Transcript Patient-Centered Care VA is changing the way health care is delivered by shifting from a problem-based health care system, to one that is.

Patient-Centered Care
VA is changing the way health care is delivered by
shifting from a problem-based health care system, to one
that is patient-centered and healing
Key Components
• Personalized Health Planning
• Whole Person; Integrative
Strategies
• Behavior Change and Skill
Building That Works
1
Patient Aligned Care Team
Replaces episodic care based on illness and patient
complaints with coordinated care and a
long term healing relationship
Takes collective
responsibility
for patient care
Is responsible for
providing all the
patient’s health care
needs
Arranges for
appropriate care
with other
specialties
THE PRIMARY CARE TEAM
Future of VA Health Care
Past
Present
Future
VA
VA
VA
“What can I fix?”
“How can we help what is
wrong with you?”
“How can we help you live
the life you want to live?”
Physician
Clinical Team
Veteran, Family and
Health Care Team
Case-Based Paper Medical
Record
Disease-Based Electronic
Medical Record
Whole-Person Electronic
Health Record
“We’ll address your
immediate concern.”
“You have a risky problem,
please follow this plan to
improve by your next visit.”
“We can design your
personalized health plan to
meet your goals.”
3
The Patient’s View of Primary
Care
Access
• I can get care
when and how
I need it
Relationship
over time
Comprehensive
services
• I have a Team
who knows
me as a
person
• My Team
takes care of
the bulk of my
health needs
Coordination
• My Team
coordinates
any care I
need in the
health system
Patient Aligned Care Team
Access
Offer same day
appointments
Increase shared medical
appointments
Increase nonappointment care
Care Management &
Coordination
Focus on high-risk pts:
oIdentify
oManage
oCoordinate
Improve care for:
oPrevention
oChronic disease
Improve transitions
between PCMH and:
oInpatient
oSpecialty
oBroader Team
Practice Redesign
Redesign team:
oRoles
oTasks
Enhance:
oCommunication
oTeamwork
Improve Processes:
oVisit work
oNon-visit work
Patient Centeredness: Mindset and Tools
Improvement: Systems Redesign, VA TAMMCS
Resources: Technology, Staff, Space, Community
Other Team Members
Clinical Pharmacy Specialist: ± 3 panels
Clinical Pharmacy anticoagulation: ± 5
panels
Social Work: ± 2 panels
Nutrition: ± 5 panels
Case Managers
Trainees
Integrated Behavioral Health
Psychologist ± 3 panels
Social Worker ± 5 panels
Care Manager ± 5 panels
Psychiatrist ± 10 panels
Other Team
Members
For each parent facility
HPDP Program Manager: 1 FTE
Health Behavior Coordinator: 1 FTE
My HealtheVet Coordinator: 1 FTE
Teamlet: assigned to 1
panel (±1200 patients)
Monitored via
Primary Care
Staffing and Room
Utilization Data
report in VSSC
• Provider: 1 FTE
• RN Care Mgr: 1 FTE
• Clinical Associate
(LPN, MA, or
Health Tech): 1 FTE
• Clerk: 1 FTE
Panel size
adjusted
(modeled) for
rooms and
staffing per
PCMM
Handbook
Patient
6
“Ways In” a practice
OLD
New
e-mail
Phone
Visits
Visits
Changes in Primary Care
Past
PACT (Patient Aligned Care Team)
The patient has one provider
The patient has a team
Care delivered only by provider
Care delivered by team members
Focus on visits
Focus on overall health
Most care delivered by visits
New care delivery routes and tools
Virtual visits uncommon
Phone, telehealth visits, secure messaging common
Continuity inconsistent
Continuity consistent
High risk patients get routine care
Identify and manage high risk patients
Hospitalizations common
Hospitalizations less frequent
Care not well coordinated
Care coordinated throughout the system
Prevention not stressed
Prevention and health promotion essential
Health Tech or
Clerk
Customer Service
•Initial point of contact
•Patient Advocate
•Address customer service
concerns & coordinating
solutions.
•Hand-off communication
Assists providers
•Prepare paperwork requested
by the Veteran and/or PCP
•Specialty consult completion
tracking
•Coordinate information
exchange for the co-managed
patient
•Manage telephone demand
(receiving and documenting)
•Manage appointment
scheduling including EWL &
recall.
