Team-Based Care Webinar #2 Forming, Implementing & Developing Care Teams Presented to

1. Team-Based Care Webinar #2 Forming, Implementing & Developing Care Teams Presented to The Community Health Center Association of CT Presented by Susan Crocetti, RN & Regina Neal, MPH, MS March 23, 2012

2. Objectives • Discuss how to form teams • Describe methods to leverage the power of the team • Explore the importance of communication among team members • Describe training needed for team-based care • Discuss how to implement teams • Describe methods of evaluating the effectiveness of teams • Explore the role of leadership in supporting team-based care

3. Imagine a High Functioning Clinical Team • Providers assess, diagnose and treat, always doing something that requires their clinical knowledge, not care coordination • Nursing role is re-established • Clinical expertise, leadership and educating becomes their focus, extending their reach • The MA/LPN role is enhanced • Using standards and training provided by providers and RN’s function more independently and enhance team delivery • Upward mobility strategy • Opportunities for stars to shine!

4. Honoring the Role of All Team Members Means… • Acknowledging and supporting the contributions made to patients and the team by: • Providing reinforcement of basic skills training • Enhancing theoretical knowledge • Supporting integration of knowledge and skills • Developing enhanced professionalism, leadership, team building and patient self-management support talents

5. What do Providers and Their Teams Want? • To be sure they have made a thorough assessment, had time to come to an accurate diagnosis, have planned for the appropriate treatments • Have made the patient feel cared for and cared about • Have a genuine therapeutic bond with their patients • Are understanding the patient as a whole person and addressing non-medical needs as appropriate

6. Planning for Team-Based Care • Empanel patients • Identify personnel and their credentials, competencies, personal characteristics and preferences • Adopt evidence-based guidelines and develop standing orders and standardized workflows based on these • Identify tasks that need to be assigned • Assign teams and individual roles and responsibilities • Educate staff (confidence and trust!) • Communicate new model to patients • Revise scheduling • Use technology

7. Who is On the Team and Who Can Support the Team?

8. What Can They Do and How Will They Work Together? • What is their scope of practice? • What are their strengths, preferences, innovative ideas? • Do they match your patients’ needs and characteristics? • Are their personalities and practice styles compatible? • Is there balance of strengths / weaknesses and preferences?

9. Take a Skills Inventory for All Team Members • What am I good at? • What do I like to do? • What am I interested in learning? • What would I prefer to do? • What am I capable of? • What do I have to offer that’s not being used? • What do patients like about me? • What do I need to improve? • What do I dislike? • What could I enhance? • What limits do I have by JD, policy, or regulations? • I once had this wild idea…

10. Role of MA’s • MAs may provide clinical support: • Rooming patients (includes vital signs and chief complaint) • Collecting information from patients • Assisting with procedures • Collecting and processing specimens • Scheduling tests and imaging after the visit • Making phone calls • Medication refills • Advice calls as directed by providers • Setting up appointments

11. The Enhanced Clinical Support Role • Team Partner, Care Coordinator, Health Coach • Allows team members to function at their highest level • Provides job satisfaction, potential for upward mobility, and retention of excellent staff • Provides enhanced, trusting relationships with patients, practical advice on self-management when cultural background is shared

12. Benefits of Enhanced Clinical Support Role McCarthy BD, Yood MU, Bolton MB, Boohaker EA, MacWilliam CH, Young MJ. Redesigning primary care processes to improve the offering of mammography. The use of clinic protocols by nonphysicians. Gen Intern Med 1997 Jun;12(6):357-63 Medical Assistants and Licensed Practical Nurses offer mammography as a routine part of the clinic encounter

13. Clinical Support in an EMR World • EMRs: 2 major unintended negative consequences: • Physicians are awash in unorganized data • Physicians are doing a tremendous amount of: • Data gathering • Data entry • The Enhanced MA/LPN role: • Moves data entry to the MA/LPN • Makes the MA/LPN a full partner in data gathering • Allows development of clinical skills through close communication with the provider

14. Impact on Licensed Professional Staff • Pro’s • Using their highest level knowledge and skills • More time to develop a formal plan of care and address complex patient needs • Enhanced leadership role • Mentor, preceptor, training and staff development • Evaluation and quality improvement • Con’s • May need enhancement of their leadership skills • May not want to give up tasks in their “comfort zone” • May have anxiety regarding role changes or be unsure if clinical support staff will be successful with new assignments

15. What Do Your Patients Need From the Team? They want high quality care in a timely fashion delivered efficiently but not hurriedly, by a skilled, knowledgeable and caring team who knows them and cares about them … • Understand your population and community resources • Construct a Responsibility/Task List • What else could you do that you haven’t done in the past or are currently not offering? ASK THEM!

