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  1. PATIENTCARE TEAMS North Hudson Community Action Corporation Health Center Maritza De La Rosa, MD Nishie Perez, MA, RN Family MedicineOrganizational Improvement Director

  2. NHCACHC Community Action Corporation Active since 1963 Services include: Immigration and Naturalization Programs Job Placement Affordable Housing Senior Services Emergency Food and Shelter Head Start WIC.

  3. NHCACHC • Health Center • Active since 1994. • Services include: • Pediatrics • Adult Medicine • Women’s Health • Behavioral Health • Addictive Services • Dental

  4. NHCACHC NHCACHC 2009 STATISTICS Patients Served: 68,955 Patients Visits: 236,362 Patients with Medicare: 3% Patients with Medicaid: 41% Patients with private insurance: 6% Uninsured patients: 50% NHCACHC is the largest FQHC in New Jersey

  5. The Care Model NHCACHC participates in this federal initiative to eliminate health disparities among underserved populations. Any identification with racial, ethnicity, language, generation, citizenship status or economic group should not lead to better or worse outcomes for a given disease. The Care Model is the brainchild of the Institute for Healthcare Improvement (http;// and puts the management of chronic disease in the hands of health professionals, patients and families.

  6. The Care ModelGoal : • Improve outcomes. Encourage high quality clinical and chronic disease care. The model can apply to different chronic illness, health care settings and target populations.

  7. The Care ModelSix Main Components : • Community Resources • Community Partnerships • Health Care Organization • Create culture promoting safety and high quality of care • Self Management Support • Patients are in Charge of their own care • Decision Support • Evidence based guidelines and protocols • Access to specialty care • Delivery System Design • Workflow • Roles • Clinical Information Systems • ie - Reminders

  8. The Care Model • Productive Interactions • Patient Centered : Informed, empowered patient & family • Coordinated - Evidence based and safe change concepts - Prepared proactive team The Care Model summarizes the basic elements for improving care in the health systems at the community, organization, practice and patient levels.

  9. Development and Implementation of Patient Care Teams at NHCAC.

  10. Reasons for the development and implementation of Care Teams • Organizational Improvement Strategy. • Identify areas that need improvement (clinical, financial, operational, etc) at each site. • Inform clinical and non-clinical staff at each specific site of audit results. • Implement changes and promote a collaborative environment. • Empower staff and clinicians to manage and improve services at their specific site.

  11. Other Reasons • To develop a well prepared, stable and proactive care team to promote the delivery of safe evidence-based clinical management. • Empower and inform patients and families.

  12. Care Team Members Responsibilities • Inform providers and staff of indicators being monitored, audit results and plan for improvement • Develop and implement recommendations and plan for improvement. • The care team meets monthly to discuss the progress in reaching goals.

  13. Organizational Improvement Department Responsibilities • Perform audits. • Provide summary of results and discuss quarterly with care teams . • Provide support when necessary as requested by the teams. • Provide tools (health plan, health disparities collaborative and indicator list). • Provide analysis of medication errors, adverse drug reactions and medical emergency reports .

  14. Select your team • Select your “new team”. Select specific members from all staff. • Team members should be regular staff members who spend the majority of their time at that specific health center.

  15. Requirements • Understand and accept changes will take place in order to meet patient needs and improve center services: • ie • Change staff hours • Redefine roles and redistribute tasks • Change or reassign staff responsibilities • Change center hours • Change services provided

  16. Requirements • Develop clinical sessions with defined starting and ending time. • This will allow to have a well prepared and proactive team. • Managers are essential for the success of the patient care team. • Managers need to engage every one at the center from housekeeping to providers. • Managers are required to monitor the patient flow “clear obstacles” and act as troubleshooters. This will enable the patient care team to provide quality services to patients instead of trying to solve operational problems.

  17. Benefits • Maximize the full resources from each staff member. • Discover and use talents and prior experiences from team members. • Provide a place where patients feel “at home” and where they know their health issues and concerns will be addressed in a professional manner. • Patients and families will be informed and empowered. They will be able to understand their disease and their role as daily self managers. • Change the services provided from: patient visits to a proactive comprehensive care of a panel of patients of a specific community. • Comprehensive system change.