•Pre-visit patient reminder
calls
Face to Face Visits
•Appointment check in
•Assists w/My HealtheVet
registration
•Performs In-Person
Authentication
•Assists with updating and
verifying demographics and
insurance information
Team Work
•Daily huddle
•Team Meeting
Clinic support
•Identify & prepare required
forms, documents/records
prior to clinic session
•Faxing, copying, mail mgt
•Manage clinic grids
•Manage office supplies &
setup
Provider
(Physician, NP, or PA)
Direct Patient Care
•Scheduled Clinic Visits
•Walk in or Urgent Visits
•Group Visits
•Telephone Visits
•Incoming telephone demand
•Pertinent Clinical Reminders
Secure Messaging
•Triaged messages from patients
•E-mail with consultants
Care Management
•Virtual review of patients
including inpatients
•Identify high risk for
hospitalization.
•Appropriate for CCHT, OEF/OIF,
HBPC
•Preventive care needs
•Non VA records
•View alerts
•Diagnostic result
•Discuss care with/refer to
specialty consultants
•Traveling veterans
•Medication Reconciliation
•Refer to other team members as
appropriate
Team Work
•Daily huddle
•Team Meeting
•Midlevel Collaboration
Education
•New patient orientation
•Provider CME , Grand Rounds
•Teaching trainees
Veteran
Schedule appointments
As needed or requested by
primary care team
Appointment check in
(including correct ID)
•Utilizes kiosk to check in
when available (performs
In-Person Authentication)
•Updates insurance &
demographic info
Face to Face Visits
•Arrive on time
•Bring medications
•Required Paperwork
•Health risk assessment
completion (with RN)
•Lab work completion
Prepare for Primary Care
Visit
•Discuss concerns and
plan of care
•Utilize My HealtheVet
•Contact PC “teamlet”
with any
problems/concerns that
arise during/after face to
face encounter.
Participate
•Attend committees,
patient advisory groups,
and task forces
RN Care Manager
Direct Patient Care
•Scheduled Clinic Visits
•Walk in or Urgent Visits
•Group Visits
•Telephone Visits
•Incoming telephone demand
•Triage/place orders by protocol
•Pertinent Clinical Reminders
Secure Messaging
•Triaged messages from patients
•E-mail with consultants
Care Management
•Virtual/F2F in-depth and ongoing
review of patients including
inpatients
•Identify high risk for
hospitalization.
•Initiate appropriate consultations
for CCHT, CM, OEF/OIF, HBPC,
hospice/palliative care
•Discuss care with specialty
consultants
•Preventive/chronic disease care
needs
•Triage to other team members as
appropriate
•Non VA records
•View alerts
•Follow-up calls
Health Tech, LPN or
Medical Assistant
Direct Patient Care
•Assist with triage
•Assist providers with
exams/procedures
•Perform treatments (EKGs, V/S,
blood sugar, etc)
•Administer meds, wound care
•Pertinent Clinical Reminders
Secure Messaging
•Triage messages from patients
Care Management
•Track/administer required
immunizations
•Triage phone calls for
appointments
•Coordinate group visits
•Identify additional services
needed by Veteran/Family
Team Work
•Daily huddle
•Team meetings
Team Work
•Daily huddle
•Team Meeting
Education
•New patient orientation
•Assist with patient education
Education
•New patient orientation
•Mentor/precept nurse trainees
•Patient health
education/coaching
Clinic Support
•Daily equipment/supply checks
•Keep exam rooms stocked
9
Huddles and Team Meetings
Huddles
• Every Day
• 10 Minutes
• All Teamlet Members and Teamlet Social
Worker
• Identify Priorities for the Day
• Communicate, Clarify, Assign
• Tie Up Loose Ends from Prior Day
10
Huddles and Team Meetings
Team Meetings
• Once a Week
• One Hour
• Teamlet, Social Worker and Others
as Related to Agenda
• Agenda
– Microsystem improvement
– Care decisions with interdisciplinary team
regarding complex Veterans
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Access: Traditional
• Saturated schedules
• Triage and rework often with high intensity
resource
• Multiple appointment types
• Needs for “urgent”, “routine” and
intermediate not met
• Capacity: Overbook and “over there”
• Continuity: Fine if you wait
11/7/2015
Open Access PACT
Continuity: Every patient sees their own provider/team
member
Capacity: Future schedule is truly open
• Backlog has been eliminated
• Increase non-appointment care
• Increase shared medical appointments
• Right team member engaged with right patient’s
needs
• Right needs addressed by right tool (phone)
Creating Schedule Space
• Work Harder = add capacity temporarily
• Work Smarter = reduce provider demand
– Improve continuity
– Reduce NS rate
– Extend RVI
– Schedule phone visit
– Delegate tasks to others
– Use group visits
– Increase self care
Contingency Plans
• Predict and respond to variation in
demand between days
– Seasons
• Plan for variation in supply between days
– Short Term
– Long Term
• Plan for variation of demand and supply
WITHIN the day
Shared Medical
Appointments
•
•
•
•
•
One-on-one care with observers
15-20 patients in 90 – 120 min.
