building the right generalist team for the right prevention care mike davies md facp mark murray and...
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Building the Right Generalist Team for the Right Prevention
CareMike Davies MD FACP
Mark Murray and Associates
The two ways to improve are…
• Increase speed
• Improve reliability
• Clinical care is about both speed and reliability: “…the right care…at the right time…..”
What is “Primary Care”?
…Responsible for providing or coordinating the majority of the patient’s care…
360 Patients are Over 65
60 Patients had more than 10 Office
Visits Last Year
130 are Clinically Depressed
228 have Hypertension
160 have Heart Disease
248 have Arthritis
113 have Asthma
66 have Diabetes
Panel Size 2000
Operational and Clinical TeamsC
linic
al T
eam
s: W
hat
to
do
?
Operational Teams: How to do it?
Close to Agreement
Far from agreement on HOW to do it (how to
implement guidelines, how to support provider’s
efficiency)
XX
XX
Far from agreement on WHAT to do (what
prevention and chronic disease guidelines to
implement)
Learning's
• The RIGHT care prolongs and enhances lives
• The best centers have teams of people partnering to deliver the right care
• The best clinics measure their own performance
• The best clinics compare their performance to others to find the best ideas for improvement
Quandary
• How to assure prevention care is done for every patient in the panel
• How to adapt the clinic processes to changing recommendations
• How to do it efficiently
Questions
• Are we responsible for prevention of illness in our patients?
• Do we do it?• Do we do it well?• Do we measure it?• Are patients aware of their own prevention
results?• Are patients queued to ask for their
prevention care?
WHAT prevention care should we provide?
Society Recommendations – Chinook Recommendations –
Other Options
Case
• A 61 year old female presents to your office for her yearly physical examination. She has no significant past medical or surgical history and currently uses no medications. She denies alcohol intake greater than 2 glasses of wine per day and smokes currently 1ppd for at least 35 years. On review of your chart, there is a family history of postmenopausal breast cancer. She is mildly overweight (greater than 5% but less than 15% above ideal body weight).
Which of the following would be appropriate at this office visit (Recommended)?
A. Screening Fasting Plasma Glucose
B. TSH screening
C. Pneumococcal Vaccination
D. Hepatitis B Vaccination
E. Counseling on Seat Belt use
Which of the following screenings would not be recommended without reservations for this patient?
A. Bilateral Mammograms
B. Pap Smear for cervical cancer screening
C. DEXA scan for osteoporosis screening
D. Lipid screening
E. Chest X-ray for pulmonary nodules given her smoking
history
Preventative Services Recommendations
From USPSTF and others as summarized by Loyola Medical
School for Adults
• Health Guidance
• Immunizations/Chemoprophylaxis
• Screening
Health Guidance…some organizations recommend
counseling
• Sexual Behavior/AIDS (esp. adolescents)
• Violence and Gun Use• Family Planning• Folate Use in Women
(preconception counseling)
Health Guidance
• Smoking• Diet• Exercise• Injuries/Motor vehicle accidents• Alcohol and Drug Use• Aspirin Use for Primary Prevention of MI
Did Not Receive Counseling AboutExercise and Diet in Past Year
3631
50
36
45
29
0
25
50
75
AUS CAN GER NZ UK US
2005 Commonwealth Fund International Health Policy Survey
Base: Adults with chronic health condition
Adult Immunizations
• Tetanus-Diphtheria
• Pneumococcal
• Influenza A
• Hepatitis B
• Hepatitis A
• MMR
• Vericella
Screening for Disease
• Cardiovascular
• Oncologic
• Endocrine
• Vision/Hearing
• Oral Examination
Cardiovascular
• Hypertension – BP Q 1-2 yrs
• Abdominal Aortic Aneurysm - Men >65 with history of any tobacco use
• Carotid Artery Disease - no
• Coronary Artery Disease – no ETT
• Peripheral Vascular Disease - no• Dyslipidemia - Total non fasting cholesterol for
men 35-65 and women 45-65.
Screening for Endocrine Diseases• Diabetes Mellitus
– Individuals with “high clinical risk” (Class II)– Cardiovascular disease (Class I)
• HTN or Dyslipidemia
– Strong family history (Class II)– Obesity (Class III or Stage I)
• Thyroid Disease – Indeterminate Recc.– Screening is effective, treatment available– Unsure of long term effects of over treatment and
asymptomatic diseas
• Osteoporosis - Routine DEXA scan is recommended by USPFTS every three years, except in some higher risk populations should be yearly.
