Epic UGM 2014 presentation
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This presentation can be seen and heard on EPIC.com. I presented with a colleague in September of 2015. The presentation discusses the many changes we implemented while applying for our PCMH certification and our outcomes. There is also a section that I introduced the steps to building a basic dashboard report in EPIC.
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Epic UGM 2014 presentation
- 2. Barb Kirk, RN Nurse Care Manager With CHNw 28 years With FMC Residency 8 years Experience Larissa Davids, RN Clinical Nurse Manager With CHNw 2 years With FMC Residency 2 years Experience
- 5. • Started 1974 • 38 Resident Classes Graduated • Expanding Resident Class Size • Current Class Size 8-10-10 • Future Class Goal 12-12-12
- 7. • 226,000 Patient clinic visits annually • Approximately 7600 patients • 60% Medicaid • 20% Medicare • 20% Private Insurance or uninsured
- 9. OB Pediatrics Home Visit On-site Nursing Home Visits Ambulatory Clinic Inpatient Rotation (ICU, Pediatrics, Service Team) Emergency Care (ED) Specialty Rotations Preparing to take Family Practice Boards
- 13. Requirement of FMC Residency Curriculum Standardization Committee Patient Advisory Group
- 16. Winter Leah R, MA Fac Fisher Fac Callahan R3 Shaver R2 Gelatt R1 Jaeger Katie, RN Snow Kaylee, MA Fac Shockley R3 Holland R2 Grindstaff R2 Tran R1 Pohlman Katie, RN Autumn Emmy, MA Fac Arrizabalaga Fac DaRosa R3 Baig R2 Jones R1 Pittman Cindy, RN/Karen, RN Wind Kaylee, MA Fac Mathew Fac Wheeler R3 Abratigue R2 Land R1 Bachman R1 King Cindy, RN/Karen, RN Summer Amber, LPN Fac Cashman R3 Polly R2 Fogelsong R2 Malicay R1 Morris Nancy, RN Sun Kellie, MA Fac Clark R3 Walcott 347 R2 Burns 277 R1 Sanderson 109 807 Nancy, RN Spring Leah C Fac Lisby R3 Auman R2 Nimmagadda R1 Brackett Barb, RN Rain Sonia Fac Hern Fac Eglen R3 Hunt R2 Mohammadi R1 Schmoll Barb, RN Weekly RN/LPN/MA/Tech Monday Mammograms Wednesday Immunizations/ WCC FMC Teams Effective 3/1/2014 RN=Care Coordinator Education *Smoking Cessation *Diabetes *Asthma *Hypertension *Obesity *Medication Adherence *Group Sessions *Diabetes IVR *Patient Appointments Health Maintenance *ED/Inpatient Follow-up *Wellness Visits *Follow-up *Reports *Workques *Telephone Triage *Telephone Encounters *Prior Authorizations High Risk Population *Routine and Frequent Follow-Up and Education *Proactive Communication *Frequent NCM Appointments *Address Social/ Economical/Behavioral Barriers Tuesday Pap Smear/ GCHL Thursday HTN, DM, Hyperlipidemia Friday Pneumovax/ Zostavax/ Tdap
- 17. Weekly RN/LPN/MA Monday Mammograms Tuesday Pap Smear/ GCHL Wednesday Immunizations /WCC Thursday HTN, DM, HLD Friday Pneumovax/ Zostavax/ Tdap RN=Care Coordinator Education *Smoking Cessation *Diabetes *Asthma *Hypertension *Obesity *Medication Adherence *Group Sessions *Diabetes IVR *Patient Appointments Health Maintenance *ED/Inpatient Follow-up *Wellness Visits *Follow-up *Reports *Workques *Telephone Triage *Telephone Encounters *Prior Authorizations High Risk Population *Routine and Frequent Follow-Up and Education *Proactive Communication *Frequent NCM Appointments *Address Social/ Economical/Behavioral Barriers Daily MA/LPN Medication Refills Telephone Encounters/ Mychart Abstracting Dianne PA’s Provider Forms Paperwork Pre-visit Planning Phase II 6/1/14 Phase III 9/1/14 Daily RN ED/Inpatient Follow-up Lab/Imaging Workque- Mammograms/DXA Scan focus Chronic Care/High Risk Patient Reports and Management Lab/Imaging Workque (MA/LPN) Phase IV 11/1/14 ALL RN’s prepared for Care Coordinator (Manager) Role Phase V 1/1/15 *RN’s Team Pools/ED, Inpatient follow-up --introducing
- 18. • Maintain PCP Panels • Pre-Visit • ED and Inpatient • Chronic Disease • Population Health • Follow-up • Pilot Projects • Audits • Reminders • Referrals
- 20. How? When?
- 25. PCP Panels Pre-visit MA Clinic ED/Inpatient Chronic Disease Monthly Audits Transition of Care Preventative Health Maintenance Group Visits IVR TOC
- 27. Report identifies patients with Diabetes and Hypertension with scheduled appointments. Report is run weekly. EMR is reviewed for missing or due health maintenance. Protocoled orders are placed and patient is notified. Goal: Patient completes orders prior to upcoming appointment.
- 28. Diabetes: HgbA1c 6 months HgbA1c > 7 3 months Lipid Panel-fasting 12 months Micro albumin/Creatinine Urine Ratio 12 months CMP-fasting 12 months Diabetic Eye Exam 12 months Diabetic Foot Exam 12 months Hypertension: BMP-fasting 12 months Hyperlipidemia: Lipid Panel-fasting 12 months CMP-fasting 12 months Hypothyroidism: TSH 12 months
- 29. Establish criteria identifying High Risk Patients Run Report daily Assess care plan and interventions Review EMR Discuss plan with patient and identify barriers Contact patient by phone, MyChart or letter Update or develop care plan
- 30. Health Maintenance Reports Identifies patients with upcoming appointments with health maintenance needs MA/LPN runs report every 3 days Comment is placed on the ‘Appointment Notes’ designating a need Clinical staff rooming the patient has information easily available
- 32. 0 5 10 15 20 25 30 35 %ofPatients Date February 1, 2013 28% of Diabetic patients had not had a HgbA1c in 6 months.
- 33. 0 10 20 30 40 50 60 70 80 90 January 2013 2% of our patients with Diabetes had a filament test
- 34. 0 5 10 15 20 25 30 35 July 2013 32.6% of our pediatric patients 0-13 had overdue state mandated immunizations
- 35. Patients overdue for Well Visit
- 37. Social Work Pharmacist Nurse Care Manager Provider • Round on inpatients • Facilitates transition home • Coordinates Provider, Nurse Care Manager, Pharmacist • Follow-up • Weekly TOC ClinicGoals
- 39. Patients • “I feel like a queen when I come here, everyone really cares.” • “I like having my labs done before my appointment. It saves a step, I have more time with my Doctor.” • “Never had a foot exam done before.” • Voiced appreciation that clinical staff was providing the foot exams • Parents voiced appreciation for less trips to the office for immunization catch-up.
- 40. MAs’ feedback • More efficient utilization of time • “Do not have to research patient’s chart to provide care.” • “I like knowing what the patient needs before I get them.”
- 41. Providers’ feedback • Foot exams consistently performed before provider sees the patient. • Not doing minimal tasks; filling out paperwork for Health Department • Detecting and treating Asthma patients outside of the green zone before an exacerbation occurs. • “My colleagues didn’t believe my Nurses could order the labs ahead of time. It saves me so much time.”
Editor's Notes
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