Phoenix Indian Medical Center Improving Patient Care

1. Phoenix Indian Medical Center Improving Patient Care

2. IPC Simplified

3. Indian Health Service 4 Priorities • To Renew and strengthen our partnership with Tribes • In the context of national health insurance reform, to bring reform to IHS • To improve the quality of and access to care • To make all our work accountable, transparent, fair, and inclusive

4. IPC Program Aim • To transform the Indian health system to a more integrated, well organized, and higher performing system of care. • Develop high performing and innovative healthcare teams to improve the quality of and access to care across all ages and chronic conditions • Build a sustainable infrastructure for the dissemination of innovative improvement throughout the Indian health system. • The results will be a medical home that is accessible, patient-centered, and provides safe, timely, effective, efficient and equitable care

6. IPC Actions • Aim Statement aligns with the mission and strategic plan • Care Teams/“Micro-systems” established • The “Green Book” Clinical Self Assessment and Process mapping - staff/clinical design and flow. • Through “The Patients Eyes:” Clinic assessment from the Patient’s perspective • Model for Improvement – PDSA with Rapid Cycle • Empanelment assignments • Data reporting

7. QILN Aim • The aim of the Quality and Innovation Learning Network (QILN) is to improve health and promote wellness for American Indians and Alaskan Natives through an active learning and innovation community that provides continued support for IHS, Tribal, and Urban programs in achieving changes for the Indian Health medical home. • Changes and improvements will continue to be tested and implemented as they were in IPC. • PCMC and Peds Clinic are now both a part of the QILN

8. So where does PIMC fit in?

9. PIMC Vision By 2020, we will be the "Medical Home” for all who choose

10. PIMC Vision • We will build a network to actively manage chronic conditions of our patients ('12) • We will deliver health care without walls ('12) • We will eliminate waste & thereby expand capacity ('12) • We will specialize inpatient services in areas of excellence that meet the high priority needs of our beneficiaries ('12) • We will support our staff to innovatively design & implement solutions ('12)

11. PIMC Community • Largest facility in the Phoenix Area • Over 350 Tribes use the Phoenix Indian Medical Center • Surrounding Service Unit Tribes (7) • Salt River Pima-Maricopa Indian Community • Fort McDowell Yavapai Nation • San Lucy District of the Tohono O’odham Nation • Tonto Apache Tribe • Yavapai-Prescott Indian Tribe • Yavapai-Apache Indian Tribe • Gila River Indian Community (District 6 /7)

12. Challenges for PIMC • “Un-Worried, Un-Well” population • PIMC has a very large, diverse and mobile population that is difficult to track • Many patients have other PCP’s and utilize PIMC as more of an urgent care center to avoid insurance copays for acute illnesses • Difficult to achieve successful large-scale changes and staff buy-in with such a large facility

13. IPC Phases • IPC 1 - 14 pilot sites in 2007 • IPC 2 - 39 sites joined in Fall, 2008 • PCMC was a member of this phase • IPC 3 - 68 sites joined in January, 2011 • Peds Clinic was part of this phase • IPC 4 - 33 sites joined in May, 2012

14. IPC in Action: Creating the “Medical Home”

15. Creating the “Medical Home” Care Centered on the Patient and Family • IPC Goal: • Health programs design their services to put the patient and family at the center of care, to provide great customer service and to support them as they strive toward wellness. • PIMC Actions: • Improvements in customer service was made a top priority in the PIMC 2012-2013 Strategic Plan • Creation of a Welcome Desk in the front lobby • Phone system upgrade • Self-management support

16. Creating the “Medical Home” Care Teams • PCMC: • Teams consist of 4 providers, 1 RN Clinical Care Coordinator, 1 LPN, 2 NA’s and 1 MSA • Each team has 3200-4000 empanelled patients • 100% of patients are empanelled and only empanelled patients receive appointments • Team names: Coral, Silver, Juniper, Ocotillo • Pediatric Clinic: • Teams consist of 2.5 – 3 providers (nursing and support staff change daily) • Open access system allows un-empanelled patients to make appointments and these patients are encouraged to pick a provider during their visit • Approx 15% of the pediatric user population (6,000 patients) are currently empanelled • Team names: Panda, Tiger, Zebra, Monkey

17. Creating the “Medical Home” Access and Continuity • IPC Goal: • Every patient has a relationship with a provider and care team, and has consistent and reliable access to that provider and care team. • PIMC Actions: • PCMC has 100% empanelment of patients • Clinical care coordinators help manage care of patients with chronic conditions • Pedsclinic provides open-access scheduling so patients are able to make same-day and next-day appointments with their personal provider or another provider on their care team

