Milking Epic in a PCMH Family

Residency

Community Hospital East Family Medicine

ResidencyIndianapolis, IN

Barb Kirk, RN Nurse Care Manager

With CHNw 28 years

With FMC Residency

8 years

Experience

Larissa Davids, RN Clinical

Nurse Manager

With CHNw 2 years

With FMC Residency

2 years

Experience

• Community-based network of healthcare providers• Serving Central Indiana since 1956• More than 2 million patient encounters each year• Over 1 million outpatient visits per year• Eight hospitals and more than 200 sites of care • 700,000 annual patient encounters• EPIC Go-Live June 2012• First Hospital in Indiana to meet Meaningful Use

Stage 2

From Seed to Stalk• Started 1974

• 38 Resident Classes Graduated

• Expanding Resident Class Size

• Current Class Size 8-10-10

• Future Class Goal 12-12-12

Home Front

Part of a Health PavilionState-of-the-art

16,000 sq. ft30 Exam rooms

Two procedure roomsOMT/Therapy room

Patient Demographics

• 226,000 Patient clinic visits annually

• Approximately 7600 patients

• 60% Medicaid

• 20% Medicare

• 20% Private Insurance or uninsured

Who’s Bailing Our Hay?

ProvidersEducation Staff

Support StaffAdditional Students

OB Pediatrics Home Visit

On-site Nursing Home Visits Ambulatory Clinic

Inpatient Rotation(ICU, Pediatrics, Service Team)

Emergency Care (ED) Specialty Rotations

Preparing to take Family Practice

Boards

Resident Education Focus

What is NCQA?What is PCMH?What is Hedis?

Before PCMH Journey

• “This is the way we have always done it”

• Lack of teamwork• No clinical team structure• No population health

management• Poor patient follow-up care

Our PCMH Journey

Goals• Clinical transformation• CULTURE transformation• Optimal patient

experience• Comprehensive patient

care

Level 3 PCMH Recognition

Residency Process Improvement

Requirement of FMC Residency Curriculum

Standardization CommitteePatient Advisory Group

Nurse Care Managers

Preventative Health

Maintenance

Chronic Disease

Management

High Risk Patient

Intervention

• Development

• Responsibilities

• Evolving position

Multidisciplinary Approach to

Care

• Diabetes IVR• Group Visits

• Transition of Care

• Office Visits• Team Time• Metrics

Winter Leah R, MA

Fac Fisher Fac Callahan

R3 Shaver R2 Gelatt R1 Jaeger

Katie, RN

Snow Kaylee, MA

Fac ShockleyR3 Holland

R2 Grindstaff R2 Tran

R1 Pohlman

Katie, RN

Autumn Emmy, MA

Fac Arrizabalaga Fac DaRosa

R3 Baig R2 Jones

R1 Pittman

Cindy, RN/Karen, RN

Wind Kaylee, MAFac MathewFac WheelerR3 Abratigue

R2 Land R1 Bachman

R1 King

Cindy, RN/Karen, RN

Summer Amber, LPN

Fac Cashman R3 Polly

R2 FogelsongR2 Malicay R1 Morris

Nancy, RN

Sun Kellie, MA

Fac Clark R3 Walcott 347R2 Burns 277

R1 Sanderson 109807

Nancy, RN

Spring Leah CFac Lisby

R3 Auman R2 Nimmagadda

R1 Brackett

Barb, RN

Rain Sonia

Fac Hern Fac EglenR3 Hunt

R2 Mohammadi R1 Schmoll

Barb, RN

Weekly RN/LPN/MA/Tech

MondayMammograms

WednesdayImmunizations/

WCC

FMC TeamsEffective 3/1/2014

RN=Care Coordinator

Education*Smoking Cessation

*Diabetes*Asthma

*Hypertension*Obesity

*Medication Adherence*Group Sessions

*Diabetes IVR*Patient Appointments

Health Maintenance*ED/Inpatient Follow-up

*Wellness Visits*Follow-up*Reports

*Workques*Telephone Triage

*Telephone Encounters*Prior Authorizations

High Risk Population*Routine and Frequent

Follow-Up and Education*Proactive

Communication*Frequent NCM Appointments

*Address Social/Economical/Behavioral

Barriers

TuesdayPap Smear/

GCHL

ThursdayHTN, DM,

Hyperlipidemia

FridayPneumovax/

Zostavax/Tdap

Weekly RN/LPN/MA

MondayMammograms

TuesdayPap Smear/

GCHL

WednesdayImmunizations

/WCC

ThursdayHTN, DM,

HLD

FridayPneumovax/

Zostavax/Tdap

RN=Care Coordinator

Education*Smoking Cessation

*Diabetes*Asthma

*Hypertension*Obesity

*Medication Adherence*Group Sessions

*Diabetes IVR*Patient Appointments

Health Maintenance*ED/Inpatient Follow-up

*Wellness Visits*Follow-up*Reports

*Workques*Telephone Triage

*Telephone Encounters*Prior Authorizations

High Risk Population*Routine and Frequent

Follow-Up and Education*Proactive Communication

*Frequent NCM Appointments

*Address Social/Economical/Behavioral

Barriers

DailyMA/LPN

Medication Refills

Telephone Encounters/

Mychart

Abstracting

DiannePA’s

Provider Forms Paperwork

Pre-visitPlanning

PhaseII

6/1/14

PhaseIII

9/1/14

Daily RN

ED/InpatientFollow-up

Lab/ImagingWorkque-

Mammograms/DXA Scan focus

Chronic Care/High Risk Patient Reports

and Management

Lab/Imaging Workque (MA/LPN)

Phase IV

11/1/14

ALL RN’s prepared for Care Coordinator (Manager) Role

Phase V

1/1/15

*RN’s Team Pools/ED, Inpatient follow-up --introducing

Milking EPIC• Maintain PCP

Panels• Pre-Visit• ED and Inpatient• Chronic Disease• Population Health• Follow-up• Pilot Projects• Audits• Reminders• Referrals

Basic Provider Report

Maintaining Provider Panels

How?

