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objectives

Family Medicine Primary Care Redesign= APEX= UNM Team Based Care EVERY JOURNEY BEGINS WITH A SINGLE STEP Jen Phillips, MD 11/6/2018 Primary Care Council 11/7/2018 UNM Family Medicine Resident School. objectives.

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objectives

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  1. Family Medicine Primary Care Redesign= APEX= UNM Team Based CareEVERY JOURNEY BEGINS WITH A SINGLE STEPJen Phillips, MD11/6/2018 Primary Care Council11/7/2018 UNM Family MedicineResident School

  2. objectives • Understand how ‘team based care’ can improve access, decrease burnout and be better for patients, providers and staff

  3. Why team based care? • Efficiency of practice • Wellness for providers and health care team- less burnout • Better for patients- more brains are better than one- my experience with interpreters • Increase access- most primary care clinics in our system see 6-8 patients a half day

  4. Why do we need a change? • Press Ganey Results from FCM clinical providers at all sites; 2017 n=55 • 27% said “It is easy to care for patients in UNM.” • 31% said “Our electronic medical record improves patient care.” When we surveyed burnout in primary care providers at UNM in 2016 they had a higher emotional exhaustion than the general population of healthcare workers and a higher perceived workload. We are researchers, educators and Innovators!

  5. Background – Changes That Work • The Triple Aim—enhancing patient experience, improving population health, and reducing cost—is accepted as a guiding principle for health care system improvement.1 • Growing recognition of the impact of healthcare workforce burnout on health and patient satisfaction has led to expanding to the Quadruple Aim.2 • Team-based care has been shown to improve health care quality and health outcomes and reduce cost.3,4 • Built upon University of Utah’s Care by Design, the University of Colorado’s APEX model is based on expanded medical assistant roles and MA-to-provider ratios. • Berwick, DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff(Millwood). 2008;27(3):759-769. • Bodenheimer T, Cinsky Christine. From Triple Aim to Quadruple Aim: Care of the Patient Requires Care of the Provider. Ann Fam Med 2014; 12:573-576. • Boult C, Green AF, Boult LB, Pacala JT, Snyder C, Leff B. Successful models of comprehensive care for older adults with chronic conditions: Evidence for the Institute of Medicine's Retooling for an Aging America report. Journal of the American Geriatrics Society. Dec 2009;57(12):2328-2337. • Naylor MD, Coburn KD, Kurtzman ET, et al. Inter-professional team-based primary care for chronically ill adults: State of the science. Unpublished white paper presented at the ABIM Foundation meeting to Advance Team-Based Care for the Chronically Ill in Ambulatory Settings. Philadelphia, PA; March 24-25, 2010. Berwick, DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff(Millwood). 2008;27(3):759-769. Boult C, Green AF, Boult LB, Pacala JT, Snyder C, Leff B. Successful models of comprehensive care for older adults with chronic conditions: Evidence for the Institute of Medicine's Retooling for an Aging America report. Journal of the American Geriatrics Society. Dec 2009;57(12):2328-2337. Naylor MD, Coburn KD, Kurtzman ET, et al. Inter-professional team-based primary care for chronically ill adults: State of the science. Unpublished white paper presented at the ABIM Foundation meeting to Advance Team-Based Care for the Chronically Ill in Ambulatory Settings. Philadelphia, PA; March 24-25, 2010. Bodenheimer T, Sinsky C. From Triple Aim to Quadruple Aim: Care of the Patient Requires Care of the Provider. Ann Fam Med 2014;12:573-576. Berwick, DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff(Millwood). 2008;27(3):759-769. Boult C, Green AF, Boult LB, Pacala JT, Snyder C, Leff B. Successful models of comprehensive care for older adults with chronic conditions: Evidence for the Institute of Medicine's Retooling for an Aging America report. Journal of the American Geriatrics Society. Dec 2009;57(12):2328-2337. Naylor MD, Coburn KD, Kurtzman ET, et al. Inter-professional team-based primary care for chronically ill adults: State of the science. Unpublished white paper presented at the ABIM Foundation meeting to Advance Team-Based Care for the Chronically Ill in Ambulatory Settings. Philadelphia, PA; March 24-25, 2010. Bodenheimer T, Sinsky C. From Triple Aim to Quadruple Aim: Care of the Patient Requires Care of the Provider. Ann Fam Med 2014;12:573-576.

  6. We can’t keep doing things the same way • Burning platform

  7. In search of a Solution; Field trip! 11/2017 • Department of FCM leaders visited University of Colorado to watch their APEX model – Awesome Patient Experience • They borrowed it from University of Utah • Team Based Care has been reproduced in many health systems and has been proven to increase volume of patients seen, decrease burnout in providers and the team and not negatively impact patient satisfaction.

