How To Improve Patient-Centered Primary Care

This document contains a portfolio of resources to aide primary care practices in their efforts to improve the quality of care and experience their patients receive.

Version 1.0

January 2012

Developed by: Kyrsten Chambers

Access HealthColumbus Staff

Kim Raderstorf Access HealthColumbus Consultant

For any questions regarding this document please contact:

Jeff Biehl, President, Access HealthColumbus: jbiehl@accesshealthcolumbus.org Kyrsten Chambers, Project Coordinator, Access HealthColumbus: kyrsten@accesshealthcolumbus.org

TABLEOFCONTENTS

I. Introduction and Overview Pages: 1-6 II. Access and Continuity of Care Pages: 7-9 III. Care Coordination Pages:10-12 IV. Patient and Family Engagement Pages:13-15 V. Patient Self-Health Management Pages: 16-18

The current national focus is targeted at promoting primary care improvement by supporting comprehensive primary care to create better health, better care and lower costs. In alignment with this national trend, Access HealthColumbus created a “How To“ portfolio to provide the information needed for patient-centered primary care practices to implement practice improvement projects in the following four areas: Access and Continuity of Care Care Coordination Patient and Family Engagement Patient Self-Health Management

Why are We Supporting Primary Care Improvement? 

The purpose of this ini a ve is to provide primary care prac ces with the tools and knowledge needed to learn “how to” improve the value of pa ent‐centered services for

pa ents/consumers based on na onal standards and best prac ces.

How To Improve Patient-Centered Primary Care Version 1.0 (DRAFT) November 2011

Con nuous Primary Care Improvement

Access & Con nuity of

Care

To enhance access to care and con nuity through improved systems/procedures, such as open scheduling, expanded hours and new op ons for communica on between pa ents, their personal provider, and prac ce staff.

(Derived from the PCMH Joint Principals. Sourced from the PCPCC: h p://www.pcpcc.net/content/joint‐principles‐pa ent‐

centered‐medical‐home)

Care Coordina on

To improve care coordina on and integra on across all elements of the complex health care system and the pa ent’s community.

(Derived from the PCMH Joint Principals. Sourced from the PCPCC: h p://www.pcpcc.net/content/joint‐principles‐pa ent‐

centered‐medical‐home)

Pa ent and Family

Engagement

To redefine pa ent‐provider rela onships in primary care by using an approach to plan, deliver and evaluate care grounded in mutually beneficial partnerships among providers, pa ents and families. (Derived from the Planetree Defini on. Sourced from the PCPCC: h p://www.pcpcc.net/files/pcpcc_cce_consumer_views_of_pcc_7‐29‐11.pdf)

Pa ent Self‐Health

Management

To ins ll the knowledge, skills and confidence integral for pa ents to manage their overall health or chronic condi on, and engage in disease preven on efforts. (Derived from Pa ent Ac va on Management Survey sourced from www.insigniahealth.com)

Each of the four improvement areas has an introduction that outlines the necessary key project steps and processes recommended for practices to learn “How To” improve patient-centered services. Tools and resources included in this “How To” portfolio are based on national standards and best practices. The following four definitions outline the purpose of each project improvement area.

Improvement Project Areas of Focus 

PROCESSFOR“HOWTO”IMPROVEYOURPRIMARYCAREPRACTICE

The following key project steps outline the process needed to start an improvement project initiative at your primary care practice. We have provided a step by step process to get you started on the pathway to improving primary care for your patients. In addition, we have included team planning worksheets to provide your practice improvement team with a good place to start.

KEY PROJECT STEPS

Step 1: Hold Practice Shared Learning Session w/Staff

Review the Primary Care Practice Improvement Portfolio and Overview

Identify Practice Improvement Team Members

Create Improvement Team Expectations and Roles (See Goal Setting Worksheet example on page 3)

Develop Shared Purpose Statement

“Why are we doing this? And ”What is our end goal?”

