Lecture lessons learned - pcmh presentation (2)

PCMH Train-the-Trainer
Lessons Learned
Greenville Health System
Greenville, South Carolina
April 2, 2014

Center For Pediatric Medicine’s Quest for
PCMH Recognition
Katy Smathers, Practice Manager V
Tammy Gladson, Clinical Manager

Who is the Center for Pediatric Medicine?
 Pediatric primary care – a.k.a. “The Peds Clinic”
 Physician providers (7), Mid-level providers (4), Residents (48) &
Faculty/Attending Physicians (25)
 3 locations
 Center for Pediatric Medicine – 20 Medical Ridge Drive
 Pediatric Rapid Access – 57 Cross Park Court
 North Greenville Outpatient Center – 807 N. Main St, Travelers Rest
 QTIP Practice (Quality through Technology and Innovation in
Pediatrics) – CHIPRA Demonstration Grant (SCDHHS & SC AAP
partnership) focus – implementing quality measures in the primary care
pediatric office
THE CAMDEN GROUP | 2/26/2014 2

 Approximately 19,000 active patients
 Approximately 40% Hispanic
 96% patients Medicaid eligible
 Annual Visits – 52,000ish
(combined 3 locations)
Patient Population

Ancillary Resources Available at CPM
 Respiratory Therapy/Asthma Educator
 Social Work
 RN Case Management (Care Coordination)
 Lactation support
 Medicaid eligibility worker on site
 Interpreters

Primary care
– well
visits/acute
care
ADHD
subspecialty
clinic
Adolescent
subspecialty
clinic
Centering
Parenting
Psychiatric
care clinic
Asthma
subspecialty
clinic
Scope of Services
High
Risk/NICU
clinic
Foster Care
Newborn
clinic
clinic

Recognition Achieved – Partially….
 Purchased a multi-site PCMH application April 2013
 Corporate tool submitted April 2013
 Center for Pediatric Medicine site-specific tool submitted August
2013
 CPM Level 3 Recognition
awarded November 2013!
 Rapid Access & North Greenville site-specific tools to be
submitted this month

Why Become a Recognized Patient Centered Medical
Home?
 Piqued our interest in 2007 – attended NCQA training (2008
PCMH Standards)
 These were things we were already doing, but needed to
engrain into the clinic culture. PCMH standards aligned with
CPM’s patient centered mission.
 Elements/Factors aligned with several other ongoing projects
 Carrots & Sticks
 Carrot – potential for enhanced reimbursement
 Stick – Dr. Schmidt (if anything less than level 3 was achieved)

Why PCMH?
 Focuses on making QUALITY the forefront of everyday
operations
 Preparation for changing reimbursement methodologies
 Importance of exposing residents to the Medical Home model
of care

Systematic approach to coordinated care

Encourage the concept of a “Care Team”

Become a true “Medical Home”

Preparation
 Project team formation
 Doreen Patterson, MD, Provider/Faculty
 Katy Smathers, Practice Manager
 Tammy Gladson, Clinical Manager
 Kristi Caballero, Office Supervisor
 Sabrena O’Connor, Physician Practice Specialist
 Cindy Garnett, EHR Technical Specialist
 Cheri Yeargin, Office Coordinator
 Established weekly meeting time
 Began our assessment – What were we doing? What
documentation existed?

How Do You Eat an Elephant?
 We had to change our approach – looking at all the
standards at one time became confusing and overwhelming!
 Made the decision to work on each standard until completed
before moving to the next
 After participation in NCQA multi-site call, decided to focus
on Corporate elements
 Developed Sharepoint site & completion status grid to track
each factors completion status
 Each meeting began with updating completion grid/ended
with assignment of new tasks

PCMH STANDARD 1 - CHALLENGES
Element C – Electronic Access
Patient portal is not available for majority of our population,
required website tweaks including building contact forms
for secure electronic requests of prescription refills,
referrals, test results, appointments & clinical advice.
Development of a process for distribution/handling these
requests was also necessary.
Element G – Practice Team
Determining how team members fulfilled the specific
functions of a patient centered medical home (i.e. who
does what?)

14

Element A – Implement Evidence Based Guidelines
Wasted time and frustration would have been avoided had we
looked ahead to the other elements in Standard 3 – and how the
important conditions were to be used later.
Element B – Identify High-Risk Patient
How do you define “high risk patients” when all of your patients are
high risk?
Process of identification not previously documented; required
involvement of other practice staff.
Element C & D – Care Management/Medication Management
Documentation of care plans for patients with ADHD required hand
mining and a definition of what meet criteria for a “care plan”.
Structured data fields would have been helpful.

Element A – Support Self-Care Process
Defining what documentation met the intent of the factor (Record
Review Workbook). Having a physician involved during this step
was crucial! Templates would have been helpful.
Record review workbook instructions were confusing – pay close
attention to the inclusion of high risk patients in record review (lost
points for CPM).
We had difficulty enlisting physicians to assist with record review.
Element B – Provide Referrals to Community Resources
This is something we all do regularly – but is it documented?
Referral tracking process developed & implemented to meet
documentation requirements– included social work, case
management.

Community Resource Referral Log

Element A – Test Tracking and Follow Up
Cleaning up the multitudes of duplicate outstanding labs in eCW
Element B – Referral Tracking and Follow Up
Defining our process highlighted organizational issues with referrals
(i.e. sending/receiving appointment dates/times and consult notes,
definition of “outgoing” and “incoming” referrals, once addressed –
difficult to track)
Element C – Coordinate with Facilities and Manage Care Transitions
We could not have done this without DMCN!
Did not get credit for this element – reviewer felt our documentation
did not demonstrate the intent of the element, only “spoke to the
intent” because the lack of a “step-by-step process”.

Element A – Measure Performance
Determining what data was available through eCW – What
were we measuring that met the requirements?
Element B – Measure Patient/Family Experience
Patient satisfaction survey did not identify the provider –
required change in the process.

Element C/D – Implement Continuous Quality Improvement
PDSA cycles a must!
Reviewer did not feel that adolescent depression screening
addressed services for a vulnerable population.
Measurement over time and the creation of run charts to
demonstrate achieved performance.
Element E – Report Performance
Developed a QI bulletin board “Hall of Fame” to share results
throughout the practice
Posted QI results in waiting room to share with patients
Challenges sharing results by clinician due to multiple
providers

Outcomes
 PCMH recognition and the process changed the way we care
for patients
 Increased awareness of the QI process & how the results of our
efforts benefit our patients – continuous quality improvement!
 Helped to define and organize care processes
 Increased structure of patient centered care
 Proactive care vs. reactive care
 Strengthened team approach & reduced silos

Tips/Lessons Learned
 Templates, templates and more templates! Build in prompts to
ease workflow change implementation.
 Include entire staff from the beginning to improve buy-in –
“What is PCMH?”
 Title all of your documents appropriately. Any data must
include a date range.
 Store and organize your documents in one place (i.e.
Sharepoint).

Tips/Lessons Learned
 Use techniques such as GE Healthcare CAP/Workout to
facilitate change management
 Establish a multidisciplinary QI team
 Advantage – breadth of knowledge
 Disadvantage – many opinions/interpretations
 Measure continuously
 Submit as many points as you can – just in case
 Use text boxes and highlights to point the reviewer to the
specific areas of a document that meets the intent of the
factor – they will not dig

Q&A

Lecture lessons learned - pcmh presentation (2)

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