Beyond the Blueprint Beyond the Blueprint Building the Patient Centered Building the Patient Centered
Medical HomeMedical Home
Wisconsin Primary Care Research & Quality Wisconsin Primary Care Research & Quality Improvement Forum Improvement Forum Wisconsin Dells, WIWisconsin Dells, WI
11.13.0911.13.09Christine Sinsky, MDChristine Sinsky, MDThomas Sinsky, MDThomas Sinsky, MD
[email protected]@mahealthcare.comMedical Associates Clinic and Health PlansMedical Associates Clinic and Health Plans
Dubuque, IowaDubuque, Iowa
AgendaAgenda
BackgroundBackground The Challenges of Primary Care The Challenges of Primary Care 8 strategies to transform practice8 strategies to transform practice DiscussionDiscussion
Take Home MessagesTake Home Messages
It’s all about It’s all about Planning ahead Planning ahead Sharing the loadSharing the load Enjoying the work!Enjoying the work!
BackgroundBackground
Primary Care Primary Care NCQA Advisory Panel: PCMH NCQA Advisory Panel: PCMH Consultant and WorkshopsConsultant and Workshops All trying to solve same equation All trying to solve same equation
Different settingsDifferent settings QE & S: quality, efficiency and satisfactionQE & S: quality, efficiency and satisfaction
We will know who you are and We will know who you are and we will be ready for you.we will be ready for you.
Borgess Ambulatory Care, Kalamazoo, MIBorgess Ambulatory Care, Kalamazoo, MI
At the center of primary care are At the center of primary care are face-to-face healing relationships.face-to-face healing relationships.
Patient: NursePatient: Nurse Nurse: PhysicianNurse: Physician
Nurse: NurseNurse: Nurse Patient: PhysicianPatient: Physician
115 physicians, owners
Health Plan: 1/3 of pt population
EHR: 2003
Staff Turnover: < 5%
Physician Satisfaction: > 95%’ile AMGA
PCP Productivity and Compensation: 85%’ile MGMA
SatisfactionSatisfaction
Patient Centered Patient Centered Medical HomeMedical Home
QualityQuality
Snapshot of PracticeSnapshot of Practice
StaffingStaffing Primary nursePrimary nurse Help nurseHelp nurse 1.5 nurse: MD1.5 nurse: MD (no MAs)(no MAs)
SpaceSpace 3 exam rooms3 exam rooms
SchedulingScheduling 1 Receptionist: 2 MDs1 Receptionist: 2 MDs Wave SchedulingWave Scheduling
Snapshot of PracticeSnapshot of Practice
Typical ScheduleTypical Schedule 6-8 Annual6-8 Annual 10-12 Planned Care10-12 Planned Care 4-6 Rapid Access4-6 Rapid Access
Panel SizePanel Size 1800-20001800-2000
Outpatient/InpatientOutpatient/Inpatient
Mrs. PetersMrs. Peters
65 year old annual exam65 year old annual exam DM2DM2 HTNHTN Depression Depression
PreventionPrevention New c/oNew c/o
HeartburnHeartburn Sleep disturbanceSleep disturbance FatigueFatigue
# of Quality measures?
There is a lot to be done!There is a lot to be done!
65 year old annual exam DM2 (9) HTN (17) Depression (10)
Prevention (27)
New c/o Heartburn (3) Sleep disturbance Fatigue
# of Quality measures? 56*McGlynn EA, N Engl J Med 2003. 348;26:2535-2645*McGlynn EA, N Engl J Med 2003. 348;26:2535-2645
There is a lot to be done!There is a lot to be done!
Too much to be done by just one person
Too important to be left to chance
Core Team Model:Core Team Model:Plan Ahead, Share the LoadPlan Ahead, Share the Load
Right thing happens by Right thing happens by defaultdefault
Staff work full level of Staff work full level of abilityability
Minimize work MD does Minimize work MD does that is within skill set of that is within skill set of othersothers
““In few other sectors of the economy is the In few other sectors of the economy is the highest-level professional responsible for the highest-level professional responsible for the majority of production, customer service, and majority of production, customer service, and clerical work.”clerical work.”
