2019 annual conference operational excellence track

2019 Annual ConferenceOperational Excellence Track


TN PCA Annual Conference

Operationalizing Integrated Care

Presented By:

April Lewis

Director, Health Center Operations

NACHC

October 3, 2019

Discussion Points

•Revisit the CHC Movement and Model

•Discussion: Identify Challenges/ Pain Points •Define Integrated Care•Recognize the Role of the Team

•How to Execute•The Critical Path: Change Management

•Exercise: The Path Ahead


A Little About Me…

The CHC Movement

“If you don’t know where you came from, you don’t know where you are going.” ~Maya Angelou

America’s Health Centers owe their existence to a remarkable turn of events in U.S. history, and to a number of determined community health and civil rights activists who fought to improve the lives of Americans living in deep poverty and in desperate need of health care.

Over fifty years ago in an urban, public housing project in Boston and in the rural Mississippi Delta, the first two Community Health Centers opened their doors.


You stand on their shoulders…

Dr. H. Jack Geiger and Dr. John W. Hatch during construction of the Delta Health Center Columbia Point Health Center in the Dorchester

neighborhood of Boston

Our Why

The Community Health Center Model was designed to remove traditional barriers to care like lack of transportation, language, literacy, and race, providing services in communities where people would otherwise not have access to doctors, primary care and other essential health services.


The Mission Continues

Community Health Centers were also among the first to go beyond the four walls of medicine to address the causes of chronic and poor health conditions such as nutrition and food insecurity, homelessness, dangerous environmental conditions, unemployment, etc.

What we now refer to Social Determinants of Health (SDH)

Our Impact

Youmake this possible!


CONGRATULATIONS ARE IN ORDER!

Congratulations to the 23 health centers who received

HRSA’s Health Center Quality Improvement Awards totaling

$1,998,370

How were you able to do it?

Clinical Quality Improvers ‐ demonstrated at least 15% improvement on a clinical quality measure (CQM) from 2017 to 2018

Health Center Quality Leaders ‐ achieved the best overall clinical performance among all health centers and achieved Gold (top 10%), Silver (top 11‐20%), or Bronze top (21‐30%) for clinical quality measures (CQMs) in 2018.

National Quality Leaders ‐ ranked in the top 1‐2% of all health centers in one or more of the clinical quality measures (CQMs) that promote behavioral health, diabetes health, and heart health in 2018.

Access Enhancers ‐ recognized health centers that increased the total number of patients served and the number of patients receiving comprehensive services between 2017 and 2018.


How were you able to do it?

Health Disparities Reducers ‐ recognized health centers that met or exceeded the Healthy People 2020 goals, or made at least a 10% improvement across different racial/ethnic groups between 2017 and 2018.

Advancing Health Information Technology (HIT) for Quality ‐ recognized health centers that utilized five HIT services and/or telehealth services to increase access to care and advance quality of care between 2017 and 2018.

Patient Centered Medical Home (PCMH) Recognition ‐ recognized health centers with patient centered medical home (PMCH) recognition in one or more deliver sites.

What the awards REALLY mean…

• You are doing great work!

• You are constantly improving

• You are making your population healthy – and can prove it

• You capture reliable data• You are reaching more and more diverse patients

• You are a high‐performers

• You are patient‐centered• You work as a team


Integrated Care

Let’s Talk… what’s hurting?


It Takes a Village

Front Desk Patient Services

Outreach and Enabling Services

Transportation

Patient Care Team Translation/Interpretation

Clinical Operations

Finance Department

IT Team

Integrated Care

… the care that results from a practice team of primary care and behavioral health clinicians, working together with

patients and families, using a systematic and cost‐effective approach to provide patient‐centered care for a defined population (Agency for Healthcare Research and Quality AHRQ)

Benefits: • Better outcomes

• Minimizes barriers to care

• Simplifies the complex process of using a healthcare system

• Supports physical and behavioral care

• Keeps the patient’s needs in the center of care


Things to Note About Integrated Care

• You can integrate services and organizations

• We will focus operationalizing the services of integrated care

• The integrated care responds to the needs of your patients and should be priority when developing, or enhancing, your staffing model

Consider the Experience: Prepare for Execution


The Patient Experience

‐ Begins at check‐in – what is the initial contact with the patient?‐ Contributes to the tone for the patient visit‐ Creates an opportunity to ease patient discomfort/ anxiety‐ Starts the clock for the cycle time and requires the team to be a successful visit

Things to remember when your patient presents:

They chose us!

For some, you may be their only option to quality care

Most visits are due to sickness or injury Consider this: how do you act when you don’t feel well?

They are part of your community

You have competitors

Social determinants of health

The Patient Experience


#SimpleHacks to Improve Your Patient Experience

You are positioned to serve high‐risk, high‐need patients to include those who are underserved and dealing with multiple chronic illness.

