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One Best Practice Change. First Up: Bala Cynwyd Medical Associates. “The One Best Practice Change” Bala Cynwyd Medical Associates. Attitude towards patients Patient as team member

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One Best Practice Change

First Up:

Bala Cynwyd Medical Associates


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“The One Best Practice Change” Bala Cynwyd Medical Associates

  • Attitude towards patients

    • Patient as team member

      • Medicine is a team sport. Until the collaborative I never viewed the patient as a member of the team. Now I realize the patient is the most important member of our team

  • Resulting Positive Impact/Outcomes

    • Retention of patients who were thinking of leaving the practice

    • Better outcomes

    • Better staff satisfaction


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“The One Best Practice Change” Project Salud

Major change

Change of diabetes self-management tool and consistent use of the tool

Self-management tool had been in English and could not be applied to the majority of our population

New self-management tool includes multiple pictures so that patients with low literacy level can understand the tool

Resulting Positive Impact/Outcomes

Patients begin thinking about an area they would like to improve on and can discuss with the provider prior to the provider entering the room

Patients get to take the self management tool home with them to have visual reinforcement of self-management goals


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“The One Best Practice Change” Crozer Medical Associates

Major change

Pre-Visit Planning

30 Day Appointment List with Deficiencies

Contact patient to arrange blood tests prior to visit

Resulting Positive Impact/Outcomes

Patients arrive at appointments with up to date labs

Providers have necessary data to make decisions

In the initial stages of rolling out to network practices


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“The One Best Practice Change” Medical Group at Marple Commons

Major change

We use a disease registry

For the first time, the doctors and MA’s can track individual diabetic patients and our entire population.

MA’s are more involved in patient care

Resulting Positive Impact/Outcomes

Patients are more involved in their care

More individual self-management support.

We have overcome clinical inertia for a number of measures.

Improvement in almost all tracked measures


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Children’s Health Center of VNA Community Services

  • Major change

    • Utilization of an Asthma Visit Form

      • An Asthma Visit Form was developed which included data fields, components of disease management and the NAEPP guidelines.

  • Resulting Positive Impact/Outcomes

    • The visit ran smoother.

    • All data fields were completed ensuring key components in asthma care were addressed.

    • NAEPP guidelines were followed.

    • Asthma visit forms are utilized on all asthma patients regardless of the reason for the visit.


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“The One Best Practice Change” Buckingham Family Medicine

Major change

Implementation of EMR

We now do all of our charting on an electronic medical record. All labs, letters and reports are imported or scanned into the system. Health maintenance rules allow us to track vaccines, cancer screening and disease specific testing needed.

Resulting Positive Impact/Outcomes

Tracking needed tests/visits

Prescription management

Access to medical record when off site

Searchable database


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“The One Best Practice Change”Abbottsford/Falls

Major change

Initiated Diabetic Group Visits with use of “Conversation Maps”

Gather 6-10 patients to share and exchange information

Discuss “action before motivation”

Patient’s help motivate each other to help control BS’s

Resulting Positive Impact/Outcomes

Decline in A1C’s

Patients are taking BS’s and recording them more consistently

One patient started her own support group in her apartment complex.

Greater patient empowerment and confidence in their ability to manage a chronic illness.

Greater compliance with medication regimen

More family involvement as a support system to patient.


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“The One Best Practice Change” Crozer Keystone Center for Family Health

Major change

Developed “Diabetic Report Card”

Created a letter to communicate results and interpretation of diabetic testing to patients that is written at a 6th grade reading level that is populated with data from our EMR

Resulting Positive Impact/Outcomes

Positive patient feedback

Now printed prior to visits to help guide MA’s and providers determine services that need to be provided to patients

Prompts providers to address diabetes even when that is not the primary purpose for the visit

DM report card has been shared with and adopted by several practices in the Collaborative


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“The One Best Practice Change” PHMC Health Connection

Major change

Social Worker will track referrals to increase attendance at specialist appointments

Make appointment

Call to remind of appointment

Check if appointment kept

If appointment is missed, call and reschedule

- repeat, as above

Resulting Positive Impact/Outcomes

More appointments kept

More reports received


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The One Best Practice ChangeJefferson Family Medical Associates

  • Expanding the role of our medical assistants to fill out diabetes flow-sheets and perform monofilament exams

  • Resulting Positive Impact/Outcomes

    • Involving medical assistants in patient care has been enjoyable for the medical assistants and for patients

    • Reviewing flow-sheets allows patients to be more involved in their care

    • Flow-sheets have helped PCP’s to identify goals of care, deficiencies in care, and overcome clinical inertia


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“The One Best Practice Change” Rising Sun Health Center

Major change

Replicating immunization follow-up for Diabetes

At time of visit - file in tickler file for one week before the next clinic visit

An addressed postcard reminder

If appointment is missed call and reschedule

Resulting Positive Impact/Outcomes

More appointments kept for follow-up


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“The One Best Practice Change” Kids First High Point

  • Major change

    • Patient Panel review with PCP and RN prior to start of office hours

      • Takes < 5 minutes

      • Significantly includes the nurse in patient care and decisions

      • Prepares for Asthma planned visit

  • Resulting Positive Impact/Outcomes

    • Have improved daily schedule:

      • Allot enough time per visit

      • Have all pertinent records available prior to pt arrival

      • Better compliance completing ACT and Asthma Intake Hx

    • More comprehensive visit -- Feels Good!


