Practice Report Out Western Slope CPC Practices
Aspen Internal Medicine Consultants Ricci Bickling, Quality Improvement Specialist 2 Providers 8 Staff EMR: GE Centricity 1755 Active Patients
Aspen Area of Focus: Walk-In Clinic for Acute Care 8:30am 9:30am, M-F Overview: We opened our walk-in clinic in 2015 Our patients are very happy with the availability of a physician early in the morning This has minimized ED visits Challenges: Physician tardiness Pager/text to alert Physician that a walk in has arrived New patients want to utilize the clinic
Aspen Successes: Patient satisfaction and improved health. Minimized ED visits Challenges for next Action Period: We do not foresee any additional challenges regarding this area of focus If the number of patients increases, we may need to add an additional MD
Foresight Family Physicians Janelle Kershner, Occupational Health Coordinator 2 Physicians / 2 Mid-Level Providers 18 Staff EMR: E Clinical Works 4700 Active Patients
Foresight Area of Focus: PHQ9 rescreening process Overview: We have changed our workflow to involve more staff instead of the process falling only to the BH workers. Challenges: Identifying patients who need rescreens (had a positive score of 10 or greater initially) and engaging them at upcoming appointments. We involved more staff to help ID pts using our registry & patient recall.
Foresight Successes: Being able to identify and rescreen those patients at the appointments. Successfully getting them engaged with the help they need. Resources: We utilized our registry capabilities to help us identify those patients needed the rescreen. Outlook for the next Action Period: Our goal is to capture those patient needing a rescreen and see them back in the office within 3 months.
Foresight Challenges for the next Action Period: It continues to be a challenge getting the identified patients to come in for appointments and to be engaged in their health Share the workload and utilize your staff to the full extent of their abilities
Glenwood Medical Associates Anna Olson, Quality Management Specialist 15 Providers 65 Staff EMR: Greenway/Intergy 14,257 Active Patients
Glenwood Area of Focus: Consideration of chronic controlled substance users at high risk for misuse and overdose. Responsibly documenting use of controlled substance. Overview: We first identified over 300 patients who use 1 dose a day over 90 days. Practice agreed upon protocol to actively monitor patients.
Glenwood Challenges: Some patients have been accustomed to getting Rx refilled upon any request and some are reluctant to new policy. CCS management does take a lot of time. (First report out will be done beginning/middle of April). Successes: Being able to identify our CCS patients. Patients are becoming more aware of high risks with opioids. Providers are now realizing how to provide good care management for controlled substances.
Glenwood Resources: CDC has recently published their guidelines http://www.cdc.gov/drugoverdose/prescribing/guideline.html Outlook for the next Action Period: Improve on baseline and set goals thereafter.
Internal Medicine Associates of Grand Valley LeAnn Greenlee, RN, RN Case Manager 4 Providers EMR: Greenway
Internal Medicine Area of Focus: Meaningful data capture and measurement to improve patient outcomes and care management. Overview: Hired third party for data extraction of meaningful clinical data unsuccessful Company used Greenway reports for data validation despite us telling them that data was unreliable Manual data validation incorrect 60% for one measure Challenges: Recent dismissal of third party so still trying to determine which direction to go.
Internal Medicine Successes: Improvement in acute care transition and case management of high risk patients. Improved patient engagement to CM activities. However, can t measure improvement. Resources: Our program is very patient-centric utilizing clinical, case management, and quality assurance skills developed during professional nursing education. Understanding exactly what the patient and providers need is paramount to its success.
Internal Medicine Outlook for the next Action Period: Further incorporation of MAs into case management activities. Challenges for next Action Period: Reporting/measurement still expected to be an issue. Unable to accurately measure improvement extremely difficult.
Mercy Family Medicine Tamra Lavengood, CPC Coordinator 20 Providers 70 Staff EMR: LSS 15,000 Active Patients
Mercy Area of Focus: Depression Screening and incorporation of Behavioral Health. Overview: Developed a workflow incorporating a LCSW into their care management of high risk patients with depression utilizing PHQ2 and PHQ9 screening tools.
Mercy Challenges: One part-time LCSW. Over 150 level 6 patients requiring BH care management. Successes: We have been able to decrease hospital utilization and therefore costs. Resources: Trainers (Quality Specialists) to teach the documentation process. Visited other practices that integrated BH to observe billing and workflow.
Mercy Outlook for the next Action Period: Participating in the first SIM Cohort. Focusing on BH integration including billing, warm hand offs, utilizing metrics, such as the PHQ9, and introducing BH care management for our pediatric population. Challenges for the next Action Period: We have to align our revenue strategies and workflows with the larger corporation.
MidValley Family Practice Danielle Lowhorn, Medical Assistant 2 Providers 9 Staff EMR: GE Centricity 1986 Active Patients
MidValley Area of Focus: Immunizations Overview: Immunization protocol has been finalized. We have been updating charts regularly as patient receives shots. We also have been giving Prevnar and Pneumovax as needed to pts 65 and older as well as the patients who are due.
MidValley Challenges: Not meeting our goals to administer Prevnar and Pneumovax. To overcome this we added an extra step to office visits by hitting the view all protocol which tells us what patient is due for. Successes: Enhancing our patients health with the care of our team whether it s preventive or acute and providing our knowledge and current information. Resources: The resources we use for questions or concerns other than the information packet that comes with each vaccine is CDC.org.
