Here are some questions teams have about core and extended teams, pre-visit planning/huddles, self-management goal setting workflows, and the coaching role: Core and Extended Teams: - How are you identifying your patient care teams (PODS) so staff and patients know their team? - What specific roles have you seen change on teams and how? - How are you training staff on team-based care? - How do you maintain team integrity with turnover/MAs covering multiple teams? - Are managers/leaders part of your core and extended team model? Pre-Visit Planning and Huddles: - How do you manage prep time for huddles? Are

1. We will begin shortly…
Welcome
1

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3. Advanced Team Based Care (TBC)
Learning Collaborative
Welcome to Session 6
April 26, 2017
3:00 - 4:30 EST
Developing core and extended team capabilities for implementing an advanced team based care model.

4. Introductions
TBC Collaborative Design, Facilitation, Faculty
 Ann Marie R Hess ANP, MS
National Cooperative Agreement
 Anna Rogers, Director
 Reema Mistry, Program Coordinator
Mentors , Coaching Faculty
 Deborah Ward, RN
 Kasey Harding
Evaluation Faculty
 Kathleen Thies, PhD, RN
Improvement Science Faculty
 Patti Feeney
 Mark Splaine, MD

6. Objectives Session 5
 Summarize Action Period 5 Milestones (6 weeks)
 Provide a team example of a playbook that documents improvement work
 Learn from questions you have for other teams
 Discuss how to develop a post collaborative improvement plan
 Provide a path forward | assignments for Action Period 6

7. Agenda
3:00 5 min Welcome and Introductions
Improvement Road Map
3:05 15 min Action Period 5 Milestones and Challenges
3:20 15 min Playbooks | Standards (10 min, 3 min questions)
Educational Health Center of Wyoming | Prescription Refills
3:35 15 min How are we doing? Core and Extended Team Structure and Roles
3:50 15 min Discussion Questions : What do you want to learn from other teams?
4:05 10 min Post Collaborative Improvement Plans Using Progress Check List
4:15 10 min Action Period 6 Assignments

8. Action Period 5 Assignments
1. Improve ‘effectiveness’ of your weekly meetings
2. Improve ‘quality’ of daily huddles , measure impact
3. Achieve Specific Aims by implementing multiple PDSAs
4. Collect and Track Data (daily|weekly, small tests of change)
5. Implement SDSAs (standards) – draft playbook(s)
6. Spread a standard to another POD, track how it is working
7. Complete progress check list (9)
8. Post all work on TBC website (moodle)
9. Improve leadership communication and engagement

9. Improvement Ramp for Implementing TBC (PCMH)
1
Action
Period 6
4-5
2-3

10.  Define Core and
Extended Team
(structure, roles)
 Achieve multiple TBC
specific aims, data
driven (PDSAs)
 Standardize (SDSAs)
roles and key processes
(Playbook, Spread Plan)
 Improve team and coach
skills (improvement
science, team work,
coaching)
 Move Practice
Assessment Data toward
Level A
 Develop a post
collaborative team
action plan
TBC Learning Collaborative
90 min
Learning
Sessions
Between Session Action Periods (6 weeks)
Complete Assignments
Weekly Team Meetings , Daily Huddles
Monthly Reporting
Share Your Work – TBC Website (Moodle)
Developing Effective Meeting and Improvement Skills
Implementing Team Based Care – Small Tests of Change
Learning from Each Other
Action Period 5
Core (POD) and
Extended Team
Roles, Spread
Achieving Aims,
Using Data
Playbook
Documentation
Weekly Team
Meetings and Daily
Huddles (92%)
Progress Check List
(9)
New Aims Between Session
Coach Mentoring (weekly – attend 2-4/mo)
Faculty Support
Moodle Resources and Discussion Board
7
Sept 21 Dec 14 Jan 25 Mar 15 Apr 26 June 14Nov 2

