office redesign: the planned care model dave eitrheim md red cedar medical center- mayo health...
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Office Redesign:Office Redesign:The Planned Care ModelThe Planned Care Model
Dave Eitrheim MDDave Eitrheim MD
Red Cedar Medical Center-Red Cedar Medical Center-
Mayo Health SystemMayo Health System
Menomonie, WIMenomonie, WI
[email protected]@mayo.edu
Red Cedar Medical Center:Red Cedar Medical Center:Providers are busy, but not seeing more patientsProviders are busy, but not seeing more patients
Visits Per Provider-FP and PA/NP 1997-2006
0
1,000
2,000
3,000
4,000
5,000
6,000
1 2 3 4 5 6 7 8 9 10
Year
Volum
eDr. Mark Deyo-Svendsen
Dr. David Eitrheim
Dr. Michael Feigal
Dr. Joseph Heimler
Dr. Tw yla Ostercamp
Dr. Michael Phillips
Dr. Nathan Rich
Dr. Steven Rosas
Dr. Hank Simpson
Dr. Kyja Stygar
Dr. James Walker
Amy Burns, PA
Jody Chilsen, PA
Anna Haus, PA
Rose Keys, NP
Dennis Ryan, PA
Barb Tysdahl, PA
Lucinda Ughetti, PA
Mary Beth Waldo, NP
The 15 minute office visitThe 15 minute office visit
Nurse tasks in rooming Nurse tasks in rooming a patient 21 years ago:a patient 21 years ago:
1) Weight.1) Weight.
2) Blood pressure.2) Blood pressure.
3) Chief complaint.3) Chief complaint.
The 15 minute office visitThe 15 minute office visit Nurse tasks when rooming a diabetic patient today:Nurse tasks when rooming a diabetic patient today:
Weigh patient.Weigh patient. Take and record BP, pulse, temperature if needed, O2 sat if Take and record BP, pulse, temperature if needed, O2 sat if
needed, LMP if applicable.needed, LMP if applicable. Record tobacco use and offer cessation counseling.Record tobacco use and offer cessation counseling. Review and update all allergies and medications listed on the Review and update all allergies and medications listed on the
Current Medication List and see if refills are needed.Current Medication List and see if refills are needed. Counsel preventative services and give appropriate Counsel preventative services and give appropriate
immunizations, help schedule pap, mammogram, lipid testing, immunizations, help schedule pap, mammogram, lipid testing, and colonoscopy.and colonoscopy.
Diabetic care includes doing annual diabetic foot exam and Diabetic care includes doing annual diabetic foot exam and recording information that is used by our diabetic registry. recording information that is used by our diabetic registry. Review diabetic knowledge assessment worksheet and provide Review diabetic knowledge assessment worksheet and provide education or make needed referrals to the dietician or diabetic education or make needed referrals to the dietician or diabetic educator.educator.
Provide and review patient education materials.Provide and review patient education materials.
Planned Care VisitsPlanned Care Visits
Most chronic care visits are not preplanned.Most chronic care visits are not preplanned. Provider lacks necessary information.Provider lacks necessary information. Patient has different expectations for visit.Patient has different expectations for visit. Staff isn’t fully utilized.Staff isn’t fully utilized. EMR can make the situation worse if more EMR can make the situation worse if more
tasks and clicks are put on to the provider.tasks and clicks are put on to the provider. ““Systems are perfectly designed to get the Systems are perfectly designed to get the
results they receive.” Dr. Don Berwick results they receive.” Dr. Don Berwick
Physicians are doing nursing tasksPhysicians are doing nursing tasks Patient satisfaction is heavily determined by the Patient satisfaction is heavily determined by the
patient’s interaction with their provider.patient’s interaction with their provider. Set an agenda: Providers should maximize the time Set an agenda: Providers should maximize the time
spent on the patient’s reason for the visit. spent on the patient’s reason for the visit. DMS, accreditation standards, EMRs and increasing DMS, accreditation standards, EMRs and increasing
documentation have led to appointments where the documentation have led to appointments where the provider is handling the patients’ medical concerns provider is handling the patients’ medical concerns plus many other tasks that take time away from the plus many other tasks that take time away from the primary purpose of the visit.primary purpose of the visit.
