Beyond the Blueprint Building the Patient Centered Medical Home Wisconsin Primary Care Research & Quality Improvement Forum Wisconsin Dells, WI 11.13.09.

Beyond the Blueprint Beyond the Blueprint Building the Patient Centered Building the Patient Centered

Medical HomeMedical Home

Wisconsin Primary Care Research & Quality Wisconsin Primary Care Research & Quality Improvement Forum Improvement Forum Wisconsin Dells, WIWisconsin Dells, WI

11.13.0911.13.09Christine Sinsky, MDChristine Sinsky, MDThomas Sinsky, MDThomas Sinsky, MD

[email protected]@mahealthcare.comMedical Associates Clinic and Health PlansMedical Associates Clinic and Health Plans

Dubuque, IowaDubuque, Iowa

AgendaAgenda

BackgroundBackground The Challenges of Primary Care The Challenges of Primary Care 8 strategies to transform practice8 strategies to transform practice DiscussionDiscussion

Take Home MessagesTake Home Messages

It’s all about It’s all about Planning ahead Planning ahead Sharing the loadSharing the load Enjoying the work!Enjoying the work!

BackgroundBackground

Primary Care Primary Care NCQA Advisory Panel: PCMH NCQA Advisory Panel: PCMH Consultant and WorkshopsConsultant and Workshops All trying to solve same equation All trying to solve same equation

Different settingsDifferent settings QE & S: quality, efficiency and satisfactionQE & S: quality, efficiency and satisfaction

We will know who you are and We will know who you are and we will be ready for you.we will be ready for you.

Borgess Ambulatory Care, Kalamazoo, MIBorgess Ambulatory Care, Kalamazoo, MI

At the center of primary care are At the center of primary care are face-to-face healing relationships.face-to-face healing relationships.

Patient: NursePatient: Nurse Nurse: PhysicianNurse: Physician

Nurse: NurseNurse: Nurse Patient: PhysicianPatient: Physician

115 physicians, owners

Health Plan: 1/3 of pt population

EHR: 2003

Staff Turnover: < 5%

Physician Satisfaction: > 95%’ile AMGA

PCP Productivity and Compensation: 85%’ile MGMA

SatisfactionSatisfaction

Patient Centered Patient Centered Medical HomeMedical Home

QualityQuality

Snapshot of PracticeSnapshot of Practice

StaffingStaffing Primary nursePrimary nurse Help nurseHelp nurse 1.5 nurse: MD1.5 nurse: MD (no MAs)(no MAs)

SpaceSpace 3 exam rooms3 exam rooms

SchedulingScheduling 1 Receptionist: 2 MDs1 Receptionist: 2 MDs Wave SchedulingWave Scheduling

Snapshot of PracticeSnapshot of Practice

Typical ScheduleTypical Schedule 6-8 Annual6-8 Annual 10-12 Planned Care10-12 Planned Care 4-6 Rapid Access4-6 Rapid Access

Panel SizePanel Size 1800-20001800-2000

Outpatient/InpatientOutpatient/Inpatient

Mrs. PetersMrs. Peters

65 year old annual exam65 year old annual exam DM2DM2 HTNHTN Depression Depression

PreventionPrevention New c/oNew c/o

HeartburnHeartburn Sleep disturbanceSleep disturbance FatigueFatigue

# of Quality measures?

There is a lot to be done!There is a lot to be done!

65 year old annual exam DM2 (9) HTN (17) Depression (10)

Prevention (27)

New c/o Heartburn (3) Sleep disturbance Fatigue

# of Quality measures? 56*McGlynn EA, N Engl J Med 2003. 348;26:2535-2645*McGlynn EA, N Engl J Med 2003. 348;26:2535-2645

There is a lot to be done!There is a lot to be done!

Too much to be done by just one person

Too important to be left to chance

Core Team Model:Core Team Model:Plan Ahead, Share the LoadPlan Ahead, Share the Load

Right thing happens by Right thing happens by defaultdefault

Staff work full level of Staff work full level of abilityability

Minimize work MD does Minimize work MD does that is within skill set of that is within skill set of othersothers

““In few other sectors of the economy is the In few other sectors of the economy is the highest-level professional responsible for the highest-level professional responsible for the majority of production, customer service, and majority of production, customer service, and clerical work.”clerical work.”

