated successes into the practice workflow as expectations, and have spread the approach to asthma, hypertension Diabetic Eye Exam Excellence Practice initiates and faxes the referral to the ophthalmologist. Two weeks later they follow up with the ophthalmologist and follow up if the patient has not gone using a referral tracking form they developed In-Office Diabetic AIC Testing The practice has its own machine and can give the patient instantaneous testing and results
Winning Category: Most Improved-Diabetes Practice Name: New Day, cont. HINTS FOR OTHER PRACTICES Everyone must be vested in a change (if the front desk, MA, etc. is not bought in, the change won t work) Develop trust in your team everyone is busy and needs a team that they can trust Incorporate prompts as cues for example, when a chronic disease patient visits, the appointment system labels as a chronic disease visit, prompting the team to see if they need tests, etc.
Dee Dailey, Integrated Health Partners PO Leader, Representing Cereal City Pediatrics and Moazami Pediatrics
Winning Category: Best Overall Pediatric Practice Practice Names: Cereal City Pediatric and Moazami Pediatric WHAT MADE A DIFFERENCE A Focus on Training The entire office (including front office) participated in in-service with an asthma educator; in-services from an Asthma Allergy Center on injections Physicians conducted an in service with the nursing staff on identifying respiratory distress. Now, the content of the in service has been included as part of the new hire training process. Useful Standard Tools and Processes In 2012, a cough protocol/algorithm for the front desk and triage was created to screen phone calls and prioritize appointments. The office also purchased a spirometer and had the supplier conduct an in service on proper use. Annual well visits with an asthma action plan is required for all medication refills and notes for medication usage at school for patients with asthma. Medication follow-up appointment is required for patients w/frequent refills. Asthma patients are tracked and flagged in PCC and Gaps in Care reports and the office has a designated Asthma Champion.
Winning Category: Best Overall Pediatric Practice Practice Names: Cereal City Pediatric and Moazami Pediatric WHAT MADE A DIFFERENCE, cont. Priority calls are placed to patients with asthma when flu vaccine arrives, along with other high risk patients before reminder calls for the healthy. Refills are monitored for compliance. Attention to Patient Education Patient Asthma Education folders are given to patients with a new asthma diagnosis. Individual care management education sessions are conducted to teach patients how to use a spacer, inhaler, or nebulizer. HINTS FOR OTHER PRACTICES Take time for training and incorporate processes and useful tools as aids to guide your work Watch for patterns (which patients are requesting frequent refills, are there repeating situations that cause rework, etc.) and act on them
Deepa Nandamudi LMSW/ACSW, Complex Care Manager, CHC Fort Gratiot
MIPCT CASE MANAGEMENT/COMMUNITY OUTREACH
PHCN MIPCT SITES PHCN ST. CLAIR CHC STONE STREET 4154 S. RIVER ROAD 1321 STONE STREET EAST CHINA, MI 48054 PORT HURON, MI 48060 DR. LISA SCHEEL DR. DANIEL WILHELM DR. SUSAN ZIELONKA DR. SREEDHAR PAKNIKAR CHC YALE CHC FORT GRATIOT 105 COMMERCE DRIVE 3030 COMMERCE DRIVE YALE, MI 48097 FORT GRATIOT, MI 48059 DR. AMIT NANDI DR. DEV NANDAMUDI
MIPICT CARE MANAGERS DEEPA NANDAMUDI, LMSW COLLEEN DEWAN, RN, BGS GLORIA SHURKEY, LPN
COMMUNITY RESOURCE CASE During a group visit I heard a parent tell her child that she really wanted to try some of the recipes, but that she would have to wait until she got a stove that worked. We gave the parent some names of community resources that she could contact to see about getting a stove. I did a follow up call to parent and that she did get a stove but now the refrigerator was going and had sparks coming out of back. I gave the parent names of community resources to contact in regards to getting a refrigerator. When I did f/u call I found out that she was able to get a refrigerator from one of the community resources. Gloria Shurkey, LPN
