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Advancing Team-Based Care Webinar:
Enhancing the Role of the Medical Assistant and Nurse through
Implementation of Care Management to Improve Chronic Conditions
Wednesday, December 7th 2022
2:00-3:00pm EST, 11:00am-12:00pm PST
Continuing Education Credits
In support of improving patient care,
Community Health Center, Inc. / Weitzman
Institute is jointly accredited by the
Accreditation Council for Continuing Medical
Education (ACCME), the Accreditation Council
for Pharmacy Education (ACPE), and the
American Nurses Credentialing Center
(ANCC), to provide continuing education for
the healthcare team.
A comprehensive certificate will be sent after
the end of the series, Summer 2022.
2
Disclosure
• With respect to the following presentation, there has been no relevant (direct or indirect) financial relationship
between the party listed above (or spouse/partner) and any for-profit company in the past 12 months which
would be considered a conflict of interest.
• The views expressed in this presentation are those of the presenters and may not reflect official policy of
Community Health Center, Inc. and its Weitzman Institute.
• We are obligated to disclose any products which are off-label, unlabeled, experimental, and/or under
investigation (not FDA approved) and any limitations on the information hat we present, such as data that are
preliminary or that represent ongoing research, interim analyses, and/or unsupported opinion.
• This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of
Health and Human Services (HHS) as part of an award totaling $2,082,933 with 0% financed with non-
governmental sources. The contents are those of the author(s) and do not necessarily represent the official
views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit
HRSA.gov.
3
At the Weitzman Institute, we value a
culture of equity, inclusiveness,
diversity, and mutually respectful
dialogue. We want to ensure that all
feel welcome. If there is anything said
in our program that makes you feel
uncomfortable, please let us know via
email at nca@chc1.com
4
National Training and Technical Assistance Partnership
Clinical Workforce Development
Provides free training and technical assistance to health centers across the
nation through national webinars, learning collaboratives, activity
sessions, trainings, research, publications, etc.
5
Speakers
• Mary Blankson, DNP, APRN, FNP-C
– Chief Nursing Officer, Community Health Center
• Tierney Giannotti, MPA
– Senior Program Manager, Population Health, Community Health
Center
6
Objectives
• Review models of complex care management, leveraging both in
person and remote teams
• Describe telehealth as an enhancement to complex care
management delivery
• Outline case examples of complex care management in action
• Discuss leveraging all team members to the fullest success of their
training
• Recognize practical examples of care management tools to ensure
success
7
Resource Allocation
• Role of RN
• Role of other team members
• Care Coordination vs. Case Management vs. Care Management
• Role of Risk Stratification
• Role of Payers
8
What is Care Coordination?
• “Deliberate organization of patient care activities between two or
more participants (including the patient) involved in a patient’s care
to facilitate the appropriate delivery of health care services” (AHRQ)
• An integral component of the National Committee for Quality
Assurance’s (NCQA) Patient-Centered Medical Home (PCMH) model
• Patient-centered care coordination is a core professional standard
and competency for all nursing practice (ANA)
9
Case Management vs.
Care Coordination vs. Complex Care Word Soup
10 Source: Implementation-Guide-Care-Coordination.pdf (safetynetmedicalhome.org)
Complex Care
Management
11
TEAM-BASED CARE
“Every Patient Has a TEAM”
12
Core Team Roles
Things to consider:
 Centralization vs. site-level care
 Generalization vs. Specialization
 Hybrid models
 Processes vs. People
13
Extended
Care Team
Core Team
Provider
MA
Teamlet
Provider
MA & RN
Teamlet
• Receptionist
• Health Coach
• Panel Manager
• Referral Coordinator
• RN Care Managers
• Behavioral Health
Specialists
• Administrative Staff
• Team RN
Virtual
Team
• Centralized Care
Manager
• Telehealth Triage
• Pharmacy
• Patient
Experience
Coordinators
• Digital Tech
Liaisons
• Scheduler
• Lay Caregivers/
CHWs
Primary Care Team
Care Teams
Virtual Care Team
1
5
●Comprehensive, team-based
oral health care; preventive,
restorative, and transformative
●“Wherever You Are” (W.Y.A)
strategy to engage kids in school,
farmworkers, homeless in
community settings
●Integration with medical:
Diabetes prevention, fluoride
varnish application, etc.