Each part of the office visit should be done by the Each part of the office visit should be done by the most appropriate employee. Nurses should be most appropriate employee. Nurses should be empowered to work to the fullest level of their empowered to work to the fullest level of their abilities and training. Minimize physician tasks abilities and training. Minimize physician tasks that are in the skill set of others.that are in the skill set of others.
Preplanned Chronic Care Preplanned Chronic Care
Patients want to discuss and ask questions about Patients want to discuss and ask questions about labwork and test results at their clinic visit.labwork and test results at their clinic visit.
Physicians are more efficient when they have all the Physicians are more efficient when they have all the info that they need at a visit.info that they need at a visit.
Preplanning the next chronic care visit prevents Preplanning the next chronic care visit prevents rework before the next visit.rework before the next visit.
Techniques such as goal-setting and Techniques such as goal-setting and motivational interviewing lead to motivational interviewing lead to better outcomes.better outcomes.
It doesn’t take a village, It doesn’t take a village, but it takes a but it takes a teamteam..
Planned Care ModelPlanned Care Model Preplanning
Patient self
management data
Preplanned Care Coordinator
contacts patient to pre-plan appointment
Registry database shows
most recent patient data and trends
Post Planning
Nursepatient education/coaching
Appointments next planned care
visit setup with pre-labs
Community Resource
communication to nursing homes, caregivers, home health nurses
Registry database updated
Nurse-chart prep-reconcile current medicine and allergy list-tobacco use-preventative medicine measures-additional tasks determined by team
Physician-SOAP-focus on patient’s reason for visit-access to evidence-based guidelines-goal setting-preplan next visit-post-planning
Planned Care Visit
Physician-Nurse Team
Preplanning:Preplanning:Patient ResponsibilitiesPatient Responsibilities
Work on goals established at last visitWork on goals established at last visit Bring self-management data to visit and act on Bring self-management data to visit and act on
data that is out of range (blood pressure, blood data that is out of range (blood pressure, blood glucose, peak flows, diet and exercise, etc.)glucose, peak flows, diet and exercise, etc.)
Preplanning:Preplanning:Preplan Care Preplan Care CoordinatorCoordinator
Letter or phone call to patient instructing patient Letter or phone call to patient instructing patient to…to… Update current medication listUpdate current medication list Pre-labs: Preorder labs to be done right before clinic Pre-labs: Preorder labs to be done right before clinic
visit per protocol (if not already ordered)visit per protocol (if not already ordered) Self management data: Bring home BPs, glucose, Self management data: Bring home BPs, glucose,
weight, exercise log, peak flows,etc. to appointmentweight, exercise log, peak flows,etc. to appointment
ANNUAL LABWORK ORDERED BY NURSING
1. Lipid Profile and ALT (12 hour fast) a. Diagnosis – Dyslipidemia , Hypercholesterolemia, Hypertriglyceridemia,
Elevated LDL Cholesterol, Low HDL Cholesterol b. Medications
Statins Simvastatin (Zocor) Atorvastatin (Lipitor) Rosuvastatin (Crestor) Lovastatin (Mevacor) Vytorin (Simvastatin/Ezetimide) Niacin Niaspan Niacin-SR Fibrates Gemfibrozil Ezetimide (Zetia) Tricor
c. Screen all patients every 5 years who are over age 20 2. Basic Profile (8 hour fast) a. Diagnosis – Essential Hypertension (when taking one of the meds listed below) b. Medications Diuretics Hydrochlorothiazide (HCTZ) Hydrochlorothiazide/Triamterene (HCTZ/Triam) Spironolactone (Aldactone) Furosemide (Lasix) Bumetanide (Bumex) ACE Inhibitors (may be combined with HCTZ) Lisinopril (Zestril) Benazepril (Lotensin) Enalapril (Vasotec) Ramipril (Altace) ARB’s (may be combined with HCTZ) Losartan (Cozaar/Hyzaar if combined with HCTZ) Irbesartan (Avapro) Valsartan (Diovan) Candesartan (Atacand)
3. PSA3. PSA a . All men age 50-70 should have a . All men age 50-70 should have screening PSAscreening PSA b. Men with history of PSA’s elevated above normal (or 4.0) should have a b. Men with history of PSA’s elevated above normal (or 4.0) should have a Free & Total PSA Free & Total PSA c. Men with history of prostatectomy, brachytherapy, or radiation therapy as treatment for prostate c. Men with history of prostatectomy, brachytherapy, or radiation therapy as treatment for prostate
