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© 2003 PeaceHealth
Using Practice Teams to Improve Efficiency and Quality of Care for Older Adults
Ron Stock MD MAThe Gerontology InstitutePeaceHealth Oregon [email protected]
© 2003 PeaceHealth
Learning Objectives
1) Understand the key attributes of a practice team and how to develop a team in practice.
2) Describe the team-based practice changes that lead to improved efficiency and quality of care.
© 2003 PeaceHealth
Acknowledgements
• PeaceHealth Oregon Region Leadership, Eugene, OR• PeaceHealth Clinical & Operational Improvement
Division, Bellevue, WA• John A. Hartford Foundation, Geriatric
Interdisciplinary Teams in Practice Initiative• AHRQ Patient Safety Implementation Challenge Grant
© 2003 PeaceHealth
Mission Statement:
"To seek to understand and meet the health, sociological,psychological, and functional needs of the aging population
through research, quality clinical care, education, andcommunity collaboration."
Research
Clinical Care
Education
Community Collaboration
Health Services Research *- Applied Geriatric Care- Transitional Care- Chronic Care
University of Oregon/Oregon Health Science University(OHSU) Collaboration *
Federal Demonstration Projects Pharmaceutical Drug Trials
Senior Health & Wellness Center(SHWC) *- Primary Care- Consultations
Regional Consultation Collaborative *- Inpatient- Outpatient
Geriatric Community Health CareServices (SNF, RCF, ALF) *
Inpatient Acute Care of the Elderly(ACE) Unit
OHSU Medical School Collaboration *
OHSU Nursing School Collaboration *
Teams in Healthcare Consultations *
Portland State University (PSU)SW Department
Advanced Training Program (ATP) inApplied Outpatient Care of older adults
Clinical Pastoral Education
OASIS *
HeartLine/Lifeline *
Chronic Disease Self ManagementProgram (CDSMP) *
Alzheimer's Association *
Senior & Disabled Services (AAA) *
Civic engagement
* current expertise/relationship
Eugene, Oregon
© 2003 PeaceHealth
Care Model Influences
•The “Senior Health Clinic” movement•Lean Thinking; “Voice of the Customer”• Institute for Healthcare Improvement (IHI) Breakthrough Series on the Chronic Care Model
• IHI Idealized Design of Clinic Office Practice
Informed,ActivatedPatient
ProductiveInteractions
Prepared,ProactivePractice Team
Improved Outcomes
DeliverySystemDesign
DecisionSupport
ClinicalInformation
Systems
Self-Management
Support
Health System
Resources and Policies
Community
Health Care Organization
Chronic Care Model
© 2003 PeaceHealth
Senior Health & Wellness Center
Aim: To develop a comprehensive senior healthcare practice through an interdisciplinary team approach
© 2003 PeaceHealth
SHWC Interdisciplinary Team
• Geriatrician• Gerontological Nurse Practitioner (GNP)• Team Nursing• Medical Social Worker/Care Coordinator• Pharmacist• Dietician• Physical Therapist• Chaplain• Home Health Coordinator• Health Information Librarian
© 2003 PeaceHealth
Senior Health Center Care Model• Geriatric expertise• Prepared, proactive interdisciplinary care team• Planned, coordinated, protocol-driven care• Informed, activated patients• Senior sensitivity trained staff• Community collaboration
Model description in:Stock RD, Reece D, Cesario L. Developing a Comprehensive
Interdisciplinary Senior Healthcare Practice. JAGS 52:2128-2133, Dec 2004.
© 2003 PeaceHealth
Hartford Senior Health Clinic Study
• “Does an interdisciplinary team (and Chronic Care Model) approach improve health/org outcomes for older adults?”
• 3 groups; n=1309; 30 month study• Results:
– Take less meds– Higher immunization rate– Fall less– Despite physical decline maintain quality of life– Depression scores improve – Pt Satisfaction unchanged– Lower Medicare costs
© 2003 PeaceHealth
© 2003 PeaceHealth
© 2003 PeaceHealth
Why “team” care?