●Comprehensive primary
medical care for all but the
most complex conditions
●Preventive health promotion
and chronic illness
management at every visit
●Chiropractors, Podiatrists,
Dieticians, OB-GYN, HIV
specialists all contribute to
meeting patient needs
●Behavioral health is central to
CHC’s primary care model
●Care may be initiated by patient
or by warm hand off-in person or
by “eWHO”
●SBHCs provides access to BH for
children and adolescents
●Trauma focused care, group
support, and access to integrated
medical/BH OUD
● Care delivered under standing and
delegated orders
● Nursing leads the team including
Medical Assistants and other
support members
● Focus on key populations such as
elderly (MAWVs, CCM), Homeless,
Transitions in Care
● Nurses also hold roles in triage,
Center for Key Populations,
leadership
Integration
Role of the Medical Assistant in Care Management
• Care gap closure
• Identifying patients lost to
follow up
• ER transition follow up
• Obtain hospital discharge
summaries and other important
documents
16
Role of Nurse
in Care Management
• Working with vulnerable patients
• Motivational interviewing and self
management goal setting
• Independent Nurse Visits under
standing and delegated orders
• Quality improvement leaders, coaches,
and team members
• Intensive coordination of community
resources, directly or through an
assigned case manager or community
worker
• Remote patient monitoring
• Telehealth nurse: transition of care
visit within seven days of discharge
• Population Health RN teams: support
care gap closure and other initiatives
17
Behavioral Health Collaboration
with RNs for Care Management
• Increased collaboration Psychiatry & RNs
– Safety
• Controlled substance visits
• Medication adherence
• Antidepressant f/u visits
• Long acting injectibles (LAI) Psychotropics
• Others
– Overall wellness
• Insomnia
• Diabetes management
• Others
18
Key Supports to Accomplish Care Management
19
Electronic Tools
• Training and education
• Dashboards
• Scorecards
• E.H.R. Tools:
– Templates
– Order Sets
– Macros
– Remote Monitoring
– Others
• E-consults
20
Weitzman ECHO:
RN Complex Care Management
21
Systems and Technology
to Support Care Management
• Integrated Scheduling System
• Call any CHC number and connected to same scheduling group
• Medical, dental, therapy and psychiatry services all scheduled through one system
• All Recalls visible at all points of contact
22
Performance
Appraisal Reviews:
Clinical Scorecards
23
Content:
Job Tools
24
New Areas of Focus in Care Management
25
Remote Patient Monitoring
Initial Questions
• Which chronic illness are you planning to utilize RPM for?
• Which devices are you planning to use?
• Are you giving away the devices? Loaning? Prescribing?
–If yes, create a process/standing order
26
Remote Patient Monitoring
Once Device Selected
• Who will train the patient to use the device?
• How and where in the E.H.R. is the data coming back to the organization?
• Who is responsible to act on the data?
– By whose authority?
– How often?
• Who is responsible to manage abnormal values?
• Develop scripting for staff to talk about RPM and why it is important
– Add a checklist to support eligibility screening
27
Remote Patient Monitoring
Evaluation
• How each team member’s success be evaluated for their part of the work?
• How will the program processes be improved over time?
• How will the program be sustainable?
– In terms of staff time & satisfaction
– In terms of financial impact/ROI
• Ensure there is a little “gatekeeping” as possible
• Break down every measure into sub-parts to identify all process measures that
contribute to the final clinical outcome
• Create an iterative feedback loop to ensure best practice development
28
Standing Orders
• Planned Care:
– Publish Clinical Expectations for teams (part of the plan of care policy)
– Create a grid of all measures
• Denominators
• Numerators
• Frequency
• Explanation of data entry options
• Follow-up or care coordination required
29
Standing Orders
• Chronic Illnesses Care Management
– Select evidence/ensure it matches organizational clinical expectations
– Outline expected data collection
– Outline optional data collection/care delivery based on assessment
completed (think “menu”)
– Create a grid of all examples
• Who it applies to (i.e. age and symptom(s))
• Any exclusions?