11. Improvement Science Theory Bursts (10 min)
Session 1 : Sept 21st
o Running effective team meetings using tools
o Developing and using a cause and effect diagram to inform PDSAs
o Writing a global and specific aim statement
Session 2 : Nov 2nd
o Developing a process map or current state workflow
o Applying PDSA methodology for improvement
Session 3 : Dec 14th
o Using data for improvement (run charts, bar graphs, sampling)
Session 4 : Jan 25th
o Standardizing (SDSAs) and Process Reliability
Session 5 : March 15th
o Spreading Change
Session 6 : April 26th
o Improve Plan Post Collaborative : 3-6 month Core Team (progress check list)
Session 7 : June 14th
o Resources for Refreshing and Learning Improvement Skills

12. 9 Completed Progress Check List

13. Progress Check List

14. 24 Specific Aims and Measures, Small Tests of Change (PDSAs)
 Behavioral Health
 Behavioral Health Integration Huddles
 Care Coordination |Management
 Lab Result Tracking and Follow Up
 Referral Process
 Prevention screening and closing gaps, MA protocols
 Population Management
 Complex care management
• Clinical Documentation
 Eliminate Paper and Duplication Role Activity |Documentation
 Rooming Standards – health maintenance, accurate BP
 Planned Care
 Pre Visit Planning
 Daily Huddles
 Pre Registration Phone Call
 Medication Management
 Prescription Refills Process
 Access and Communication
 Appointment Scheduling Guidelines
 Patient Portal Activation

15. FQHA Possible Playbooks
Educational Health
Center of Wyoming
Prescription Refills
Healthcare for the
Homeless
Core and Extended Team
El Rio Well Child Checks
Peach Tree MA Rooming |Documentation
Via Care MA Led Huddles
Holyoke Health
Center
Behavioral Health Huddle
Integration
The Children's Clinic Colon Cancer Screening
How are teams getting your
improvement work
documented….
not only to stay on track,
but to :
share with others,
train teams,
spread,
optimize EHR workflows ?
Documentation :PDSAs, SDSAs, Data Over Time, Processes and Protocols, Playbooks

16. Sustaining and Holding the Gains: Team Meetings
 We have a team leader who keeps us engaged and motivated,
this is not our meeting leader.
 Our coach has transitioned effective meeting and improvement
skills to our team. We meet without our coach when not
available.
 We invite leaders and managers to our meetings as needed
based on our work and challenges.
 Our team members ‘onboard’ new staff to our TBC model
(turnover, staffing issues)
 Meeting as a team improves care for our patients and families.

18. 30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Nov 09 Dec 09 Jan 10 Feb 10 March 10 April 10 May 10 June 10 July 10 Aug 10 Sept 10 Oct 10
% Pts w/ Up-to-Date A1C Testing
UW Health Trained Microsystem Team Pilot Teams
Registry management and
standardized lab ordering per
protocol
UW.hess.2011Ihi.org
Higher Performing PODS : Building Organization Capacity
Top Down Projects
Business as usual
High Performing POD

19. Transformational Team Based Care Improves Outcomes

20. Agenda
3:00 5 min Welcome and Introductions
Improvement Road Map
3:05 15 min Action Period 5 Milestones and Challenges
3:20 15 min Playbooks | Standards (10 min, 3 min questions)
Educational Health Center of Wyoming | Prescription Refills
3:35 15 min How are we doing? Core and Extended Team Structure and Roles
3:50 15 min Discussion Questions : What do you want to learn from other teams?
4:05 10 min Post Collaborative Improvement Plans Using Progress Check List
4:15 10 min Action Period 6 Assignments

25. Tasks by Workflows

26. Healthcare for Homeless

27. Standardizing
Team
Meetings
and Huddles

28. UW FM Playbook

29. What is the problem we attempting to remedy?
• Based on comments received from our patient satisfaction
survey
• There were a significant number of patient complaints
regarding our telephone system
o Patients expressed concern over
o Phone calls not answered promptly by the nursing
staff/provider
o Patients often left multiple messages
• Q: For the team – is it possible that the telephone problems
may not be system itself, but rather our internal processes?
Family Medicine Residency Program at Cheyenne 820 East 17th Street Cheyenne WY