•Changing healthcare models and environment, regulatory and training requirements
•Clinical outcomes better•Safer, more reliable care•Happier patients•Happier staff
© 2003 PeaceHealth
Challenges to Developing Effective Teams
•Different disciplines•Not trained together•Hierarchy•Asynchronous care•Lack of continuity•Culture slow to change
© 2003 PeaceHealth
What is a “team”?
Work Group
Ad hoc committee
“Unit”
Clinic
“Practice”
© 2003 PeaceHealth
What is a team?
Multidisciplinary Interdisciplinary
Interdependent
© 2003 PeaceHealth
What is a Team?
•Task-oriented vs relationship-oriented•Membership defined by healthcare vs. patient/family
•Teams develop around the core principle of “trust”
© 2003 PeaceHealth
“…two or more individuals who have specific roles, perform interdependent tasks, are adaptable, and share a common goal. Moreover, members of teams must possess specific knowledge, skills, and attitudes (KSAs), such as the ability to exchange information, which enable individual team members to coordinate.”
Baker et al. The Role of Teamwork in the Professional Education of Physicians. Jt Comm J Qual Saf 31(4): 185-202, April 2005.
© 2003 PeaceHealth
Teamwork Model (Baker et al, 2005)
Organization
Team
Individual
© 2003 PeaceHealth
Team Structure
1. Core Team
2. Coordinating Team
3. Contingency Team
- TeamSTEPPS
© 2003 PeaceHealth
The Team “Bundle” Intervention•Leadership Commitment
– Practice/Unit level– Organization
•The Team Development Measure– Feedback to team with discussion– Target improvements
• Intra-staff communication skills training•Patient/case-focused care conferences or “huddles”
© 2003 PeaceHealth
How will you know whether you’re a team…. or not?
The Team Development Measure (TDM)www.teammeasure.org
31 Items
Rasch survey measurement methodology
Psychometric testing:
250 teams; n=956
Mplus factor analysis= 4 factors best sol’n
Cronbach’s alpha=0.90
The Team Development Measure (TDM)
Cohesion
Communication
Roles Clarity
Goals Clarity
“…the social glue that binds the team members as a unit.”
Team members…. Say what they feel and think; are truthful, respectful and positive; address conflict maturely
Clearly defined roles and expectations. Accomplishments of the team are placed above individuals
Clearly defined team goals and the means to reach these goals.
Building
PreTeam
Stage 1
Fully Developed
Stage 8
Stage 7
Stage 6
Stage 5
Stage 4
Stage 3
Stage 2
Established
© 2003 PeaceHealth
Typical 1st Assessment Results
© 2003 PeaceHealth
Same Team 4 Months Later
© 2003 PeaceHealth
What have we learned about teams?
• Teams don’t just happen, formalized training is necessary• Requires ongoing maintenance • Use the Team Measure to inform and improve• Weekly Care Conference/huddle helps the team
“practice” • Teams are a prerequisite for sustainable quality
improvement• Clinical outcomes are better• Organizational health improves
© 2003 PeaceHealth
Team Practice Interventions That Make a Difference
• Practice re-design• Protocol-Driven Standardized Processes • Care Management Services• Managing “Transitions”• Engagement of Patients and Families
© 2003 PeaceHealth
Practice Re-Design
•One-stop shop•Nursing care teams•Advance Practice Nurses
© 2003 PeaceHealth
Protocol-Driven Standardized Processes
•Very Important Papers (VIP) process• Immunizations•Medication Management•Disease-specific management
© 2003 PeaceHealth
Immunization Pearls
•Agree on immunization protocol•Educate all staff•Provide standing orders •Assign the role of immunization management to a staff nurse and provide appropriate training and resources
•Measure and have a process for follow-up
© 2003 PeaceHealth
Pneumovax and influenza vaccination rates are significantly higher in the Intervention Group, the Senior Health & Wellness Center (SHWC) model.
