Care by design overview 11 2011


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OVERVIEW -- Care by Design - Putting Care back into healthcare the University of Utah experience in building PCMH level care over the decade of 2001 to . 2011

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Care by design overview 11 2011

  1. 1. Key Principles • Planning • Education and Communication • Measurement • Do Today’s Work Today • Continuity of Care • Understand Demand and Capacity • Work Down Bad Backlog • Standardize and Reduce Appointment Types • Establish Contingency Plans • Engage Providers • Daily Huddles • Process Redesign
  2. 2. • Tactics – Identify sponsors – Identify stakeholders – Create a planning team – Involve physicians and staff – Develop an Aim Statement (overall goals) – Identify priorities based on current performance – Define scope, tasks, and timelines – Identify resources needed Planning
  3. 3. Education & Communication • Tactics – Share best practice standards and data – Develop a communication strategy – Obtain buy-in from physicians and staff – Share resource availability
  4. 4. Measurement • Tactics – Determine data needs and select appropriate tools – Identify and validate data sources – Identify data analysis resources – Share measurement results with stakeholders, providers, and staff
  5. 5. Do Today’s Work Today • Tactics – Define what this means by specialty – Create disease criteria • Pre-assessment guidelines • Care bundles • templates
  6. 6. Continuity of Care • Tactics – Set up care teams (Microsystems) – Identify use of mid-level and non-provider staff – Communicate with referring physicians – Identify patient’s responsibility to communicate – Physicians communicate with patient (after-visit summaries) – Patient education (pre and post visit) – Define expectations for patients
  7. 7. Demand and Capacity • Tactics – Measure demand and capacity by provider – Identify capacity constraints – Determine how to meet the demand and adjust capacity – Match demand with capacity
  8. 8. Reduce Bad Backlog • Tactics – Define good and bad backlog – Measure by provider – Share data with providers – Identify steps to reduce bad backlog – Phased implementation with physician stories of success
  9. 9. Reduce Appointment Types • Tactics – Evaluate existing visit types – Standardize appointment types and duration by specialty – Set up appointment type rules – Determine number of closed appointment slots (good backlog) – Build scheduling template – Adjust scheduling process and staff
  10. 10. • Tactics – Measure demand and identify peak demand times – Establish rules to adjust capacity Contingency Plans
  11. 11. Engage Providers • Tactics – Identify physician champions – Involve physicians to educate physicians – Share patient experiences – Share referring physician experiences
  12. 12. Daily Huddles • Tactics – Identify care team members – Select time and process for care team to meet – Share purpose, plan, and objective
  13. 13. Process Redesign • Tactics – Engage providers through physician leadership – Create a blameless culture that fosters teamwork and cooperation – Analyze processes – map current and future states – Understand what process capabilities exist – Train on new process design
  14. 14. “A Different System is Needed… … one that is reliable, proactive, efficient and engages patients in ways that ensure the best outcomes” Institute for Healthcare Improvement, 2006
  15. 15. Care Team Objectives • Micro team approach to care • Staff roles and responsibilities realigned • MA’s work in an expanded role • Patient centered, personalized, efficient visit • Cycle time reduced • Provider focus on patient • Patients develop relationship with care team • Increase in visits and WRVU’s • Patient, staff and provider satisfaction improved • Increase in market share and referrals
  16. 16. Care Team Configuration • Providers and MA’s work in teams • A small number of providers are supported by a pool of medicals assistants - typical ratio is 2-2.5 MA’s per physician • Two to three physicians work interchangeably with 5-7 MA’s • Impact of increasing MA staffing offset by decreases in other support staff
  17. 17. Expanded Role of MA • MA’s work in rotation – greeting, rooming and supporting the visit regardless of provider • MA’s responsible for the “full cycle” of visit • MA acts as facilitator • MA documents the visit in the EMR – acts as scribe during the exam • Patients develop a personal relationship • Allows physicians to focus on services they uniquely provide – (cost of MA vs. Physician)
  18. 18. MA’s work in Rotation • Greeting, rooming and supporting the visit for the next arriving patient (regardless of the provider they are seeing) • Responsible for other support processes – messages, running lab tests, paperwork, stocking rooms etc. • Rotation maximizes MA resources, reduces disruption and delays in patient flow