SGIM Blue Ribbon Panel Report. Redesigning the Practice SGIM Blue Ribbon Panel Report. Redesigning the Practice Model for General Internal Medicine: A Proposal for Model for General Internal Medicine: A Proposal for
Coordinated Care. Coordinated Care. J Gen Intern MedJ Gen Intern Med 2007;22:400-109 2007;22:400-109
Episodic CareEpisodic Care
Check-inCheck-in
receptionistreceptionist
Room ptRoom pt
nursenurse
MD MD
Check-Check-outout
Vital signsVital signs Medication Medication
reconciliationreconciliation HistoryHistory ExamExam Data GatheringData Gathering Data entryData entry Decision makingDecision making Relationship buildingRelationship building Prescription writingPrescription writing DocumentationDocumentation PaperworkPaperwork Behavior Behavior
ModificationModification Results reporting Results reporting Order entryOrder entry
Insurance Insurance verificationverification
Collect Collect co-payco-pay
Verify Verify contact infocontact info
¼ MA: MD¼ MA: MD
??
Work Within Skill-set of OthersWork Within Skill-set of Others
Check-inCheck-in
receptionistreceptionist
Room ptRoom pt
nursenurse
MD MD
Check-Check-outout
Vital signsVital signs Medication Medication
reconciliationreconciliation HistoryHistory/History/History ExamExam Data GatheringData Gathering Data entryData entry Decision makingDecision making Relationship buildingRelationship building Prescription writingPrescription writing DocumentationDocumentation PaperworkPaperwork Behavior Behavior
ModificationModification Results reporting Results reporting Order entryOrder entry
Insurance Insurance verificationverification
Collect Collect co-payco-pay
Verify Verify contact infocontact info
¼ MA: MD¼ MA: MD
??
Integrated, Continuous CareIntegrated, Continuous Care
Office VisitOffice Visit
Between Between Visit CareVisit Care
Efficiencies and care coordination
Nurse-MD Team
Build-inrather than Carve-out
Pre-apptlab
Core Team Model:Core Team Model: Planning Ahead & Sharing the LoadPlanning Ahead & Sharing the Load
Planned Care ApptPlanned Care Appt Order setsOrder sets Empowered TeamEmpowered Team Pt. QuestionnairePt. Questionnaire Prescription Mgm’tPrescription Mgm’t Visit SummaryVisit Summary Annual ExamAnnual Exam Rapid AccessRapid Access Intentional BehaviorsIntentional Behaviors
Planned Care AppointmentPlanned Care Appointment
Pre-appt labPre-appt lab Majority lab prior to apptMajority lab prior to appt Patient part of decision makingPatient part of decision making
67 yo diabetic67 yo diabetic A1c 6.2A1c 6.2 LDL 160LDL 160
Bill P.Bill P.
