Internal Medicine Associates – GJ: Care Management/Huddle CPC Learning Collaborative 10/28/16 – Grand Junction, CO

Key Learning Points:

• Select the right team members

• Identify barriers for change

• Closing the loop with Team/Patient Involvement

Our Process: • Patient identified through OV, recent

ED, Hosp, clinic staff • Nurse then assesses, schedules call

time, educates, notes f/u, reports to Huddle or MDPOA

• Provider notified and wraps it up with OV, Tests/lab, referrals

• Front office records referral • Provider reviews referral completion • Data reviewed by QIA team bimonthly

for changes

Challenges: • Finding the time when all team mbrs

available • Finding time to contact patients • Getting Patient buy-in/ compliance • Identifying which patients to use

team’s resources on

Lessons Learned: • Use tool, (Excel) for pt schedule, notes

on call for Huddle, Next appt, etc • Document contact in EHR • Cont reaching out to resistance pts

Additional Resources: • https://cepc.ucsf.edu/healthy-huddle • www.partners.org/innovaation ( select huddle) • www.stepsforward.org/modules/teaj-huddles

Peach Valley Family Practice - Advanced CM Strategy: Self-Management Support

CPC Learning Collaborative 10/28/16 – Grand Junction, CO

Key Learning Points:

• Make it as easy for the staff & providers as possible

• Keep information readily available

• Use a variety of tools & processes

Our Processes: • Handouts available in the rooms for

DM, COPD, CHF, Obesity & Depression • No-cost counseling appointments

offered • Group visits offered monthly for DM

and COPD • Web sites & materials on the portal • List of all handouts placed in waiting

room • Monitor quarterly and discuss at staff

meetings, CPCi meetings, etc.

Challenges: • Remembering to “check the boxes” -

nursing staff extremely important here • Non-compliant patients – how do you

get them engaged?

Lessons Learned: • Involve all staff in the processes • Keep trying!

Additional Resources: • http://www.ahrq.gov/ • http://www.ihi.org/resources/Pages/Tools/GroupVisitStartKit.aspx • http://www.ihi.org/IHI/Topics/ChronicConditions/Diabetes/Tools

Note: we struggled with our EMR reports in 2015, but they resolved the issues by mid-year. Also, our EMR vendor restarts calculations on the measures for each reporting period, so the beginning of the year shows higher numbers due to controlled patients not being seen yet in 2016. Current measure is 13.8% on 9/13/16.

Mid Valley Family Practice – Advanced CM Strategy: Integrated Behavioral Health

CPC Learning Collaborative 10/28/16 – Grand Junction, CO

Key Learning Points:

• Finding the right BHP is critical – and not easy

• Workflows and EHR templates are complex and take time to develop

• Ultimately improves care for patients and culture of office

Our Goals: • Initial goal was to have a certain

number of visits per day directly with BHP

• Current goal is to decrease percentage of patients with positive PHQ

• Future goal is a Level 6 integration score on the IPAT

Our Process: • 3 types of visits:

• Stand alone Behavioral Health Visit • Pre-identified need for BHP after

medical visit • MD pull in BHP during visit on as

needed basis • Team huddles at the end of the day to

identify patients who would benefit from behavioral health visit after medical visit

• Smoking Cessation • Depression, Anxiety, etc. • Health Coaching

Challenges: • Payment is still an issue • Difficult to find BHP with experience in

integrated primary care • Documenting in the EHR is a work in

progress Lessons Learned: • Clearly outline goals with all providers

– behavioral health and physical • Find a good personality fit with office

culture • The benefit is not only from patient

interactions with the BHP. Our LCSW changed the way everyone in the office communicates with patients.

Additional Resources: • http://www.integration.samhsa.gov/

• Core Competencies, IPAT survey • https://integrationacademy.ahrq.gov/

Glenwood Medical Associates – Patient Experience: PFAC

CPC Learning Collaborative 10/28/16 – Grand Junction, CO

Key Learning Points:

Careful panel selection

Consistent structure to meetings

Create action plan and report results

Our Process: • Bi- Monthly meetings • PFAC advisory Council agenda sent to

members in advance • Review and approval of minutes • Result reporting and open discussion • Closed executive session including

market strategy.

