GENTLE MEDICINE ASSOCIATES

BOYNTON BEACH,FL

Learning Session 2

April 27-28, 2012

Disclosure

I have no relevant financial relationships with the manufacturers of any commercial

products and/or provider of commercial services discussed in this CME activity.

I do not intend to discuss an unapproved/investigative use of a commercial product/device in their

presentation.

LOCATION BOYNTON BEACHSMALL PRIVATE PRACTICE.• ONE PHYSICIAN• ONE NURSE PRACTITIONER• VERY DIVERSE POPULATION• ELECTRONIC RECORDS SINCE 2002

• Patient population management has been a focus of our organization since 2006

• Previously limited to creating a reminder list for patients with Asthma and Sickle cell disease for Influenza vaccine.

• With the help of our EMR the medical assistant was able to pull the list yearly

• After our return from the first training meeting we decided to expand it to patients with Diabetes, Seizure disorder, Autism and Cerebral Palsy.

Background

AIM STATEMENT

• By March 30, 2012, we will expand our identification of our patients with special needs to improve management of that patient population by coordinating care with CMS and making sure they had timely follow-up.

Step 1: Create report by diagnosis

Step 2: Includes parameters

Data collection

• The review was conducted over 2 months including collection.• The entire team was involved in recalling patients with poor compliance.

• The following 2 months we compared ourpatient visits to a list provided by CMS and other insurances.• We also reviewed the charts to make sure we

received reports from specialists.

Results we obtained after review

Diabetes care• 100% of our patients were enrolled with CMS• Had same nurse and nutritionist• Most had problem following the prescribed diet• Family education needed • Help with school cafeteria needed

Results after review 2

Asthma care• Identify at least half of patients with mild to moderate

asthma who did not return for their follow up appointment.

• Those who did not refill their maintenance medication

• Those with no school authorization for their asthma meds use in school.

Results obtained after review 3

Autism care• Average time between suspicion and final diagnosis

by a neurologist was between 12 and 18m.• Main issue is paucity of programs for patients

younger than 3 y of age.• Plan is to work closely with CMS and school system

to get services for the children as soon as they are diagnosed.

Results obtained after review 4

Sickle cell program well establishedin the community

• 100% of patients are with CMS. • All except one outlier with poor compliance

getting regular care.• Our focus is on getting newborn screening results

on all infants for early identification of all hemoglobinopathies.

Results obtained after review 5

Seizure disorder • Usually no problems getting services. • Most are enrolled in CMS and have access to

neurologist and medications.• Some patients with poor control might need

closer follow up.

Changes made

All patients with chronic illness get a follow up appointment after each visit

All patients asked to bring their medication with them to the office

All asthmatic patients get medication forms for school

CMS nurse asked to send copies of officevisits by specialists

Changes we made to get results

Recall patients with missed visits in both our office and with specialists.

Recall patients with abnormal reports from specialists.

Schedule all patients to return for follow up visitsat least one month after any referral to specialists or speech evaluation.Check immunization status on all patients at any

visits.

Immunization status update

Immunization update 2

FL SHOTS has a feature that enables practices to create their own recall list for patients who need immunization update•Open your Florida SHOTS site•Reminder recall recall list•Patient reminder list searchIn that page you can search any period from last 30 days to a particular interval

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% of patients with patient and/or family concerns elicited at this vist

Your Practice GOAL All Practices

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% of patients with all expressed concerns addressed or with plans made to address them

Your Practice GOAL All Practices

Reflections

We learned that we had a lot of capabilities in our EMR. It is a very good tool to use for this purpose

Importance of creating a registry as a tool for improving care and really knowing your patients.

Importance of getting input from parents regarding the barriers they have to overcome to get care for their children.

How to use the registry to work with our patient/parent partners.

CMS can be a very helpful partner to reach the goal of establishing a medical home.

More reflections

Difficulty in getting info on patient compliance when they get prescriptions from different sources.Need for more communication with schoolnursesIt takes dedication, persistence and strong leadership to deal with the challenges, changesnecessary to maintain results.Without buy in from all team members it is impossible to reach goals.

Even more reflections

It is very satisfying to work with parentsto help them care for their childrenIt is good medicine to provide them witha medical homeIt is a time consuming endeavor It is also good businessThink HEDIS

1. My advice is to invest in an EMR and insist on having those features that would help you reach the stated goal of knowing and managing your patient population.

2. The next step is the patient portal which will increase the patient’s participation in their care and provide them with their information at all times.

3. It is possible to use Excel sheet if you use paper charts but it is more difficult to access and update the data.

Small piece of advice

Greetings From Gentle Medicine