For Primary Care Practices: Why Link with Community Resources

Why Primary Care Should Get Involved with Cities for Life

• The Cities for Life model can help primary care offices provide services to patients that they may not otherwise have the time or resources to provide.

• Primary care practices consistently report they do not have the time they need to counsel patients on the importance of making behavioral and lifestyle change.

• Community resources dedicated to healthy eating, physical activity and other lifestyle changes can fill this gap.

• A process – such as that provided by Cities for Life – is needed to enable clinicians to effectively link patients to community resources.

Getting Started

The following steps will help establish a Cities for Life program within primary care practices, and will be a useful guide for how the practices can implement a system to refer patients to patient navigators.

Step 1: Determine the Motivation and Interest of Practice

Forming linkages with community resources requires the clinicians and staff to engage in behavior change.

- Remember behavioral change is never easy!

To help ensure success:• Identify Cities for Life champions within the practice.– A physician champion for leadership support.– A project champion responsible for specific tasks and

activities.• Work to capture the “buy-in” of the majority of the care

team through the practice champions.

Step 2: Find, Connect with, and Evaluate Potential Partners

• Communicate that the primary care practices no longer have to work to identify community resources that may help their patients. That is the role of the Cities for Life Community Action Team.

• Practices will need to trust the patient navigators and feel comfortable referring patients to them.

• The physician and project champions can be responsible for getting to know the patient navigators and introducing them to the rest of the practice.

• Logistics tips: – Provide the patient navigators with the preferred contact information

for the practice champions.– Be sure patient navigators understand primary care practices.

Step 3: Establish Systems

• Patient navigators work with office champions to establish:– Types of patients to be addressed– Screening tools to be used, if desired– Referral systems including data to include for

navigator, forms and feedback system– Frequency and content of preferred feedback – Summary reports at patient or practice level

Step 4: Identify the Patients

• There are two steps for identifying patients for referral: 1. Does the patient fit the physiological profile of someone

who can benefit from community resources?2. Does the patient demonstrate a minimal level of

“readiness to change”?

Step 4: Identifying the Patients

• Identify patients by physiological measurements such as:– Elevated BMI– Elevated blood pressure– Elevated A1c

Step 4: Identifying Patients

• Determining at risk status:– BMI > 34– A1c >5.8 but < 6.5– History of gestational diabetes– Elevated risk score on ADA risk assessment

• Obese– BMI > 30

Step 4: Identifying Patients

• Note: Previous efforts found that physical or at risk eligibility alone was insufficient in prompting a patient to take the next step and actually act on the referral.

• Assessing readiness to change will improve navigators chances of success.

Step 4: Identifying Patients

• Two methods of identifying patients can be used interchangeably or simultaneously:– Preemptive approach– Point-of-care identification

Preemptive Identification

• The “wide net” approach: – Search all possible patients who might be

physiologically appropriate for referral to the patient navigator.

– Search the electronic health records (EHR) using different combinations of ICD-9 codes and clinical data for elevated blood glucose, diabetes, obesity, hypertension, and hyperlipidemia to identify potential patients.

Preemptive Identification

• “Flag” these eligible patients through: – “Pop-up” reminders within its EHR.– Highlight eligibility information in their records.

Preemptive Identification

• Track patients:– Through your EHR.– Through a stand-alone registry with a

spreadsheet. • Use a simple but formal registry for the

patients you intend to refer. It will enhance your ability to track patients and generate reports.

Preemptive ID Advantages

• Advantages include:– Allows practices to review the entire spectrum of

patients, including those who are overdue for a visit. – Allows practices to adapt the strategy for other quality

improvement efforts that require identification of a population of patients.

– Allows clinicians to review the patient list ahead of visits and think about which patient might be the best candidate for referral.

– Allows practices to proactively reach out to those patients.

Preemptive ID Disadvantages

• Disadvantages include:– Requires an EHR for searches.– Requires necessary resources and staff to compile

the patient list.– Does not consider a patient’s “readiness to

change.”

Point-of-Care Identification

• During a visit, clinicians or other staff members identify potential patients for referral through physiological markers and patient attitudes towards making lifestyle changes.