Patients learn from staff and from each other
Appeals to about ½ of those offered option
Requires substantial planning & help
When to Schedule
an Appointment?
1. Is a physical exam needed?
2. Is this a “relationship” visit?
3. Is there a need for a critical conversation?
The harder the problem, the more valuable the
appointment strategy.
Delivering Telephone Care in PACT
• 30% patient care can be done by telephone
• Telephone Care by all team members needs
to be legitimized, formalized and accepted.
• Scheduled time on appointment grids &
unscheduled visits
• Documentation of Telephone Care via
telephone stop codes, telephone clinics,
coding/encounters and progress notes
supports VERA allocation & workload.
CPT
Description
Work RVU
Telephone Non Physician & Non Licensed Independent Professionals
(RN, SW, RD, LPN/LVN, Pharm)
98966
98967
98968
HC Prof Phone Call 5-10 min
HC Prof Phone Call 11-20 min
HC Prof Phone Call 21-30 min
0.25
0.50
0.75
Telephone Physician & Licensed Independent Professionals
(PA, NP, MD)
99441
99442
99443
Phone E/M by Phys 5-10 min
Phone E/M by Phys 11-20 min
Phone E/M by Phys 21-30 min
0.25
0.5
0.75
Primary Care Provider Face to Face Visit
99211
Office Visit, E/M est. pt, Minimal, Typically 5 min
0.18
99212
99213
Office Visit, E/M est. pt, Problem Focused, 10 min
Office Visit, E/M est. pt, Expanded Problem, 15 min
0.48
0.97
IMPORTANT: Telephone note must include history,
assessment & plan
POSTER
Why Secure Messaging?
• 62% of Veteran population has access to the Internet
• Veterans are requesting timely access to their health information
• Veterans want to play an active role in partnering with primary
care providers to manage their healthcare
Goals of Secure Messaging
• Improved Quality: patient-provider partnership promoting health,
wellness, and informed decision-making.
• Improved Veteran Satisfaction: patients’ desire this type of automated
service for enhanced efficiency, convenience, and satisfaction.
• Improved Access: reduction in unnecessary office visits, expansion of
case management and ease of access to services.
• Improved Patient Growth: new generation of veterans are highly
acclimated to the electronic environment
Increase Supply
• Look inside of the appointment
– What is the work?
– Who is doing it now?
– Who could be doing it?
• What is the provider doing that someone else
could do?
PACT Access Opportunities
Secure
Messaging
Face to Face
Visits
Telephones
Group Visits
• Transitions-DC/ED
• Chronic Illness
• HPDP
• Acute/Episodic
• Follow up FtF visit
• Face to Face
• Telemed
(CVT)
TeleHealth
• Telemedicine (CVT)
• CCHT
• Store & Forward
Why Patients Call?
Questionconcern about
medication
38%
Test Results
9%
Next Step in
Care?
14%
ChronicLongterm
Medical Issue
12%
Urgent Medical
Issue
14%
Clarification of
Information on
Last Visit
13%
Source: 2009 Voice of the Veteran Survey
PCMH Provider Time
Sample Weekly Schedule
Mon
8 Unscheduled Care
Tue
Wed
Thu
Fri
Unscheduled Care
Unscheduled Care
Unscheduled
Care
Unscheduled Care
9
Telephone Clinic
Telephone Clinic
Telephone Clinic
Telephone Clinic
Telephone Clinic
10
Huddle/
Scheduled PC
Huddle/
Scheduled PC
Huddle/
Scheduled PC
Huddle/
Scheduled PC
Huddle/
Scheduled PC
11
Scheduled PC
Scheduled PC
Scheduled PC
Scheduled PC
Scheduled PC
12
Unscheduled
Care/ Lunch
Unscheduled
Care/ Lunch
Grand Rounds
Lunch
Unscheduled
Care/ Lunch
Unscheduled
Care/ Lunch
1
Scheduled PC
Scheduled PC
Scheduled PC
Scheduled PC
Scheduled PC
2
Scheduled PC
Scheduled PC
Scheduled PC
Scheduled PC
Scheduled PC
3
Scheduled PC
Scheduled PC
Scheduled PC
Scheduled PC
Scheduled PC
4
PC team meeting
Unscheduled Care
Group Visit
NP/PA oversight
Unscheduled Care
Care Management
• Prevention and Health Promotion
• Chronic Disease Management
• Transitions
– Inpatient
– Primary Care
– VA
Outpatient
Specialist
Community
28
The Global Burden of Chronic Diseases
• Chronic diseases are the largest cause of death in the world.
• In 2002, the leading chronic diseases—cardiovascular
disease, cancer, chronic respiratory disease, and diabetes—
caused 29 million deaths worldwide
• Global response to the problem remains inadequate
– elevating chronic diseases on the health agenda of key
policymakers
– persuading them of the need for health systems change.