WINNING CATEGORY: MOST IMPROVED-PEDIATRIC PRACTICE PRACTICE NAME: CHC FORT GRATIOT WHAT MADE A DIFFERENCE: MiPCT Dedicated process and staff focus on closing gaps in care Office staff diligently follow up with parents by phone and via letters. Each visit (regardless of reason for visit) is used as an opportunity to close gaps in care ED calls are made to patients who visit the ED to remind them of extended access hours and arrange a follow-up visit, if appropriate Using data to identify opportunities for improvement Data analysis indicated that the most frequent driver of ED visits was constipation. Discussion with parents found that they didn t know what to do when their child was in pain, or how to prevent constipation The practice offered a group visit that included how to prevent constipation (e.g., with a high fiber diet that is appealing to kids), and offered information on what do if constipation reoccurs Care Managers and physicians identified patients who could benefit The group visit was held at a convenient time for parents (from 5:30 to 7:30) and was a hit! Now, group visits are conducted for asthma, nutrition, and ADHD
WINNING CATEGORY: MOST IMPROVED-PEDIATRIC PRACTICE PRACTICE NAME: CHC FORT GRATIOT WHAT MADE A DIFFERENCE: The Care Managers are centrally located but huddle once a week to discuss cases One Care Manager is a social worker and has good relationships with community mental health agencies and behavioral health resources Community resources are monitored and published on their website and in a hardcopy binder. All employees are trained on community resources and there are good relationships with local agencies. The practice helps the agencies by documenting activity for funders so that they can provide it to their funders as evidence of use HINTS FOR OTHER PRACTICES The whole team must know they play important roles and that others depend on them Connect your offices with community resources Define and document processes. Create standard work and expectations. Use your data to find out what your issues are; Add a midlevel or increase your after-hours schedule if needed. MiPCT
CARE MANAGEMENT A 6 year old patient was refereed to a care manager for help with behavior issues. Care manager met with mother and conducted initial assessment. While conducting the medication review, it came to light that parent was giving her daughter homeopathic medications for her seizures. Mom stated she believed in alternative natural therapy. Per mom, her traveling homeopathic doctor told her that her daughter s symptoms would get worse before they got better. Mom stated that her homeopathic doctor also told her that toxins would be drawn out and cause some skin reactions. It turned out that the child had developed impetigo. Mom was reluctant to report the homeopathic medications to her daughter s pediatrician stating it was not necessary. Mom was informed about drug interactions between seemingly harmless homeopathic medicines and her daughter s seizure medicines. The composition of the homeopathic medication could interfere with the seizure medicines. The care manager educated mom about seizure activity and what happens during a seizure using visual aids. The efficacy of homeopathic treatment was unknown and no clinical data was present to back its claims. Mom was also informed that her decisions were based on anecdotal success stories. Mom was encouraged to talk about this with her child s pediatrician. This was her self-management goal. With mom s consent, the care manager spoke to the pediatrician and informed him of this. The pediatrician spoke to the mom, and advised her to hold off on the homeopathic medication until her daughter had no active seizures. Mom weighed the pros and cons of alternative medicines and made the informed decision of holding off on homeopathic medicines until her child was older and had no active seizures. Mom stated that she did not rule out alternative medicines completely but was thankful in understanding that there could be drug interactions between homeopathic and allopathic medications. DEEPA NANDAMUDI, LMSW
Dr. Gerald Lee, Alpine Internal Medicine & Pediatrics, Spectrum Health Medical Group
Winning Category: Most Improved Practice Name: Alpine IM/FM/PED s WHAT MADE A DIFFERENCE (Process Change, etc.): We embraced a culture of change, collaboration, team work, dedication and commitment in putting our patients first. We developed workflows as a team, and discussed gaps and barriers that could improve our process daily during our team huddles. We empowered our front line staff. We utilized all areas of our care team to their fullest clinical scope including our NP s, PA s, Care Managers, MA s and Providers. We created Standard work, and tracked our teams success by auditing, planning, studying and developing action plans that we could implement HINTS FOR OTHER PRACTICES Build trust within your team. Celebrate the small wins. Huddle daily. Empower your front line staff- when you do, they will do great things.
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