  19. 19. Standardization • Standardized documentation templates • Condition-specific questionnaires • Order sets based on protocol • Exam rooms organized and stocked in a standard manner – same place in each room • Printers are standard equipment in each room
  20. 20. Real-time Communication • Communication enhanced between team members • Use of technology – vocera, hand-held radios, white boards, electronic screens etc. • Improves provider efficiency • Improves flow • Supports smooth transition from one patient to another • Messaging through EMR – MA works the pool
  21. 21. Planning for Daily Work • Share information about changes in schedule or staffing • Identify opportunities to work in walk-ins or unscheduled patients with urgent needs • Huddles – brief, stand-up care team meetings at the start of the day and after lunch • Identify patients that need additional work-up prior to seeing the provider
  22. 22. Patient Accompanied at all Times • MA’s act as the facilitator of the patient’s visit • Same MA with the patient the entire visit • MA present during assessment, diagnosis and treatment • MA knows patient background and care plan • MA answers appropriate questions and refer others to the provider
  23. 23. Waiting Times • Patient does not wait – services brought to patient – do not move the patient • MA facilitation reduces patient waiting times • MA anticipates and responds to service needs of patient • Labs drawn in exam room by MA’s • Referral appointment made in exam room • Instructions and after-visit summaries given and reviewed with patient in exam room
  24. 24. Call Management • Centralized call center • Minimal telephone disruption – QUIET CLINIC • Call center does scheduling and registration – streamlines check-in • Call center routes messages through EMR • Standards for response times set and monitored • Triage and escalation protocols used to address urgent and emergent situations
  25. 25. Support Resources • Electronic Medical Record – Access to complete medical record – Offers point of care reminders – Allergy and interaction alerts – Ability to export data • Nursing resource pool
  26. 26. Planned Care “Currently Americans receive only about 55% of the recommended medical care they need, regardless of their race, gender, income, or where they live.”
  27. 27. “Studies show it would require 31.6 hours a day for a provider to manage the care needed for an average panel of 2,500 patients.” Not Enough Time in the Day
  28. 28. Planned Care…The Solution Provide all the recommended care and services at the right time Supports patients in maintaining or improving their health status Creates positive outcomes in quality, satisfaction and financial performance Competitive advantages
  29. 29. Apply evidence-based guidelines to the individual needs of individual patients Facilitate population management, coordination/ conformity of care, chronic disease management, and self-management Relationships with Patients
  30. 30. Expected Outcomes of Planned Care The patient receives all recommended care according to guidelines Achieve care plan goals Increase in quality measures performance Personalized, patient-centered care Increase in patient satisfaction Increased revenue Increased referrals and market share
  31. 31. Elements of Planned Care Population management Coordination of care Pre-visit planning Care management Self-management support
  32. 32. Population Management Assessment of patients to identify groups Determine specific services and notification to patients of services needed Services include preventive care/health maintenance; follow-up visits; patient safety alerts; medication recalls Outreach and reminders to patients
  33. 33. Coordination of Care Management of the transition of care between facilities and external care sources Providing clinical information at the time of admission Contacting patients after discharge Coordinating follow-up care & appointments
  34. 34. Pre-visit Planning Pro-active management of scheduled appointments Ensure effective use of time & activities associated with the patient’s visit Medication management Arrangement of lab & preventive care orders
  35. 35. Care Management Use of expanded team to develop individualized care plan Individualized care plan to meet patient’s specific needs, treatments, and goals Collaborative practice agreements Referral coordination
  36. 36. Self Management Support Use of resources and tools to help patients and families manage their conditions outside the office visit Use of technology resources such as MyChart Group education classes and workshops
  37. 37. Expanded Team Members Case managers Pharmacists Social workers Self management facilitators Other support members ad