• Clinicians and staff members can approach patients individually, building upon past positive conversations and their existing relationship to make the case for lifestyle change.

Point-of-Care ID Advantages

• Advantages include:– Works in practices where a practice-wide patient query

might be difficult to initiate.– Allows clinicians to embrace the “art” of medicine, using

their intuition and patient relationship to make decisions about the timing of the referral process and subsequent conversation about lifestyle change.

Point-of-Care ID Disadvantages

• Disadvantages include:– Will miss the large percentage of patients who are not

coming for regular visits. – Depends upon key members of the care team

remembering to identify the patient at the point-of-care.

– Doesn’t support a more inclusive practice-wide activity.– Puts a larger burden (remembering to identify and

approach patient) on an already overburdened clinician.

Deciding on an Approach Considerations:

Practice Buy-in: How many clinicians will be willing to participate? Will this be a practice-wide effort, or confined to just one clinician and care team?

Patient Outreach: Do we have an established way of reaching patients outside the office walls – email, Web site, letters, etc.? How much time/energy/resources would it take to develop a method suitable for this endeavor?

Similar QI Projects: Has our practice done other quality improvement projects, similar to this one, where we can repeat/reuse query requests, patient outreach methods, etc.? Or, are we starting completely from scratch?

Clinician Passion: Is the physician champion heavily invested and committed to the success of the project, enough to remember to self-identify appropriate patients and initiate a referral?

EHR: How accommodating will our current EHR be in efforts to query patients and/or build a registry? How much help can we expect to get from our EHR vendor?

Assessing Patient Readiness

• Use motivational interviewing for assessing readiness to change.– Simply referring is not enough – patients need to

be ready to act on the referral. – See http://www.motivationalinterview.org/ for

more information.

Step 5: Refer Patients

• If your Cities for Life approach includes a centralized patient data system, you may need to train your office personnel (clinicians and other staff) to complete the referral forms.

• If not, you will need to create a referral form for the patient navigator. A template form is provided in the Cities for Life Toolkit.

• First, identify the exact details that the patient navigator will need to initiate contact with the patient – and include nothing more.

Step 5: Refer Patients • Have clinicians provide clinical information. Any non-clinical

information should be provided by non-clinicians. For example, do not have a clinician fill out the patient’s address – the patient navigator can complete that part on the phone. However, only the clinician can check whether or not a patient’s blood work indicates a certain condition.

• If the practice still uses paper referrals, what is the preferred physical format of the referral form? For example, full sheet? Half-sheet? Even some “paperless” practices using the EHR for referrals still liked having the visual trigger of the paper format, and the ability to hand the form to the patient once the referral went through the EHR.

Step 5: Refer Patients

• Who will fill out the referral form and at what point during the patient encounter? (e.g., physician, medical assistant, referral coordinator, other?)

• How will the referral form be entered and/or “sent” through the system, and how will this referral then be documented in the patient’s chart? (e.g., typed directly into the EHR, customize a drop-down referral screen, scan a paper form, etc.)

Step 6: Integrate the Process within the Patient Path

• A successful referral system requires: – A committed physician/clinician champion who works

to connect to the patient inside the exam room.– Enough practice team members willing to reinforce

that message at appropriate moments outside the exam room.

• Determine how the practice staff and clinicians will interact with the patient to reinforce the importance of working with the patient navigators.

Step 6: Integrate the Process within the Patient Path

• Start by “walking” through your practice: – Initial contact/outreach– Waiting room– Vital signs/ weight station– Exam room– EHR prompts– Non-patient areas (to remind staff and clinicians to

think about it)• At each point, consider how the message of working

with patient navigators can be reinforced.

Step 7: Develop a Feedback System

• Ensure the patient navigator knows what kind of information the practice wants as well as how and to whom to send the information.

• Be very explicit about the importance of data and feedback to the clinicians. Navigators may assume the patient is keeping the clinician up to date, but the patient may assume the navigator is.

• For more information, see Linking Primary Care Patients to Local Resources for Better Management of Obesity toolkit.– http

://www.ahrq.gov/professionals/prevention-chronic-care/improve/community/obesity-toolkit/index.html