Slide 1

Care Teams – Beyond PCMH Recognition

Julie Peskoe & Maia BhirudPrimary Care Development Corporation

Judy P. MitchellFranklin Primary Health Center, Inc.

June 17th, 2014

Slide 2

A Definition

Team-based health care is the provision of health services to individuals, families, and/or their communities by at least two health

providers who work collaboratively with patients and their caregivers—to the extent preferred by each patient—to accomplish shared goals within and across settings to achieve coordinated, high-quality care.

Institute of Medicine, Core Principles & Values of Effective Team-Based Health Care, 2012

Slide 3

Care Team Domains

• Office Visit Team – aka Microsystem, Pod, or Teamlet– Practitioner(s), medical assistant, receptionist with lab, pharmacy, financial,

etc

• Care Management Team– Teamlet plus patient, care manager, coach, dietitian, behavioral health, social

services

• Care Coordination Team– Teamlet plus care manager, external (specialty or other) providers

Slide 4

Bodenheimer on Teams• Care Teams are a basic building block of High Performing Primary

care• Large teams are difficult

– Energy and time spent with many team members having to communicate information and coordinate tasks

– If one person is not cooperative, the entire team can fail

• Smaller teams or teamlets are easier– Divide the practice into small 2 person teams/teamlets– Each teamlet responsible for a panel of patients– Same 2 people always work together, patients know them and they know the

patients– Patients learn to trust the teamlet

• Bodenheimer and Laing, Ann Fam Med 2007;5;457;Bodenheimer T. Building Teams in Primary Care, Parts 1 and 2, California Healthcare Foundation, 2007. www.chcf.org

Slide 5

How do you create and support high functioning teams?

Slide 6

Principles of Team-Based Care

1) Shared goals2) Clear roles3) Mutual trust4) Effective communication5) Measurable processes and outcomes

Slide 7

Requirements

NCQA PCMH 2014:Enhanced emphasis on team-based care – Revised standards

emphasize collaboration with patients as part of the care team and establish team-based care as a “must-pass” criterion for NCQA Recognition.”

Slide 8

Supporting Team-Based Care

• Relationships and Trust• Processes/Systems• Resources

Slide 9

Relationships and Trust

• Solutions– Define organizational and team member roles – Set performance expectations based on these roles– Provide training to enable staff to fulfill roles– Provide an environment in which individuals and teams can

succeed– Support team members with performance information,

incentives and feedback

Slide 10

Processes/Systems– Organizational structure to support goals

• Foundation– Care team structure– Alignment with job descriptions

• Regular communication– Huddles– Team meetings– Establish culture of respectful communication

• Quality assurance for care team– Share care plans and templates– Chart review and quality reporting

• Adjust panel size appropriate to performance expectations– Registries to identify care team patients

Slide 11

Resources

• Solutions–Stable care teams–Allocated structured time to achieve team goals–Leadership oversight –Team space appropriate to support team work, workflow, and communication

Slide 12

WorkflowsDefine:•Team member roles•Communication links between roles•Hand-offs to team members/Care transitions

Source: AccountableCareInstitute.com

Slide 13

Implementing An Innovative and Dynamic “Care Team”

Slide 14

Introduction to Franklin Primary Health Center, Inc.

Franklin’s mission is to be a caring, compassionate, and viable community health center, proactively improving the lives of those we serve by providing accessible, affordable, quality, and comprehensive health services.

Franklin has been in operation for over 30 years. We are a 501-C3 local and community-owned private not-for-profit corporation financed by Medicaid, Medicare and private insurance payments as well as federal, state and local contributions.

We have a dynamic 16 member Board of Directors , over 230 professional employees, including over 30 highly trained providers including board certified/board eligible physicians, dentists, optometrists, nurse practitioners, pharmacists. Franklin has 15 locations and currently serve patients in Mobile, Baldwin and Choctaw counties. Annually we serve over 34,000 patients and generate over 100,000 encounters.

We are accredited by the Joint Commission for Ambulatory and Behavioral Healthcare. We are also accredited by The Joint Commission as a Primary Care Medical Home (PCMH).