• Don’t forget data entry issues
– i.e. order sets, templates, order link with diagnosis/ symptom, CPT codes
– What to do if something else comes up?
– References
30
Medical Assistants:
Planned Care Dashboard
31
E.H.R. Templates & Order Sets
Designed to ensure:
→ Minimum data set
→ Consistency in documentation of encounters
→ Emphasis on MI and SMG setting
→ Appropriate education
→ Ensures safety
→ Creates efficiency
32
Complex Care Management Dashboard:
Diabetes
33
Example: Patients with Diabetes
• Population: 7,440 patients with diabetes
• Subgroup: 866 patients whose last A1c > 9.0 who did not have an
upcoming visit scheduled and no visit in the prior 3 months
• Assign and Train: 5 Patient Service Associates to schedule telehealth
encounters
• Results: 32% of patients were scheduled for a visit with PCP.
• Any patient who had been seen by a PCP within the past 3 months
with last A1c > 9.0 were scheduled with an RN for care management
34
Telehealth Population Health Approach:
Patients with Chronic Conditions
• Define the population
• Scale the subgroup of patients to meet the operational capacity ->
highest of the high risk
• Develop and test scripts
• Identify who should see the patient (PCP, RN, CDCES, etc.)
• Obtain feedback iteratively from those reaching out to patients
35
Monthly IMZ File
• On a monthly basis the Population Health Team, with data from dashboards created
by Business Intelligence, sends two targeted lists of patients due for childhood
immunizations.
• The information is sent to Nurse Managers and include:
– The first list separated by site, identifies infants 12 to < 15 weeks who are due for
their first Rotavirus vaccine.
– The second list, also separated by site, identifies children 18-23 months old who
are not up to date on their 24 month old immunizations. The specific
immunizations that are due for the child are highlighted.
• Nurse managers are expected to review the information and outreach to patients as
needed. They report their follow up in the Excel file and return it to population
health.
36
Potential Points of Friction
• Physical plant space for longer teaching sessions vs. use of the
virtual environment
• Gatekeeping vs Top of license/training practice
• The art of medicine vs. evidence basis
• Duplicative work/duplication of efforts
• Feedback seen as punitive instead of routine
• Others?
37
Managing Culture
• Create an environment of team-based care that is based on the
value of every role (not just as a downstream catchall to support
providers)
• Focus on measurement in everything that you do
– Normalize feedback and data as an invitation to partner and troubleshoot
• Invite patients to help you test new technology
• Embrace failure as just another data point on the way to a best
practice
• Celebrate success (often!)
38
References
• Bauer, L., & Bodenheimer, T. (2017). Expanded roles of registered nurses in primary care delivery of the future. Nursing
Outlook, 65(5), 624-632.
• Bodenheimer, T., & Laing, B. (2007). The Teamlet Model of Primary Care. Annals of Family Medicine, 5, 457-461.
• Community Health Center, Inc. & The MacColl Center for Health Care Innovation. (2016). HRSA National Cooperative
Agreement: Workforce Development: Complex Care Management in Primary Care. Retrieved from
https://www.slideshare.net/CHCConnecticut/advancingteambased-care-complex-care-management-in-primary-care
• Flinter, M., Blankson, M., & Ladden, M.J. (2016). Registered Nurses in Primary Care: Strategies that Support Practice at the Full
Scope of the Registered Nurse License. Registered Nurses: Partners in Transforming Primary Care. Recommendations from the
Macy Foundation
• Flinter, M., Hsu, C., Cromp, D., Ladden, M., & Wagner, E. (2017). Registered Nurses in Primary Care: Emerging New Roles and
Contributions to Team-Based Care in High-Performing Practices. Journal of Ambulatory Care Management, 40(4), 287-296.