18. Creating the “Medical Home” Clinical Information Systems: • IPC Goal: Organize patient and population data to facilitate efficient and effective care. • PIMC Systems used: • iCare • EHR • RPMS

19. Creating the “Medical Home” Quality and Transparency • IPC Goal: • Everyone in the system has the skills and tools for making improvement, and uses measurement and data to build better care. • PIMC Actions: • Bulletin boards in common areas and waiting rooms allow staff and patients to view current projects and progress • Surveys allow patients and staff to voice opinions. • Survey data should be visibly posted in care areas and uploaded to the IPC knowledge portal on a regular basis • Clinical care is consistent with scientific evidence and patient preferences. • Ideas for change and improvement should be encouraged and systematically tested using the PDSA Model

20. Change Implementation: PDSA

21. Model for Improvement: PDSA • The Plan-Do-Study-Act (PDSA ) cycle is a process for testing a change: • (Plan) –develop a plan to test the change, • (Do)- carry out the test, • (Study) – observe and learn from the consequences, • (Act) – determine what modifications should be made to the test.

22. Model for Improvement: PDSA

23. Model for Improvement: PDSA Now Try it!

24. IPC Terms and Resources

25. IPC Terms and Resources • IPC Home Page: http://www.ihs.gov/ipc/index.cfm • Advanced Access: A model to reduce delays and wait times in the clinical setting. The core principle of Advanced Access is that patients calling to schedule a clinic visit are offered an appointment the same day. The goal of Advanced Access is to build a system in which patients have the opportunity to see their own provider when they choose. For additional information about Advanced Access see http://www.ihi.org/explore/PrimaryCareAccess/Pages/default.aspx • Chronic Care Model (CCM): A model that represents the ideal system of healthcare for people with chronic disease and an approach to re-designing healthcare to mirror that ideal system. Developed by Improving Chronic Illness Care, the model has six components: community resources and policies, healthcare organization, self-management support, decision support, delivery system design, and clinical information systems. For additional information see http://www.improvingchroniccare.org • “Green Book”: Officially known as “Assessing, Diagnosing, and Treating Your Outpatient Primary Care Practice” and can be found at http://www.clinicalmicrosystem.org. A workbook that provides tools and methods that clinical teams can use to improve the quality and value of patient care as well as the work-life of all staff who contribute to patient care. These methods can be adapted to a wide variety of clinical settings, large and small, urban and rural, community-based and academic.

26. IPC Terms and Resources • iCare: iCare is a Population Management software tool that helps organizations manage the care of their patients. The ability to create multiple panels of patients with common characteristics (e.g., age, diagnosis, community) allows personalization of the way patient data can be viewed. iCare is a Windows-based, client-server graphical user interface (GUI) to the IHS RPMS. It retrieves important patient information from various components of the RPMS database and brings it together under a single, user-friendly interface. http://www.ihs.gov/CIO/CA/icare/ • Microsystem: a small group of people who work together on a regular basis to provide care to discrete subpopulations of patients. It has clinical and business aims, linked processes, a shared information environment, and produces performance outcomes. Microsystems evolve over time and are (often) embedded in larger organizations. As a type of complex adaptive system, they must: (1) do the work, (2) meet staff needs, and (3) maintain themselves as a clinical unit. Many resources and tools can be found at http://www.clinicalmicrosystem.org • Model for Improvement: Shown on the right, an approach to process improvement, developed by Associates in Process Improvement, which helps teams accelerate the adoption of proven and effective changes. For additional information on the Model for Improvement, go to: http://www.ihi.org/knowledge/Pages/HowtoImprove/ • Process Mapping: An activity that diagrams the steps, decision points, and influencing factors in a workflow process to bring forth a clearer understanding of that process or series of parallel processes.

27. IPC Terms and Resources • Patient Centered Care: Care that is truly patient-centered considers patients’ cultural traditions, their personal preferences and values, their family situations, and their lifestyles. It makes the patient and their significant other(s) an integral part of the care team who collaborate with health care professionals in making clinical decisions. Patient-centered care puts responsibility for important aspects of self-care and monitoring in patients’ hands — along with the tools and support they need to carry out that responsibility. Patient-centered care ensures that transitions between providers, departments, and health care settings are respectful, coordinated, and efficient. When care is patient centered, unneeded and unwanted services can be reduced. For additional information and ideas: http://www.ihi.org/explore/PFCC/ • Self-Management Support (SMS): The care and encouragement provided to people with chronic conditions to help them understand their central role in managing their illness, make informed decisions about care, and engage in healthy behaviors. http://www.ihi.org/knowledge/Pages/Changes/SetandDocumentSelfManagementGoalsCollaborativelywithPatients.asp • Transparency: Sharing performance data in an effort to make organizations more accountable and promote improvement.