Building the Right Generalist Team for the Right Prevention

CareMike Davies MD FACP

Mark Murray and Associates

The two ways to improve are…

• Increase speed

• Improve reliability

• Clinical care is about both speed and reliability: “…the right care…at the right time…..”

What is “Primary Care”?

…Responsible for providing or coordinating the majority of the patient’s care…

360 Patients are Over 65

60 Patients had more than 10 Office

Visits Last Year

130 are Clinically Depressed

228 have Hypertension

160 have Heart Disease

248 have Arthritis

113 have Asthma

66 have Diabetes

Panel Size 2000

Operational and Clinical TeamsC

linic

al T

eam

s: W

hat

to

do

?

Operational Teams: How to do it?

Close to Agreement

Far from agreement on HOW to do it (how to

implement guidelines, how to support provider’s

efficiency)

XX

XX

Far from agreement on WHAT to do (what

prevention and chronic disease guidelines to

implement)

Learning's

• The RIGHT care prolongs and enhances lives

• The best centers have teams of people partnering to deliver the right care

• The best clinics measure their own performance

• The best clinics compare their performance to others to find the best ideas for improvement

Quandary

• How to assure prevention care is done for every patient in the panel

• How to adapt the clinic processes to changing recommendations

• How to do it efficiently

Questions

• Are we responsible for prevention of illness in our patients?

• Do we do it?• Do we do it well?• Do we measure it?• Are patients aware of their own prevention

results?• Are patients queued to ask for their

prevention care?

WHAT prevention care should we provide?

Society Recommendations – Chinook Recommendations –

Other Options

Case

• A 61 year old female presents to your office for her yearly physical examination. She has no significant past medical or surgical history and currently uses no medications. She denies alcohol intake greater than 2 glasses of wine per day and smokes currently 1ppd for at least 35 years. On review of your chart, there is a family history of postmenopausal breast cancer. She is mildly overweight (greater than 5% but less than 15% above ideal body weight).

Which of the following would be appropriate at this office visit (Recommended)?

A. Screening Fasting Plasma Glucose

B. TSH screening

C. Pneumococcal Vaccination

D. Hepatitis B Vaccination

E. Counseling on Seat Belt use

Which of the following screenings would not be recommended without reservations for this patient?

A. Bilateral Mammograms

B. Pap Smear for cervical cancer screening

C. DEXA scan for osteoporosis screening

D. Lipid screening

E. Chest X-ray for pulmonary nodules given her smoking

history

Preventative Services Recommendations

From USPSTF and others as summarized by Loyola Medical

School for Adults

• Health Guidance

• Immunizations/Chemoprophylaxis

• Screening

Health Guidance…some organizations recommend

counseling

• Sexual Behavior/AIDS (esp. adolescents)

• Violence and Gun Use• Family Planning• Folate Use in Women

(preconception counseling)

Health Guidance

• Smoking• Diet• Exercise• Injuries/Motor vehicle accidents• Alcohol and Drug Use• Aspirin Use for Primary Prevention of MI

Did Not Receive Counseling AboutExercise and Diet in Past Year

3631

50

36

45

29

0

25

50

75

AUS CAN GER NZ UK US

2005 Commonwealth Fund International Health Policy Survey

Base: Adults with chronic health condition

Adult Immunizations

• Tetanus-Diphtheria

• Pneumococcal

• Influenza A

• Hepatitis B

• Hepatitis A

• MMR

• Vericella

Screening for Disease

• Cardiovascular

• Oncologic

• Endocrine

• Vision/Hearing

• Oral Examination

Cardiovascular

• Hypertension – BP Q 1-2 yrs

• Abdominal Aortic Aneurysm - Men >65 with history of any tobacco use

• Carotid Artery Disease - no

• Coronary Artery Disease – no ETT

• Peripheral Vascular Disease - no• Dyslipidemia - Total non fasting cholesterol for

men 35-65 and women 45-65.

Screening for Endocrine Diseases• Diabetes Mellitus

– Individuals with “high clinical risk” (Class II)– Cardiovascular disease (Class I)

• HTN or Dyslipidemia

– Strong family history (Class II)– Obesity (Class III or Stage I)

• Thyroid Disease – Indeterminate Recc.– Screening is effective, treatment available– Unsure of long term effects of over treatment and

asymptomatic diseas

• Osteoporosis - Routine DEXA scan is recommended by USPFTS every three years, except in some higher risk populations should be yearly.

Oncologic Diseases

• Ovarian using ultrasound PPV is 2.6% with per 100,000 screened 40 TP, 5398 FP and 160 laparotomy complications

• Testicular if 1500 male patients in practice would see 1 case every 20 years

• Lung – no reccs• Pancreatic – no reccs• Bladder – periodic UA after 60• Skin – “sun” counseling

Oncologic Diseases

• Breast – many organizations: Screening Mammography and Clinical Breast exam in women ages 50-69.