SGIM Blue Ribbon Panel Report. Redesigning the Practice SGIM Blue Ribbon Panel Report. Redesigning the Practice Model for General Internal Medicine: A Proposal for Model for General Internal Medicine: A Proposal for

Coordinated Care. Coordinated Care. J Gen Intern MedJ Gen Intern Med 2007;22:400-109 2007;22:400-109

Episodic CareEpisodic Care

Check-inCheck-in

receptionistreceptionist

Room ptRoom pt

nursenurse

MD MD

Check-Check-outout

Vital signsVital signs Medication Medication

reconciliationreconciliation HistoryHistory ExamExam Data GatheringData Gathering Data entryData entry Decision makingDecision making Relationship buildingRelationship building Prescription writingPrescription writing DocumentationDocumentation PaperworkPaperwork Behavior Behavior

ModificationModification Results reporting Results reporting Order entryOrder entry

Insurance Insurance verificationverification

Collect Collect co-payco-pay

Verify Verify contact infocontact info

¼ MA: MD¼ MA: MD

??

Work Within Skill-set of OthersWork Within Skill-set of Others

Check-inCheck-in

receptionistreceptionist

Room ptRoom pt

nursenurse

MD MD

Check-Check-outout

Vital signsVital signs Medication Medication

reconciliationreconciliation HistoryHistory/History/History ExamExam Data GatheringData Gathering Data entryData entry Decision makingDecision making Relationship buildingRelationship building Prescription writingPrescription writing DocumentationDocumentation PaperworkPaperwork Behavior Behavior

ModificationModification Results reporting Results reporting Order entryOrder entry

Insurance Insurance verificationverification

Collect Collect co-payco-pay

Verify Verify contact infocontact info

¼ MA: MD¼ MA: MD

??

Integrated, Continuous CareIntegrated, Continuous Care

Office VisitOffice Visit

Between Between Visit CareVisit Care

Efficiencies and care coordination

Nurse-MD Team

Build-inrather than Carve-out

Pre-apptlab

Core Team Model:Core Team Model: Planning Ahead & Sharing the LoadPlanning Ahead & Sharing the Load

Planned Care ApptPlanned Care Appt Order setsOrder sets Empowered TeamEmpowered Team Pt. QuestionnairePt. Questionnaire Prescription Mgm’tPrescription Mgm’t Visit SummaryVisit Summary Annual ExamAnnual Exam Rapid AccessRapid Access Intentional BehaviorsIntentional Behaviors

Planned Care AppointmentPlanned Care Appointment

Pre-appt labPre-appt lab Majority lab prior to apptMajority lab prior to appt Patient part of decision makingPatient part of decision making

67 yo diabetic67 yo diabetic A1c 6.2A1c 6.2 LDL 160LDL 160

Bill P.Bill P.


Planned Care AppointmentPlanned Care Appointment

EfficiencyEfficiency ““Just in time” info processingJust in time” info processing Close the loop during that apptClose the loop during that appt

Results reportingResults reporting 4 hr clinic 4 hr clinic →→ 2 hr post-appt 2 hr post-appt

SafetySafety Missing or overlooked informMissing or overlooked inform Pt & family part of safety netPt & family part of safety net

Planned Care ApptPlanned Care Appt Order setsOrder sets Empowered TeamEmpowered Team Pt. Questionnaire Pt. Questionnaire Prescription Mgm’tPrescription Mgm’t Visit SummaryVisit Summary Annual ExamAnnual Exam Rapid AccessRapid Access Intentional BehaviorsIntentional Behaviors

Lab SummaryLab Summary

Post-Appointment Order SetsPost-Appointment Order Sets


Acute Symptom Acute Symptom EvaluationEvaluation

Planned Care ApptPlanned Care Appt

Annual Comprehensive Annual Comprehensive Care VisitCare Visit

Place Today’s Care in Place Today’s Care in Continuum of TimeContinuum of Time

Last PELast PEUpcoming appts/labUpcoming appts/lab


73 yo est. pt Rapid w/ fever, 73 yo est. pt Rapid w/ fever, coughcough



64 yo DM 2, hypothyroidism, 64 yo DM 2, hypothyroidism, atrial fibrillation, CRIatrial fibrillation, CRI



““The next appointment The next appointment starts today”starts today”

A plan, a promise to A plan, a promise to continue the relationshipcontinue the relationship

““We want to see you again, We want to see you again, and we will plan ahead to and we will plan ahead to make that most make that most meaningful.”meaningful.”


