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Beyond the Blueprint Building the Patient Centered Medical Home. Wisconsin Primary Care Research & Quality Improvement Forum Wisconsin Dells, WI 11.13.09 Christine Sinsky, MD Thomas Sinsky, MD csinsky1@mahealthcare.com Medical Associates Clinic and Health Plans Dubuque, Iowa. Agenda.
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Beyond the Blueprint Building the Patient Centered Medical Home Wisconsin Primary Care Research & Quality Improvement Forum Wisconsin Dells, WI 11.13.09 Christine Sinsky, MD Thomas Sinsky, MD csinsky1@mahealthcare.com Medical Associates Clinic and Health Plans Dubuque, Iowa
Agenda • Background • The Challenges of Primary Care • 8 strategies to transform practice • Discussion
Take Home Messages • It’s all about • Planning ahead • Sharing the load • Enjoying the work!
Background • Primary Care • NCQA Advisory Panel: PCMH • Consultant and Workshops • All trying to solve same equation • Different settings • QE & S: quality, efficiency and satisfaction
We will know who you are and we will be ready for you. Borgess Ambulatory Care, Kalamazoo, MI
At the center of primary care are face-to-face healing relationships. Patient: Nurse Nurse: Physician Nurse: Nurse Patient: Physician
115 physicians, owners Health Plan: 1/3 of pt population EHR: 2003
Satisfaction Staff Turnover: < 5% Physician Satisfaction: > 95%’ile AMGA PCP Productivity and Compensation:85%’ile MGMA
Quality Patient Centered Medical Home
Snapshot of Practice • Staffing • Primary nurse • Help nurse • 1.5 nurse: MD • (no MAs) • Space • 3 exam rooms • Scheduling • 1 Receptionist: 2 MDs • Wave Scheduling
Snapshot of Practice • Typical Schedule • 6-8 Annual • 10-12 Planned Care • 4-6 Rapid Access • Panel Size • 1800-2000 • Outpatient/Inpatient
65 year old annual exam DM2 HTN Depression Prevention New c/o Heartburn Sleep disturbance Fatigue Mrs. Peters # of Quality measures?
65 year old annual exam DM2 (9) HTN (17) Depression (10) Prevention (27) New c/o Heartburn (3) Sleep disturbance Fatigue There is a lot to be done! # of Quality measures? 56 *McGlynn EA, N Engl J Med 2003. 348;26:2535-2645
Too much to be done by just one person Too important to be left to chance There is a lot to be done!
Core Team Model:Plan Ahead, Share the Load • Right thing happens by default • Staff work full level of ability • Minimize work MD does that is within skill set of others
“In few other sectors of the economy is the highest-level professional responsible for the majority of production, customer service, and clerical work.” SGIM Blue Ribbon Panel Report. Redesigning the Practice Model for General Internal Medicine: A Proposal for Coordinated Care. J Gen Intern Med 2007;22:400-109
Episodic Care MD Room pt nurse Check-in receptionist Check-out • Medication reconciliation • History • Exam • Data Gathering • Data entry • Decision making • Relationship building • Prescription writing • Documentation • Paperwork • Behavior Modification • Results reporting • Order entry • Vital signs • Insurance verification • Collect co-pay • Verify contact info ? ¼ MA: MD
Work Within Skill-set of Others MD Room pt nurse Check-in receptionist Check-out • Medication reconciliation • History/History • Exam • Data Gathering • Data entry • Decision making • Relationship building • Prescription writing • Documentation • Paperwork • Behavior Modification • Results reporting • Order entry • Vital signs • Insurance verification • Collect co-pay • Verify contact info ? ¼ MA: MD
Pre-appt lab Build-in rather than Carve-out Integrated, Continuous Care Office Visit Nurse-MD Team Between Visit Care Efficiencies and care coordination
Planned Care Appt Order sets Empowered Team Pt. Questionnaire Prescription Mgm’t Visit Summary Annual Exam Rapid Access Intentional Behaviors Core Team Model:Planning Ahead & Sharing the Load
Pre-appt lab Majority lab prior to appt Patient part of decision making 67 yo diabetic A1c 6.2 LDL 160 Bill P. Planned Care Appt Order sets Empowered Team Pt. Questionnaire Prescription Mgm’t Visit Summary Annual Exam Rapid Access Intentional Behaviors Planned Care Appointment