• Implementation-Guide-Care-Coordination.pdf (safetynetmedicalhome.org)
• Norful, A., Martsolf, G., de Jacq, k., & Poghosyan, L. (2017). Utilization of registered nurses in primary care teams: A systematic
review. International Journal of Nursing Studies, 74, 15-23.
39
Questions?
Interested in receiving coaching support to
move your health center from planning to
implementation of replicable models?
Our NTTAP offers learning collaborative
opportunities in Training the Next Generation,
Team-Based Care, and HIV Prevention!
For more information, please reach out to
Meaghan Angers (angersm@chc1.com)
41
Contact Information
42
For information on future webinars, activity
sessions, and learning collaboratives:
please reach out to nca@chc1.com or visit
https://www.chc1.com/nca

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NTTAP Webinar Series - December 7, 2022: Advancing Team-Based Care: Enhancing the Role of the Medical Assistant and Nurse through Implementation of Care Management to Improve Chronic Conditions: Enrollments

  • 1. Advancing Team-Based Care Webinar: Enhancing the Role of the Medical Assistant and Nurse through Implementation of Care Management to Improve Chronic Conditions Wednesday, December 7th 2022 2:00-3:00pm EST, 11:00am-12:00pm PST
  • 2. Continuing Education Credits In support of improving patient care, Community Health Center, Inc. / Weitzman Institute is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. A comprehensive certificate will be sent after the end of the series, Summer 2022. 2
  • 3. Disclosure • With respect to the following presentation, there has been no relevant (direct or indirect) financial relationship between the party listed above (or spouse/partner) and any for-profit company in the past 12 months which would be considered a conflict of interest. • The views expressed in this presentation are those of the presenters and may not reflect official policy of Community Health Center, Inc. and its Weitzman Institute. • We are obligated to disclose any products which are off-label, unlabeled, experimental, and/or under investigation (not FDA approved) and any limitations on the information hat we present, such as data that are preliminary or that represent ongoing research, interim analyses, and/or unsupported opinion. • This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $2,082,933 with 0% financed with non- governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov. 3
  • 4. At the Weitzman Institute, we value a culture of equity, inclusiveness, diversity, and mutually respectful dialogue. We want to ensure that all feel welcome. If there is anything said in our program that makes you feel uncomfortable, please let us know via email at nca@chc1.com 4
  • 5. National Training and Technical Assistance Partnership Clinical Workforce Development Provides free training and technical assistance to health centers across the nation through national webinars, learning collaboratives, activity sessions, trainings, research, publications, etc. 5
  • 6. Speakers • Mary Blankson, DNP, APRN, FNP-C – Chief Nursing Officer, Community Health Center • Tierney Giannotti, MPA – Senior Program Manager, Population Health, Community Health Center 6
  • 7. Objectives • Review models of complex care management, leveraging both in person and remote teams • Describe telehealth as an enhancement to complex care management delivery • Outline case examples of complex care management in action • Discuss leveraging all team members to the fullest success of their training • Recognize practical examples of care management tools to ensure success 7
  • 8. Resource Allocation • Role of RN • Role of other team members • Care Coordination vs. Case Management vs. Care Management • Role of Risk Stratification • Role of Payers 8
  • 9. What is Care Coordination? • “Deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient’s care to facilitate the appropriate delivery of health care services” (AHRQ) • An integral component of the National Committee for Quality Assurance’s (NCQA) Patient-Centered Medical Home (PCMH) model • Patient-centered care coordination is a core professional standard and competency for all nursing practice (ANA) 9
  • 10. Case Management vs. Care Coordination vs. Complex Care Word Soup 10 Source: Implementation-Guide-Care-Coordination.pdf (safetynetmedicalhome.org)