Empowered TeamworkEmpowered Teamwork

Nursing staff full partners Nursing staff full partners Planned Care ApptPlanned Care Appt Order setsOrder sets Empowered TeamEmpowered Team Pt. Questionnaire Pt. Questionnaire Prescription Mgm’tPrescription Mgm’t Visit SummaryVisit Summary Annual ExamAnnual Exam Rapid AccessRapid Access Intentional BehaviorsIntentional Behaviors

•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

Mini-huddleMini-huddle

Staff deeply engaged Staff deeply engaged Mentor nursesMentor nurses Physician better prepared Physician better prepared Stronger handoffStronger handoff


Mini-huddleMini-huddle

47 yo “Rapid Access” new patient47 yo “Rapid Access” new patient

CC: dysphagiaCC: dysphagia Nurse Mini-huddleNurse Mini-huddle

““She seems depressed”She seems depressed” ““Is anyone hurting you?”Is anyone hurting you?”

Physician better preparedPhysician better prepared


Introduction to PartnershipIntroduction to Partnership


Pre-appointment QuestionnairePre-appointment Questionnaire

Identifies the patients agenda Identifies the patients agenda MD plan visit before enteringMD plan visit before entering Systems approachSystems approach

Update PFSHUpdate PFSH Complete ROSComplete ROS Behavior issuesBehavior issues: : exercise, smoking, alcoholexercise, smoking, alcohol

webmeeting.nih.gov/introwebmeeting.nih.gov/intro

FutureFuture Kiosk in waiting areaKiosk in waiting area Web portal from homeWeb portal from home


Prescriptions are killing us…Prescriptions are killing us…my my nurse is spending so nurse is spending so much time on refills that much time on refills that we can’t seem to get anything we can’t seem to get anything done.done.

Minnesota Family PhysicianMinnesota Family Physician20072007

Prescription ManagementPrescription Management

Survey:Survey: majority calls for scripts majority calls for scripts Systems:Systems: all scripts 1 yr at annual all scripts 1 yr at annual Efficiency:Efficiency: ↓ phone calls by 50% ↓ phone calls by 50% Synchronized, Bundled RenewalsSynchronized, Bundled Renewals


Prescription ManagementPrescription Management

We don’t use scripts as hookWe don’t use scripts as hook Planned care appts (not expired Planned care appts (not expired

script) trigger disease monitoringscript) trigger disease monitoring

Avoid loading interval visits with Avoid loading interval visits with unnecessary, redundant workunnecessary, redundant work

Before: six calls or faxes/yearBefore: six calls or faxes/year After: zero After: zero MaggieMaggie


Annual Comprehensive Care Annual Comprehensive Care VisitVisit

Cornerstone of careCornerstone of care Dedicated apptDedicated appt

prevention/ annual review of prevention/ annual review of chronic dzchronic dz

CustomizedCustomized not one-size-fits-allnot one-size-fits-all



Prevention built-in Prevention built-in Not dependent on random Not dependent on random

acute visitsacute visits Not overload interval visitsNot overload interval visits


I spend several minutes with each I spend several minutes with each appointment rifling through the appointment rifling through the chart looking for the last chart looking for the last mammogram and colonoscopy. mammogram and colonoscopy. And then I spend less time on the And then I spend less time on the patient’s main concern. patient’s main concern.

Family physician, WI 5.06Family physician, WI 5.06


CC:CC: DM 2, HTN, ↑chol, new depr. DM 2, HTN, ↑chol, new depr. PreventionPrevention

Mammo aheadMammo ahead Ca, BMI, immunization (nurse)Ca, BMI, immunization (nurse)

Chronic CareChronic Care Diabetes, HTN lab done ahead Diabetes, HTN lab done ahead Foot and eye exam (nurse)Foot and eye exam (nurse)

AcuteAcute Energy to address depressionEnergy to address depression


Rapid AccessRapid Access

Scheduling for same day accessScheduling for same day access Today not TriageToday not Triage Triage takes timeTriage takes time

30 sec “yes”, 5 min “no” “later”30 sec “yes”, 5 min “no” “later” One staff touch vs 5One staff touch vs 5