Oncologic Diseases
• Ovarian using ultrasound PPV is 2.6% with per 100,000 screened 40 TP, 5398 FP and 160 laparotomy complications
• Testicular if 1500 male patients in practice would see 1 case every 20 years
• Lung – no reccs• Pancreatic – no reccs• Bladder – periodic UA after 60• Skin – “sun” counseling
Oncologic Diseases
• Breast – many organizations: Screening Mammography and Clinical Breast exam in women ages 50-69.
• Cervical – common reccs: Screening Pap Smears at age 18 or sexually active then every 3 years until age 65.
• Colorectal – screen: FOBT, Sigmoid, or Colonoscopy
• Prostate - Education
Another way to approach screening: Tests and Exam
Tests:• BP, Height and Weight, Cholesterol, Hearing,
Mammograms, Pap smear, PSA, FOBT or Sigmoidoscopy or Colonoscopy, Urinalysis
Exam:• Dental, Eye, Breast, Cancer exams (thyroid,
oral, ovaries, testicles, lymph nodes, rectum, prostate
• Orals are questionable but no harm, • vision biyearly if no impairment
Women’s Preventive Care Guide
Women’s Prevention Tests
Men’s Prevention Issues
Men’s Prevention Tests
Healthy People 2010
• Physical Activity • Overweight and Obesity • Tobacco Use • Substance Abuse • Responsible Sexual Behavior • Mental Health • Injury and Violence • Environmental Quality • Immunization • Access to Health Care
Clinical Care: Possible Choices
• Prevention– Flu Vaccination– Pneumonia
Vaccination – Breast Cancer– Cervical Cancer– Colon Cancer
TruePositives
F/U Positives
Screen some of panel for everything
ScreenAllOf
The PanelFor
AFew
Things
Prevention and Screening
Entire Panel
Operational and Clinical TeamsC
linic
al T
eam
s: W
hat
to
do
?
Operational Teams: How to do it?
Close to Agreement
Far from agreement on HOW to do it (how to
implement guidelines, how to support provider’s
efficiency)
XX
Close to agreement on WHAT to do in
Prevention
XX
Team
Doctor’s Office Has a NurseRegularly Involved in Care Management
16 19
47
36
52
41
0
25
50
75
AUS CAN GER NZ UK US
Base: Adults with chronic disease
Percent have nurse involved
2005 Commonwealth Fund International Health Policy Survey
Options
What• Don’t do any prevention• Do prevention sporadically• Do prevention systematically with few topics• Do prevention systematically with all topics
HOW• Doctor does it all• RN or LPN does it all• MA does it all• Team splits the work
Options
• None• Sporadically• Systematically – few• Systematically - all
• MA• Nurse• Doc/Provider
Options
• Systematically – few• Systematically - all
• MA• LPN• RN• Doc/Provider
Financial Implications of Team Choices
MA? LPN? RN? APN?
Variables…
• How much work is there?
• What level of staff is needed to do the work? (and who is paying the bill!?)
• What is the process for doing the work?– Supplement– Substitute
• What tools are needed to do the work?
Prevention Bundle (5 topics) as an example…..
Prevention Bundle Topics
– Flu Vaccination– Pneumonia Vaccination – Breast Cancer– Cervical Cancer– Colon Cancer
Prevention Bundle Tasks
• Assess compliance with prevention bundle (Immunization and Cancer Screening Care)
• Provide Care– Do Screening Exam (breast, cervical)
– Educate on options (for colon cancer screen) (FOBT, Flex Sig, or Colonoscopy) and choose one
– Order or provide appropriate test
• Document Care
Time for Each Task (Estimate)
Tasks Time (min)
Assess 2
Exam 10
Educate 4
Order 2
Document 2
Total 20
Tasks Provider APN RN LPN MA
Assess X X X X
Exam X X
Educate X X X X
Order X X X* X*
Document X X X X X
Who Could Perform Tasks?
* = under protocol
Thought Experiment….Doc
• Doc does it all– Cost = Doc time @ $1.42/min X 20 min= $28.40
– Doc doing work someone else could do! (Not doing other high value work)
– Quality good– Access may be poor for other patients– Income ++ for pay-by-visit– Income – - for pay-by-panel– Time spent relatively low value (others could do it)
Thought experiment….Nurse
• Nurse does it all– Cost = Nurse time @ $0.66/min X 20 min = $13.20
– Nurse not able to do all parts of the work (order/interpret)…although APN may…..
– Quality presumably good – Access to doc probably better – Value of doc visits probably higher– Access to nurse may be poor if not enough nurses
Thought Experiment MA
• MA does it all– Cost = MA time @ $0.24/min X 20 = $4.80– MA cannot do all parts of the work (assess, or
order tests)– Quality poor since all tasks not completed– Access to doc and nurse both probably better
if MA takes some of work away– Value of doc and nurse time both higher
Tasks Provider APN RN LPN MA
Assess X X
Exam X X
Educate X
Order X*
Document X X X
Who Should Perform Tasks?Assuming everyone performs at highest level..