Efficiency “Just in time” info processing Close the loop during that appt Results reporting 4 hr clinic → 2 hr post-appt Safety Missing or overlooked inform Pt & family part of safety net Planned Care Appt Order sets Empowered Team Pt. Questionnaire Prescription Mgm’t Visit Summary Annual Exam Rapid Access Intentional Behaviors Planned Care Appointment
Planned Care Appt Order sets Empowered Team Pt. Questionnaire Prescription Mgm’t Visit Summary Annual Exam Rapid Access Intentional Behaviors Post-Appointment Order Sets
Upcoming appts/lab Last PE Place Today’s Care in Continuum of Time
73 yo est. pt Rapid w/ fever, cough Planned Care Appt Order sets Empowered Team Pt. Questionnaire Prescription Mgm’t Visit Summary Annual Exam Rapid Access Intentional Behaviors Post-Appointment Order Sets
64 yo DM 2, hypothyroidism, atrial fibrillation, CRI Planned Care Appt Order sets Empowered Team Pt. Questionnaire Prescription Mgm’t Visit Summary Annual Exam Rapid Access Intentional Behaviors Post-Appointment Order Sets
“The next appointment starts today” A plan, a promise to continue the relationship “We want to see you again, and we will plan ahead to make that most meaningful.” Planned Care Appt Order sets Empowered Team Pt. Questionnaire Prescription Mgm’t Visit Summary Annual Exam Rapid Access Intentional Behaviors Post-Appointment Order Sets
Nursing staff full partners Planned Care Appt Order sets Empowered Team Pt. Questionnaire Prescription Mgm’t Visit Summary Annual Exam Rapid Access Intentional Behaviors Empowered Teamwork
Nexus of organization of our practice • Filter • Between Visit • Extension of me when dealing with patients; patients recognize this. • Coordinates transitions (hospital, NH, Hospice) • Manages & returns most phone calls • Does prescriptions • Updates EHR • Completes all paperwork • Visit • Med. Reconcil. • Initial review of lab • Pt education • Immunizations • Colonoscopy • Sx driven tests (PFT, EKG) • Diabetic foot exam/eye exam • Present patient • (↓ info drop-off) The Boss
Staff deeply engaged Mentor nurses Physician better prepared Stronger handoff Planned Care Appt Order sets Empowered Team Pt. Questionnaire Prescription Mgm’t Visit Summary Annual Exam Rapid Access Intentional Behaviors Mini-huddle
47 yo “Rapid Access” new patient CC: dysphagia Nurse Mini-huddle “She seems depressed” “Is anyone hurting you?” Physician better prepared Planned Care Appt Order sets Empowered Team Pt. Questionnaire Prescription Mgm’t Visit Summary Annual Exam Rapid Access Intentional Behaviors Mini-huddle
Planned Care Appt Order sets Empowered Team Pt. Questionnaire Prescription Mgm’t Visit Summary Annual Exam Rapid Access Intentional Behaviors Introduction to Partnership
Identifies the patients agenda MD plan visit before entering Systems approach Update PFSH Complete ROS Behavior issues: exercise, smoking, alcoholwebmeeting.nih.gov/intro Future Kiosk in waiting area Web portal from home Planned Care Appt Order sets Empowered Team Pt. Questionnaire Prescription Mgm’t Visit Summary Annual Exam Rapid Access Intentional Behaviors Pre-appointment Questionnaire
Prescriptions are killing us…my nurse is spending so much time on refills that we can’t seem to get anything done. Minnesota Family Physician 2007
Survey: majority calls for scripts Systems: all scripts 1 yr at annual Efficiency: ↓ phone calls by 50% Synchronized, Bundled Renewals Planned Care Appt Order sets Empowered Team Pt. Questionnaire Prescription Mgm’t Visit Summary Annual Exam Rapid Access Intentional Behaviors Prescription Management
We don’t use scripts as hook Planned care appts (not expired script) trigger disease monitoring Avoid loading interval visits with unnecessary, redundant work Before: six calls or faxes/year After: zero Maggie Planned Care Appt Order sets Empowered Team Pt. Questionnaire Prescription Mgm’t Visit Summary Annual Exam Rapid Access Intentional Behaviors Prescription Management
Cornerstone of care Dedicated appt prevention/ annual review of chronic dz Customized not one-size-fits-all Planned Care Appt Order sets Empowered Team Pt. Questionnaire Prescription Mgm’t Visit Summary Annual Exam Rapid Access Intentional Behaviors Annual Comprehensive Care Visit