30. Purpose for Patient Phone Calls to Our Practice?
• Data collection occurred over a two week period
to identify the reason(s) for incoming phone calls
(i.e. scheduling, RX refill) and the frequency of
the calls.
• All staff who receive in-coming calls participated
in the phone call tracking process.
• Phone call tracking occurred from 02/06/17-
02/24/17
Family Medicine Residency Program at Cheyenne 820 East 17th Street Cheyenne WY

31. Family Medicine Residency Program at Cheyenne 820 East 17th Street Cheyenne WY
#
calls

32. What did the data tell us?
• Our clinic experiences a highly daily call
volume
• We spend a great deal of day answering
and responding to the phone.
• RX and scheduling accounted for about
8% of our total phone calls.
Family Medicine Residency Program at Cheyenne 820 East 17th Street Cheyenne WY

33. PDSA #1
Specific AIM: To decrease the number of phone
calls related to prescription refills.
• Our goal is to identify individual providers who
are prescribing patients sufficient medication
and refills until their next follow up visit.
Family Medicine Residency Program at Cheyenne 820 East 17th Street Cheyenne WY

34. Family Medicine Residency Program at
Cheyenne 820 East 17th Street Cheyenne
WY

35. UW FM Playbook
Family Medicine Residency Program at Cheyenne 820 East 17th Street Cheyenne WY

36. Family Medicine Residency Program at Cheyenne 820 East 17th Street Cheyenne WY

37. Family Medicine Residency Program at Cheyenne 820 East 17th Street Cheyenne WY

38. Family Medicine Residency Program at Cheyenne 820 East 17th Street Cheyenne WY

39. Family Medicine Residency Program at Cheyenne 820 East 17th Street Cheyenne WY

40. Lisinopril Prescribing Pattern – Sept 1, 2016 – 3-31-2017
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
Number of Day Supply
Percent of Day Supply Prescribed

41. Next Steps
• Continue to monitor all providers to ensure that a
majority of patients prescribed Lisinopril receive a 6
month – 1 year refill
– Provided the patient’s labs are within range and their
current health status allows this
• As necessary offer ongoing education to providers
regarding the benefits of long term vs. short term
Lisinopril scripts
Family Medicine Residency Program at
Cheyenne 820 East 17th Street Cheyenne
WY

42. What is the problem we attempting to remedy?
• Evaluate that purpose(s) for patient phone calls to our practice
• Process
– UW FM conducted a patient satisfaction survey
• Observations
– There were a significant number of patient complaints regarding our
telephone system
o Patients expressed concern over phone calls not answered promptly by the
nursing staff/provider
o Patients often left multiple messages without a response
The UW FM process improvement team discussed the possibility that
telephone problems may not be the system itself or the patients, but rather
our internal processes?
Family Medicine Residency Program at Cheyenne 820 East 17th Street Cheyenne WY

43. Family Medicine Residency Program at Cheyenne 820 East 17th Street Cheyenne WY
0
50
100
150
200
250
300
350
400
450
2/6/2017 2/8/2017 2/10/2017 2/20/2017 2/22/2017 2/23/2017 2/24/2017
Date Date Date Date Date Date Date
UW FM Phone Calls -
Feb 2017
RX Refill Scheduling Other Total

44. Lisinopril Prescribing Pattern – Sept 1, 2016 – 3-31-2017
0
10
20
30
40
50
60
70
80
90
100
45
60
90
120
150
180
210
240
270
360
390
420
450
540
630
# of Scripts
Days
Family Medicine Residency Program at Cheyenne 820
East 17th Street Cheyenne WY
New Lisinopril scripts accounted for
16% of the total Lisinopril scripts or 53
out of 332 scripts
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
35.00%
NewPescription
30
45
60
90
120
150
180
210
240
270
300
330
360
390
420
450
480
510
540
570
600
630
Number of Day Supply
Percent of Day Supply Prescribed

45. Agenda
3:00 5 min Welcome and Introductions
Improvement Road Map
3:05 15 min Action Period 5 Milestones and Challenges
3:20 15 min Playbooks | Standards (10 min, 3 min questions)
Educational Health Center of Wyoming | Prescription Refills
3:35 15 min How are we doing? Core and Extended Team Structure and Roles
3:50 15 min Discussion Questions : What do you want to learn from other teams?
4:05 10 min Post Collaborative Improvement Plans Using Progress Check List
4:15 10 min Action Period 6 Assignments