  • 13. Core Team Roles Things to consider:  Centralization vs. site-level care  Generalization vs. Specialization  Hybrid models  Processes vs. People 13
  • 14. Extended Care Team Core Team Provider MA Teamlet Provider MA & RN Teamlet • Receptionist • Health Coach • Panel Manager • Referral Coordinator • RN Care Managers • Behavioral Health Specialists • Administrative Staff • Team RN Virtual Team • Centralized Care Manager • Telehealth Triage • Pharmacy • Patient Experience Coordinators • Digital Tech Liaisons • Scheduler • Lay Caregivers/ CHWs Primary Care Team Care Teams Virtual Care Team
  • 15. 1 5 ●Comprehensive, team-based oral health care; preventive, restorative, and transformative ●“Wherever You Are” (W.Y.A) strategy to engage kids in school, farmworkers, homeless in community settings ●Integration with medical: Diabetes prevention, fluoride varnish application, etc. ●Comprehensive primary medical care for all but the most complex conditions ●Preventive health promotion and chronic illness management at every visit ●Chiropractors, Podiatrists, Dieticians, OB-GYN, HIV specialists all contribute to meeting patient needs ●Behavioral health is central to CHC’s primary care model ●Care may be initiated by patient or by warm hand off-in person or by “eWHO” ●SBHCs provides access to BH for children and adolescents ●Trauma focused care, group support, and access to integrated medical/BH OUD ● Care delivered under standing and delegated orders ● Nursing leads the team including Medical Assistants and other support members ● Focus on key populations such as elderly (MAWVs, CCM), Homeless, Transitions in Care ● Nurses also hold roles in triage, Center for Key Populations, leadership Integration
  • 16. Role of the Medical Assistant in Care Management • Care gap closure • Identifying patients lost to follow up • ER transition follow up • Obtain hospital discharge summaries and other important documents 16
  • 17. Role of Nurse in Care Management • Working with vulnerable patients • Motivational interviewing and self management goal setting • Independent Nurse Visits under standing and delegated orders • Quality improvement leaders, coaches, and team members • Intensive coordination of community resources, directly or through an assigned case manager or community worker • Remote patient monitoring • Telehealth nurse: transition of care visit within seven days of discharge • Population Health RN teams: support care gap closure and other initiatives 17
  • 18. Behavioral Health Collaboration with RNs for Care Management • Increased collaboration Psychiatry & RNs – Safety • Controlled substance visits • Medication adherence • Antidepressant f/u visits • Long acting injectibles (LAI) Psychotropics • Others – Overall wellness • Insomnia • Diabetes management • Others 18
  • 19. Key Supports to Accomplish Care Management 19
  • 20. Electronic Tools • Training and education • Dashboards • Scorecards • E.H.R. Tools: – Templates – Order Sets – Macros – Remote Monitoring – Others • E-consults 20
  • 21. Weitzman ECHO: RN Complex Care Management 21
  • 22. Systems and Technology to Support Care Management • Integrated Scheduling System • Call any CHC number and connected to same scheduling group • Medical, dental, therapy and psychiatry services all scheduled through one system • All Recalls visible at all points of contact 22
  • 25. New Areas of Focus in Care Management 25
  • 26. Remote Patient Monitoring Initial Questions • Which chronic illness are you planning to utilize RPM for? • Which devices are you planning to use? • Are you giving away the devices? Loaning? Prescribing? –If yes, create a process/standing order 26
  • 27. Remote Patient Monitoring Once Device Selected • Who will train the patient to use the device? • How and where in the E.H.R. is the data coming back to the organization? • Who is responsible to act on the data? – By whose authority? – How often? • Who is responsible to manage abnormal values? • Develop scripting for staff to talk about RPM and why it is important – Add a checklist to support eligibility screening 27
  • 28. Remote Patient Monitoring Evaluation • How each team member’s success be evaluated for their part of the work? • How will the program processes be improved over time? • How will the program be sustainable? – In terms of staff time & satisfaction – In terms of financial impact/ROI • Ensure there is a little “gatekeeping” as possible • Break down every measure into sub-parts to identify all process measures that contribute to the final clinical outcome • Create an iterative feedback loop to ensure best practice development 28
