Dr. Tina Bettin DNP, MSN, RN, FNP- BC, APNP

Dr. Tina Bettin DNP, MSN, RN, FNP- BC, APNP

OBJECTIVES Describe concepts related to team-based care & give examples of the concepts in practice. Discuss the impact of team-based care on quality outcomes. Recognize ways to keep team-based care patientcentered Apply this information to professional practice

Team-based health care is the provision of health services to individuals, families, and/or their communities by at least two health providers who work collaboratively with patients and their caregivers to the extent preferred by each patient to accomplish shared goals within and across settings to achieve coordinated, highquality care. Naylor MD, Coburn KD, Kurtzman ET, et al. Inter-professional team-based primary care for chronically ill adults: State of the Science. Unpublished white paper presented at the ABIM Foundation meeting to Advance Team- Based Care for the Chronically Ill in Ambulatory Settings. Philadelphia, PA; March 24-25, 2010.

THEDACARE S PRINCIPLES Mission ThedaCare s mission is to improve the health of our communities. Vision Our vision is to always set and deliver the highest standard of health care performance in measurable and visible ways so our customers are confident they are making the right decision in choosing us. Values Our values are the internal compasses that guide our day-today decisions. They are the glue that holds the organization together.

NEW LONDON CALL GROUP

POPULATION SERVED Rural population Portion is in a federal designated Health Professional Shortage Area (HPSA) Providers serve as PCPs for 13,000 individuals 98% Caucasian 89% HS diploma ( than WI average) 16% Bachelor s or higher ( than WI average)

POPULATION SERVED Median Income $48,000 19% Persons age 65 & older (WI average 14%) 11.2% families below poverty level 17% of children considered in poverty 42% children eligible for free/reduced lunch 27% of children in single parent homes 24% binge drinking 32% BMI above 30

THE BEGINNING Initially 1 MD & 1 NP in 1995 Culture was started patient-focused; on-call & hospital responsibilities for NP 2000-2001 expanded; 3 MDs & 3 NPs (1 male); worked in teams of 2 2002 expanded; 5 MDs & 3 NPs Interviewing included questions on team concepts, interactions with NPs & PAs; change concepts

CLINICAL TEAM MAKE UP Providers: 7 MDs, 6 APRNs & 3 PAs-all but 1 PCPs Manager & 2 supervisors Practice Associates Patient Service Representatives Triage (11 nurses; 5.8 FTEs) Cell Leads Disease Management (1 PT RN) Medical records, coding, laboratory & radiology

TEAMS New London Business Pod Team NL, Manawa & Weyauwega Teams within the team Providers have 1-2 practice associates Hallway placement or outlying clinic placement 2 providers per hallway with 3 practice associates 1 provider w/2 & 1 provider w/1 1 Cell lead per 2 hallways Floating Patient Service Representatives (PSRs)

PERSONAL VALUES OF TEAM MEMBERS Honesty-transparency; critical to improvement & maintaining mutual trust Discipline-seeking & sharing new ideas Creativity-excited to tackle new & emerging problems Humility-recognize differences in training; individuals are human & will make mistakes Curiosity-reflection; continuous improvement Mitchell P, Wynia M, Golden R, et al. Core principles & values of effective team-based health care. Discussion Paper, Institute of Medicine; October 2012. www.iom.edu

THEDACARE VALUES ThedaCare values are: Focus on the customer their needs are our top priority Have a thirst for learning continuously seek out ways to do our work better Be courageous challenge each other s ideas to come up with the best thinking and solutions Love your work let your passion show every day

TEAM-BASED CARE CONCEPTS CONCEPT Shared goals work to establish shared goals that reflect patient & family priorities. EXAMPLE Mission statement ThedaCare s mission is to improve the health of our communities. Lori developed in 2010 Transparency of goals with staff Goal directed problem list Patient as part of LEAN team

Shared Goals-continued Across the board, just as they preach, ThedaCare is patient-centered. Lori (the patient) is a word that's heard and seen all over the hospital. Lori is their patient and their true north. She has a face and a name and is a real person. On each floor, on each board there is a picture of Lori. Every project, mission, and objective actually connects back to Lori. Lori is why ThedaCare wants to build healthy communities McGuinness D, More Evidence That ThedaCare Rocks. The Lean Post. October 9, 2013

TEAM-BASED CARE CONCEPTS CONCEPT Clear roles Clear expectations of team members functions, responsibilities & accountabilities thereby optimizing team s efficiency & take advantage of divisions of labor EXAMPLE All providers as paneled PCPs Rooming standards for practice associates All practice associates certified MA schedule Scheduling PSR

TEAM-BASED CARE CONCEPTS CONCEPT Mutual Trust Earn each other s trust, create a shared interest in teammates & their protection resulting in shared achievement EXAMPLE 3 practice associates working as a team Call rotation Outlying clinics coverage for providers & staff Community Health Assessment Team (CHAT) Rural Health Initiative Mental health Obesity

TEAM-BASED CARE CONCEPTS CONCEPT Effective Communication Consistent channels for transparent communication which are used by all team members EXAMPLE Daily huddles Weekly provider meetings Staff meetings Leadership updates Monthly CEO memos Common calendars Charter communications

TEAM-BASED CARE CONCEPTS CONCEPT Measurable Processes & Outcomes Implements feedback mechanisms to track & improve performance/outcomes EXAMPLE Monthly provider updates on quality data Tracking boards Annual metrics target set by Senior leadership True North metrics Wisconsin Collaborative for Healthcare Quality (WCHQ)