Planned Care ApptPlanned Care Appt Order setsOrder sets Empowered TeamEmpowered Team Pt. QuestionnairePt. Questionnaire Prescription Mgm’tPrescription Mgm’t Visit SummaryVisit Summary Annual ExamAnnual Exam Rapid AccessRapid Access Intentional BehaviorsIntentional Behaviors
Planned Care AppointmentPlanned Care Appointment
EfficiencyEfficiency ““Just in time” info processingJust in time” info processing Close the loop during that apptClose the loop during that appt
Results reportingResults reporting 4 hr clinic 4 hr clinic →→ 2 hr post-appt 2 hr post-appt
SafetySafety Missing or overlooked informMissing or overlooked inform Pt & family part of safety netPt & family part of safety net
Planned Care ApptPlanned Care Appt Order setsOrder sets Empowered TeamEmpowered Team Pt. Questionnaire Pt. Questionnaire Prescription Mgm’tPrescription Mgm’t Visit SummaryVisit Summary Annual ExamAnnual Exam Rapid AccessRapid Access Intentional BehaviorsIntentional Behaviors
Lab SummaryLab Summary
Post-Appointment Order SetsPost-Appointment Order Sets
Planned Care ApptPlanned Care Appt Order setsOrder sets Empowered TeamEmpowered Team Pt. QuestionnairePt. Questionnaire Prescription Mgm’tPrescription Mgm’t Visit SummaryVisit Summary Annual ExamAnnual Exam Rapid AccessRapid Access Intentional BehaviorsIntentional Behaviors
Acute Symptom Acute Symptom EvaluationEvaluation
Planned Care ApptPlanned Care Appt
Annual Comprehensive Annual Comprehensive Care VisitCare Visit
Place Today’s Care in Place Today’s Care in Continuum of TimeContinuum of Time
Last PELast PEUpcoming appts/labUpcoming appts/lab
Post-Appointment Order SetsPost-Appointment Order Sets
73 yo est. pt Rapid w/ fever, 73 yo est. pt Rapid w/ fever, coughcough
Planned Care ApptPlanned Care Appt Order setsOrder sets Empowered TeamEmpowered Team Pt. QuestionnairePt. Questionnaire Prescription Mgm’tPrescription Mgm’t Visit SummaryVisit Summary Annual ExamAnnual Exam Rapid AccessRapid Access Intentional BehaviorsIntentional Behaviors
Post-Appointment Order SetsPost-Appointment Order Sets
64 yo DM 2, hypothyroidism, 64 yo DM 2, hypothyroidism, atrial fibrillation, CRIatrial fibrillation, CRI
Planned Care ApptPlanned Care Appt Order setsOrder sets Empowered TeamEmpowered Team Pt. QuestionnairePt. Questionnaire Prescription Mgm’tPrescription Mgm’t Visit SummaryVisit Summary Annual ExamAnnual Exam Rapid AccessRapid Access Intentional BehaviorsIntentional Behaviors
Post-Appointment Order SetsPost-Appointment Order Sets
““The next appointment The next appointment starts today”starts today”
A plan, a promise to A plan, a promise to continue the relationshipcontinue the relationship
““We want to see you again, We want to see you again, and we will plan ahead to and we will plan ahead to make that most make that most meaningful.”meaningful.”
Planned Care ApptPlanned Care Appt Order setsOrder sets Empowered TeamEmpowered Team Pt. QuestionnairePt. Questionnaire Prescription Mgm’tPrescription Mgm’t Visit SummaryVisit Summary Annual ExamAnnual Exam Rapid AccessRapid Access Intentional BehaviorsIntentional Behaviors
Empowered TeamworkEmpowered Teamwork
Nursing staff full partners Nursing staff full partners Planned Care ApptPlanned Care Appt Order setsOrder sets Empowered TeamEmpowered Team Pt. Questionnaire Pt. Questionnaire Prescription Mgm’tPrescription Mgm’t Visit SummaryVisit Summary Annual ExamAnnual Exam Rapid AccessRapid Access Intentional BehaviorsIntentional Behaviors
•Nexus of organization of our practice•Filter
Between Visit
•Extension of me when dealing with patients; patients recognize this.
•Coordinates transitions (hospital, NH, Hospice)
•Manages & returns most phone calls
•Does prescriptions
•Updates EHR
• Completes all paperwork
Visit
•Med. Reconcil.