Challenges: • Consistent attendance • Being respectful of meeting time limits • Following agenda

Lessons Learned: • Not to make assumptions based on an

insider view • Community leaders are willing to donate

time and advice if we are willing to listen.

Additional Resources: • www.engagingpatients.org • https://www.hcfama.org/pfac-resources

Insert data here

QI Processes—Performance Measurement to Drive Change Facilitated Session by: Wray Paul, October 28th, 2016

“Measuring the processes and outcomes of your practice will allow you to make informed de-

cisions and implement new ideas. Creating systems that collect and use data to improve per-

formance can lead to increased revenue and consistent, evidence-based care. Measuring and

improving performance isn’t a one-time project. Make it part of your practice culture in order

to improve workflow, eliminate waste, and improve both clinical performance and, profitabil-

ity.” - AAFP, A Guide to Performance Measurement: Using Data to Improve.

Types of Measures:

Structure - “Do you

have a registry of

patients who have

diabetes?”

Process— “How many

of your patients with

diabetes have a

documented HgbA1c

less than 9.0?”

Outcome— “What

percentage of diabetic

patients have a HgbA1c

greater than 9.0?”

Does your practice have identified and adopted clinical practice guidelines?

Does your practice have a shared vision for continuous quality improvement?

What systems are currently in place for collecting data and measuring perfor-mance?

Does your practice have specific care or clinical outcomes goals?

Steps to Success:

1. Assess your current measurement strategy and capa-

bility

2. Decide what you should measure clinically

3. Identify how you will measure clinical performance

4. Optimize the use of HIT

5. Build your measurement strategy

6. Test and Implement positive changes — PDSA’s

http://www.ahrq.gov/

http://www.ihi.org/Pages/default.aspx

http://www.himss.org/

https://pcmh.ahrq.gov/sites/default/

files/attachments/Using%20Health%

20IT%20Technology%20to%20Support%

20QI.pdf

http://www.qualishealth.org/sites/

default/files/White-Paper-Clinical-

Quality-Reports.pdf

www.qualityforum.org

https://www.healthit.gov/

YOU CAN’T MANAGE WHAT

YOU CAN’T MEASURE

1. The foundation for quality improve-

ment is Measurement

2. Measurement and data collection

should be efficient

3. Utilize dashboards to display results

so the entire team can see

4. Continuously report on results iden-

tifying best practices

Created: 9/12/2016

Primary Care Partners - Shared Decision Making CPC Learning Collaborative 10/28/16 – Grand Junction, CO

Key Learning Points:

• Importance of Patient Engagement

• Partnering with Patients and Employers

• SDM leads to better care but not without challenges

Our Process: • IT – provide access to shared decision

making tools • Educate staff and provider • Collaborate with employers and TPAs • Educate the patients regarding the

tools

Challenges: • Patient engagement • Physician engagement • Alignment with health plan design • IT – access to SDM tool • Cost

Lessons Learned: • Some patients appreciate the

information • Can help avoid unnecessary care • Difficulties in utilization among

providers and patients remain • Difficult IT challenges

Additional Resources: • http://med.dartmouth-hitchcock.org/csdm_toolkits.html • http://www.ahrq.gov/

Roaring Fork Family Physicians- Care Coordination CPC Learning Collaborative 10/28/16 – Grand Junction, CO

Key Learning Points:

• Care Compacts between Hospitals and Specialists

• Clear transitions of care process with identified accountability

• 24/7 access to the PCP can prevent ED visits and Admissions

Our Process: • Quality Coordinator (QC) monitors for

patient admissions and discharges daily through ADTs via QHN.

• QC contacts patient within 48 business hours of discharge.

Reviews/updates Medications Reviews discharge instructions Reviews Discharge Summary Reviews pending follow-up

appointments with specialists Checks for Home Health orders and

contacts agency Reminds patient of 24/7 availability

of our Providers and encourages calling prior to going to ED

• Appointment made for follow-up if patient seems confused about medications and/or discharge instructions.

• Provider receives copy of Discharge Summary from admission and requests follow-up appointment if deemed necessary.

Challenges: • Unidentified patients due to wrong PCP

listed at admission • Unable to reach patient • Coordination with specialists Lessons Learned: • Need reliable and timely method for

identifying admitted and discharging patients

• Process for transitions of care critical with coordination between PCP and Hospital

• Identified accountability for process key • Care compacts between PCP and Specialists

needed