  18. Results • Improve quality of care to patients – improvement in quality indicators • Improve outcomes with same resources • Improve patient satisfaction • Improve employee morale and satisfaction • Accountability • Opportunity for staff development and creativity

  19. PDSA – IMPROVEMENT MODEL • Provides a process to improve the quality of care at an accelerated pace. • Small cycle test of change to evaluate if changes will have benefits at a larger scale. PLAN = Objective Who, What, Where, When, Why DO = Carry out plan Study = Analyze data and compare to predictions. Summarized what was learned. Act = What changes to be made.

  20. Quality IndicatorsCare Team Pilot Site : NHCAC-Hackensack *1st Qtr 90% of patients with HTN who were not compliant with BP ≤ 140/90 had an intervention at time of visit. Core measures of our Health Plan

  21. PDSA #1 Medical Record Completion • Internal Medicine residents and attending practice: WH, PEDS, IM • Training provided to all IM residents on NHCAC required documentation in medical records. • Assigned HIM staff member to prepare incomplete charts and work with residents during clinic hours. • Residents instructed to complete medical records at the beginning of their clinical sessions. • CMA’s are assigned to prepare charts for NHCAC providers for completion.

  22. North Hudson Community Action Health CenterPDSA #1 Medical Record Completion # Incomplete Medical Records

  23. PDSA #2 Appointment Confirmation • CMA’s were responsible for confirming appointments at the end of the day. • CMA’s were unable to make calls – involved in active patient care. • Responsibility for confirmation appointments was reassigned to registration staff. • Site Coordinators to measure and monitor percentage of missed appointments.

  24. North Hudson Community Action CorporationHackensack Health CenterPDSA #2 Appointment Confirmation % of Missed Appointments

  25. PDSA #3 LABORATORY REPORTS PENDING FOR FILING • Excessive amount of unfiled lab reports. • Determine how lab reports come into the Health Center and streamline the process. • Assign a nurse to separate and sort lab reports. • Provider review and signs lab reports on a daily basis and send to HIM department. • HIM staff file lab reports daily. • Decrease patient visit waiting time. • Decrease in duplicate lab reports. • Decrease in lab reports awaiting provider review and signature.

  26. North Hudson Community Action CorporationHackensack Health CenterPDSA #3 Lab Reports Pending for filing # Unfiled lab reports

  27. North Hudson Community Action Corporation Hackensack Health CenterPDSA #3 Lab Reports Pending for fillingFiled Laboratory Reports

  28. PDSA #4 Help Desk Users • Create a “Help Desk” located in the front registration area during peak morning hours. • The help desk staff will act as a patient advocate and address the patient’s needs in a timely fashion. • Duties: • Assist patients arriving without appointments: • Determine reason for their visit: Triage & medications refill forms developed • Obtain medical record • Communicate to patient how the request will be resolved. • Bridges communication gap between NHCAC staff, patients & families. • Periodically updates patients in waiting room. • Develop patient satisfaction survey to measure the success and on going need of the help desk.

  29. North Hudson Community Action CorporationHackensack Health CenterPDSA #4 Help Desk UsersMarch 15, 2010 – April 30, 2010

  30. PDSA #4 Help Desk Users March 15, 2010 - April 30, 2010 IM patients who requested information at help desk


  32. ChangesImplemented • IM residents receives training on completion of medical records. • “Help Desk” – Help desk forms developed and assigned staff as patient advocate. • HIM employee works with residents to complete records. • Laboratory reports reviewed daily by clinicians & filed by HIM personnel. • Appointments are confirmed on a daily basis.

  33. ChangesImplemented • Staff realigned to match clinic sessions. • Courtesy Service training provided to all staff. • Patient education classes (DM, HTN, Hyperlipidemia and nutritional) given weekly. • Medical Management Intervention for patients not achieving goals are done at time of visit.

  34. Care Team Meetings • Monthly – Set up dates/calendars • Start & finish on time – 1 hr • Agenda/minutes • Discuss audits results • Discuss team accomplishments • Divide group/sections discussions – New issues • Team discussions summary • Plan for improvement

  35. Organizational Improvement Department • Quarterly Audits Results • Pediatrics • Adult Medicine • Women’s Health • Dental • Care Team Drivers: • J. Verea, MD, Chief Medical Officer • M. De la Rosa, MD, Family Practice • N. Perez, RN, Director of OI • O. Love, RHIT, Director of HIM • C. Brillantes, Quality Analyst

  36. Contact us: Maritza De La Rosa, MD Nishie Perez, MA, RN nishiep@