46. Blue Pod
(Core Teams)
Dr. Etheridge
Jackie, MA
MA
Dr. Brant
Joe, MA
Porcelyn, MA
Richie Hall, NP
Vicky, LPN
MA

47. RN and MA Roles
What do you want to learn from other teams?

48. RN Role

49. Optimization
RNs in Primary Care
Webinar 3

50. Healthcare for Homeless

51. Level D: Just Getting Started
Level C: Early Stages of Change
Level B: Implemented Basic Changes
Level A: Achieved Most or All of the Important Change Required

52. Primary Care Team Guide Assessment Data (n=16 Teams)
0
2
4
6
8
10
Level A Level B Level C Level D
Medical Assistant (MA)
0
2
4
6
8
Level A Level B Level C Level D
Registered Nurse (RN)
0
5
10
Level A Level B Level C Level D
Medication Management
0
5
10
Level A Level B Level C Level D
Planned Care
0
5
10
Level A Level B Level C Level D
Population Management

53. What new MA roles have you
been implementing?
Any lessons learned?
What do you want to learn from other teams?

54. Level D: Just Getting Started
Level C: Early Stages of Change
Level B: Implemented Basic Changes
Level A: Achieved Most or All of the Important Change Required

55. Agenda
3:00 5 min Welcome and Introductions
Improvement Road Map
3:05 15 min Action Period 5 Milestones and Challenges
3:20 15 min Playbooks | Standards (10 min, 3 min questions)
Educational Health Center of Wyoming | Prescription Refills
3:35 15 min How are we doing? Core and Extended Team Structure and Roles
3:50 15 min Discussion Questions : What do you want to learn from other teams?
4:05 10 min Post Collaborative Improvement Plans Using Progress Check List
4:15 10 min Action Period 6 Assignments

56. What do you want to learn from other teams?
Core and Extended Team Model
 How are you identifying your PODS in your health center so that know
their team ? *Scrub colors, wall colors, door colors, badges, business cards,
pictures?
 What specific roles on your team have you seen change, and how?
 How are you training and educating staff about team based care?
 How do you maintain the integrity of your CORE team with turnover and
/or MAs covering multiple teams/PODS.
 Are manager and leaders part of your core and extended team model?

57. Pre Visit Planning and Huddles
 How do you manage the prep time for huddles? Are you using EHR in real time to reduce
prep time?
 Is anyone allowing patient to give verbal consent for records release new patient visit?
Future Aims:
 What is your self management goal setting workflow – forms, who , when , and follow
up?
Coaching Role:
 We are dependent on the coach to prepare and help us run weekly meetings. We have
difficulty getting work done between meetings. How are teams managing these
challenges? Who is stepping up as your improvement leader ?
 How are teams managing the challenge of documenting their work using the tools
(Specific Aims, PDSAs, SDSAs, Data Over Time, Playbooks)?
What do you want to learn from other teams?

58. Agenda
3:00 5 min Welcome and Introductions
Improvement Road Map
3:05 15 min Action Period 5 Milestones and Challenges
3:20 15 min Playbooks | Standards (10 min, 3 min questions)
Educational Health Center of Wyoming | Prescription Refills
3:35 15 min How are we doing? Core and Extended Team Structure and Roles
3:50 15 min Discussion Questions : What do you want to learn from other teams?
4:05 10 min Post Collaborative Improvement Plans Using Progress Check List
4:15 10 min Action Period 6 Assignments

59. Complete Progress Check List

60. Action Periods 4, 5, 6 and Post Collaborative
Access |Efficiency
and Communication
Care Coordination
Population Health
Medication Management

61. Post Collaborative Improvement Plan

62. How will we know we have made a difference?

63. Action Period 6 Assignments
1. Work on specific aims (PDSAs, SDSAs). Use Data.
2. Draft Playbook(s )| Documentation of Your Work
 Define Core and Extended Team (benchmark CHA)
 Huddles
 Specific Aim You Have Achieved (e.g. prescription refill)
3. Spread a standard to another POD
4. Improve ‘effectiveness’ of your team meetings and
daily huddles