  8. Similar to this: • The Visit • https://www.youtube.com/watch?v=pXatZM_Rie8&t=12s

  9. Buy in by top leadership created:Our UNM Primary Care Redesign Team • Melanye Nez, Medical Assistant • Anjelica Zamora, PCMH Coordinator • Arlenda Thompson, Unit Director • Elizabeth McManus, RN Sup • Dinah Lucero, Office Supervisor • Stephanie Richmond, PA • Dr. David Rakel, Chair of Family and Community Medicine • Dr. Jennifer Phillips, Medical Director, Associate Chair FCM • Dr. Nancy Pandhi (MD, MPH, PhD), Associate Professor FCM • Susan Tobin, RN Primary Care Nurse Educator • Dr. Charles North, Vice Chair of F&C Medicine, senior medical director primary care • Karen Ellingboe, Executive Director, Primary Care • David Padilla, IT Analyst • Rene Saavedra, IT Analyst • Gwendolyn Blueeyes, CHW • Sheryl Wolf, IT Analyst • Yvette Sena, Strategic Project Director • Karen Prince, Project Manager • Al Urbano, Cerner Scheduling • Christina C’deBaca, Project Manager

  10. Your Design Team worked16 hours Planning Implementation4 RPEs

  11. What we did ………………. • Identified differencesbetween UNMH Primary Care and the APEX (team based care) model flows • Agreed on what differences to adopt from APEX • Reviewed current resources and identified resource gaps for APEX model • Calculated cost of additional resources and revenue needed to support additional cost • Determined provider template to meet revenue needs • Smoothed provider schedules across the week/year • Identified provider teams • Identified metrics to measure our success • Developed action plan and PDSA to pilot

  12. Staff and Provider Resources Current Proposed Assumptions 5 staff/2 providers = APEX model staffing 2 MAs/provider & 1/2 staff to manage provider inboxes Staffing needs = 11.7 MA/4.6 providers (12 MA/5) For front desk-additional 10 more patients per session to check-in : 52 patients per session total= 2 Clerks • 6 MAs • 3 RNs (includes RN Sup) • 1 PCMH coordinator • 1 CHW • 1 office Supervisor • 1 unit Director • 1 clerk

  13. Success Metrics

  14. Cost of Pilot/Needed Revenue

  15. Four Phase Implementation Highlights • Phase 1: (started 7/1/2018) • 1:1 MA/provider ratio • Linked visits/More Triage Time • New MA Responsibilities • Identify agenda with patient and set visit length expectation • Ask if patient brought forms and complete as much as possible • Ask if refills are needed and what meds patient is no longer taking • Huddle with provider • Complete consult request with help • Schedule linked return visit • New Provider Responsibilities • Huddle with MA b/4 seeing patient • Acknowledge patient’s agenda and reinforce visit length expectation • Monitors time spent with patient • Assist MA with consult completion • Phase 2: (starting soon) • 2:1 MA/provider ratio • Requires MA enhanced Cerner access • New MA Responsibilities • Starts provider note • Gathers and documents Review of Symptoms (ROS) • Updates Medication History • Adds, deletes, pulls in from external pharmacies • New Provider Responsibilities • Reviews and clarifies ROS with patient • Reviews medication history and completes med reconciliation

  16. Four Phase Implementation Highlights • Phase 3: • 2:1 MA/provider ratio • No schedule template changes • New Provider Responsibilities: • Narrates: • Chief complaint: key phrases • Physical Exam • Edits to problem list • New MA Responsibilities • Documents as provider narrates: • Chief complaint: key phrases • Physical Exam • Edits to problem list • Phase 4: • 2.5:1 MA/provider ratio • New schedule template utilized • .5 MA Responsibilities • Stocking rooms • Stocking lab trays • Supports Patient care • Covers leaves • Covers breaks • Monitors flow • Manages provider portal, phone and pool messages • Manages provider paperwork

  17. What’s Different ?????? Medical Assistant Provider Huddles with ma before visit Gaps and screenings completed by ma Has full appt time with patient (20-25 minutes) Reinforces agenda & appt length Has documentation support for: Starting of note Medication history update Review of systems Chief c/o Physical exam Consults entry Form completion Note completion as you go Sees 2 more patients • Longer, dedicated triage time, linked visit • Fewer patients (1/2 as many) • Updates medication history • Identifies RX renewal needs • Sets Visit agenda & appt length • Collects Review of Systems • Collects and helps complete any needed pt. forms • Starts provider note • Briefs provider before visit • Scribes physical exam & chief c/o • Enters Consult requests

  18. What’s happening Now?? Phase 1 of 4!! • Implementing/Evaluating Phase 1: • Medical Terminology Training completed • MA Training on Phase 1 completed • Rapid cycle PDSA • 1 provider/1 ma at a time • Meeting weekly with Team • What’s working? • What’s not? • Tweaking the process • Doing Audits and giving feedback • Refining the training

  19. What is a learning health system? Disseminate Share results to improve care for everyone In a learning health system, research influences practice and practice influences research Internal and External Scan Identify problems and potentially innovative solutions Internal External Adapted from Greene et al. 2012. Ann Intern Med. 2012.

  20. Preliminary Results • Increased Health Care Maintenance Orders- which will improve quality metrics. These are being ordered by MA in Acute Care visits and going back to PCP. • “Clerk Treats me with Courtesy/Respect” : 24th%ile 89% in July-12/2017, Now 94%ile, 97% in July 2018 trending up • Average arrived Visits per session 2/2017- 2/2018 was 7.9 and now is 8.2 in 9/2018, was 8.4 in July 2018 but steadily trending up even without more slots • Room utilization up from 30% Jan 2018- Feb 2018 and is now 69% in September

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