Step 2: Perform Discovery Assessment

Hold Team Meeting to Answer Overall Discovery Assessment Questions

What are your needs and expectations for your improvement project?

How would you know if you were doing a good job? (State ways (performance indicators) that show how you judge the quality of your practice.)

What goals do you have?

Name 1 thing your team could do better, differently, or change?

Step 3: Choose Improvement Project and Track Progress

Determine Improvement Project Action Plan and Process

Set Goals and Timeline

Develop and Set Team Member Responsibilities

Track Improvement Project Success

Step 4: Review Improvement Project Progress and Determine Next Steps

Discovery Assessment Worksheet-Overall

1. What are your needs and expectations for your improvement project?

2. How would you know if you were doing a good job? (State ways (performance indicators) that show how you judge the quality of your practice.)

3. What goals do you have?

4. Name 1 thing your team could do better, differently, or change?

Goal Planning Sheet

Target Date

Champion

Goal

Step Number

Action Start Date

Who Date Completed

Measures of Progress

l ----- l ----- l ----- l ----- l -----l ----- l ----- l ----- l ----- l ----- l ----- l 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Goal Tracking

How to Measure Goal Achievement

Step 1 ________________________________________________10%

Is the goal well-defined? Has a champion been assigned? Have basic

steps and timing been estimated?

Step 2________________________________________________30%

Have the means for achieving the goal been identified? Have

equipment, material, staffing and methods been initially approved?

Have all the necessary resources been acquired?

Step 3________________________________________________40%

Has a detailed action plan been developed?

Step 4________________________________________________50%

Means of achieving the goal are fully designed, developed and ready

for implementation. Have all final approvals been received?

Step 5________________________________________________90%

All action steps have been implemented to achieve the goal.

Step 6________________________________________________100%

We need to assess the effectiveness and degree of success.

Performance indicators have been discussed and the team is satisfied.

Has the implementation also passed the test of time?

Goal Planning Sheet

Completion Date

1/12/2012

Champion Smith

Goal

Customize goal setting and tracking sheets to be used with patients for self-health coaching.

Step Number

Action Start Date

Who Date Completed

1. Read CHAP – Take Action (insert link) 1/3/12 Team

2. Have Team write an action plan for chronic problem in their life. They can utilize the Asthma and Diabetes Action Plans as a template.

1/3/12 Smith and team

3. Team asks self – How sure are you that you can follow your action plan? Who can help? What barriers will prevent action? Team discusses answers to these questions.

1/3/12 Team

4. Team monitors and charts progress towards goal on run chart.

1/3 – 1/10/12

Team

5. Team reconvenes to discuss experience. Led by Smith, team now customizes action plans and run charts to meet patient needs.

1/10/12 Smith and team

6. Team distributes customized sheets to assigned providers. Provides training as needed on the spot. Describes how progress towards self-health coaching will be monitored (e.g. patient count).

1/12/12 Team

7. After conversation, team member checks off provider’s name on VMS (Visible Measurement System-like a poster) as trained in coaching methods and documents.

Ongoing Team

8. Each team member recycles this conversation on a weekly basis with assigned providers to encourage coaching.

Ongoing Team

Measures of Progress

l ----- l ----- l ----- l ----- l -----l ----- l ----- l ----- l ----- l ----- l ----- l 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

PROCESSFOR“HOWTO”IMPROVEPATIENTACCESSANDCONTINUITYOFCARE

The following key project steps outline the process needed to start an improvement project focused on improving patient access and continuity of care with their assigned or preferred primary care provider. This improvement project area focuses on enhancing access to care and continuity through improved systems/procedures, such as open scheduling, expanded hours and new options for communication between patients, their personal provider, and practice staff.

KEY PROJECT STEPS Step 1: Complete Discovery Assessment

Activity: Answer “Access and Continuity of Care” Discovery Assessment Worksheet

What are your needs and expectations for creating better access for patients?

How do you know if you are doing a good job creating access for patients? (State ways (performance indicators) that show how you judge the access of your practice.)

