cultivating a robust primary care home team. team-based care 1.who we are, early steps and successes...

Cultivating a Robust Primary Care Home Team

Team-Based Care

1. Who We Are, Early Steps and Successes2. Developing Staff Buy-In3. Work Streams and Barrier Analysis4. Roles Definition Process5. Our Team-Based Care Model and Roles6. Next Steps

Who We Are• Mosaic Medical is a 501(c)3 non-profit

organization operating Federally-Qualified Health Centers since 2002. • Our health centers are located in Prineville,

Bend, and Madras, Oregon (and soon to be Redmond!).

Mission-Driven

• The mission of Mosaic is “to improve the lives and health of individuals and families in the communities we serve.” • In 2011, Mosaic served over 14,000 patients.

As from the beginning, each of our clinics offer high-quality, comprehensive, culturally competent primary care services, regardless of age, healthcare insurance coverage,

language of origin or any other demographic characteristic.

Care: From volume driven to value driven

Early Steps• Empanelment

Empanelment process at Mosaic was developed – a cultural shift

Significant education provided to all staff and patients regarding importance of continuity of care with one PCP

Increased clinic access by adding a second evening clinic• Electronic Medical Records

Went live with Epic EMR Spring 2011• PCPCH Tier 3 Recognition

All three Mosaic Sites Recognized as Tier 3 Fall 2011

PCMH PilotOur Pilot Project • 100 Medicaid patients with the HIGHEST medical

bills in early 2010 • Stay in regular contact with the patient • ER Diversion by: Setting up standing orders, Nurse

Visits, Care Coordination, Same-Day Access, Monthly planning meetings with ER Staff, Frequent ―Huddles

with PCP, RNCC, ERCM, CHW, On-going ―connection‖ with primary care team

A Success Story…

A Rare Win-Win When the medical home program began, the goal was to reduce hospitalizations and emergency room visits by 5% • By fall, 24% fewer emergency room visits & 20%

fewer hospitalizations • Reported in the Bulletin on 07-01-2011: Our

program “Decreased medical system costs by $621,000”

PCMH Pilot Successes

Developing Staff Buy-In

• Initial PCPCH Meetings• Monthly Site Meetings• New Employee Orientation• Huddle Boards• Next Steps: Increasing Provider Participation

Clinical Improvement Teams

Teams: Clinical Team – MA Focus

Clinical Team – RN Focus

Epic Workflows

Team Members:

2 Providers1 Clinic Medical Director1-2 Medical Assistants1 RN 1 Team Care AssistantPCPCH Specialist

2 Providers1 Clinic Medical Director1 MA1-2 RN Care Coordinators1 Team Care AssistantCHW & Referrals PRNPCPCH Specialist

2 Providers1 Clinic Medical DirectorEpic Site SpecialistsBilling ManagerIT DirectorClinic ManagersNursing SupervisorPCPCH Specialist

Tentative Topics:

Huddles, Chart Scrubbing, Registries, Advanced Directives, After Visit Summary

Transitions of Care, Care Plans, Referral Tracking, Pt Room Resources, Patient Self-Management

Health Information Exchange, Test and Referral Tracking, MyChart, Implementing new facets of EPIC, Systematizing decisions made by other clinical groups

Barrier Analysis

Work Stream Analysis

Challenges Along the Way

• Leadership transition• Remote locations• Balancing patient care and meeting time• Epic limitations

Defining Our Teams: Basic Model• All team members

operating at the top of their scope.

• Care Services, Education & Support also available to multiple teams.