64. Action Period 6 Assignments
5. Schedule a team meeting with Leaders. Share your work, discuss
organizational implications TBC model.
6. Complete progress check list. Upload for conversion to draft
post collaborative improvement plan.
7. Complete Post Assessments – May 29 – June 9
 Team Improvement Skills Assessment
 Coach Skills Assessment
 Primary Care Team Guide Assessment
8. Post your work on Moodle Learning Network site
https://moodle.weitzmaninstitute.org/login/index.php

65. Next and Final Session June 14
Celebration of Your Work Together
oPresent what you team accomplished that they are most proud of ?
Approach as if your audience were other teams in your practice and leaders. Be creative.
oHow has your collaborative participation helped your team?
oWhat were some of your lessons learned?
oDo you have your draft post collaborative improvement plan?

66. Thank You All
Survey Post Session
Thank you for your participation today and your feedback : Session Evaluation

67. Mentor Name of FQHC State Coach Team Members Team
Kasey Avenal Community Health Center CA John Kalfayan
Frances Silva, Behavioral Health
Vivian Stafford, Physician
Khuong Phui, Medical director
Betty Mora, MA
Christina Castaneda, Receptionist
1 BH, 1 Physician, 1 MA, 1 Medical
Director, 1 Front Desk
Deb
Carolina Family Health Centers ,
Inc.
NC Mary Williams
Amparito Fiallo, MD
Al Abaya, NP
Lisa Vinson, LPN
Bernadette Mangum, LPN
Cheyenne Robbins, Care Coordinator
Betty Lucas, Front Desk
Zenaida Aguilar, Interpreter
Raquel Milbourne, CNA
Sandra Botello, Referral Specialist
1 MD, 1 NP, 2 LPN, 1 Care
Coordinator, 1 Front Desk, 1
Interpretor, 1 CAN, 1 Referral
Sepcialist
Deb
Educational Health Center of
Wyoming
WY Pamela Oiler
Donna Romain, RN
LaDonna Whittaker, Radiologic Tech
Liz Bravo-Alcon, Executive Assistant
Stephanie Schneider, MA
Patrick Monahan, Clinical Manager
Marianne Ploucha, Business Office Manager
Kimberly Broomfield, Faculty Physician
Jennifer Walsh, MA
Christie Novy, MA
Evan Norby, Clinical Team Lead
Monette McKee, RN
Thanh-Nga Nguyen, Faculty Pharm D.
Pamela Oiler, Faculty LCSW
1 Provider, 2 RN, 1 Radiologic
Technologist, 1 EMR Manager, 3 MA, 1
Clinical Manager, 1 Pharmacist, 1
LCSW

68. Mentor Name of FQHC State Coach Team Members Team
Kasey El Rio Santa Cruz AZ Josh Carzoli
Crystal Chavira, MA
Yomaira Preciado, RN
Jennifer Stivers, LPN
Rajiv Modak, Physician
Stephanie Pinedo, Reception
Linda Beauchesne, Medical Informatics Supervisor
Sonia Reidy, Physician
1 MA, 1 RN, 1 BH, 1 Chief Clinical
Officer, 1 LPN, 2 Physician, 1 Front
Desk, 1 COO, 3 RN Clinic Manager, 1 IT
Deb Healthcare for the Homeless TX Carlie Brown
The core team:
Henry Siem, MD
Luis Huerta, MA
Krissy Joubert, MA – Intake/Registration
Unfilled RN Position
Extended team:
Cidney Aae, Case Manager
Joseph Benson, Community Health Worker
Need new team
Kasey Holyoke Health Center MA
Megan T.
Wechsler, Rosie
Romero
Core Team:
Dr. Kefah Al-Ramahi, Internal Medicine, MD
Karen Horgan, RN
Natalie Alicea, MA
Juan Acevedo-Behavioral Health Integration
Program Manager
Mariluz Vargas, Front Desk
Extended Team:
Dr. Alejandro Esparza, CMO
Martha Fisk, Director of Quality and Compliance
1 Director of Quality and Compliance,
1 Physician, 3 RN, 1 MA, 1 Front Desk
Deb
Johnson City Community Health
Center
TN Flo Weierbach
Martiza Ramirez, Front Desk
Rebecca Morrison, PNP
Amy Mclaughlin, LCSW
Mae Crestinger, RN
Laura Gentles Gonzales, Interpreter
1 Dfront Desk, 1 PNP, 1 LCSW, 1 RN, 1
Interpreter