Pt’s don’t have to plead casePt’s don’t have to plead case


Nurse-MD Team

HTN HTN CholChol GlucoseGlucoseOsteoporosisOsteoporosisDepressionDepression

LLAABB

OORRDDEERRSS

Planned CarePlanned Care

Same Day Same Day Surgery ApptSurgery Appt

Integrated, Continuous CareIntegrated, Continuous Care

LDL 75, LDL 75,

A1c 6.2A1c 6.2

LabLabMammoMammo

SeptSept

PreventionPrevention

HTN HTN CholChol GlucoseGlucoseOsteoporosisOsteoporosisDepressionDepressionLipids,FBSLipids,FBSCr, K, MamCr, K, Mam

LLAABB

OORRDDEERRSS

ComprehensiveComprehensive

MarMar


MammoMammo

SSCCRRIIPPTTSS

Nurse-MD Team

LLAABB

OORRDDEERRSS

JunJun

HTN HTN DM 2 DM 2 DepressionDepressionLL

AABB

OORRDDEERRSS


FBS, A1cFBS, A1c

LipidsLipids

Integrated, Continuous careIntegrated, Continuous care

HTN HTN DM 2 DM 2 DepressionDepression


MarMar

Rapid Rapid AccessAccess

LBPLBP

AprApr

Rapid Rapid Access Access

PneumoniaPneumonia

AugAug

A1c 6.8A1c 6.8

LDL 145LDL 145


HTN HTN DM 2 DM 2 DepressionDepression


SeptSept

FBS, A1cFBS, A1c

LLAABB

OORRDDEERRSSCXRCXR

CHF CHF Education/Education/

Clinic Clinic

Diabetic Diabetic Education Education

Home Care Home Care

Family Family

INRINR

INRINR

INRINR

INRINR INRINR

INRINR

INRINR

INRINR

INRINR

INRINR

INRINR

INRINR

Hospital Hospital CHFCHF

NovNov

PreventionPrevention

HTN HTN DM 2 DM 2 DepressionDepressionLL

AABB

OORRDDEERRSS

ComprehensiveComprehensive

FBS, A1c, FBS, A1c, lipids, alb,lipids, alb,

mammomammo

DecDec

SSCCRRIIPPTTSS

Architecture Architecture Of Of

Care Care

Intentional BehaviorsIntentional Behaviors

Eye contact/physical touchEye contact/physical touch Key phrasesKey phrases

What else do I need to know?What else do I need to know? Did we cover everything you Did we cover everything you

wanted?wanted? How are you handling this?How are you handling this?

Planned Care ApptPlanned Care Appt Order setsOrder sets Empowered NursingEmpowered Nursing Pt. QuestionnairePt. Questionnaire Prescription Mgm’tPrescription Mgm’t Visit SummaryVisit Summary Annual ExamAnnual Exam Rapid AccessRapid Access Intentional BehaviorsIntentional Behaviors

Intentional BehaviorsIntentional Behaviors

More Key phrasesMore Key phrases What do you do for fun?What do you do for fun? Could you bring me a picture Could you bring me a picture

of ….at your next appointmentof ….at your next appointment Social notes at end of Social notes at end of

dictationdictation

Planned Care ApptPlanned Care Appt Order setsOrder sets Empowered NursingEmpowered Nursing Pt. QuestionnairePt. Questionnaire Prescription Mgm’tPrescription Mgm’t Visit SummaryVisit Summary Annual ExamAnnual Exam Rapid AccessRapid Access Intentional BehaviorsIntentional Behaviors

Sister Mary Owen, what Sister Mary Owen, what have you been up to lately?have you been up to lately?

Sister Mary Owen, what Sister Mary Owen, what have you been up to lately?have you been up to lately?

Sr. Mary Owen, what have you Sr. Mary Owen, what have you been up to lately?been up to lately?

At the center of primary care are At the center of primary care are face-to-face healing relationships.face-to-face healing relationships.

Patient: NursePatient: Nurse Nurse: PhysicianNurse: Physician

Nurse: NurseNurse: Nurse Patient: PhysicianPatient: Physician

We will know who you are and We will know who you are and we will be ready for you.we will be ready for you.

Borgess Ambulatory Care, Kalamazoo, MIBorgess Ambulatory Care, Kalamazoo, MI

DiscussionDiscussion

Beyond the Blueprint Building the Patient Centered Medical Home Wisconsin Primary Care Research & Quality Improvement Forum Wisconsin Dells, WI 11.13.09.

Documents

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