AccessDecrease wait timeGreet your patient with a smileMake eye contactAcknowledge everyone with your patientInform and explain their visit

#SimpleHacks to Improve Your Patient Experience

Be upfront if there are delaysPay undivided attention to your patient

Show, or remind them, where the restroom is located (note: consider the cause of the visit and necessary labs) It’s the small things that matter most

Secure confidentiality and privacy when speaking

Always reassure your patient you are there to help them

Acknowledge your patient if there is an extended wait


Effective Communication

‐ Not a script but a framework‐ Will foster consistency‐ Decreases patient anxiety‐ Build loyalty and trust‐ Promotes empathy while delivering care

‐ Can save provider time because your patient is well‐informed

‐ Helps patient be active in their well‐being because they understand the “why”

‐ It keeps care personal

A – ACKNOWLEDGE: Greet the patient by name. Smile.

I – INTRODUCE: Introduce yourself with your name, skill set, professional certification, and experience.

D – DURATION: Give an accurate time expectation for tests, when they will see the doctor. Explain next steps. Give the best update you can.

E – EXPLANATION: Provide steps so your patient knows what to expect.

T – THANK YOU!! Show gratitude for coming, being patient and cooperative.

Execution


What does the team‐based care model look like?

A teamlet: a primary care provider and their dedicated support staff, typically a MA.

The core “care team” may also include, nursing, behavioral health specialists, a health coach, oral health clinicians, and administrative

support.

The extended care team may include additional staff who focus on a group of patients of multiple teams such as RN care managers,

pharmacists, dieticians, CDEs, podiatrists and other extended care team members appropriate to the patient population.

PATIENT

Other BH Providers

MA

NP

Physician

PA

Nurses

Licensed Clinical Social

Workers

Required Mentality: A Team‐based Approach


Team‐Based Care

Guides Practice Transformation

Improves staff satisfaction and

retention

Improves patient

satisfaction and loyalty

Streamline workflow and maximizes the use of staff

Allows staff to work to the “top of their license”

Improves efficiency

Recognized as a an essential feature of

providing high quality

healthcare

What is needed to be successful?

Four essential elements for effective integrated care:

1. Leadership & Organizational Commitment

2. Team Development

3. Team Process

4. Team Outcome


Leadership & Organizational Commitment

• Ensure the Integrated Care is part of your broader infrastructure

• Executive Sponsorship

• Provide access to resources and development

• Support and create space to embrace and apply Change Management

Note: It is important to know what is working well and what is not before making changes to your model.

Team Development

•Attract and hire the right people

•Does everyone on your team know what the team‐based care model is? Looks like? Their role? The bigger picture?

• Active participation is a must

• Set clear expectations for each role• Communicate. Communicate. Demonstrate.


Team Process

• Constant evaluation

• Proper on‐boarding of new team members

• Communicate in a manner that works for the team.

• One size does not fit all

• Trust and competency of team

Team Outcome

•Begin with the end in mind. –Stephen Covey• Be aware of the outcomes you want for your patients• Communicate those outcomes with the team, patient and family

•Develop process to evaluate patient's treatment plans


Communication:• Requires trust

• Open‐Mindedness

• Patient Feedback

• Team Feedback

• Acceptance of Uncomfortable, but necessary, Conversations

• Bi‐Directional Support

Full Collaboration Integration

COORDINATION CO‐LOCATION INTEGRATION

• Utilizing one system (EHR) with possible interfaces e.g. third party reporting tools, PRAPARE, etc.

• Consistent communication with the team (huddles, meetings, instant messaging)

• Collective understanding and shared concept of team care

• Cross‐departmental roles and cultures may be disruptive

www.integration.SAMHSA.gov | SAMHSA‐HRSA CENTER FOR INTEGRATED HEALTH SOLUTIONS


Process to Better Outcomes

SHARE Approach – Shared Decision Making

Patient‐IntegrationStep I:Seek your patient’s

participation

Step II: Help your patient

explore and compare

treatment options

Step III: Assess your

patient’s values and preferences

Step IV: Reach a decision

with your patient

Step V: Evaluate your

patient’s decisions

AHRQ

Selecting the Right Program

Collaborative Care

BH Care Management + Consulting with MH specialist

BH manager becomes part of the patient’s treatment team

Care Manager follows‐up with the patient to check on process

Report out to team – adjust care as needed.