Baseline 6 Months 18 Months 30 MonthsWave
828384858687888990919293949596
Per
cen
t
Care Model
Intervention
Comparison 1
Comparison 2
Percent Patients Having Pnuemonia Vaccination by Wave by Care Model
© 2003 PeaceHealth
Medication Management Pearls
•Agree and educate on “bad” drugs•Screen for patients on >4 meds•Referral to geriatric pharmacist for med review if on >4 drugs (standing order)
•Standardize process components of med reconciliation in ambulatory setting
© 2003 PeaceHealth
Medications
SHWC participants (intervention group) were prescribed significantly less medications and use did not increase over time.
6 Months 18 Months 30 MonthsWave
3.6
3.7
3.8
3.9
4.0
4.1
4.2
4.3
4.4
Est
imat
ed M
arg
inal
Mea
ns
Estimated Marginal Means of Number of Prescription Medications by Wave by Care Model
Intervention
Comparison 1
Comparison 2
© 2003 PeaceHealth
Care Management Services
•Primary care-based•RN/MSW•High intensity/low volume•Care Management Plus
© 2003 PeaceHealth
Managing Care Transitions
•Develop services that address care across the care continuum
•Leverage EMR capabilities•www.caretransitions.org
© 2003 PeaceHealth
Patient & Family Engagement
•Self-management support (Group visits; Chronic Disease Self-Management Program)
•Office practice volunteers•New patient and family orientation•Quality Improvement project participation•Patient Advisory Council
© 2003 PeaceHealth
What have we learned?
• This model of care has features that produce better outcomes; Implement a “bundle” of improvement changes
• Interdisciplinary, Interdependent team approach• Planned, coordinated care• Protocol-driven processes (standardization)• Continually involve patients and caregivers;
Patients and families need to be “partners”, not just “consumers”
© 2003 PeaceHealth
References• www.teammeasure.org• GITT program (www.gitt.org)• TeamSTEPPS http://www.ahrq.gov/qual/teamstepps• Drinka T and Clark PG. Health Care Teamwork:
Interdisciplinary Practice and Teaching. Westport, CT: Auburn House, 2000.
• Grumbach K and Bodenheimer T. Can Health Care Teams Improve Primary Care Practice? JAMA 2004;291(10):1246-1251.
• Baker et al. The Role of Teamwork in the Professional Education of Physicians. Jt Comm J Qual Saf 31(4): 185-202, April 2005.
• Pronovost P, Berenholtz S, et al. Improving communication in the ICU using daily goals. J Crit Care. June 2003; 18(2):71-75.
© 2003 PeaceHealth
References• Singh H, et al. Medical errors involving trainees. Arch Intern
Med Oct 2007; 167(19):2030-2036.• Baker et al. The Role of Teamwork in the Professional
Education of Physicians. Jt Comm J Qual Saf 31(4): 185-202, April 2005.
• Cohen, S.G. and Bailey, D.E What makes teams work: Group effectiveness research from the shop floor to the executive suite. Journal of Management, 23, 1997, 239-290.
• Gaba et al. Simulation-based training in anesthesia crisis resource management (ACRM): A decade of experience. Simulation Gaming 2001; 32:175-193.
• Pizzi L, Goldfarb N, and Nash D. Chapter 44. Crew Resource Management and its Application in Medicine. http://www.ahrq.gov/clinic/ptsafety/chap44.htm
© 2003 PeaceHealth
The Team Development Initiative
•Development of a comprehensive senior healthcare practice using the Chronic Care Model and IDT principles
•Funded by the Hartford Foundation Geriatric Interdisciplinary Teams in Practice (GIT-P) Initiative and subsequent 3-year Dissemination Project
•Spread: PeaceHealth; Group Health; Providence-Oregon; preliminary discussions with Kaiser