primary care innovations - primary care collaborative · 6/29/2012 · community health martin’s...
TRANSCRIPT
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Primary Care Innovations: Stories from the Field
PCPCC Webinar Christine A Sinsky, MD Thomas A. Sinsky, MD
June 29, 2012
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In Search of Joy in Practice Co-Investigators
• Christine Sinsky- PI • Tom Bodenheimer-PI • Rachel Willard • Tom Sinsky • Andrew Schutzbank • David Margolius
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Advisory Council
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Places Where PC Physicians & Staff are Thriving?
• Where the work of primary care is do-able • Enjoyable as a life’s vocation
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Clinica Family Health Services
Group Health Olympia
Multnomah County Health
Dept
South Central Foundation
Univ of Utah- Redstone Newport News
Family Practice
Cleveland Clinic- Strongsville
Quincy, Office of the Future
West Los Angeles- VA
La Clinica de la Raza
Clinic Ole
Sebastopol Community
Health
Martin’s Point- Evergreen Woods
Harvard Vanguard Medford Brigham and
Women’s Hospital
North Shore Physicians Group Medical Associates
Clinic
Mercy Clinics
ThedaCare
Fairview Rosemont Clinic
Mayo Red Cedar
Medical Center
Allina
Site visits to 23 high-performing practices (most PCMHs)
Mass. General Hospital
Joy in Practice
Workflow Task distribution Physical space Technology
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Challenges
Chaotic visits
Teams function poorly
Inadequate support
Time documentation
EHR →work to MD
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• Pre-visit planning
• Pre-appt labs • Systematic
Prescriptions
Challenges Innovations
1. Chaotic visits with overfull agendas
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MA pre-visit call Agenda, Med review Depression screen Advanced directive
Fairview: Care Model Redesign
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Mayo-Red Cedar arranges for pre-visit lab
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Same day pre-visit lab (15 min) ThedaCare
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Annual Prescription Renewals
• Physician time – 0.5 hour/day
• Nursing time – 1 hour/day per physician
• 80 million PC visits/year
350,000 PCPs x 220d/yr x1 visit/d
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Challenges Innovations
1. Chaotic visits with overfull agendas
Insurers • Single co-pay lab/visit
Institutions • Hold future orders • Staff order entry
Pharmacies and Board • Prescription 15 mo • Resynchronize • No automated faxes
Action Steps
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Challenges Innovations
2. Inadequate support to meet the patient demand for care
Sharing the care among the team • 2:1 or 3:1 • Rooming protocol • Between visit
– Health coaching – Care coordination – Panel mgm’t
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Mayo Red Cedar : New Model of Nursing (2:1)
Physician centric to team based model Immunization, ca, diabetic foot, lifestyle, HTN visits; even though 25% more visits/day, less harried; proud
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New Model of Nursing
• Doctor to nurse: – I was behind an hour every
day. Thank God you are back! • Nurse to doctor
– I enjoyed my time away from the daily grind that I was tempted not to return.
• Doctor and nurse – Our practice needs to change
Genesis: 3 week vacation
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Challenges Innovations
2. Inadequate support to meet the patient demand for care
Action Steps
Educators • MA, nurse: MI, SMS
Institutions/Regulators • Staffing • Scope of practice ↑
Payers • Fund non-MD services
Technology • Team log-in
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Challenges Innovations
3. Vast amounts of time spent documenting care
More time doc than delivering care
• Scribing • Assistant order
entry
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I used to be a doctor. Now I am a typist.
Personal communication. Beth Kohnen, MD, internist Anchorage AL 8.3.11
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The Doctor 1891 Fildes
Undivided attention
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The Doctor 2012
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Challenges Innovations
3. Vast amounts of time spent documenting care
• Scribing • Assistant order
entry
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Scribing: Newport News Family Practice
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Collaborative Care Newport News n What we all hoped for n Team: 3:1 Nurse/physician
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Collaborative Care Newport News n Four Components to Visit
n Data gathering, organizing and documenting n Data analysis and exam n Decision making, creating a plan n Plan implementation, order entry, pt ed
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Collaborative Care Newport News n Four Components to Visit
n Data gathering, organizing and documenting n Data analysis and exam n Decision making, creating a plan n Plan implementation, order entry, pt ed
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Pre-visit: Nurse with Pt (8-12 min)
n Nurse gathers, records n Vitals, Med Rec., n Previous two notes n ER, Consult notes, n New lab or x-ray n Agenda, HPI n ROS guided by templates
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Visit: Nurse, Patient and MD
n Nurse gives report n M.D.
n Hx, PE
n M.D. n verbalizes med changes n lab, x-ray orders n diagnosis/billing codes n next followup appt.
n Nurse records
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Post-visit: Nurse with Patient
n Nurse n Reviews plan n Prints and reviews visit summary n Escorts the patient to checkout
n US Army
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Scribing at Cleveland Clinic
Kevin Hopkins M.D.