* = under protocol
Team Cost
Tasks Time (min) Cost Total Cost
Assess 2 0.24 * 2 0.48
Exam 10 1.42 * 10 14.20
Educate 4 0.44 * 4 1.70
Order 2 0.44 * 2 0.88
Document 2 1.42 *1 + 0.24 * 1
1.66
Total 20 18.92
Bottom Line Prevention Bundle Cost Comparison
Doc Alone Team
Time (min) 20 20
Cost ($) 28.40 18.92
Quality Good Good
Access Less More
Assuming 400 Panel Patients
• 400 patients X $10 savings = $4000
• 10 min Doc savings X 14.20 X 400 = $5680
• Total improvement in $ = 9680
Doc Alone Team
Time (min) 20 20
Cost ($) 28.40 18.92
Quality Good Good
Access Less More
Prevention Example: Process
P a tie nt C a lls R e c e ptio nis tN urs eo rM D
A ppo intm e nt
G o to la b
H is to ry a ndP hys ic a l
T re a tm e nt
La b fo r te s ts
F o llo w -up
Prevention Process: Option 1
Prevention Process: Option 2
Receptionist
Nurse
Doc
AssessDocument
EducateOrderDocument
ExamDocument
Process: Option 3
Process and Tasks linked
• Substitute – Team members can do much of prevention
care– Not possible to do independent of provider
• Supplement– Only option
Clerk/MA
Old• Update demographics• Make appointments• Answer phone and
refer calls
New• Manage demand in
concert with team• Assist with prevention
and chronic illness care (health prompts)
• Collect D/S/SU info
Nurse
Old
• Check in patients• Take VS• Room patients
New• Screen for prevention• Screen for chronic
disease• Order by protocol• Basic patient education• F/U phone calls for panel
patient tests• Field phone calls and
give advice
Doctor’s new role
• Evaluate and manage acute illness
• Coordinate care for chronic patients
• Promote prevention and wellness
• Interact with other team members
• Manage patients with non-visit care
• Maintain access
Primary Care Core Competencies
• . Screen blood pressure and recommend further evaluation if elevated. For confirmed high
• blood pressure, offer diet and exercise recommendations.• 2. Diagnose and manage simple infectious diseases using commonly
recognized treatment standards. This would include such diseases as: a. upper respiratory infections b. pharyngitis c. gastroenteritis (uncomplicated, short-term diarrhea and/or vomiting) d. urinary
• tract infections.• 3. Be familiar with preventive medicine guidelines and be able to advise
patients about necessary procedures/tests based on the CIPS preventive medicine screen. This would include reminding patients about flu shots, mammograms, flexible sigmoidoscopy, etc, and
• ordering as appropriate. "• 4. Recognize alcoholism, cigarette addiction, substance abuse, depression,
and domestic• violence/sexual abuse and refer for appropriate management.
Indiana Hospital Prevention and Chronic Disease Solutions
• Expand CM Activities to All Support Staff :
FunctionMedical
Assistant LPN RN APN CMVital sign monitoring X X X XAccuchek X X X XClinical guideline screening X X X XAdministring medications X X XNursing assessment X XTelehealth monitoring X XOrdering medications X
Prevention Example: Space
Indiana Room Turnover Project
Exam Room
Exam Room
Exam Room
Exam Room
Exa
m R
oom
Exam Room
Exam Room
RN Station
Exam Room
Exam Room
Exam Room
Exam Room
Exam RoomE
xam
Roo
m
Exa
m R
oom
Exa
m R
oom
Check-in
ProviderCharting
Procedures
Calls Patient
“6+ Miles per Day”
In My Experience…
• Doc responsible for all prevention care• Doctor’s participation is:
– Choose topics– Design process– F/U positives
• Nurse and/or MA does majority of prevention care
• Measurement and feedback regularly occur
Tele-Eye Outcomes
• 68% reduction in demand for diabetic eye exams in Eye Clinic– 93% of Primary Care Exams do
not require Eye clinic follow-up
• Increased diabetic screening rate75% 91% completed annual
exam
• Reduced eye clinic waiting time80 days 11 days
Case ManagerReviews on VA
PC
Data Analysis&
Data Storage
Case Manager Reviews on
VA PC
Telephonic Follow-up of
Alerts
Telehealth Monitor
Peripheral Devices
Telehealth OverviewThe FutureTele-homecare
Group Visioning Exercise
• Split up into new groups
• Introduce each other
• Design the ideal prevention care clinic– Choose topics– Sketch out process– Assign tasks– Design measurements
• Competition: Best design gets prizes
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