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“The One Practice Change” Health Annex

  • Major change

    --Dedicated 2 new staff members to work exclusively with diabetic patients.

    --RN and CDE dietitian conduct one on one education and intensive case management total 106 visits over 3 months.

    Positive Impact/Outcomes

    -- More glucometer use and testing

    -- 56 Podiatry visits were scheduled by RN

    -- Patients are seeing behavioral health therapist at time of visit.

    -- Building trust, confidence and empowerment


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“The One Best Practice Change” Mt. Airy Family Practice

A paradigm shift from “I tell the patients and it is up to them to follow my advice.” to “How can I empower patients to manage their diabetes?”

Causes of this changed attitude:

NCQA certification process/ Medical Home

SEPA CCC educational process and program

RMD Registry

Impact for patients and the practice:

Higher level of accountability on both sides

Improved satisfaction and outcomes of care


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“The One Best Practice Change” Holland Medical Associates

Major change

Institution of Case Management

CRNP and RN

Focused Case Management

Resulting Positive Impact/Outcomes

Patient Empowerment

Lower A1c’s

Increase in Compliance


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“The One Best Practice Change” North Willow Grove Pediatrics, PC

Major Change

Implemented new asthma visit template that incorporates evidence based guidelines.

All providers involved in Asthma Chronic Care Model.

Documentation now matches care of patients!

Resulting Positive Impact/Outcomes

Efficiency!!

Implementing our new asthma template has increased our goal percentages.

Each provider can follow previous provider’s plan of care.

Has spread to other chronic diseases/diagnoses; now have templates for ADHD, injuries, newborn weight checks.


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“The One Best Practice Change” Greenhouse Internists

Major change

Implementing SMS

New staff/staff roles

Enhanced educational resources

Patient outreach and follow up

Planned visits

Resulting Positive Impact/Outcomes

Appreciative patients

Empowered and accountable patients

Healthy behavior changes

Engaged staff


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“The One Best Practice Change” Lower Bucks Pediatrics, P.C.

Major change

Asthma Nurse

Educator

Case Management

Action Plan

Triage

Medication Management

Resulting Positive Impact/Outcomes

Better Understanding of Disease

Self Management

Fewer ER visits, hospitalization


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“The One Best Practice Change” Mary Howard Health Center

  • Major change

    • Starting of open access last calendar year.

  • Resulting Positive Impact/Outcomes

    Patients are seen same day.

    Patient’s are aware of process, so no one is turned away

    No more long lines of patients waiting to be seen.


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“The One Best Practice Change” Founders Medical Practice

Institution of Self-management Education for all DM patients

Stratification of DM pts

Staff initiates SM education for all DM pts

High and medium risk patients referred for direct SM education by CRNP

Staff provided additional education

Resulting Positive Impact/Outcomes

Improvement in SM goals for all DM Pts

Improved referrals for podiatry, eye exams

Closer to goals for HgA1c results


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The One Best Practice Change”Ninth Street Internal Medicine

Major Change

Adoption of the PDSA Process as a Change Agent

-Impetus/focus for weekly meetings

- Smooth transitions to new protocols

- Gave “permission” to take chances and try new things

Resulting Positive Impact/Outcomes

Development and Use of Innovative tools

Implemented Pre-Visit Planning

Improved Preventive Care

Increased Accuracy of Medication Lists

Standardized Data

Increased Patient Involvement in Self- Management

Strengthened Team Concept


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The One Best Practice Change” Kids First Chestnut Hill

Major change

Blending of PNP’s into the CCI project within our site

Descriptor

Initially attempted to utilize traditional management and clinical support staff; conclusion was that initial development and implementation required a higher level of clinical and operational training and experience

Currently have 32/hrs per week of PNP carved out and funded “time” allocated to the collaborative project, who are higher level clinicians in terms of training and experience

Develop, implement and support CCI goals throughout entire three year program on a daily and consistent basis

Provide leadership, education and resource roles to all staff

Resource to newly named team champions and care coordinator

Resulting Positive Impact/Outcomes

Incorporated evidence based practices within all clinical decisions

Developed an infrastructure that imbeds clinical goals into workflow and is sustainable

Developed workflows that are efficient and fiscally sound

Professional development of all staff members

Generalization (Halo Effect) to other processes within the office

Best Practice Model for other sites in our network


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The One Best Practice Change” 11t Street Family Health Services

Ophthalmology Clinic Developed

Access to on site retinal exams

Planned visits – pts called from registry

“Captured” patients seen by PCP and LCSW also

Positive Outcomes

We overcame our fear of planned visits damaging OPEN ACCESS appt scheduling

We obtained care for the uninsured, underinsured and non compliant patient reducing barriers

From this we modeled our Friday AM “Intense” focus group visits – targeting lowering BP first!


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