• Cervical – common reccs: Screening Pap Smears at age 18 or sexually active then every 3 years until age 65.

• Colorectal – screen: FOBT, Sigmoid, or Colonoscopy

• Prostate - Education

Another way to approach screening: Tests and Exam

Tests:• BP, Height and Weight, Cholesterol, Hearing,

Mammograms, Pap smear, PSA, FOBT or Sigmoidoscopy or Colonoscopy, Urinalysis

Exam:• Dental, Eye, Breast, Cancer exams (thyroid,

oral, ovaries, testicles, lymph nodes, rectum, prostate

• Orals are questionable but no harm, • vision biyearly if no impairment

Women’s Preventive Care Guide

Women’s Prevention Tests

Men’s Prevention Issues

Men’s Prevention Tests

Healthy People 2010

• Physical Activity • Overweight and Obesity • Tobacco Use • Substance Abuse • Responsible Sexual Behavior   • Mental Health  • Injury and Violence   • Environmental Quality   • Immunization   • Access to Health Care

Clinical Care: Possible Choices

• Prevention– Flu Vaccination– Pneumonia

Vaccination – Breast Cancer– Cervical Cancer– Colon Cancer

TruePositives

F/U Positives

Screen some of panel for everything

ScreenAllOf

The PanelFor

AFew

Things

Prevention and Screening

Entire Panel

Operational and Clinical TeamsC

linic

al T

eam

s: W

hat

to

do

?

Operational Teams: How to do it?

Close to Agreement

Far from agreement on HOW to do it (how to

implement guidelines, how to support provider’s

efficiency)

XX

Close to agreement on WHAT to do in

Prevention

XX

Team

Doctor’s Office Has a NurseRegularly Involved in Care Management

16 19

47

36

52

41

0

25

50

75

AUS CAN GER NZ UK US

Base: Adults with chronic disease

Percent have nurse involved

2005 Commonwealth Fund International Health Policy Survey

Options

What• Don’t do any prevention• Do prevention sporadically• Do prevention systematically with few topics• Do prevention systematically with all topics

HOW• Doctor does it all• RN or LPN does it all• MA does it all• Team splits the work

Options

• None• Sporadically• Systematically – few• Systematically - all

• MA• Nurse• Doc/Provider

Options

• Systematically – few• Systematically - all

• MA• LPN• RN• Doc/Provider

Financial Implications of Team Choices

MA? LPN? RN? APN?

Variables…

• How much work is there?

• What level of staff is needed to do the work? (and who is paying the bill!?)

• What is the process for doing the work?– Supplement– Substitute

• What tools are needed to do the work?

Prevention Bundle (5 topics) as an example…..

Prevention Bundle Topics

– Flu Vaccination– Pneumonia Vaccination – Breast Cancer– Cervical Cancer– Colon Cancer

Prevention Bundle Tasks

• Assess compliance with prevention bundle (Immunization and Cancer Screening Care)

• Provide Care– Do Screening Exam (breast, cervical)

– Educate on options (for colon cancer screen) (FOBT, Flex Sig, or Colonoscopy) and choose one

– Order or provide appropriate test

• Document Care

Time for Each Task (Estimate)

Tasks Time (min)

Assess 2

Exam 10

Educate 4

Order 2

Document 2

Total 20

Tasks Provider APN RN LPN MA

Assess X X X X

Exam X X

Educate X X X X

Order X X X* X*

Document X X X X X

Who Could Perform Tasks?

* = under protocol

Thought Experiment….Doc

• Doc does it all– Cost = Doc time @ $1.42/min X 20 min= $28.40

– Doc doing work someone else could do! (Not doing other high value work)

– Quality good– Access may be poor for other patients– Income ++ for pay-by-visit– Income – - for pay-by-panel– Time spent relatively low value (others could do it)

Thought experiment….Nurse

• Nurse does it all– Cost = Nurse time @ $0.66/min X 20 min = $13.20

– Nurse not able to do all parts of the work (order/interpret)…although APN may…..

– Quality presumably good – Access to doc probably better – Value of doc visits probably higher– Access to nurse may be poor if not enough nurses

Thought Experiment MA

• MA does it all– Cost = MA time @ $0.24/min X 20 = $4.80– MA cannot do all parts of the work (assess, or

order tests)– Quality poor since all tasks not completed– Access to doc and nurse both probably better

if MA takes some of work away– Value of doc and nurse time both higher

Tasks Provider APN RN LPN MA

Assess X X

Exam X X

Educate X

Order X*

Document X X X

Who Should Perform Tasks?Assuming everyone performs at highest level..