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Collaborative Care Cleveland Clinic: Stonebridge n Turbo practice
n 2 MA: 1 MD n 2 pt/d cover cost n 21 → 28 visits/d n 20-30% ↑ revenue n Spread to others n We’re having FUN ” “
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The MA’s are more fully engaged in patient care than they have ever been and they enjoy their work…They have increased knowledge about medical care in general and about their individual patients in particular. Kevin Hopkins M.D.
I
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Collaborative Care University of Utah: Redstone n 2.5 MA: 1 MD
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I get to look at my patients and talk with them again. We’re reconnecting…. Our patient satisfaction numbers are up, our quality metrics have improved, our nurses are contributing more, and I am going home an hour earlier to be with my family..
Amy Haupert MD, family physician, Allina-Cambridge 11.29.11 personal communication
1.
1.
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Office Practice of the Future Quincy Family Practice Residency n 2 MA: 1 LPN: 1 MD
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Collaborative Care
• Six sites • Similar results
– Access 30% ↑ – Costs covered – Satisfaction ↑ – Quality metrics ↑ – Physician
• home hour earlier • no work at home
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Challenges Innovations
3. Vast amounts of time spent documenting care
Action Steps
Institutions • Rooms: 2 computers • Assistant order entry
Institutions/Regulators • Team log-in
Technology • Seamless transitions
between users
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Challenges Innovations
4. Computerized technology that pushes more work to the clinician
• Verbal messages • In-box
management
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The task list is unbearable. I spend 1.5 hours clearing out my task list before leaving and another 1.5 hours at home after the kids go to bed.
Primary Care Physician, Des Moines, IA; 2011
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Challenges Innovations
4. Computerized technology that pushes more work to the clinician
• Verbal messages • Inbox managment
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Fairview: Filtering Inbox
Reduce “backpack” 90min/d to few min
Line of Sight
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Verbal messaging at Fairview rather than getting tangled in a thicket of e-messaging.
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Semi-circular desk, APF
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Iora Health, Dartmouth-Hitchcock
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Printer in every room University of Utah Redstone
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APF, Massachusetts General Hospital
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Challenges Innovations
4. Computerized technology that pushes more work to the clinician
Action Steps
Institutions • ↓ message generation • Nurses filter inbox
Regulators • Security modifications • ↓signature requirements
Technology • Quick log in • Save a click
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Challenges Innovations
5. Teams that function poorly and complicate rather than simplify the work
• Co-location • Huddles • Team meetings • Workflow mapping • Structuring the
physical and personnel environment to support trust and reliance
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Flow station at North Shore Physicians Group
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Fairview Co-location of scheduler
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Co-location at South Central Foundation, Alaska
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APF, Massachusetts General Hospital
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Pre-clinic Huddle
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Team Meetings Do Work + Make Work Better
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Health coach running meeting “we all own practice, own meeting”
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ThedaCare: All staff trained in QI, Pulling in same direction, capacity for change
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Clinic walls lined with data
ThedaCare
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Lean Problem solving
Harvard Vanguard Medical Associates
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Harvard Vanguard Medical Associates
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26 Improvement Specialists
South Central Foundation, Alaska
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Challenges Innovations
5. Teams that function poorly and complicate rather than simplify the work
Action Steps
Institutions • Co-location • Line of sight • Space for huddles • Time for meetings • Improvement specialists • Aligned reporting (MA/
nursing to clinical lead)
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Key Lessons For ↓ Burnout and ↑Joy
• Share the care with team – 2:1 or 3:1 staffing in stable – Physician-centric to team-based care
• Clear communication – Co-location – Team meetings
• Systematic Planning – Workflow mapping – Everyone: do the work & to make work better
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Next Steps
• Individual Stories – Will be published on line at ABIMF p paper
• Video project – 10 of the 23 sites
• Toolkits/Learning community – Practical advice
• Campaign for “envy and demand” – BWH
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Discussion