TEAM-BASED CARE CONCEPTS CONCEPT Adaptability Adjust strategies based on environmental information & reallocation of resources Altering course of team in response to changing conditions EXAMPLE Use of NP for hospitalist Central Command Providing care for patients in clinic when scheduled provider is in an urgent situation LEAN Changing reimbursement from production to quality

TEAM-BASED CARE CONCEPTS CONCEPT Backup Behavior Ability to anticipate other s needs Ability to shift workload among members to achieve balance EXAMPLE Refill protocol-triage Protime protocol-protime nurse Strep & urine protocols MDs & APCs seen as equals Procedure set up book Secret sauce for time off Collegiality among providers

TEAM-BASED CARE CONCEPTS CONCEPT Team/collective Orientation Belief of team s goals over individual member s goals EXAMPLE Health maintenance alerts addressed by all who contact patient Patient treated like provider is PCP, even when not Disease management RN CHAT Community service Women s Health Day Mission of Hope

TEAM-BASED CARE CONCEPTS CONCEPT Mutual performance monitoring Ability to develop common understandings of team environment & apply appropriate task strategies in order to accurately monitor teammate performance EXAMPLE PDPs for staff Provider reviews Twice yearly provider/employee surveys Skills check off list Models for providers Interactive Employee Education data base & electronic data base for performance (Halogen)

TEAM-BASED CARE CONCEPTS CONCEPT Team Leadership Ability to direct & coordinate activities of team members Assess performance of team Assign tasks Motivate Establish positive atmosphere EXAMPLE Lead projects A-3; value streams; PDSA; SBAR Monitor/track outcomes Thank you cards Challenges-w/in business pods and between pods Volunteer opportunities

PATIENT OUTCOMES ThedaCare is repeat top performer in WCHQ New London business pod is usually in the top 2 performers within system annually September 2014-CMS reported Bellin-ThedaCare HealthCare Partners were ranked #1 out of the 23 Pioneer Affordable Care Organizations (ACOs); quality score 94.11; lowest cost; measured on 33 factors

TEAM SATISFACTION Overall very good Bi-annual reviews over 3.0 on 4 point scale by both staff & providers Sought after clinical rotation site for future providers and staff Advancement of individuals w/in organization Workload distributed Staff turnover is 3%, less than state & national average

TEAM SATISFACTION Public recognition helps ACO Pioneer-top performer Top 100 Most Wired Healthcare Organizations for over 10 years National Rural Health Association-TCMC-NL Top 20 CAH in country in area of financial stability x 2 VHA Sustainability Excellence Award efforts to recycle single-use plastics

CHALLENGES Maintaining culture as clinic expands Complacency minimal; team challenges help; staff turnover <3% (less than state & national average) Changing roles with ACA Change itself Payment still mostly production based

CELEBRATIONS Team challenges Breakfast served by the providers T-shirt days Picnics Team lunches/dinners Celebration/Appreciation cards ThedaCare Follies Fall Fest for Families

COMMUNITY GARDENS

www.youtube.com/watch?v=9bcmpdv3fdc

Questions?

REFERENCES *American Hospital Association. Workforce roles in a redesigned primary care model. Executive summary. September 2011. *Bendix J. Building a team-based medical practice. Medical Economics. September 10, 2013. http://medicaleconomics.modernmedicine.com/medicaleconomics/content/tags/accountable (accessed on May 9, 2015) *Bettin, T, Personal Experiences *Gruman J, What does team-based care mean for patients? Center for Advancing Health. January 8, 2014. http://www.cfah.org/blog/2013/what-does-team-based care mean for patients (accessed May 9, 2015) *Hupke C, Team-based care: Optimizing primary care for patients & providers. Safety first blog, IHI. http://www.ihi.org/communities/blogs/_layouts/ihi/community/blog/itemview.a spx? (accessed May 8, 2015). *Institute of Medicine (US); Olsen LA, Saunders RS, McGinnis JM, editors. Patients charting the course: Citizen engagement & the learning health system: Workshop summary. Washington DC: National Academies Press; 2011.

REFERENCES *King H, Battles J, Baker D, Alonso A, Salas E, Webster J, Toomey L, & Salisbury M, TeamSTEPPS: Team strategies & tools to enhance performance & patient safety. http://www.ncbi.nlm.nih.gov/books/nbk43686/ (accessed May 9, 2015) *McGuinness D, More Evidence That ThedaCare Rocks. The Lean Post. October 9, 2013. *Mitchell P, Wynia M, Golden R, et al. Core principles & values of effective teambased health care. Discussion Paper, Institute of Medicine; October 2012. www.iom.edu *Naylor MD, Coburn KD, Kurtzman ET, et al. Inter-professional team-based primary care for chronically ill adults: State of the Science. Unpublished white paper presented at the ABIM Foundation meeting to Advance Team-Based Care for the Chronically Ill in Ambulatory Settings. Philadelphia, PA; March 24-25, 2010. *Patient-Centered Primary Care Collaborative. Team-based care: A critical element of primary care transformation. Population Health Management. February 2013.

REFERENCES *Quinn T, Bringing a management model to healthcare: Team-based care. http://www.forbes.com/sites/groupthink/2014/12/09/bringing -a-managementmodel-to-healthcare (accessed May 9, 2015). *Rodak S, 5 core principles of team-based healthcare. Becker s Hospital Review. October 4, 2012. http://www.beckerhospitalreview.com/strategic-planning/5- core-principles-of-team-based-care (accessed May 8, 2015). *Toussaint J, & Gerard R, On the mend. Cambridge, MA. Lean Enterprise Institute, 2010. *Wynia MK, Von Kohom I, Mitchell PH. Challenges at the intersection of teambased & patient-centered healthcare. JAMA 2012; 308(13): 1327-8. (accessed May 8, 2015)