•Initial review of lab
•Pt education
•Immunizations
•Colonoscopy
•Sx driven tests (PFT, EKG)
•Diabetic foot exam/eye exam
•Present patient(↓ info drop-off)The Boss
Mini-huddleMini-huddle
Staff deeply engaged Staff deeply engaged Mentor nursesMentor nurses Physician better prepared Physician better prepared Stronger handoffStronger handoff
Planned Care ApptPlanned Care Appt Order setsOrder sets Empowered TeamEmpowered Team Pt. QuestionnairePt. Questionnaire Prescription Mgm’tPrescription Mgm’t Visit SummaryVisit Summary Annual ExamAnnual Exam Rapid AccessRapid Access Intentional BehaviorsIntentional Behaviors
Mini-huddleMini-huddle
47 yo “Rapid Access” new patient47 yo “Rapid Access” new patient
CC: dysphagiaCC: dysphagia Nurse Mini-huddleNurse Mini-huddle
““She seems depressed”She seems depressed” ““Is anyone hurting you?”Is anyone hurting you?”
Physician better preparedPhysician better prepared
Planned Care ApptPlanned Care Appt Order setsOrder sets Empowered TeamEmpowered Team Pt. QuestionnairePt. Questionnaire Prescription Mgm’tPrescription Mgm’t Visit SummaryVisit Summary Annual ExamAnnual Exam Rapid AccessRapid Access Intentional BehaviorsIntentional Behaviors
Introduction to PartnershipIntroduction to Partnership
Planned Care ApptPlanned Care Appt Order setsOrder sets Empowered TeamEmpowered Team Pt. QuestionnairePt. Questionnaire Prescription Mgm’tPrescription Mgm’t Visit SummaryVisit Summary Annual ExamAnnual Exam Rapid AccessRapid Access Intentional BehaviorsIntentional Behaviors
Pre-appointment QuestionnairePre-appointment Questionnaire
Identifies the patients agenda Identifies the patients agenda MD plan visit before enteringMD plan visit before entering Systems approachSystems approach
Update PFSHUpdate PFSH Complete ROSComplete ROS Behavior issuesBehavior issues: : exercise, smoking, alcoholexercise, smoking, alcohol
webmeeting.nih.gov/introwebmeeting.nih.gov/intro
FutureFuture Kiosk in waiting areaKiosk in waiting area Web portal from homeWeb portal from home
Planned Care ApptPlanned Care Appt Order setsOrder sets Empowered TeamEmpowered Team Pt. QuestionnairePt. Questionnaire Prescription Mgm’tPrescription Mgm’t Visit SummaryVisit Summary Annual ExamAnnual Exam Rapid AccessRapid Access Intentional BehaviorsIntentional Behaviors
Prescriptions are killing us…Prescriptions are killing us…my my nurse is spending so nurse is spending so much time on refills that much time on refills that we can’t seem to get anything we can’t seem to get anything done.done.
Minnesota Family PhysicianMinnesota Family Physician20072007
Prescription ManagementPrescription Management
Survey:Survey: majority calls for scripts majority calls for scripts Systems:Systems: all scripts 1 yr at annual all scripts 1 yr at annual Efficiency:Efficiency: ↓ phone calls by 50% ↓ phone calls by 50% Synchronized, Bundled RenewalsSynchronized, Bundled Renewals
Planned Care ApptPlanned Care Appt Order setsOrder sets Empowered TeamEmpowered Team Pt. QuestionnairePt. Questionnaire Prescription Mgm’tPrescription Mgm’t Visit SummaryVisit Summary Annual ExamAnnual Exam Rapid AccessRapid Access Intentional BehaviorsIntentional Behaviors
Prescription ManagementPrescription Management
We don’t use scripts as hookWe don’t use scripts as hook Planned care appts (not expired Planned care appts (not expired
script) trigger disease monitoringscript) trigger disease monitoring