69. Mentor Name of FQHC State Coach Team Members Team
Kasey Peach Tree Healthcare CA Ruben Ruiz
Core Team:
Margarita Cuevas, MA
Rene Minnaar, NP
Jose Alvarado, MA
Kathleen Hawes, Site Manager
Alex Castro, Customer Service Specialist
Tang Yang, Operations Specialist
Tameka Frank, Quality Coordinator
Hakeem Adeniyi, Chief Medical Officer
Ruben Ruiz, Quality Coordinator
Sheila Arnold, Clinical Support Services Manager
Other Team Members in Monthly Meetings:
Michelle Woodard, Director of Operations
Mary Renner, Director of HR
Dalip Rai, Data Analyst
1 Chief Quality Officer, 1 Quality
Coordinator, 1 Director of
Operations, 1 Site Manager, 1
Director of HR, 1 NP, 3 MA, 1
Data Analyst, 1 Operations
Specialist, 1 Clinical Support
Services Manager
Deb Sumter Family Health Center SC Sandra Sturkie
Core Team:
Linda Brice, Adult Health Clinical Manger
Dr. Etheridge, Adult Health MD
Porcelyn Scarborough, MA
Ebony Singleton, Call Center/Registration
Sondra Richardson, Referrals Manager
Extended Team:
Kitty Kulungowski, RN Behavioral Health
Wendy Bonds- Chapman, Case Management
Mary Byrd, Case Management
Tina Thompson, Behav Health RN
Jolie Costello, Dental Services Coordinator
Joyce Bair, Patient Financial Coordinator
Marti Martin, Clinical IT/EMR
Melvina Chappell, Pharmacist
1 Director of Patient Services, 1
Clinical Manager, 1 BH Clinical
Manager, 1 BH RN, 1 Physician,
2 Case Managers, 1 MA, 1
Dental Services Coordinator, 1
Patient Financial Coordinator, 1
Clinical IT, 1 Pharmacist, 1 Call
Center Rep, 1 Referrals
Manager

70. Mentor Name of FQHC State Coach Team Members Team
Deb
Syracuse Community Health
Center, Inc.
NY Cathy Brigden
Dr. Roy Smith, Physician
Ms. Zarina Smith, FNP
Ms. Stephanie Green, LPN
Ms. Rebecca Wright, RN
Ms. Shanieka Smith, MA
Ms. Tania Guntin-Bernal, MA
Ms. Tiffany Senke, MA
Ms. Stephanie Montgomery, Office Manager
Ms. Verna Griffith Payne, RN
1 Physician, 1 FNP, 1 LPN, 2 RN, 3 MA,
1 Office Manager
Kasey The Children’s Clinic CA Karla Rodriguez
Dr. Shea Suskin, Provider
Joana Rios, MA
Elizabeth Castruita, LVN
Angela Moreno, Clinic Manager
1 Provider, 1 MA, 1 Care Team Rep
Deb Tyler Family Circle of Care TX Sherri Gould
Carolyn Risinger, CMO
Linda Isabell, COO
Nadra Miller, Lead LVN
Juana Crespin, OA
Robin Hogue, PNP
Vanessa Vela, Process Improvement Manager
1 CMO, 1 COO, 1 LVN, 1 OA, 1 PNP, 1
Process Improvement Manager
Kasey
Via Care Community Health
Center
CA Lourdes Olivares
Agustin Jaime Lara, CMO
Anamaria Lopez-Chavelas, MSW
Ema Hernandez, LVN
Laura Andrade, MA
Julio Arellano, Enroller
Maria Valdez, Director of Operations
Maricela Romero, MA/Front Desk lead
Victoria Moreno, RN
1 FNP, 1 MA, 1 Outreach & Enrollment
Specialist, 1 MSW, 1 Front Office Lead
MA