Slide 15

Patient Centered Medical HomeOur home is still under construction

Slide 16

How did we get started?• Franklin began its journey of transformation in May of 2011. It was then

we began our small group meetings to determine our strategy for NextGen EHR implementation.

• We learned some valuable lessons of what NOT to do from our implementation of the NextGen EPM in January of 2011.

• We utilized our EHR planning to build in PCMH principles including the basic care teams

• We established a Franklin plan that was titled “Blueprint for Practice Transformation”. This work plan included Goals, objectives, the PCMH change principal related to the Goal and objectives, barriers encountered, actions, timelines and responsible parties.

• The “Blueprint for Practice transformation” became a working document that was utilized to ensure that we were addressing barriers and making progress towards our transformation.

Slide 17

What were the challenges?• Shortage of Providers and staff• Staff turnover• Stabilization of the “Care Team”• Staff learning curve and acceptance related to changes• Patients learning curve related to changes• Usual issues related to EHR implementation

– Decrease in the number of patients seen– Decrease in revenue– Lots of extra audits to ensure quality of care– System slowness– System down– Staff documentation inconsistent and all over the place– Reporting not as easy as the sales person made it look before we bought

the system

Slide 18

One of the most challenging PCMH principals was establishing the “Care Team” and defining the roles

• We tried several different strategies while trying to implement a successful care team structure

• We had to re-evaluate the responsibilities placed on the care team and ensure that we had enough support to successfully accomplish all of the PCMH standards of care and meet all of the requirements placed on us by everyone who holds us accountable including but not limited to HRSA, Joint Commission, Medicaid, Third party entities and any other grants and contracts.

Slide 19

What is working for us?• We implemented a basic PCMH care team that is provider lead.• We built a multilayered support system for the PCMH care teams in

the form of a care coordination department.• The multilayered system consists of RN case managers, patient

navigators and community health workers to assist with coordination of services and case management support for the PCMH care teams at Franklin.

• The objectives of the care coordination department:*Improve compliance rates of preventative care screening guidelines in all life cycles*Improve patient access to the Franklin PCMH by linking patients to appropriate care.*Improve chronic care compliance utilizing established guidelines.

Slide 20

Care coordination support• The multilayered system consists of the following roles and responsibilities:

Level one- Community Health Workers- carry a wide case load; utilized to make reminder calls, locate and educate patients and facilitate care as directed. The CHW will also support the level 2 and level 3 navigators as necessary by assisting the patients to deal with barriers such as transportation, scheduling appointments, following up on patients who miss appointments to encourage compliance, assisting with coordination of medical records and health literacy issues. We will also utilize the CHW in special health promotion outreach initiatives to provide education on appropriate screening initiatives, linking patients to community resources and assisting patients in accessing care and establishing a medical home.

Level two- Highly trained medical assistants - Level two navigators identify and follow up on patients with test results requiring additional actions, noncompliant patients with abnormal results requiring additional interventions, identify patients requiring care based on standing orders and implement standing orders as necessary.

Level three – RN Case managers – Work with Intense chronic diseases requiring longer and more intensive interventions. An example of this would be a patient at risk for readmission to an inpatient facility, patients with multiple ER visits, Anyone the provider has determined is high risk.

Slide 21

Success so far• With this model of care team we have seen the following successes: All third party payers (Cigna HealthSpring, VIVA, United Healthcare,

Humana) have shown a tremendous amount of interest in this type of care team implementation and that has brought opportunities for increased quality incentives and shared savings which means more money for Franklin

We have seen our hospital readmission rate for one third party drop from 17% to 13%

We are fully involved in the patient planning process with the provider care teams and third parties

We have improved documentation related to learning needs assessments, patient follow up, care coordination plans

We have had tremendous success in implementing patient care initiatives such as WISEWOMAN ( cardiovascular screening initiative for women receiving breast and cancer screening), Prostate cancer screening initiative

Increased patient compliance when care coordination is involved More engaged patient care teams

Slide 22

Conclusion• Remember we are still under construction and there is much more

work to be done• This model looks very promising and our plan is to continue to build • We are collecting the data in order to show the return on

investment with this type modelThank You

Slide 23

Questions?

Slide 24

Contact:[Name][Phone][Email]

www.pcdc.org