Beyond the Blueprint Building the Patient Centered Medical Home

Beyond the Blueprint Building the Patient Centered Medical Home Wisconsin Primary Care Research & Quality Improvement Forum Wisconsin Dells, WI 11.13.09 Christine Sinsky, MD Thomas Sinsky, MD [email protected] Medical Associates Clinic and Health Plans Dubuque, Iowa

Agenda Background The Challenges of Primary Care 8 strategies to transform practice Discussion

Take Home Messages It’s all about Planning ahead Sharing the load Enjoying the work!

Background Primary Care NCQA Advisory Panel: PCMH Consultant and Workshops All trying to solve same equation Different settings QE & S: quality, efficiency and satisfaction

We will know who you are and we will be ready for you. Borgess Ambulatory Care, Kalamazoo, MI

At the center of primary care are face-to-face healing relationships. Patient: Nurse Nurse: Nurse Nurse: Physician Patient: Physician

115 physicians, owners Health Plan: 1/3 of pt population EHR: 2003

Satisfaction Staff Turnover: 5% Physician Satisfaction: 95%’ile AMGA PCP Productivity and Compensation: 85%’ile MGMA

Quality Patient Centered Medical Home

Snapshot of Practice Staffing Space Primary nurse Help nurse 1.5 nurse: MD (no MAs) 3 exam rooms Scheduling 1 Receptionist: 2 MDs Wave Scheduling

Snapshot of Practice Typical Schedule Panel Size 6-8 Annual 10-12 Planned Care 4-6 Rapid Access 1800-2000 Outpatient/Inpatient

Mrs. Peters 65 year old annual exam DM2 HTN Depression Prevention New c/o Heartburn Sleep disturbance Fatigue # of Quality measures?

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

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: Plan Ahead, Share the Load Right thing happens by default Staff work full level of ability Minimize work MD does that is within skill set of others

“In few other sectors of the economy is the highest-level professional responsible for the majority of production, customer service, and clerical work.” SGIM Blue Ribbon Panel Report. Redesigning the Practice Model for General Internal Medicine: A Proposal for Coordinated Care. J Gen Intern Med 2007;22:400-109

Episodic Care Check-in MD Room pt receptionist nurse Insurance verification Collect co-pay Verify contact info Vital signs ¼ MA: MD Medication reconciliation History Exam Data Gathering Data entry Decision making Relationship building Prescription writing Documentation Paperwork Behavior Modification Results reporting Checkout ?

Work Within Skill-set of Others Check-in MD Room pt receptionist nurse Insurance verification Collect co-pay Verify contact info Vital signs ¼ MA: MD Medication reconciliation History/History Exam Data Gathering Data entry Decision making Relationship building Prescription writing Documentation Paperwork Behavior Modification Results reporting Checkout ?

Integrated, Continuous Care Pre-appt lab Build-in rather than Carve-out Office Visit Nurse-MD Team Efficiencies and care coordination Between Visit Care

Core Team Model: Planning Ahead & Sharing the Load Planned Care Appt Order sets Empowered Team Pt. Questionnaire Prescription Mgm’t Visit Summary Annual Exam Rapid Access Intentional Behaviors

Planned Care Appointment Pre-appt lab Planned Care Appt Majority lab prior to appt Order sets Patient part of decision making Empowered Team 67 yo diabetic Pt. Questionnaire A1c 6.2 Prescription Mgm’t LDL 160 Visit Summary Bill P. Annual Exam Rapid Access Intentional Behaviors

Planned Care Appointment Efficiency Planned Care Appt “Just in time” info processing Order sets Close the loop during that appt Empowered Team Pt. Questionnaire Results reporting Prescription Mgm’t 4 hr clinic 2 hr post-appt Visit Summary Safety Annual Exam Missing or overlooked inform Rapid Access Pt & family part of safety net Intentional Behaviors

Lab Summary

Post-Appointment Order Sets Planned Care Appt Order sets Empowered Team Pt. Questionnaire Prescription Mgm’t Visit Summary Annual Exam Rapid Access Intentional Behaviors

Acute Symptom Evaluation

Planned Care Appt

Annual Comprehensive Care Visit

Upcoming appts/lab Last PE Place Today’s Care in Continuum of Time

Post-Appointment Order Sets Planned Care Appt Order sets Empowered Team Pt. Questionnaire Prescription Mgm’t Visit Summary Annual Exam Rapid Access Intentional Behaviors 73 yo est. pt Rapid w/ fever, cough

Post-Appointment Order Sets Planned Care Appt Order sets Empowered Team Pt. Questionnaire Prescription Mgm’t Visit Summary Annual Exam Rapid Access Intentional Behaviors 64 yo DM 2, hypothyroidism, atrial fibrillation, CRI

Post-Appointment Order Sets Planned Care Appt Order sets Empowered Team Pt. Questionnaire Prescription Mgm’t Visit Summary Annual Exam Rapid Access Intentional Behaviors “The next appointment starts today” A plan, a promise to continue the relationship “We want to see you again, and we will plan ahead to make that most meaningful.”