When?

Building a Basic Report

Reconcile Health Maintenance

PCP Panels

Pre-visit

MA Clinic

ED/Inpatient

Chronic Disease

Monthly Audits

Transition of Care

Preventative

Health Maintenance

Group Visits

IVR

TOC

Reports

Identify Needs• Preventative/Maintenance

Labs• Diabetic Foot Exams• ACT• SPO2• Immunizations• Controlled Medications• Preventative Procedures• Preventative Imaging• Appointments

Report identifies patients with Diabetes and Hypertension with scheduled appointments.

Report is run weekly. EMR is reviewed for missing or due health maintenance.

Protocoled orders are placed and patient is notified.

Goal: Patient completes orders prior to upcoming appointment.

Pre-Visit Planning

Diabetes:HgbA1c 6 months HgbA1c > 7 3 monthsLipid Panel-fasting 12 monthsMicro albumin/Creatinine Urine Ratio 12 monthsCMP-fasting 12 monthsDiabetic Eye Exam 12 monthsDiabetic Foot Exam 12 months

Hypertension:BMP-fasting 12 months

 Hyperlipidemia:Lipid Panel-fasting 12 monthsCMP-fasting 12 months

 Hypothyroidism:TSH 12 months

Pre-Visit Protocol

Establish criteria

identifying High Risk Patients

Run Report daily

Assess care plan and

interventions

Review EMR

Discuss plan with patient

and identify barriers

Contact patient by

phone, MyChart or letter

Update or develop

care plan

High Risk Patients

Health Maintenance Reports

Identifies patients with upcoming appointments with health maintenance needs

MA/LPN runs report every 3 days

Comment is placed on the ‘Appointment Notes’ designating a need

Clinical staff rooming the patient has information easily available

Health Maintenance Reports

Fruits of our Labors

10/1/

2012

12/1/

2012

2/1/20

13

4/1/20

13

6/1/20

13

8/1/20

13

10/1/

2013

12/1/

2013

2/1/20

14

4/1/20

14

6/1/20

14

8/1/20

1405

101520253035

Date

% of Patients

Diabetic Patients w/o HgbA1c in 6 Months

February 1, 2013 28% of Diabetic

patients had not had a HgbA1c in 6

months.

2/1/20

13

3/1/20

13

4/1/20

13

5/1/20

13

6/1/20

13

7/1/20

13

8/1/20

13

9/1/20

13

10/1/

2013

11/1/

2013

12/1/

2013

1/1/20

14

2/1/20

14

3/1/20

14

4/1/20

14

5/1/20

14

6/1/20

14

7/1/20

14

8/1/20

140

10

20

30

40

50

60

70

80

90

Patients with Diabetes w/o a Foot Exam in 1 year

January 2013 2% of our patients with Diabetes had

a filament test

Percentage of Pediatric Patients with Overdue Immunizations

7/1/20

13

8/1/20

13

9/1/20

13

10/1/

2013

11/12

013

12/1/

2013

1/1/20

1405

101520253035

July 2013 32.6% of our pediatric patients 0-13 had overdue state mandated

immunizations

Patients overdue for Well Visit

Diabetes IVR Pilot

EDand

Inpatient

Transition of Care ProgramSocial WorkPharmacist

Nurse Care Manager

Provider

• Round on inpatients• Facilitates transition

home• Coordinates

Provider, Nurse Care Manager, Pharmacist

• Follow-up• Weekly TOC ClinicGoals

Additional Uses• Smart Phases

• Workques• Triage• Letters• Photos• Reminders• Billing• Referrals• Call Backs

FeedbackPatients• “I feel like a queen when I come here, everyone really

cares.”• “I like having my labs done before my appointment. It

saves a step, I have more time with my Doctor.”• “Never had a foot exam done before.”• Voiced appreciation that clinical staff was providing the

foot exams • Parents voiced appreciation for less trips to the office for

immunization catch-up.

FeedbackMAs’ feedback

• More efficient utilization of time• “Do not have to research patient’s chart to provide

care.”• “I like knowing what the patient needs before I get

them.”

Providers’ feedback• Foot exams consistently performed before provider sees

the patient.• Not doing minimal tasks; filling out paperwork for Health

Department• Detecting and treating Asthma patients outside of the

green zone before an exacerbation occurs.• “My colleagues didn’t believe my Nurses could order the

labs ahead of time. It saves me so much time.”

Feedback

Outcomes

• Elevate quality of care• Improve patients’

outcomes• Efficiency• Motivate clinical staff• Decrease ED/hospital

admissions• Decrease health care

spending• Policies and protocols• Healthier work

environment

• Patient Centered Comprehensive Care

What Have We Learned?

Question

s