cancer now have very lowPSAs and should have a cancer now have very lowPSAs and should have a diagnostice PSA diagnostice PSA
4. Diabetic Flow Sheet Labs – Indicated for:4. Diabetic Flow Sheet Labs – Indicated for: Diagnosis – Diabetes Mellitus I and IIDiagnosis – Diabetes Mellitus I and II If on these MedicationsIf on these Medications
InsulinInsulin Oral AgentsOral Agents
Humalog GlypizideHumalog Glypizide Novolog Glyburide Novolog Glyburide Lantus Glimepiride (Amaryl)Lantus Glimepiride (Amaryl) Levemir MetforminLevemir Metformin Humulin Pioglitozone (Actos)Humulin Pioglitozone (Actos) Novolin Rosiglitazone (Avandia)Novolin Rosiglitazone (Avandia) a. Annual labs include Glucose, Creatinine, Urine Microalbumin, Lipid Profile; (Glucose anda. Annual labs include Glucose, Creatinine, Urine Microalbumin, Lipid Profile; (Glucose and
creatinine are included in fasting basic profile if on hypertension meds noted above)creatinine are included in fasting basic profile if on hypertension meds noted above) b. HgbA1c – every 6 monthsb. HgbA1c – every 6 months 5. Fasting Blood Glucose, HgbA1c – 8 hour fast5. Fasting Blood Glucose, HgbA1c – 8 hour fast a. Diagnosis – Prediabetes, impaired glucose tolerance (previous FBS 100 or greater)a. Diagnosis – Prediabetes, impaired glucose tolerance (previous FBS 100 or greater) b. Medications – only diet and exerciseb. Medications – only diet and exercise 6. TSH6. TSH a. Diagnosis – Hypothyroidisma. Diagnosis – Hypothyroidism b. Medications – Levothyroxineb. Medications – Levothyroxine c. Screen all women over age 50 every 5 yearsc. Screen all women over age 50 every 5 years
7. Diabetes Screen – FBS every 5 years after age 457. Diabetes Screen – FBS every 5 years after age 45
Preplanning:Preplanning:RegistryRegistry
Searchable databaseSearchable database Most recent dataMost recent data Trends in dataTrends in data Improves population careImproves population care Motivational toolMotivational tool
Planned Care Visit:Planned Care Visit:Provider/Nurse TeamProvider/Nurse Team
Planned Care Visit:Planned Care Visit:NurseNurse
Chart prep (EMR included)Chart prep (EMR included) Reconcile current medication and Reconcile current medication and
allergy listallergy list Tobacco use discussed and Tobacco use discussed and
counseling offeredcounseling offered Preventative medicine measures Preventative medicine measures
counseled and orderedcounseled and ordered Mammography, pap, colon CA screensMammography, pap, colon CA screens ImmunizationsImmunizations
Additional tasks determined by teamAdditional tasks determined by team
Planned Care Visit:Planned Care Visit:PhysicianPhysician
Focus on patient’s agenda or Focus on patient’s agenda or reason for visitreason for visit
Access to evidence-based Access to evidence-based guidelinesguidelines
Goal-setting with motivational Goal-setting with motivational interviewinginterviewing
Set up post-planning including Set up post-planning including preplanning next visitpreplanning next visit
Post-planning:Post-planning:PhysicianPhysician
Additional orders: Labs can Additional orders: Labs can usually be added to blood drawn usually be added to blood drawn before planned care visit before planned care visit (lab stores blood for 6 days)(lab stores blood for 6 days)
Follow-Up Planner Order SheetFollow-Up Planner Order Sheet Preplan next visit with pre-labs orderedPreplan next visit with pre-labs ordered
Post-planning:Post-planning:NurseNurse
Patient education or coaching Patient education or coaching Teach off of patient education Teach off of patient education
handouts or websiteshandouts or websites Patient education materials don’t need Patient education materials don’t need
to be physician driven (ex) pedometer to be physician driven (ex) pedometer programprogram
Diabetes knowledge worksheet used to Diabetes knowledge worksheet used to make dietician and diabetic educator make dietician and diabetic educator referralsreferrals
Post-planning:Post-planning:Appointments or schedulingAppointments or scheduling
Follow-Up Planner Order SheetFollow-Up Planner Order Sheet Sets up:Sets up:
Next planned care visit with any prelabs or x-ray Next planned care visit with any prelabs or x-ray (appointment set up or reminder letter sent)(appointment set up or reminder letter sent)
Referral visits to other clinic physicians, dietician, Referral visits to other clinic physicians, dietician, diabetic educator, PT/OT/ST, nursediabetic educator, PT/OT/ST, nurse
Referral visits to outside specialists done by Referral visits to outside specialists done by routing order sheet to specialty care coordinatorrouting order sheet to specialty care coordinator
Dear _______________________,Dear _______________________,
This is to inform you that your next physical exam with lab work is due This is to inform you that your next physical exam with lab work is due soon. It works well if you can have your blood drawn a few days before soon. It works well if you can have your blood drawn a few days before your exam so that you and your provider can discuss the results at your your exam so that you and your provider can discuss the results at your visit. Since most tests require 12 hours of fasting, please do not eat or visit. Since most tests require 12 hours of fasting, please do not eat or drink for 12 hours (except for water) before coming. Ideally, you should drink for 12 hours (except for water) before coming. Ideally, you should do this no more than 3 days prior to your physical exam appointment. do this no more than 3 days prior to your physical exam appointment. An order has been sent to the lab for you.An order has been sent to the lab for you.
Lab hours:Lab hours:Monday 6 a.m. – 8 p.m.Monday 6 a.m. – 8 p.m.Tuesday through Thursday 6 a.m. – 6 p.m.Tuesday through Thursday 6 a.m. – 6 p.m.Friday 6 a.m. – 5 p.m.Friday 6 a.m. – 5 p.m.Saturday and Sunday 9 a.m. – 3 p.m.Saturday and Sunday 9 a.m. – 3 p.m.
Report to the Urgent Care registration desk for your lab work.Report to the Urgent Care registration desk for your lab work.Please call 715-233-7777 to schedule an appointment for your physical Please call 715-233-7777 to schedule an appointment for your physical exam.exam.
Thanks you,Thanks you,
Post-planning:Post-planning:RegistryRegistry
Database updated for next planned care visitDatabase updated for next planned care visit Patient notified if next planned care Patient notified if next planned care
appointment is missed or labs not doneappointment is missed or labs not done Providers receive monthly reports that shows Providers receive monthly reports that shows
their own population data compared to other their own population data compared to other providers and benchmarks providers and benchmarks (unblinded)(unblinded)
Post-planning:Post-planning:Community ResourcesCommunity Resources
Good communication to home health Good communication to home health nurses, nursing homes and caregiversnurses, nursing homes and caregivers
Referrals to community health programs:Referrals to community health programs: Department of Human Services: Birth to 3, WIC, Department of Human Services: Birth to 3, WIC,
County Office on AgingCounty Office on Aging Know community resources and provide info on Know community resources and provide info on
themthem
Planned Care ModelPlanned Care Model Preplanning
Patient self
management data
Preplanned Care Coordinator
contacts patient to pre-plan appointment
Registry database shows
most recent patient data and trends
Post Planning
Nursepatient education/coaching
Appointments next planned care
visit setup with pre-labs
Community Resource
communication to nursing homes, caregivers, home health nurses
Registry database updated
Nurse-chart prep-reconcile current medicine and allergy list-tobacco use-preventative medicine measures-additional tasks determined by team
Physician-SOAP-focus on patient’s reason for visit-access to evidence-based guidelines-goal setting-preplan next visit-post-planning
Planned Care Visit
Physician-Nurse Team
Pursuing IdealPursuing Ideal
……Through Through Frontline SolutionsFrontline Solutions
Frontline SolutionsFrontline Solutions is a is a simplifying, enabling methodology simplifying, enabling methodology
based on the Toyota Production based on the Toyota Production System that gets the patient System that gets the patient exactly what they need at exactly what they need at continually lower costs.continually lower costs.