Yach et al. JAMA, June 2, 2004—Vol 291, No. 21
Chronic Disease in the United States
• Affects more than 180 million Americans
• Accounts for more than 75 cents of every dollar
spent and nearly 2/3 of the total healthcare
expense
• By 2030: Anticipated increase in healthcare costs
tied to chronic disease, 25% to 54%
• 45% of the American population have at least one
chronic condition
30
Care Management
Medication
reconciliation
Making sure
the right things
get done at the
right time by
the right
person in the
right place
Labs and
other tests
Institutional
knowledge
• Orders
• Results
Patient’s
Care
Needs
Contacts,
local
resources
Consults
and
Referrals
• Pre-requisites
• Results
Protocols,
SOPs,
standing
orders
32
Coordination
Emergency
Department
Diagnostic
Tests
PCMH
Teamlet
Specialty
Care
Patient
Family
In-Patient
Care
Home
Care
Tools of Care Coordination
Care Plan for
Life
Patient Registries
Email Alerts
Flags and
Clinical
Reminders
Templates
Huddles
Team Meetings
Screening Tools
Community
Resources
Protocols:
• RN Driven
• LPN/HT Driven
• Clerk Driven
34
CCHT uses Evidenced Based
Disease Management Protocols (DMP)
Existing DMP’s
Developing DMP’s
•
•
•
•
•
•
•
•
•
•
•
•
Diabetes
CHF
COPD
HTN
Major Depression
Substance Use Disorder
Weight Management
TBI
Palliative Care
Dementia
PTSD
SCI
35
Katherine Corrigan, MD
Bridging Primary and Specialty Care
(Any Discipline)
Shared
Vision
• Patient-Centered
• Team-Based
• Coordinated
• Continually
Improving
Shared
Agenda
• Meet face-to-face
• Involve key
players
• Educate
• Seek common
goals
36
Outpatient and Inpatient Care Coordination:
How To Do It
Admission Notification
• PCMM or CPRS alerts
• ED visits
• Admissions
• Phone call
• Review admission list
Service Agreement with Hospitalists Nursing Policy/Procedure
• Contact PACT soon after admission
• PACT involvement in care
• Contact PACT before discharge
Pre-discharge involvement
• Visit inpatients
• Virtual chart review
• Meet with discharge planners
37
VA and Non-VA Care Coordination:
Directory of Community
Services/Resources
How To Do It
• Point of Contact
• Phone numbers
• Standard location
Contact Local providers
•
•
•
•
Identify POC
What
When
How
Contact local hospitals
•
•
•
•
Identify POC
What
When
How
38
The Journey for a Patient with Diabetes
85%
P
R
E
V
E
N
T
I
O
N
Diagnosis
Initial
Continuing
Management
Care
Non
diabetes
admissions
new
complic
ations
heart
disease
life
events
stroke
treatment
change
eg insulin
ED
EVENTS
Pregnancy
Severe
hypos
Institutional
care
ketoacidosis
protenuria
Eye
problems
Foot
issues
PC
P ROVIDER
CLERK
CLINICAL
A S S O C I AT E
RN C A R E
MANAGER
F A M I LY
40
Practice Redesign Principles
Balance supply and demand for tasks and processes
Synchronize patient, provider, equipment, room, and information
Predict and anticipate patients needs
Optimize staff, rooms and equipment
Manage constraints
Synchronizing to the Appointment Time
How do we get the provider, the patient, the
equipment, the information to an available
room-on time, every time?
Room
Provider
Patient
Equipment
10:00
Appt.
Information
Supply: The Link Between Access
and Practice Redesign
Improved
access leads
to more
efficient office
processes
Increased supply leads
to improved access
Supply
More efficient
processes increase
supply
VHA Preventive Care Program
1
How will we know?
•
•
•
•
•
•
•
•
45
Readmission rates
Ambulatory care sensitive admissions
ED monthly rates
Prevention (package) rates
Outcome data by chronic disease
Patient satisfaction
Staff satisfaction
Provider satisfaction
PACT Implementation at a Glance
46
High Performing PACTs: Outcome Measures
43%
47%
Better Performance
Better Performance
6% decrease
(8% FY11)
6% decrease
(4% FY11)
48
ACP Medical Home Builder
VHA Average
Oct-09 69% Jul-11 80%
High Performing PACTs: Access Measures
6 days
6%
Better Performance
Better Performance
Mountain Home
Nine sites for Primary Care
300
1500
500
400
2200
Existing
CBOC
ROC
1100
Planned
clinic
22,000
1800
15,000
51
Mountain Home
Renewing Our PACT with Veterans