Empowered Teamwork Planned Care Appt Order sets Empowered Team Pt. Questionnaire Prescription Mgm’t Visit Summary Annual Exam Rapid Access Intentional Behaviors Nursing staff full partners

Nexus of organization of our practice Filter Updates EHR Completes all paperwork Between Visit Visit Extension of me when dealing with patients; patients recognize this. Med. Reconcil. Initial review of lab Coordinates transitions (hospital, NH, Hospice) Pt education Manages & returns most phone calls Sx driven tests (PFT, EKG) Immunizations Colonoscopy Diabetic foot exam/eye exam Does prescriptions The Boss Present patient ( info drop-off)

Mini-huddle Planned Care Appt Order sets Empowered Team Pt. Questionnaire Prescription Mgm’t Visit Summary Annual Exam Rapid Access Intentional Behaviors Staff deeply engaged Mentor nurses Physician better prepared Stronger handoff

Mini-huddle Planned Care Appt Order sets Empowered Team Pt. Questionnaire Prescription Mgm’t Visit Summary Annual Exam Rapid Access Intentional Behaviors 47 yo “Rapid Access” new patient CC: dysphagia Nurse Mini-huddle “She seems depressed” “Is anyone hurting you?” Physician better prepared

Introduction to Partnership Planned Care Appt Order sets Empowered Team Pt. Questionnaire Prescription Mgm’t Visit Summary Annual Exam Rapid Access Intentional Behaviors

Pre-appointment Questionnaire Planned Care Appt Order sets Empowered Team Pt. Questionnaire Prescription Mgm’t Visit Summary Annual Exam Rapid Access Intentional Behaviors Identifies the patients agenda MD plan visit before entering Systems approach Update PFSH Complete ROS Behavior issues: exercise, smoking, alcohol webmeeting.nih.gov/intro Future Kiosk in waiting area Web portal from home

Prescriptions are killing us my nurse is spending so much time on refills that we can’t seem to get anything done. Minnesota Family Physician 2007

Prescription Management Planned Care Appt Order sets Empowered Team Pt. Questionnaire Prescription Mgm’t Visit Summary Annual Exam Rapid Access Intentional Behaviors Survey: majority calls for scripts Systems: all scripts 1 yr at annual Efficiency: phone calls by 50% Synchronized, Bundled Renewals

Prescription Management Planned Care Appt Order sets Empowered Team Pt. Questionnaire Prescription Mgm’t Visit Summary Annual Exam Rapid Access Intentional Behaviors We don’t use scripts as hook Planned care appts (not expired script) trigger disease monitoring Avoid loading interval visits with unnecessary, redundant work Before: six calls or faxes/year After: zero Maggie

Annual Comprehensive Care Visit Cornerstone of care Planned Care Appt Dedicated appt Order sets prevention/ annual review of Empowered Team chronic dz Pt. Questionnaire Customized Prescription Mgm’t not one-size-fits-all Visit Summary Annual Exam Rapid Access Intentional Behaviors

Annual Comprehensive Care Visit Prevention built-in Planned Care Appt Not dependent on random Order sets acute visits Empowered Team Not overload interval visits Pt. Questionnaire Prescription Mgm’t Visit Summary Annual Exam Rapid Access Intentional Behaviors

I spend several minutes with each appointment rifling through the chart looking for the last mammogram and colonoscopy. And then I spend less time on the patient’s main concern. Family physician, WI 5.06

Annual Comprehensive Care Visit Planned Care Appt Order sets Empowered Team Pt. Questionnaire Prescription Mgm’t Visit Summary Annual Exam Rapid Access Intentional Behaviors CC: DM 2, HTN, chol, new depr. Prevention Chronic Care Mammo ahead Ca, BMI, immunization (nurse) Diabetes, HTN lab done ahead Foot and eye exam (nurse) Acute Energy to address depression

Rapid Access Planned Care Appt Order sets Empowered Team Pt. Questionnaire Prescription Mgm’t Visit Summary Annual Exam Rapid Access Intentional Behaviors Scheduling for same day access Today not Triage Triage takes time 30 sec “yes”, 5 min “no” “later” One staff touch vs 5 Pt’s don’t have to plead case

Integrated, Continuous Care Lab Mammo Mammo Mar Sept Comprehensive Planned Care HTN O Chol R L Glucose D A Osteoporosis E Depression B LDL R 75, S A1c 6.2 Nurse-MD Team HTN O Chol R L Glucose D A Osteoporosis E Depression B Lipids,FBS R Cr, K, Mam S Prevention Efficiencies and care coordination Same Day Surgery Appt S C R I P T S

Integrated, Continuous care Dec Nov INR Hospital CHF Comprehensive HTN DM 2 L Depression A FBS, A1c, B lipids, alb, mammo INR S C R I P T S Architecture Of Care INR INR Prevention CHF Education/ Clinic Sept O R D E R S INR Home Care Planned Care Planned Care HTN DM 2 L Depression Mar O R D A FBS, A1c E B R INR CXR S HTN DM 2 L Depression Diabetic Education Aug INR Nurse-MD Team Efficiencies and care coordination Rapid Access Pneumonia Family INR Rapid Access LBP Planned Care INR A B FBS, A1c Lipids INR LDL 145 Apr Jun HTN DM 2 L Depression A A1c 6.8 B O R D E R S INR INR O R D E R S

Intentional Behaviors Eye contact/physical touch Planned Care Appt Key phrases Order sets What else do I need to know? Empowered Nursing Did we cover everything you Pt. Questionnaire wanted? Prescription Mgm’t How are you handling this? Visit Summary Annual Exam Rapid Access Intentional Behaviors

Intentional Behaviors More Key phrases Planned Care Appt What do you do for fun? Order sets Could you bring me a picture Empowered Nursing of .at your next appointment Pt. Questionnaire Social notes at end of Prescription Mgm’t Visit Summary dictation Annual Exam Rapid Access Intentional Behaviors

Sister Mary Owen, what have you been up to lately?

Sister Mary Owen, what have you been up to lately?

Sr. Mary Owen, what have you been up to lately?

At the center of primary care are face-to-face healing relationships. Patient: Nurse Nurse: Nurse Nurse: Physician Patient: Physician

We will know who you are and we will be ready for you. Borgess Ambulatory Care, Kalamazoo, MI

Discussion