  • 29. Standing Orders • Planned Care: – Publish Clinical Expectations for teams (part of the plan of care policy) – Create a grid of all measures • Denominators • Numerators • Frequency • Explanation of data entry options • Follow-up or care coordination required 29
  • 30. Standing Orders • Chronic Illnesses Care Management – Select evidence/ensure it matches organizational clinical expectations – Outline expected data collection – Outline optional data collection/care delivery based on assessment completed (think “menu”) – Create a grid of all examples • Who it applies to (i.e. age and symptom(s)) • Any exclusions? • Don’t forget data entry issues – i.e. order sets, templates, order link with diagnosis/ symptom, CPT codes – What to do if something else comes up? – References 30
  • 32. E.H.R. Templates & Order Sets Designed to ensure: → Minimum data set → Consistency in documentation of encounters → Emphasis on MI and SMG setting → Appropriate education → Ensures safety → Creates efficiency 32
  • 33. Complex Care Management Dashboard: Diabetes 33
  • 34. Example: Patients with Diabetes • Population: 7,440 patients with diabetes • Subgroup: 866 patients whose last A1c > 9.0 who did not have an upcoming visit scheduled and no visit in the prior 3 months • Assign and Train: 5 Patient Service Associates to schedule telehealth encounters • Results: 32% of patients were scheduled for a visit with PCP. • Any patient who had been seen by a PCP within the past 3 months with last A1c > 9.0 were scheduled with an RN for care management 34
  • 35. Telehealth Population Health Approach: Patients with Chronic Conditions • Define the population • Scale the subgroup of patients to meet the operational capacity -> highest of the high risk • Develop and test scripts • Identify who should see the patient (PCP, RN, CDCES, etc.) • Obtain feedback iteratively from those reaching out to patients 35
  • 36. Monthly IMZ File • On a monthly basis the Population Health Team, with data from dashboards created by Business Intelligence, sends two targeted lists of patients due for childhood immunizations. • The information is sent to Nurse Managers and include: – The first list separated by site, identifies infants 12 to < 15 weeks who are due for their first Rotavirus vaccine. – The second list, also separated by site, identifies children 18-23 months old who are not up to date on their 24 month old immunizations. The specific immunizations that are due for the child are highlighted. • Nurse managers are expected to review the information and outreach to patients as needed. They report their follow up in the Excel file and return it to population health. 36
  • 37. Potential Points of Friction • Physical plant space for longer teaching sessions vs. use of the virtual environment • Gatekeeping vs Top of license/training practice • The art of medicine vs. evidence basis • Duplicative work/duplication of efforts • Feedback seen as punitive instead of routine • Others? 37
  • 38. Managing Culture • Create an environment of team-based care that is based on the value of every role (not just as a downstream catchall to support providers) • Focus on measurement in everything that you do – Normalize feedback and data as an invitation to partner and troubleshoot • Invite patients to help you test new technology • Embrace failure as just another data point on the way to a best practice • Celebrate success (often!) 38
  • 39. References • Bauer, L., & Bodenheimer, T. (2017). Expanded roles of registered nurses in primary care delivery of the future. Nursing Outlook, 65(5), 624-632. • Bodenheimer, T., & Laing, B. (2007). The Teamlet Model of Primary Care. Annals of Family Medicine, 5, 457-461. • Community Health Center, Inc. & The MacColl Center for Health Care Innovation. (2016). HRSA National Cooperative Agreement: Workforce Development: Complex Care Management in Primary Care. Retrieved from https://www.slideshare.net/CHCConnecticut/advancingteambased-care-complex-care-management-in-primary-care • Flinter, M., Blankson, M., & Ladden, M.J. (2016). Registered Nurses in Primary Care: Strategies that Support Practice at the Full Scope of the Registered Nurse License. Registered Nurses: Partners in Transforming Primary Care. Recommendations from the Macy Foundation • Flinter, M., Hsu, C., Cromp, D., Ladden, M., & Wagner, E. (2017). Registered Nurses in Primary Care: Emerging New Roles and Contributions to Team-Based Care in High-Performing Practices. Journal of Ambulatory Care Management, 40(4), 287-296. • Implementation-Guide-Care-Coordination.pdf (safetynetmedicalhome.org) • Norful, A., Martsolf, G., de Jacq, k., & Poghosyan, L. (2017). Utilization of registered nurses in primary care teams: A systematic review. International Journal of Nursing Studies, 74, 15-23. 39