16. Put It All Together = Who Does What ?

17. “Standard” Work = Gold “Standard” From Chaos to Control Standardization is a defined series of events required to complete a specific task • Prevents mistakes, improves quality and safety • Leads to improved efficiency & eliminates waste • Allows work to be done the best way every time • Assures the highest quality of work • Allows identification of waste • Is the foundation for making improvements • Ensures that improvements are sustained • Assists with training • Specifies responsible person and the expected time for completion of every task

18. Evidence-Based Guidelines as Standards • Patients benefit by receiving care based on proven knowledge • Providers have clear recommendations to follow • Systems can be set up to engage care teams to assist with implementing the guidelines • Quality of care can be measured using the specifications defined within the guidelines • Costs are contained when procedures and testing are limited to appropriate situations

19. Prompting the Team to Remember • Flow sheets, structured visit notes or templates in an EHR can offer enhance decision support and prompting for team members to remember to inquire and offer services based on guidelines • Standard operating procedures, workflows and standing orders guide team members to support provider efforts to provide all preventive and chronic care services

20. Standing Orders for Proactive Team Efficiency and Quality • Patient Prep • What clothing to remove • What vital signs to measure • POC Lab Testing • Urine Pregnancy, microalbumin • Rapid Strep • Glucose (fingerstick) • HbA1C • Well Child Visits • Hearing and vision screenings • Ht/length, Weight, Head Circum. • Lead testing • Immunizations • Follow up series (hep B, HPV) • Flu, pneumovax • Initiation of Referrals • Mammogram • Eye Exam • Podiatry • Other Services • EKG • Pulse oximetry • Spirometry • Peak Flow • Fluoride treatments • Patient Education and Self Management Support • Collecting Patient History, Risk Factor and Preventive Service Information

21. Workflows in the Patient Visit Cycle Access PatientVisit Post-Visit Pre-Visit Pre-registration Reception Exam Room Nursing Station Other Patient Management • Appointment scheduling • Respond to patient questions • Manage capacity and demand • Registration • Eligibility Screening • Apply Sliding Fee Scale • Update patient information • Pay outstanding balances • Patient info collected/verified • Payment collection • Vitals taken and recorded • Nurse documents reason for visit • Physician encounter • Patient education • Check-out • Schedule follow-up appointments • Schedule tests or referrals • Patient Recalls • Appointment reminders • Coordination of care with other providers • Referrals Activity • Phones • PMS • Email • Portal • PMS • Kiosks • EMR • Phones • PMS • Internet • EMR-disease registry • Phones • Portal • EMR • Vitals devices • Portal • Phones Tools • Receptionists • Medical Assistants • Call Center • RN Triage • Call Center Staff • Billing Office Staff • Receptionists • Patient Liaison • Medical Assistants- Room • Patient Liaison • Care Team Supervisor/ • Care Manager • Medical Assistants- Phone • Patient Liaison • Care Team Supervisor/Care Manager • Referral Coordinator • Medical Assistants- Phone • Care Team Supervisor/Care Manager • Referral Coordinator Staff

22. Workflows Within Stages of The Care Cycle

23. Before the Visit – Arrival • Start the day with a team huddle • Review schedule: who needs information for follow-up? • Plan health maintenance and chronic illness tasks for each patient (may also be done days before as pre-visit planning) • Clerk/receptionist greets patient • Verify demographics (address & phone are critical!), insurance, assigned PCP • Give a copy of clinical lists (problems, medications, allergies) for patient to review while in waiting room • Review appointment history • Assist with obtaining missing reports

24. Before the Visit – Rooming • Vital signs, chief complaint, preparing patient for provider visit • Facilitate medication reconciliation for provider review, prints patient handouts or other documents • Health maintenance/chronic illness services based on standing orders from evidence-based guidelines • Initiates routine referral or test orders • Information gathering from tests, consultation notes, updates by patient to share with provider • Discussion of self management goals • Agenda setting for provider visit time

25. During the Visit – Provider Exam • Clinical Support staff (MA or LPN) notifies the provider when patient is ready, summarizes the patient’s needs for the provider • Provider reviews the history and continues to question the patient • MA / LPN might act as scribe • Provider discusses diagnosis and treatment options with patient • MA / LPN carries out services ordered by provider, assists with procedures, prints documents as requested by provider • Care management opportunities by RN, dietician, pharmacist interactions; self-management support

26. After the Visit – Discharge and Checkout • Process orders, if not completed during the visit • Draws blood, gets EKG, gives injections • Schedules imaging tests and referrals • Gives patient the visit summary/plan of care, educational handouts, self-monitoring tools • Makes follow-up appointments for patient • Gives referrals, test requisitions • Reviews plan of care and allows patient to ask questions • 50% of patients don’t understand the provider’s advice • Work on realistic goal-setting and self-management support, MA or nurse depending on complexity

27. In Between Visits • Outreach for no-show or missed visits/services based on guidelines; population management • Test and referral tracking with follow-up • Reach out to facilities and specialists for consultation notes and results • Contact patient if the did not obtain service • Communicate with facilities if patient received care outside of practice (e.g., hospital, emergency department, urgent care center) • Follow-up with patient as advised by provider • Mail educational materials, new patient information, self-monitoring tools, missed opportunity letters • Make reminder calls (these can be automated)… • Update patient registry and service information, run and interpret reports • Telephone triage and clinical advice calls