Roles DefinitionTeam-Based Planning Worksheet

Full document available through Safety Net Medical Home Initiative Elevating the Role of the MA Training Materials

Who Does What?Providers Registered Nurses Clinical Support Staff

- Assess, diagnose and treat patients

- Prescribe, manage and reconcile medications

- Perform procedures

- Consult with specialists and facilities

- Lead the team(s)

- Lead the practice’s strategic QI plan

- Choose evidence based guidelines and establish standing orders

- Mentor, leader, role model

- Clinical advice expert

- Triage

- Interpret reports and plan for population management

- Planned care and group visit organizer and participant

- Care management, care coordination, patient education and self management support for high risk and complex patients

- Train and supervise team

- Assist with policies, guidelines, standing order development

- Mentor, leader, role model

- Patient flow

- Collect information and populate records

- Cue up orders, referrals

- Clinical list changes, RX refill requests

- Populate registry

- Planned care and group visit participant

- Care coordination

- Patient education and self-management support for less complex patients

- Use guidelines and standing orders to support evidence based care

Source: Safety Net Medical Home Initiative Elevating the Role of the MA Training Materials

Scheduler Operator• Schedules patient

appointments• Screens symptom-

based calls for urgency

• Routes to appropriate department

Education & Support• Billing• Front Desk• Interpreting• Health IT• Patient Navigator• Community Health

Worker• Referral Coordinator• Medication

Assistance Program

Community Health Worker• Integrated in Clinic Care Team.• Case management, home visits and support for

high-need patients. • Health promotion instructors. • Staffing support for outreach events.

Referrals Coordinator: • Processes and tracks all referrals.• Coordinates authorized visits with patients and

specialty offices. • Maintains logs and tracking mechanisms.

Medication Assistance Program Coordinator:• Serves as liaison between pharmaceutical

companies and the patient. • Processes, tracks and dispenses all prescriptions

ordered through pharmacy assistance programs.

Care Services• Lab/phlebotomist• RN Triage• RN Lead• Pharmacist (soon to

come)• Behavioral Health• Mental Health

Mental Health Specialist• Comprehensive Mental Health care.• Individual/group counseling.• Case management. • Caseload consists of adults on OHP with a variety

of mental health and alcohol/drug problems. • Predominant focus is on solution-focused brief

treatment, strengths based perspective, trauma therapy, group treatment, and case management responsibilities. 

Longitudinal Care Plan Management

•RN Care Coordinator

•Team Care Assistant

RN Care Coordinator• Education, coaching and follow-up to improve

patients’ self-management skills. • Manage a panel of complex patients • Facilitates care coordination between others

involved in the care of the patient, including the patient's primary care team, medical specialists, hospitals and health plans.

• Uses Motivational Interviewing techniques for education and health promotion.

Team Care Assistant• Clinical and administrative support to optimize

care coordination for the panel of patients assigned to the primary care team.

• Panel management• Provider and patient support (including chart

reviews, processing pharmacy refill requests, and assisting with patient messages)

• Assists with coordinating the patient’s care between other members of the care team.

Visit-Level Care• Provider• Medical Assistant

Medical Assistant• Patient-centered clinical support related to visit-level care. • Facilitates the coordinated planning of office visits • Initial rooming of patients during office visits (including

medication reconciliation, risk factor review, and health maintenance review)

• Provider support• Reviews with patient the plan of care and AVS• Assists with follow-up as needed. • In addition, the MA may also perform in-office testing and clinic

services (phlebotomy, EKG, hearing and vision testing, etc.), preparation and maintenance of exam rooms, maintenance of patient records, and other tasks as requested by medical providers.

Next Steps

• Adoption of Clinical Guidelines and Standing Orders across sites

• Clinical Improvement Teams develop workflows

• Complex Care definitions• Expanded Motivational Interviewing Training• Continue to optimize Epic for team-based

care coordination

Team-Based Care Feedback From the Staff • My Diabetic patients HgA1Cs are quickly improving • I am enjoying participating and being part of a team that is making a difference

each day‖ • Although we are not 100% Patient-Centered – but once we have our teams 100%

in place; we will be an amazing clinic.‖ • I feel important; my ideas about care and treatment plans can be shared with the

provider and nurses.‖ • I go home on time feeling effective and fulfilled, having had the time to do a good

job with each patient.‖ From the Patients • I love knowing the face of the nurse always helping me.‖ • None of my friends have their own health advocates---I have a lot of fighters‘ for

me.‖ • I am treated as an individual at Mosaic Medical.‖ • I don‘t just get medical care at Mosaic Medical—I get life care.‖