Toyota Production System Toyota Production System PrinciplesPrinciples
Problem recognition and understanding Problem recognition and understanding begins with begins with directdirect observation.observation.
Problems are best solved by those actually Problems are best solved by those actually involved in the work, with assistance from involved in the work, with assistance from management/leadership.management/leadership.
Everyone is responsible for problem Everyone is responsible for problem identification and solution.identification and solution.
Comments about Frontline SolutionsComments about Frontline Solutions
““This is changing the culture one problem at a time” This is changing the culture one problem at a time” (Learning Line Trainer)(Learning Line Trainer)
““Its more efficient – within a couple of days of Its more efficient – within a couple of days of identifying a problem, a solution is available to try” identifying a problem, a solution is available to try” (office nurse)(office nurse)
““I am constantly thinking how we can do things I am constantly thinking how we can do things better for our patients or how we can do things more better for our patients or how we can do things more efficiently for our Dr./Nurse teams The great thing is efficiently for our Dr./Nurse teams The great thing is that these are often things that we can change that these are often things that we can change immediately and we do not have to wait weeks or immediately and we do not have to wait weeks or even months to get approval from someone.” even months to get approval from someone.”
““The nice thing is that the people who are doing the The nice thing is that the people who are doing the work are actually finding the solutions to problems.”work are actually finding the solutions to problems.”
Many healthcare systems and Many healthcare systems and processes are so complex that top-processes are so complex that top-down design will inevitably lead to down design will inevitably lead to
defects, breakdowns, and work-defects, breakdowns, and work-arounds.arounds.
------------------------------------------------------------------------------------Frontline SolutionsFrontline Solutions is a is a
methodology that can address methodology that can address these breakdowns with frontline these breakdowns with frontline
level problem solvinglevel problem solving..
How Does Frontline Solutions How Does Frontline Solutions Actually Work?Actually Work?
Direct observation as the method of problem Direct observation as the method of problem identificationidentification
Involve frontline staff in problem Involve frontline staff in problem identification and solution as a “Learning identification and solution as a “Learning Line” with assistance from LLTs and Line” with assistance from LLTs and managementmanagement
The rules in useThe rules in use
Problem Solving with Frontline Problem Solving with Frontline SolutionsSolutionsThe A3The A3
Frame the Problem in Frame the Problem in the Context of Ideal the Context of Ideal Patient CarePatient Care
Map the Current Map the Current ConditionCondition
Find the Root Cause(s)Find the Root Cause(s)
Propose a Solution Propose a Solution (Target Condition)(Target Condition)
List the Steps Needed List the Steps Needed (Counter-Measures). (Counter-Measures). Who does What, When, Who does What, When, etc.?etc.?
How do you know if the How do you know if the counter-measure failed counter-measure failed (Test)?(Test)?
How is this different?How is this different?
Not just another Not just another improvement improvement tooltool
A different way A different way of thinking and of thinking and actingacting– A Culture shiftA Culture shift
Additional Resources:Additional Resources: Frontline Solutions Frontline Solutions
Designed to Adapt: Leading Healthcare in Designed to Adapt: Leading Healthcare in Challenging Times;Challenging Times; John Kenagy, M.D. John Kenagy, M.D.
Jim Haemmerle, M.D.; Red Cedar Medical Jim Haemmerle, M.D.; Red Cedar Medical Center-Mayo Health System: Center-Mayo Health System: [email protected]@mayo.edu
Rule 4 Consulting: www.rule4consulting.comRule 4 Consulting: www.rule4consulting.com