  • 41. Interested in receiving coaching support to move your health center from planning to implementation of replicable models? Our NTTAP offers learning collaborative opportunities in Training the Next Generation, Team-Based Care, and HIV Prevention! For more information, please reach out to Meaghan Angers (angersm@chc1.com) 41
  • 42. Contact Information 42 For information on future webinars, activity sessions, and learning collaboratives: please reach out to nca@chc1.com or visit https://www.chc1.com/nca

Editor's Notes

  1. Bianca (2:00-2:05)
  2. Bianca (2:00-2:05)
  3. Bianca (2:00-2:05)
  4. Bianca (2:00-2:05)
  5. Bianca (2:00-2:05)
  6. Bianca (2:00-2:05)
  7. Mary (2:05-2:20)
  8. Mary (2:05-2:20)
  9. Mary (2:05-2:20)
  10. Mary (2:05-2:20)
  11. Mary (2:05-2:20)
  12. Mary (2:05-2:20) CHC wholeheartedly believes in an evolving team-based model of care that we know will deliver improved clinical outcomes to support our complex patients—evolving because we have added telehealth and other roles related to the transformation that took place during the COVID-19 pandemic and analysis from our needs assessment. By empowering every member of the care team to be empaneled to a group of patients, we leverage their unique skill set to improve patient access to a variety of resources. Not only does this ensure compliance and ongoing improvement of our Patient Centered Medical Model and therefore our recognition, but it also reduces burnout by delineating each team member’s role and overall responsibilities. This allows us to have accountability for all of our operational and clinical metrics because we can break them into parts---each team member knows they are absolutely vital and valuable to the overall team, and also accountable for their individual contribution to the whole.
  13. Mary (2:05-2:20) Team RNs Independently scheduled visits include visits for preventive care, chronic illness care, and acute care including visits conducted under standing orders, protocols, and delegated order sets Both independent and conjoint visits with PCPs and other team members. Triage, both electronic, telephonic and in-person Transition Management post hospital or SNF discharge Patient education Medication reconciliation Self management goal setting Managing patient flow Supervision of medical assistants and other team member Strongly engaged in quality improvement activities In some practices, incorporated complex care management into practice
  14. Mary (2:05-2:20)
  15. Mary (2:05-2:20)
  16. Mary (2:05-2:20)
  17. Mary (2:05-2:20) Pop health nurse AWV
  18. Mary (2:05-2:20) Role for psych Role for the therapist Getting patients in – working with psych to make meds contigent on attending therapy- and RN pick up of meds. No evidence in literature- perhaps we could add to thte lit- definitely able to get pts off of BZDs with this approach- may take a long time even a year. Works for some and not al. Case of M.L trauma nect pt to try this with- setting alert no visit without therapy.
  19. Mary (2:05-2:20) Transition slide
  20. Tierney (2:20-2:40)
  21. Tierney (2:20-2:40)
  22. Tierney (2:20-2:40)
  23. Tierney (2:20-2:40)
  24. Tierney (2:20-2:40) Make automatic what should be automatic, so huddle becomes less about getting pt a mammogram but how do we help the patient at 3pm get the support she needs to manage DM
  25. Tierney (2:20-2:40) Transition slide
  26. Tierney (2:20-2:40)
  27. Tierney (2:20-2:40)
  28. Tierney (2:20-2:40)
  29. Tierney (2:20-2:40) Planned Care = MA Standing Order
  30. Tierney (2:20-2:40)
  31. Tierney (2:20-2:40)
  32. Tierney (2:20-2:40)
  33. Tierney (2:20-2:40)
  34. Tierney (2:20-2:40)
  35. Tierney (2:20-2:40)
  36. Tierney (2:20-2:40)
  37. Mary (2:40-2:45)
  38. Mary (2:40-2:45)
  39. Mary (2:45-2:55)
  40. Bianca (2:55-3:00)
  41. Bianca (2:55-3:00)