RI-CSI: Best Practice Sharing Conclusion by NWiF1Ybs


									CSI-RI: Best Practice Sharing
     A continuum of change…

                              August 19, 2011
          The Practice Sites

   Hillside      Family Health      Coastal
Avenue Family      & Sports       Medical, Inc.
& Community        Medicine       (Greenville)

         Thundermist       University
        Health Center      Medicine
        (Woonsocket)      Governor St.
The Practice Sites
                        Overview of Events

November   December      January   February      March       April      May         June        July
  2010       2010          2011      2011        2011        2011       2011        2011        2011

Clinical              Using Data Creating       Reducing       Pearls from       Sharing       Sharing
 Team                 to Improve Clinical     Readmissions       IHI’s 12th     Strategies   Strategies
Building                Your CSI Sessions           &             Annual       to Improve        to
                       Outcomes    that       Unnecessary International           Blood       Improve
                                 Work for       ED Visits:     Summit on         Pressure      HbA1C
                                   You        Practical Best    Improving        Control       Control
                                                Practices     Patient Care
                                                              in the Office
                                                             Practice & the
                Hillside Avenue Family
                & Community Medicine
• MA utilizing a template (past and present vitals, smoking status,
  depression screen status, etc.) and meets with all patients prior
  to MD to appropriately screen patients to ensure a more focused
  visit with MD
   – Increase pre-visit planning and improve quality of care
• ER and hospital notifications directed to quality office and
  reviewed by NCM. Appropriate forms are included in EHR and
  sent for electronic signature to MD.
   – Increased follow-up with patients and less paperwork for MD

      “The best practices shared stimulated
         great conversations and ideas.”
    Family Health & Sports Medicine

• Monthly educational breakfasts for MAs by physicians
    – Topics: Cardiovascular, EKG, diabetes, and hypertension
    – YMCA provided motivational interview training
• Expansion of Medical Assistant role and responsibilities
    – Include patient education on self-management and screening

“Our best practice of BP control involved the
MA, Physician, and RN in developing slides
together. The BP meeting was very positive
for the MA, Megan Converse, as she was able
to interact with the group in sharing her role
as an MA and the patient with hypertension.”
   Coastal Medical, Inc. - Greenville

Improvement in data collection and reporting:
• Meet to discuss data with team and brainstorm plans for
• Creating staff memos regarding outcomes data to identify gaps
• Utilizing implementation teams for making changes to processes
  to improve patient outcomes.
            Thundermist Health Centers
            Woonsocket and Wakefield
• Utilization management workflows and high-risk patient
   – Implementing use of a template to complete on telephone outreach for ER
     and post-hospital follow up (RNs and NCMs)
   – Started labeling for high risk/high utilization within in EHR
• Increase patient education and engagement efforts with
   – Posters in waiting rooms to ask patients to think about 1-2 concerns of
     highest priority for their visit
   – Provider champions participating in exercise programs with patients and
     accompanying patients to farmers markets.
         Thundermist Health Centers
         Woonsocket and Wakefield
• Data use for clinical improvement:
   – Pre-visit planning reports including many of MA responsibilities
     related to outcome measures
   – Weekly missed opportunities reporting
   – Quarterly provider level reporting are posted and distributed
       • Highlight areas of focus and PDSA activities

NCMs better incorporated into team,
data distribution increases team
awareness of outcomes, and we have
had positive patient feedback
regarding new engagement activities.
    University Medicine – Governor St.
           Primary Care Center
• Pre-visit planning with each provider and care team each
   – Provider, NCM and MA determine needs of patients for the following
• Planning sessions prepare everyone for more productive
  patient visits. Helps to achieve goal of creating activated
    “One great take-away from the sessions has been
    how others have maximized their use of the same
    EHR to support clinical practice and reporting. For
    example, the use of the flow-sheets to track
    diabetes care and preventative health.”
                  Memorial Hospital
                  Family Care Center
• NCMs
   – Follow-up on hospitalized patients
   – Ensure care of the high risk patients for DM, hyperlipidemia, CAD,
     Depression, tobacco abusers with direct care, phone call care and
     Logician notes
• PCMH residents work on transition of care following
• Monthly faculty meetings for clinical updates of the PCMH
• Implementation of a CAD summary sheet, DM summary sheet
  for patients at their visit as patient self-management tool
• Increase staff (resident) education outside of normal business
  hours and via telephone
               Kristine A. Cunniff, DO
• Implementing PCMH bulletin board in waiting room:
  educational material and good health tips.
   – Encourages self-management resources
• Weekly huddles and CSI meetings within practice emphasizing
  team work
• Creates increased attention to entering and managing patient
  prevention data daily.

      Each person in the practice is an
        important part of the team
                  Stuart V. Demirs, MD
• Increased team collaboration to improve patient care:
   – Physician: Initial patient education and prescribing of appropriate
     disease-state medications.
   – Nurse Practitioner: Increased role in patient education and recording
     data in EMR.
   – NCM: Greater patient education & communication with physician and
     nurse practitioner for lab or medication changes.
       • Ensures compliance with medications and diet, especially for diabetic
• Regular monthly CSI meetings to review data and look at ways
  to improve our measures.
• Offering combined patient education opportunities free to
  patients within the medical home (Dr. Cunniff, Dr. Demirs, and
  Coastal Medical of Wakefield)
       South County Family Medicine
               Dr. Henseler
• Modification of “visit time” to improve the overall patient
• NCM and practice staff contact patients seen in ER or
  admitted to hospital post discharge to coordinate necessary
• Patients with chronic conditions referred to NCM for
  additional support in patient self management, medication
  adherence and community resources
     Coastal Medical, Inc. - Wakefield
• Monthly team meetings incorporating anonymous questions on
  index cards to be addressed or answered within a week
• Questions alternate between negative (“what is driving you
  crazy”) to positive (“what one thing can you say that is positive, is
  working for you”)
• On site psychologist, nurse care manager, and access to a
  pharmacist as a resource now
• Team meetings may also include short in-service and discussion of
  CSI data

       “These new strategies empower staff
           and encourage teamwork.”
      South County Internal Medicine
• Medication Reconciliation starts when patients arrive
   – Front desk staff prints medication list from EMR and patients are asked to
     review and note any changes
   – Physician notes any medication changes and records in EMR and patient is
     given an updated medication list
• Practice is utilizing a disease registry to proactively manage
  chronic disease
   – 50 patients contacted by NCM every 4-6 weeks
   – NCM coaches patient for self management, discusses adherence with
     medications and nutrition
• ER and Hospital utilization monitored by NCM
   – NCM contacts patients who have been in the ER or admitted to hospital and
     coordinates PCP follow-up
         South County Independents

• Increase in meaningful use of EMR to help create data reports
  to show areas for improvement.
• Patients with chronic conditions have become well-known to
  NCM and are appreciative of extra support.
• The NCM or another staff member contacts every patient
  seen in the hospital within 72 hours of discharge.
• Monthly meetings improve communication.

   “We continue to improve upon our relationship with VNS services and
      various departments throughout South County Hospital which
          strengthens our patient centered medical community.”
          Facilitating Change
• How far have you come along in the process
  of change?
• What challenges do you face when making
  changes in your practice?
• How have you conquered these challenges?
• What advice would you have for those ready
  to make changes to improve?
Thank you for your ongoing commitment to
   improving care for your patients. Your
 innovations and achievements continue to
     drive the evolution of the PCMH.

       Quality Partners of Rhode Island
  CSI-RI Training & Technical Assistance Team

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