2011 Patient Centered Medical Home Monthly Webinar Series

1. 2011 Patient Centered Medical Home Monthly Webinar Series

2. Before we get started… • If you have questions during the webinar, please • type them in for the presenter. • After the presentation we’ll open up the phone • lines for our interactive question and answer • session. • Please mute your phone to avoid any • background noise. Let’s get started.

3. Best Practice: Access to Care & Communication Gretchen Geist, RN; BSN Brad Meyers, MD

4. Objectives • Identify the concepts of open access (OA) • Understand the application of OA to PCMH • Identify strategies for integrating communications among staff • Identify strategies for implementing improved access and communications with patients

5. What is Open Access? Same-day scheduling, also called advanced access or open access, is a method of scheduling in which all patients can receive an appointment slot on the day they call, almost always with their personal physician. (AHRQ) The goal is to reduce or eliminate wait times both for appointments and at the time of the appointment.

6. Do Today’s Work Today Mark Murray, MD

7. Supply (clinicians’ time) = Demand (appointment visits) BALANCE

8. Why improve access? • Increased productivity • Greater patient satisfaction • Better care/continuity/clinical outcomes • More efficient predictable work flows • Physician/staff well-being • PCMH 2011 NCQA Standards & CAHPS • New payment models

9. NCQA-PCMH 2011 Standards • Enhance Access and Continuity • Identify and Manage Patient populations • Plan and Manage Care • Provide Self-Care Support and Community resources • Track and Coordinate Care • Measure and Improve Performance

10. PCMH1: Enhance Access and Continuity • Access during office hours** CF • After-hours access CF • Electronic access MU • Continuity • Medical Home responsibilities • Culturally and linguistically appropriate services (CLAS) • Practice Team CF **Must Pass Element CF=Critical Factor MU=Meaningful Use

11. PCMH1A: Access During Office Hours—Must Pass Practice has written process/standards and demonstrates that it monitors performance against the standards to: • Provide same-day appointments--CRITICAL FACTOR • Provide timely advice by telephone • Provide timely advice by electronic message • Document clinical advice

12. How to improve access? • Improvement Discipline • Principles for Same-Day Scheduling

13. Improvement Discipline* Take action using closed loop feedback process with these or similar steps: • Define the problem • Assemble a team • Set an aim or goal (measurable) *Adapted from six sigma DMAIC steps

14. Improvement* cont’d • Develop data collection tools; collect data from different sources to determine magnitude of problem • Create solutions and implement action (mini-testing cycles to find best fit) 6) Monitor and measure outcomes *Adapted from six sigma DMAIC steps

15. Principles for Same-Day Scheduling A principle is the beginning of an action. • Understand, measure and achieve a balance between supply and demand • Recalibrate the system (reduce the backlog)

16. Principles cont’d 3) Reduce the number of queues • Create contingency plans for times of ↑ Demand or ↓ Supply • Influence the Demand • Manage the constraints/bottlenecks

17. Achieving Access at Rockwood • Established “no-waiting” as fundamental expression of respect for patients—shared value • Designed office, exam rooms for efficient work flow • Placed physician’s office near front for quick access to staff—communication • Modified-wave scheduling balances supply and demand hourly

18. Access at Rockwood cont’d • Recall list (monthly) for chronic disease management (planned care) and preventive screenings—influence demand • Three types of appointments plus procedures • Chart review day before all visits, both lab and return (RN, CMA, Billing, Scheduler)

19. Access cont’d • Annual chart review of all active files • Regular staff meetings—scheduling on agenda every time—all staff except office manager and physician rotated chair role/responsibilities CHALLENGES

20. …places that function most like a system are most successful. By system I mean that the diverse people actually work together to direct their specialized capabilities toward common goals for patients. They are coordinated by design. They are pit crews. To function this way, however, you must cultivate certain skills which are uncommon in practice and not often taught.~Atul Gawande, MD from commencement address, Harvard Medical School May 2011

21. The Pit Crew PCMH1

22. PCMH1G: The Practice Team Practice provides patient care services by: • Defining roles for clinical/non-clinical team members • Holding regular team meetings-Critical Factor • Using standing orders • Training and assigning care team to coordinate care • Training on self-management, self-efficacy and behavior change • Training on patient population management • Training on communication skills • Care team involvement in performance evaluation and QI (quality improvement)

23. Healthcare Teams—Interprofessional Collaborative Practice Competencies Domain 1: Values/Ethics. Work with individuals of other professions to maintain a climate of mutual respect and shared values. Domain 2: Roles/Responsibilities. Use the knowledge of one’s own role and those of other professions to appropriately assess and address the healthcare needs of the patients and populations served.

24. Healthcare Teams—Interprofessional Collaborative Practice Competencies Domain 3: Communication. Communicate with patients, families, communities, and other health professionals in a responsive and responsible manner that supports a team approach to the maintenance of health and treatment of disease. Domain 4: Teams and Teamwork. Apply relationship-building values and the principles of team dynamics to perform effectively in different team roles to plan and deliver patient-/population-centered care that is safe, timely, efficient, effective, and equitable.

25. Teams-Teamwork-Team-based Care Communication Take the time to do it well • Clarity “My role is…” • Complexity “How can we begin…” • Consensus “We all value…” • Conflict “I see your point…” • Continuous Quality Improvement “We can do…better” • Coordination “I care…you care…we care…” • Cooperation “I can help with…” • Commitment “Yes, and…” Teach others by example

26. Who is Driving the Car?

27. References Agency for Healthcare Quality and Research. http://www.cahps.ahrq.gov/QIguide/content/interventions/OpenAccessSchedulingforRoutineandUrgentAppointments Green, L., & Savin, S. (2008). Reducing delays for medical appointments: A queuing approach. Operations Research, 56(6), 1526-1538. Institute for Healthcare Improvement (IHI). Primary care access. Retrieved from http://www.ihi.org/IHI/Topics/OfficePractices/Access/ Interprofessional Education Collaborative Expert Panel (2011). Core competencies for IP collaborative practice: Report of an expert panel. Washington, DC: Interprofessional Education Collaborative. Murray, M. (2005). Answers to your questions about same-day scheduling. Family Practice Management, 12(3), 59-64.Retrieved from http://www.aafp.org/fpm National Committee for Quality Assurance (NCQA, n.d.). Patient Centered Medical Home Standards Workshop 2011. Retrieved from http://www.ncqa.org/ Rose, K., Ross, J., & Horwitz, L. (2011). Advanced access scheduling outcomes. Archives of Internal Medicine (online version) doi:10.1001/archinternmed.2011.168