MidValley Outlook for the Next Action Period: Keep improving with using the protocol and following up with patients as they receive a vaccine from somewhere else. Challenges for Next Action Period: As we continue to become even busier than we are, to continue to view protocols and update charts with current shot Rx.
Primary Care Partners Carol Schlageck, Managing Associate 22 Providers 63 Clinic Staff EMR: Touchworks HER (Allscripts) 34,000 Active Patients
Primary Care Partners Area of Focus: Standardize clinical workflows across the various CPCI practices. Goal is to identify best practice workflow. Overview: We began by looking at the provider with the best CQM outcomes. The provider was asked to explain their workflow process so that we could compare. Challenges: Each provider has a unique style and workflow preference. Support staff skills also vary. Training sessions provided opportunity to share processes and enhance skills.
Primary Care Partners Successes: We began with one clinical workflow (Diabetes) but have now expanded to three including hypertension and asthma. Resources: Provider and staff recreating their workflow and sharing with their peers in training sessions. Outlook for the next Action Period: We will continue to evaluated additional clinical workflows to design best practice approaches.
Primary Care Partners Challenges for next Action Period: The biggest hurdle is having available time to devote to the necessary provider and staff training. Healthy competition incentivizes providers and staff to engage in training.
Peach Valley Family Medical Center Debbie Pennay, Manager 2.5 Providers 9.75 Staff EMR: Greenway 3,100 Active Patients
Peach Valley Area of Focus: Improved communication with the Hospitalists and ED Dept. Overview: We do not export information to QHN yet, so patients would show up in the ED/Hospital with limited medical information. We needed to develop a process for improving communication in a timely manner so that the hospitalists had current information on medications, history, immunizations, etc. In addition, we felt that we could improve access for the ED providers that would eliminate them having to listen to our long after-hours message so they could leave a message.
Peach Valley Challenges: We had multiple notification processes that involved different staff, so the biggest challenge was just getting organized so that no matter which method was used, we had a process in place. Our verification process is manual and time-consuming. Successes: We started consistently sharing information in mid-march and it is going pretty well. We were also able to add a telephone line and voice mail for the ED Department to use.
Peach Valley Outlook for the next Action Period: We are currently in the process of tracking our compliance rate with the information exchange, with our goal at 85% or more. Changes and/or additional work will depend on compliance. Challenges for next Action Period: Our current process relies on staff memory. We d like to develop some type of automatic reminder and/or check box for easy tracking.
Surface Creek Family Practice Sheryl Hieber, Office Administrator Kara Cowan, LPN, Care Coordinator 5 Providers 9 Staff EMR: Practice Partners 2335 Active Patients
Surface Creek Area of Focus: Integration of Behavioral Health. Overview: Full time Integrated Health counselors on staff now. Templates have been created for documentation and capturing data we can track. Superbill created to track patients seen by IHC and the type of visit. Challenges: Finding the balance between follow up visits and co-visits. Lack of providers for referrals of patient s needing higher level of treatment.
Surface Creek Successes: Providers and support staff engaged and using IHC in office for brief interventions. Flow charts are catching data we are able to see improvement or decline in patient progress. Resources: Health Teamworks CO-Earth Pilot Program On-site training at Foresight Family Practice CPCI QI, Mary Beckner
Surface Creek Outlook for the next Action Period: Negotiate care compact with Center for behavioral health. Tele psych will be implemented. Continue refining and identifying areas of patient care where IHC would be beneficial. Challenges for the next Action Period: Keeping staff engaged in new process. Working out the scheduling and visits with the tele psych.
Telluride Medical Center Bridget Taddonio, Care Manager 6 Providers 65 Staff EMR: ecw 4,966 Active Patients
TMC Aim Statement: Achieve a 75% fall risk screening rate for applicable patients in 2016 Overview: 2014 performance was at 11%. Educated staff on CPCi dashboard and how ecw captures this measure. We wanted to focus on staff training around this measure to hopefully improve our rate to 75% or higher by the end of 2016.
TMC Challenges: Limited space/time to collect vitals, medication reconciliation and ask CQM questions. Not knowing where to document. Lack of organization. Successes: Staff engagement and awareness of QI work. Resources: CDC Poster: What You Can Do To Prevent Falls
TMC Outlook for the next Action Period: We will add additional trainings during our weekly Q&A sessions if needed. We will monitor CQM performance on our CPCi dashboard. Challenges for next Action Period: None foreseen at this point.
Yampa Valley Medical Associates Alicia Morton, Diabetes Care Manager 10 Providers 21 Staff EMR: Allscripts Professional +12,000 Active Patients
Yampa Area of Focus: High risk diabetic patients. Moderate risk diabetic patients. Overview: Initiated group sessions with a turnout of 10 people. This group provides a visit with a physician. Catch up on all lab work and provide an area of specialty i.e. nutrition.
Yampa Challenges: Challenges include getting people to commit to the 6 session commitment. Overcoming the challenge just requires persistence and constant reminders. Successes: Only one (1) session under way. Haven t determined where improvements need to be made. Resources: Utilizing all resources in the community and the professional in the area.
Yampa Outlook for the next Action Period: Continue to fine tune group sessions as needed reinitiate walking group Continue to work on CP. Challenges for next Action Period: The change of sessions and keeping people motivated to come to group sessions during the summer.