* = under protocol

Team Cost

Tasks Time (min) Cost Total Cost

Assess 2 0.24 * 2 0.48

Exam 10 1.42 * 10 14.20

Educate 4 0.44 * 4 1.70

Order 2 0.44 * 2 0.88

Document 2 1.42 *1 + 0.24 * 1

1.66

Total 20 18.92

Bottom Line Prevention Bundle Cost Comparison

Doc Alone Team

Time (min) 20 20

Cost ($) 28.40 18.92

Quality Good Good

Access Less More

Assuming 400 Panel Patients

• 400 patients X $10 savings = $4000

• 10 min Doc savings X 14.20 X 400 = $5680

• Total improvement in $ = 9680

Doc Alone Team

Time (min) 20 20

Cost ($) 28.40 18.92

Quality Good Good

Access Less More

Prevention Example: Process

P a tie nt C a lls R e c e ptio nis tN urs eo rM D

A ppo intm e nt

G o to la b

H is to ry a ndP hys ic a l

T re a tm e nt

La b fo r te s ts

F o llo w -up

Prevention Process: Option 1

Prevention Process: Option 2

Receptionist

Nurse

Doc

AssessDocument

EducateOrderDocument

ExamDocument

Process: Option 3

Process and Tasks linked

• Substitute – Team members can do much of prevention

care– Not possible to do independent of provider

• Supplement– Only option

Clerk/MA

Old• Update demographics• Make appointments• Answer phone and

refer calls

New• Manage demand in

concert with team• Assist with prevention

and chronic illness care (health prompts)

• Collect D/S/SU info

Nurse

Old

• Check in patients• Take VS• Room patients

New• Screen for prevention• Screen for chronic

disease• Order by protocol• Basic patient education• F/U phone calls for panel

patient tests• Field phone calls and

give advice

Doctor’s new role

• Evaluate and manage acute illness

• Coordinate care for chronic patients

• Promote prevention and wellness

• Interact with other team members

• Manage patients with non-visit care

• Maintain access

Primary Care Core Competencies

• . Screen blood pressure and recommend further evaluation if elevated. For confirmed high

• blood pressure, offer diet and exercise recommendations.• 2. Diagnose and manage simple infectious diseases using commonly

recognized treatment standards. This would include such diseases as: a. upper respiratory infections b. pharyngitis c. gastroenteritis (uncomplicated, short-term diarrhea and/or vomiting) d. urinary

• tract infections.• 3. Be familiar with preventive medicine guidelines and be able to advise

patients about necessary procedures/tests based on the CIPS preventive medicine screen. This would include reminding patients about flu shots, mammograms, flexible sigmoidoscopy, etc, and

• ordering as appropriate. "• 4. Recognize alcoholism, cigarette addiction, substance abuse, depression,

and domestic• violence/sexual abuse and refer for appropriate management.

Indiana Hospital Prevention and Chronic Disease Solutions

• Expand CM Activities to All Support Staff :

FunctionMedical

Assistant LPN RN APN CMVital sign monitoring X X X XAccuchek X X X XClinical guideline screening X X X XAdministring medications X X XNursing assessment X XTelehealth monitoring X XOrdering medications X

Prevention Example: Space

Indiana Room Turnover Project

Exam Room

Exam Room

Exam Room

Exam Room

Exa

m R

oom

Exam Room

Exam Room

RN Station

Exam Room

Exam Room

Exam Room

Exam Room

Exam RoomE

xam

Roo

m

Exa

m R

oom

Exa

m R

oom

Check-in

ProviderCharting

Procedures

Calls Patient

“6+ Miles per Day”

In My Experience…

• Doc responsible for all prevention care• Doctor’s participation is:

– Choose topics– Design process– F/U positives

• Nurse and/or MA does majority of prevention care

• Measurement and feedback regularly occur

Tele-Eye Outcomes

• 68% reduction in demand for diabetic eye exams in Eye Clinic– 93% of Primary Care Exams do

not require Eye clinic follow-up

• Increased diabetic screening rate75% 91% completed annual

exam

• Reduced eye clinic waiting time80 days 11 days

Case ManagerReviews on VA

PC

Data Analysis&

Data Storage

Case Manager Reviews on

VA PC

Telephonic Follow-up of

Alerts

Telehealth Monitor

Peripheral Devices

Telehealth OverviewThe FutureTele-homecare

Group Visioning Exercise

• Split up into new groups

• Introduce each other

• Design the ideal prevention care clinic– Choose topics– Sketch out process– Assign tasks– Design measurements

• Competition: Best design gets prizes