Avoid loading interval visits with Avoid loading interval visits with unnecessary, redundant workunnecessary, redundant work
Before: six calls or faxes/yearBefore: six calls or faxes/year After: zero After: zero MaggieMaggie
Planned Care ApptPlanned Care Appt Order setsOrder sets Empowered TeamEmpowered Team Pt. QuestionnairePt. Questionnaire Prescription Mgm’tPrescription Mgm’t Visit SummaryVisit Summary Annual ExamAnnual Exam Rapid AccessRapid Access Intentional BehaviorsIntentional Behaviors
Annual Comprehensive Care Annual Comprehensive Care VisitVisit
Cornerstone of careCornerstone of care Dedicated apptDedicated appt
prevention/ annual review of prevention/ annual review of chronic dzchronic dz
CustomizedCustomized not one-size-fits-allnot one-size-fits-all
Planned Care ApptPlanned Care Appt Order setsOrder sets Empowered TeamEmpowered Team Pt. QuestionnairePt. Questionnaire Prescription Mgm’tPrescription Mgm’t Visit SummaryVisit Summary Annual ExamAnnual Exam Rapid AccessRapid Access Intentional BehaviorsIntentional Behaviors
Annual Comprehensive Care Annual Comprehensive Care VisitVisit
Prevention built-in Prevention built-in Not dependent on random Not dependent on random
acute visitsacute visits Not overload interval visitsNot overload interval visits
Planned Care ApptPlanned Care Appt Order setsOrder sets Empowered TeamEmpowered Team Pt. QuestionnairePt. Questionnaire Prescription Mgm’tPrescription Mgm’t Visit SummaryVisit Summary Annual ExamAnnual Exam Rapid AccessRapid Access Intentional BehaviorsIntentional Behaviors
I spend several minutes with each I spend several minutes with each appointment rifling through the appointment rifling through the chart looking for the last chart looking for the last mammogram and colonoscopy. mammogram and colonoscopy. And then I spend less time on the And then I spend less time on the patient’s main concern. patient’s main concern.
Family physician, WI 5.06Family physician, WI 5.06
Annual Comprehensive Care Annual Comprehensive Care VisitVisit
CC:CC: DM 2, HTN, ↑chol, new depr. DM 2, HTN, ↑chol, new depr. PreventionPrevention
Mammo aheadMammo ahead Ca, BMI, immunization (nurse)Ca, BMI, immunization (nurse)
Chronic CareChronic Care Diabetes, HTN lab done ahead Diabetes, HTN lab done ahead Foot and eye exam (nurse)Foot and eye exam (nurse)
AcuteAcute Energy to address depressionEnergy to address depression
Planned Care ApptPlanned Care Appt Order setsOrder sets Empowered TeamEmpowered Team Pt. QuestionnairePt. Questionnaire Prescription Mgm’tPrescription Mgm’t Visit SummaryVisit Summary Annual ExamAnnual Exam Rapid AccessRapid Access Intentional BehaviorsIntentional Behaviors
Rapid AccessRapid Access
Scheduling for same day accessScheduling for same day access Today not TriageToday not Triage Triage takes timeTriage takes time
30 sec “yes”, 5 min “no” “later”30 sec “yes”, 5 min “no” “later” One staff touch vs 5One staff touch vs 5
Pt’s don’t have to plead casePt’s don’t have to plead case
Planned Care ApptPlanned Care Appt Order setsOrder sets Empowered TeamEmpowered Team Pt. QuestionnairePt. Questionnaire Prescription Mgm’tPrescription Mgm’t Visit SummaryVisit Summary Annual ExamAnnual Exam Rapid AccessRapid Access Intentional BehaviorsIntentional Behaviors
Nurse-MD Team
HTN HTN CholChol GlucoseGlucoseOsteoporosisOsteoporosisDepressionDepression
LLAABB
