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CSI-RI: Best Practice Sharing Meeting. A continuum of change…. August 19, 2011. The Practice Sites. The Practice Sites. Overview of Events. Clinical Team Building. Using Data to Improve Your CSI Outcomes. Creating Clinical Sessions that Work for You.

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csi ri best practice sharing meeting

CSI-RI: Best Practice Sharing Meeting

A continuum of change…

August 19, 2011

overview of events
Overview of Events

Clinical Team Building

Using Data to Improve Your CSI Outcomes

Creating Clinical Sessions that Work for You

Reducing Readmissions & Unnecessary ED Visits: Practical Best Practices

Pearls from IHI’s 12th Annual International Summit on Improving Patient Care in the Office Practice & the Community

Sharing Strategies to Improve Blood Pressure Control

Sharing Strategies to Improve HbA1C Control

November 2010

December 2010

January 2011

February 2011

March 2011

April 2011

May 2011

June 2011

July 2011

Group Visits


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 improvement.
  • Creating staff memos regarding outcomes data to identify gaps visually.
  • Utilizing implementation teams for making changes to processes to improve patient outcomes.

Utilization management workflows and high-risk patient identifiers

    • 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 patients.
    • 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

Thundermist Health Centers Woonsocket and Wakefield

NCMs better incorporated into team, data distribution increases team awareness of outcomes, and we have had positive patient feedback regarding new engagement activities.


Pre-visit planning with each provider and care team each week

    • Provider, NCM and MA determine needs of patients for the following week
  • Planning sessions prepare everyone for more productive patient visits. Helps to achieve goal of creating activated patients.

University Medicine – Governor St. Primary Care Center

“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 hospitalization
  • 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
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 patients.
  • 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 experience
  • NCM and practice staff contact patients seen in ER or admitted to hospital post discharge to coordinate necessary follow-up
  • Patients with chronic conditions referred to NCM for additional support in patient self management, medication adherence and community resources
coastal medical inc wakefield
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.”


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 Internal Medicine


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.

South County Independents

“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
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?
quality partners of rhode island csi ri training technical assistance team

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