Selecting the Right Program

Patient‐Centered Medical Home (PCMH)

A model of care to address all the patient needs

Comprehensive Care

Patient‐Centered

Coordinated Care

Accessible Services

Quality and Safety

Variables to Consider

• Staff

• Patient population• Acuity levels

• Social Determinants of Health

• Panel Size

• Facilities

• Credentialing & Privileging

• Primary Data


How to make it work

• Ensure you have a comprehensive process for screening• Know what is reimbursable

• Identify the best screening tool

• Recognize the provider can not do it all

• Consider who the patient feels most comfortable with when establishing a care team

• Allow each team member to operate at the top of their license (Note: services rendered vs. reimbursements)

How to make it work

• Ensure your facility is conducive to your care team model (co‐location of the team for effective huddling)

• Provider incentives for achieving quality goals

• Try the care team model and use your cycle time and patient feedback to determine success


How to make it work • Ensure all your patients are being track and monitored

• Adjust treatment plans as needed – allow your data to drive your decisions

• Utilize evidence‐based care

• Ensure Care Coordination is efficient

• Rinse and repeat as needed… outcomes, outcomes, outcomes!

Operational Improvements

• Focus on creating work processes and not work arounds.

• Do you have the right people in the right positions doing the right thing? … per your goals?

• Is your staff to patient ratio appropriate?

• Are you conducting workflow assessment with your integrated model?• Always consider the patient experience



• Do you have bottlenecks? Is there a meeting area where staff tend to frequent?

• Location, location, location… patient flow!

• Is your facility conducive to efficiency?

• Who talks to who, when, why and how?• Front Desk Staff

• Finance Department

• Back Office

• Scheduling

• Providers

• Create standardization where possible


• Build your team around your patients

• Cultivate consistency

• Know when your care team will be out (leave, training, etc.) • How do you “cover down” and minimize the overwhelm – plan ahead

• Improve the efficiency of your front desk operation• Listen to the “gatekeepers”



• Consider all you do when the patient presents… what can be streamlined?

• Automation• Pre‐visit• Use of technology (always consider compliance) – Online assessments, iPads, Kiosk

• What can you do in advance?• Eligibility checks• Chart prep• Effective and timely confirmation calls• Huddles

• Short period of time that can impact the entire day• Include everyone on care team and make it strategic

Scheduling Hacks

• Determine the appointment types you need to load:• Same day• New• Complex• Routine• Unique • BH (15‐30 minute consultations)

• Ensure everyone has access to the patient chart • Encourage proper charting

• Ensure the patient’s needs aligns with the appointment type • Proper training of the scheduling team• Constant communication with the clinical team


Scheduling Hacks

• Stop midday, if possible, to review the morning and ensure you are set for the afternoon

• Can any scheduling adjustments be made?• Has all “prep work” been completed?• Communicate from front to back• Leaders: Compassionate check‐in

Implementing Change


Implementing Change

Change Blog

Implementing ChangeIdentify and Respond to Barriers

Is the team equipped to be successful?

Conduct Skills Assessment

Fear of Change

Seasoned Employees having negative impact on the team

Personal biases of caring for people with mental illnesses

Another process – increased workload

Lack of buy‐in from leadership


What happens in the absence of Integration

•Mental illnesses go undetected and untreated

•Mental illnesses may be undertreated if the BH model is not prevalent

•Vulnerable populations may receive inadequate care

•Stigmas remain


The Success of Integrated Care

•Reduce health disparities•Eliminate the early mortality gap

•Early intervention • Provider/ Patient relationship is fostered

•Access… increase the chances of getting to patients who need it most

•Creates space for open communication with patients

•Reduce errors

Simple Checklist for Integrated Care Model

Collective understanding of the model

Discuss with the team

Present to leadership

Hire the right people Stay interviews to increase retention

Identify needsTrainingFacilitiesPatient CommunicationScheduling/ Template Changes

Cross‐departmental discussion and buy‐in How will different teams and systems be impacted


Simple Checklist for Integrated Care Model

Remember the basics:Improve Health OutcomesImprove the Patient ExperienceReduce Cost of CareImprove the Staff Experience/ Joy at Work

Reporting & compliance regulations

Referral process (updated and mutually beneficial*

Shared space and services agreements*

*be mindful of federal and state law pertaining to PHI

• Workload

• Lack of Control/ Autonomy

• Absence of Reward

• No sense of community

• Equality

• Internal Conflict

Don’t Forget… Reduce Burnout


Don’t start the day until you finish it.” ~Jim Rohn

First…. Visualize and plan. Second… Do the work – as a team.

An improved workflow gives you a sense of control.

Accept change before it comes… because it IS coming

Tips for YOU

The Path Ahead


Communicate with your team.

Support each other.

Embrace a spirit of Excellence.

Thank You!

April LewisDirector, Health Center Operations and HR Training National Association of Community Health Centers

(NACHC)www.nachc.org

Mobile: 301-575-7081Office: 301-347-0483

2019 annual conference operational excellence track

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