OORRDDEERRSS
Planned CarePlanned Care
Same Day Same Day Surgery ApptSurgery Appt
Integrated, Continuous CareIntegrated, Continuous Care
LDL 75, LDL 75,
A1c 6.2A1c 6.2
LabLabMammoMammo
SeptSept
PreventionPrevention
HTN HTN CholChol GlucoseGlucoseOsteoporosisOsteoporosisDepressionDepressionLipids,FBSLipids,FBSCr, K, MamCr, K, Mam
LLAABB
OORRDDEERRSS
ComprehensiveComprehensive
MarMar
Efficiencies and care coordination
MammoMammo
SSCCRRIIPPTTSS
Nurse-MD Team
LLAABB
OORRDDEERRSS
JunJun
HTN HTN DM 2 DM 2 DepressionDepressionLL
AABB
OORRDDEERRSS
Planned CarePlanned Care
FBS, A1cFBS, A1c
LipidsLipids
Integrated, Continuous careIntegrated, Continuous care
HTN HTN DM 2 DM 2 DepressionDepression
Planned CarePlanned Care
MarMar
Rapid Rapid AccessAccess
LBPLBP
AprApr
Rapid Rapid Access Access
PneumoniaPneumonia
AugAug
A1c 6.8A1c 6.8
LDL 145LDL 145
Efficiencies and care coordination
HTN HTN DM 2 DM 2 DepressionDepression
Planned CarePlanned Care
SeptSept
FBS, A1cFBS, A1c
LLAABB
OORRDDEERRSSCXRCXR
CHF CHF Education/Education/
Clinic Clinic
Diabetic Diabetic Education Education
Home Care Home Care
Family Family
INRINR
INRINR
INRINR
INRINR INRINR
INRINR
INRINR
INRINR
INRINR
INRINR
INRINR
INRINR
Hospital Hospital CHFCHF
NovNov
PreventionPrevention
HTN HTN DM 2 DM 2 DepressionDepressionLL
AABB
OORRDDEERRSS
ComprehensiveComprehensive
FBS, A1c, FBS, A1c, lipids, alb,lipids, alb,
mammomammo
DecDec
SSCCRRIIPPTTSS
Architecture Architecture Of Of
Care Care
Intentional BehaviorsIntentional Behaviors
Eye contact/physical touchEye contact/physical touch Key phrasesKey phrases
What else do I need to know?What else do I need to know? Did we cover everything you Did we cover everything you
wanted?wanted? How are you handling this?How are you handling this?
Planned Care ApptPlanned Care Appt Order setsOrder sets Empowered NursingEmpowered Nursing Pt. QuestionnairePt. Questionnaire Prescription Mgm’tPrescription Mgm’t Visit SummaryVisit Summary Annual ExamAnnual Exam Rapid AccessRapid Access Intentional BehaviorsIntentional Behaviors
Intentional BehaviorsIntentional Behaviors
More Key phrasesMore Key phrases What do you do for fun?What do you do for fun? Could you bring me a picture Could you bring me a picture
of ….at your next appointmentof ….at your next appointment Social notes at end of Social notes at end of
dictationdictation
Planned Care ApptPlanned Care Appt Order setsOrder sets Empowered NursingEmpowered Nursing Pt. QuestionnairePt. Questionnaire Prescription Mgm’tPrescription Mgm’t Visit SummaryVisit Summary Annual ExamAnnual Exam Rapid AccessRapid Access Intentional BehaviorsIntentional Behaviors
Sister Mary Owen, what Sister Mary Owen, what have you been up to lately?have you been up to lately?
Sister Mary Owen, what Sister Mary Owen, what have you been up to lately?have you been up to lately?
Sr. Mary Owen, what have you Sr. Mary Owen, what have you been up to lately?been up to lately?
At the center of primary care are At the center of primary care are face-to-face healing relationships.face-to-face healing relationships.
Patient: NursePatient: Nurse Nurse: PhysicianNurse: Physician
Nurse: NurseNurse: Nurse Patient: PhysicianPatient: Physician
We will know who you are and We will know who you are and we will be ready for you.we will be ready for you.
Borgess Ambulatory Care, Kalamazoo, MIBorgess Ambulatory Care, Kalamazoo, MI
DiscussionDiscussion