28. TrainingPCMH 1 G: The Practice Team • The practice uses a team to provide a range of patient care services by: • Defining roles for clinical and nonclinical team members • Having regular meetings or a structured communication process • Using standing orders for services • Training and assigning care teams to coordinate care for individual patients • Training and assigning care teams to support patients and families in self-management, self-efficacy and behavior change • Training and assigning care teams for patient population management • Training and designating care team members in communication skills • Involving care team staff in the practice’s performance evaluation and quality improvement activities

29. Put It In Writing!! Develop documentation to support team-based care: • Revise job description • Performance evaluation tool • Training program description • Clinical guidelines • Standing orders • Competency checklists • Standards for medical record/EMR documentation using standardized tools and templates

30. Investing in Written Documents

31. Example of Job Description

35. Implementation: Start Out on a Small Scale • Identify an enthusiastic, dependable champion • Define the goals, actions, measurement methods, etc. • Rehearse! Staff first, patients later.. • Analyze, critique, measure, brainstorm and try again! • Consider the environment • Layout, team color coding, seating of provider/support • Spread and sustainability strategy

36. Re-Evaluation of Workflows and Roles • Use tools to identify best practices and standardize work based on this evidence • Flow charting processes • Time studies • PDSA Cycles • Process and Outcomes Data by PCP/team • Do today’s work today (Point of Care, no batching) • Change Management and team dynamics need to be attended to • Strong education and competency assessment program is critical

37. Monitoring the Effectiveness of the Team • Competencies up to date • Patient Experience Surveys • Staff Engagement Survey • Employee Turnover Rates • Culture of Safety Questionnaires • Operational Efficiency / Productivity Reports • Cycle Time • Clinical Quality Metrics

39. Provider Time Study 41 min Check-in Vital Signs Med reconciliation Update PSFHRF 3 minutes 1 minute MD-Patient Bonding/History/Exam/Plan Mini-huddle 15 minutes 1 minute Operationalize Decisions Documentation Follow-up 5 minutes 6 minutes 10 minutes Modified from Kim Davis MD, MUSC

40. Impact of Strong Team Support 22 minutes Update PSFHRF and follow standing orders Check-in Vital Signs Med reconciliation Pre-appt tests MD-Patient Bonding/History/Exam/Plan Mini-huddle 15 minutes 1 minute Operationalize Decisions Documentation 6 minutes Modified from Kim Davis MD, MUSC

41. Making the Most of Office Time Typical Office Visit (Lead Time = 60 Minutes) Rooming by Medical Assistant 10 Minutes Medical Visit by Physician 20 Minutes Discharge by PSR 10 Minutes Wait 10 Minutes Wait 10 Minutes Waste = 60 Minutes – 40 Minutes = 20 Minutes

42. Eliminating Waste to Improve Workflow • Includes: patient wait times, extra walking due to disorganization and lack of coordination between providers and staff • In order to eliminate waste • Must consider all the processes • Standardize all the operations • Tidiness leads to efficiency • Conduct repeated PDSA cycles

43. Team-Based Care Work = Performance Improvement! • Examples include: • Adding or modifying decision support prompts • Enhancing patient education and self-management support activities • Offering more point-of-care services such as HgA1c POC testing, on-site phlebotomy • Pre-visit planning activities and outreach • Closed loop test and referral tracking • Enhanced team education regarding the guidelines • Standing orders and other protocols

44. Habits of Effective Teams Team Goal Setting Team Decision-Making Participation Leadership Conflict Problem Solving Risk-Taking & Creativity Communication & Feedback

45. Let the Team Establish Their Own Standards / Ground Rules • What is the best way to communicate? • Daily communication with huddles • Monthly staff meetings • Ad hoc email, flags, etc. • How should we be held accountable? • How should we handle conflict?

46. A Culture of Safety and Transparency • No intimidating behavior • Mistakes are expected, and are not penalized, but must be reported and learned from • Communicate clearly and ask for confirmation of understanding • Conflict is normal but must be used constructively; stay focused on the issue, not the person; the goal is always to do the right thing for the patients

47. Leadership Support • Allow time for planning and implementation of the Team-Based model • Defining roles • Establishing guidelines/protocols • Revising policies and job descriptions • Developing training program • Provide leadership training • Delivering initial training • Allow time for sustaining the model • Team meeting time • Continuing education • Measurement and improvement initiatives • Rewards!

48. Leadership Support • Invest in technology to support the team • EMR, patient registry, patient portals or interactive website, lab and imaging interfaces/tracking systems, automated phone systems, walkie-talkies, headsets • Ensure training to use systems effectively and efficiently • Written policies and standards • Written training materials – team based training! • Customization options for the EMR • Always involve the team in planning for technology design and use!

49. That Sounds Great But….

50. Next Session • Population Health • Care Management and Care Coordination • Self Management Support Prepare by reviewing NCQA’s PCMH Standards 2A, 2B, 2C, 2D, 3C, 3D, 4A, 4B, 5A, 5B, & 5C Think about what work can be shifted from the provider to the team. An exercise with instructions will be provided.