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Office Redesign for Best Chronic Illness Care. Carrie Nelson, MD, MS, FAAFP The Nuts and Bolts of the Patient Centered Medical Home Conference June 25, 2010. Purpose.

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Office Redesign for Best Chronic Illness Care

Carrie Nelson, MD, MS, FAAFP

The Nuts and Bolts of the Patient Centered Medical Home Conference

June 25, 2010


Purpose

The goal of this presentation is to understand how the Planned Care Model can be put into practice to improve the quality and reliability of patient care.

(And make practice more fun!)


Learning Objectives

Following this presentation, participants should be able to:

  • Describe the goals and key components of the Planned/Chronic Care Model.

  • Describe how planned care, an optimal health care team and a prepared, proactive patient come together to support a successful care delivery system.

  • Describe the goals of self-management support and articulate the key sources for successful health behavior change.

  • Describe the model for improvement.


Implementing Change

Results

Process

Relationships


Planned Care Model

We must move away from rewarding individual heroic efforts and focus on building smooth, effective processes and teamwork throughout the office.

OR


The Media Loves a Hero…but Success Loves a Team

I'm proud of the fact that my crew and I were up to the challenge with which we were confronted.


Planned Care Model

We can consciously design our systems so that providing the best care is the default outcome even on the busiest, most chaotic of days.


A Typical Day at the Office


The AAFP Perspective

PCMH

Practice-based

Care Team

Great Outcomes

Great Outcomes

Health Information Technology

Practice

Management

Practice Organization

Health IT

Care Management

Quality Built In

Patient Experience

Access to Care and Information

Quality and Safety

Family Medicine Foundation

Continuity of

Care Services

Practice

Services

*c/o AAFP


Developed by The MacColl Institute ®ACP-ASIM Journals & Books


The Essential Basis for Good Planned Care

Prepared

Practice

Team

Informed,

Activated

Patient

Productive

Interactions


What characterizes a “prepared” practice team?

Prepared

Practice

Team

  • At the time of the visit, they have

  • the patient information

  • decision support

  • skills

  • equipment

  • and time

  • required to deliver evidence-based clinical management and self-management support.


What characterizes an “informed, activated” patient?

Informed,

Activated

Patient

  • Understands the disease process,

  • Realizes his/her role as the daily self manager

  • Has the tools to do so effectively

  • With the support of family and caregivers.


Clinical Information Systems

Registry and/or EHR?

Reminder systems?

Recall plans?


Clinical Information Systems

  • We know who our patients with each condition are.

  • We are reminded of what care they need.

  • We can recall patients for timely care.

  • We can monitor the performance of our team and system.


Registry References

  • EHR capable of reminders, recalls and reports

  • C-DEMS or commercial registry

  • California Healthcare Foundation review: http://www.chcf.org/~/media/Files/PDF/C/ChronicDiseaseRegistryReview.pdf

  • Build your own in Excel or Access

  • Paper cards


Lest We Think IT Will Solve Everything…

There’s more to the Planned Care Model


Decision Support

Evidence-based care?

Accessible patient info?

Guidelines embedded into daily practice?

Staff decision rules?


Decision Support

What is the best care and how do we

make it happen every time?

Don’t fall victim

to the crystal ball…

What kind of day will today be?


Delivery System Design

Care team roles optimized?

Proactive planned visits?

Patient-centered access?

Efficient flow of patients &

information?

Group visits?


Delivery System Design

We know what the right care is. How do design our care processes so that right thing to do is the easy thing to do?


Delivery System Design

  • Schedule set times to plan care

  • Standing orders and protocols

  • Optimize care team roles

  • Huddles

  • Group visits


Group Visits

  • Many different structure options

  • A Guide to Group Visits for Chronic Conditions Affected by Overweight and Obesity: http://www.aafp.org/online/etc/medialib/aafp_org/documents/clinical/pub_health/aim/groupvisits.Par.0001.File.tmp/GroupVisitAIM.pdf

  • Group Visit Starter Kit


Self-management Support

Collaborative goal-setting?

Emphasis on patient’s role?

Incentives & support

for self-management?


Self-management Support

  • A major culture change, for patients and the health care team

  • It can take time and patience (less so than you might think), but is ultimately more efficient

  • It is rewarding


What’s does it take to change?

  • Readiness

  • Importance

  • Confidence

Motivation


Self-management Support

X

Remove guilt

No more “noncompliant” patients

Use customized tools

Discover how each patient learns best


New Health Partnerships

www.newhealthpartnerships.org

Initiative of the IHI

Designed to raise awareness of self-management support

Supported by more than 20 organizations, including AAFP, AAP, NCQA, NQF and RWJF


The Model for Improvement


Act

Plan

Study

Do

Model for Improvement

Aim

What are we trying to accomplish?

How will we know thata change is an improvement?

Measures

What change can we make that will result in improvement?

Ideas

Act

Plan

Study

Do

From: Associates in Process Improvement


The PDSA Cycle for Learning and Improvement

Act

Plan

  • Objective

  • Questions and

  • predictions (why)

  • Plan to carry out the cycle

  • (who, what, where, when)

  • Plan for data collection

  • What changes

  • are to be made?

  • Next cycle?

Study

Do

  • Complete the

  • analysis of the data

    • Compare data to

  • predictions

    • Summarize

    • what was

    • learned

  • Carry out the plan

  • Document problems

  • and unexpected

  • observations

  • Begin analysis

  • of the data

From: Associates in Process Improvement


Repeated Use of the PDSA Cycle

Model for Improvement

What are we trying to

accomplish?

How will we know thata

change is an improvement?

What change can we make that

will result in improvement?

A

P

S

D

D

S

P

A

A

P

S

D

A

P

S

D

Changes That Result in Improvement

Evidence & Data

Implementation of Change

Test new conditions

Learning and Improvement

Follow-up Tests

Hunches Theories Ideas

Small Scale Testing

From: Associates in Process Improvement


Multiple PDSA Cycle Ramps

P

P

P

P

A

A

A

A

D

D

D

D

S

S

S

S

S

S

S

S

D

D

D

D

A

A

A

A

P

P

P

P

A

A

A

A

P

P

P

P

S

S

S

S

D

D

D

D

P

P

P

P

A

A

A

A

D

D

D

D

S

S

S

S

Testing and adaptation

Group visits

Adopt guideline

Non-MD roles in visit flow

Registry

Change Concepts

From Associates in Process Improvement


CME: www.YHPlus.com New and Improved IT Platform

  • How to Conduct a Quality Improvement Program in Primary Care Practice

  • Managing Childhood Asthma in Primary Care: A Quality Improvement Program

  • Managing Adult Depression in Primary Care: A Quality Improvement Program

  • Managing COPD in Primary Care: A Quality Improvement Program

  • Managing Heart Failure in Primary Care: A Quality Improvement Program

  • Managing Diabetes in Primary Care: A Quality Improvement Program

  • Managing Substance-Use Disorders in Primary Care: A Quality Improvement Program


Supplement Volume 8 2010: Review of the AAFP National Demonstration Project

  • Both facilitated and self-directed NDP practices made substantial progress toward implementing the predominantly technological components of the NDP model

  • Roles and identities need to change if a practice is to get beyond incremental change and actually transform

  • Such change may require personal transformation


Home Sweet Home


Thank You

Carrie Nelson, MD, MS,FAAFP

Medical Director, Your Healthcare Plus

McKesson Health Solutions

224-542-8071

Carrie.nelson@mckesson.com


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