2011 Patient Centered Medical Home Monthly Webinar Series

1. 2011 Patient Centered Medical Home Monthly Webinar Series

2. PCMH and Coordinated Care: A Team Based ApproachFebruary 16, 201112:15 – 1:15 pm Bob Lyon MD Annette Gagnon BSN

3. ProblemConsider the following patient… • 55 yr. old female with DM, HTN • Everyday she needs to : -Take insulin, other medications, record BS’s -Follow a diabetic and low salt diet -Exercise -Monitor and respond to her symptoms -Carry on with other daily responsibilities as best as she can M Heisler

4. The ProblemConsider the following doctor… • 48 yr. old physician with a panel of 1500 patients • Each day they need to spend: -7.4 hours providing recommended Preventive Care -10.6 hours following recommended chronic care guidelines -Address the acute care needs of their patients M. Heisler

5. Current State of Chronic Disease Management • 100 million Americans have a chronic disease • 80% health care costs • Only 50% of those with chronic illnesses get accepted treatments • <50% have satisfactory levels of disease control • Physicians and patients are frustrated with state of chronic disease management M Heisler

6. What does work? • Cochrane Collaborative review of trials of System change interventions • 40 studies – mostly randomized • Interventions classified as decision support, delivery system design, information systems, self management • 19/20 studies which included self management support showed improved outcomes • All 5 studies with all 4 domains showed improved outcomes Renders et al, Diabetes Care, 2001:24:182 Bodenheimer,Wagner, Grumbach, JAMA 2002; 288:1910

8. Coordinating Care: What Does it Mean? • Know your patient – Population management and registries • Proactively engage your patient • Educated patients and staff on “Self Management” principles • Clear roles for team members – for internal and external coordination of care • Systems in place to evaluate team functioning and outcomes

9. Know your patients: Registries • The first and most important step is to develop an ACCURATE, READER FRIENDLY, REPRODUCIBLE registry • It should be: -Physician specific -Contain patient specific data -Compare to peer and national standards -Updated at frequent intervals

10. Develop Clear Team Roles: • DM team – MD, MA, RN MA – Assures labs, vaccinations, referrals, appointments, planned visits all through the use of Standing Orders RN – Provides education, interval f/u, medication adjustments, f/u of self management goals (case management). MD – Sets the agenda and prioritizes patient care issues

11. Patient Self Management • Staff education on Motivational interviewing, coaching, goal setting, action plans and stages of change theory • Advance “self management” principles for patients with monthly group visits in DM • Connect with community resources (YMCA Stanford model, Living Well through AHEC)

12. RN Care Coordinator • 60% FTE position whose sole responsibility is to develop Patient Care Plans with Physician input. This includes: • Education • Motivational Interviewing • Stages of Change behavioral assessment • Actions plans/goal setting • Case management • Connection with community resources • Follows up on health status changes- i.e. admissions

13. MA binder • Contains registry of patients who need chronic disease management or preventive screening (mammograms, colon cancer screening, immunizations)

14. Preventive Screening Rates

15. Examples of External Care Coordination • Referrals • Inpatient care • Laboratory testing follow up

16. Systems needed for Care Coordination • Central source of information for all team members • Data Flowsheet • Care Plan management EHR template

17. Where do you get the time? • Q 2 mths, registry data and team meeting • 30 minutes every 2 months during patient care time the RN and MD get together to develop Care Plans for high risk patients. (5-7) • Warm handoffs during patient visits • Follow up and documentation is done through the EHR workflow and Care Plan Templates • Is there a loss of Revenue?

18. How to develop effective teams? • Chronic disease management and PCMH education to entire staff • Culture shift must occur from physician centered episodic care to team centered, continuous and patient centered care • Regular team meetings to distribute data and outcomes, review difficult cases and assess team processes and functioning – every 2 months

19. Practical tools • Chronic disease and prevention registries – example of MA binder with DM, Mammography, Colon cancer screening and influenza and pneumovax • Standing orders – Labs, immunizations, mammograms, colonoscopy or FOBT, referrals (DM eye exams), office visits.

20. Practical tools • Centralized access to disease and care plan templates • Stratification of patients by risk – HgA1c>9, or BP >160/100 • Utilization of Community resources – YMCA, AHEC Living Well, etc. • Team Incentives, awards and recognition

21. Our results- after 14 months • 600 patients, 70% Mcaid, uninsured • HgA1c: 8.86 to 7.97 • HgA1c in past 12 months 64% to 79% • LDL in past 24 months 71% to 82% • LDL <100 32% to 41% • Pneumovax rate- 61% to 80% • BP <130/80 34% to 37%

22. Key Points • Take things that don’t require an MD degree out of physicians hands – Standing orders • Define team members roles and responsibilities • Educate entire staff to create a culture of team based patient centered care - Ownership • Make sure registry data is accurate and easily accessible to all team members • Make time to meet • Incentivize success

23. References Coleman EA, Eilertsen TB, Kramer AM, Magid DJ, Beck A, Conner D. Reducing emergency visits in older adults with chronic illness: a randomized controlled trial of group visits. Effective Clinical Practice 2001;4(2):49-57. McCulloch DK, Price MJ, Hindmarsh M, Wagner EH. A population-based approach to diabetes management in a primary care setting: early results and lessons learned. Effective Clinical Practice 1998;1(1):12-22. The Robert Wood Johnson Foundation. Improving Chronic Illness Care Program: Group Visit Starter Kit. http://www.improvingchroniccare.org/improvement/docs/startkit.doc Accessed 4 March 2004. Wagner EH, Grothaus LC, Sandhu N, Galvin MS, McGregor M, Artz K, et al. Chronic care clinics for diabetes in primary care: a system-wide randomized trial. Diabetes Care 2001;24(4):695-700. http://www.improvingchroniccare.org/downloads/group_visit_starter_kit_copy1.doc

24. End of PowerPoint Presentation 210 Green Bay Road Thiensville, WI 53092 Phone: (262) 512-0606 Email: academy@wafp.org www.wafp.org/pcmh