Name 1 thing your medical practice could do better, differently or change to give patients better access?

Explore and discuss “Discovery Assessment” results

Review existing access and continuity of care policies at the practice

Brainstorm access and continuity of care activities staff would like to work on

Step 2: Solve Problems Related to Appointment Scheduling

Activity: Review Current Practice Policies Related to Appointment Scheduling

Review data related to scheduling:

Do we know how long patient wait times are at our practice?

Do we know how large our practice schedules patient backlog is?

List and review current scheduling practices

Propose tools and solutions to reduce backlog and other issues using proposed resources:

Backlog Reduction Worksheet:

http://www.ihi.org/knowledge/Pages/Tools/BacklogReductionWorksheet.aspx

Third Next Available Appointment Process and Example

http://www.ihi.org/knowledge/Pages/Measures/ThirdNextAvailableAppointment.aspx

Appointment Sequencing Worksheet

http://www.ihi.org/knowledge/Pages/Tools/BacklogReductionWorksheet.aspx

Group Visits

http://www.aafp.org/online/etc/medialib/aafp_org/documents/clinical/pub_health/aim/groupvisits.Par.0001.File.tmp/GroupVisitAIM.pdf

After-Hours and Email Access

http://www.aafp.org/online/en/home/policy/policies/e/evisits.html

http://www.qhmedicalhome.org/safety-net/upload/EnhancedAccess_ImpGuide.pdf (pg.13)

Create action plan for team to implement practice scheduling solutions

Step 3: Specify Process to Assure Greater Patient Responsibility for Managing Care

Activity: Develop Patient Responsibility Checklist for Appointments

Create Patient Responsibility Checklist

Patient Responsibility Appointment Checklist

http://www.pcpcc.net/files/pcmhpatientchecklist_0.pdf

Create reminder policy and process to ensure patients bring checklist to appointment

Create action plan that assures follow-up before the appointment with the patient to ensure they have all of the necessary information needed for the appointment.

Utilize team huddles to determine what each patient will need for their appointment and confer with patient checklist to prep patients efficiently before their appointment

Team Huddles

http://www.ihi.org/knowledge/Pages/Changes/UseRegularHuddlesandStaffMeetingstoPlanProductionandtoOpti-mizeTeamCommunication.aspx

Step 3: Implement and Evaluate

Activity: Evaluate Progress Towards Improved Access and Continuity of Care

Develop at least two performance indicators for improving access and continuity of care

Establish simple process for measuring progress towards access and continuity of care improvement

Track progress and performance

Discovery Assessment Worksheet Access and Continuity of Care

1. What are your needs and expectations for creating better access for patients?

2. How do you know if you are doing a good job creating access for patients? (State ways (performance indicators) that show how you judge the access of your practice.)

3. Name 1 thing your medical practice could do better, differently or change to give patients better access?

PROCESSFOR“HOWTO”IMPROVECARECOORDINATION

The following key project steps outline the process needed to start an improvement project focused on improving care coordination and integration across all elements of the complex health care system and the patient’s healthcare community. This improvement project area focuses on better coordinating patient’s care across their primary care practice through improved systems/procedures, implementing referral tracking processes and developing patient follow-up policies, working towards enhancing communication between patients, their personal provider, practice staff and other members of the patient’s healthcare community.

KEY PROJECT STEPS

Step 1: Complete Discovery Assessment

Activity: Answer “Care Coordination” Discovery Assessment Worksheet

What are your needs and expectations for coordinating care for patients?

How do you know if you are doing a good job coordinating care for patients? (State ways (performance indicators) that show how you judge patient care coordination in your practice.)

Name 1 thing your practice could do better or differently related to care coordination?

Explore and discuss “Discovery Assessment” results

Review existing care coordination policies at the practice

Brainstorm care coordination activities staff would like to work on

Step 2: Develop Staffing Model to Support Care Coordination

Activity: Visualize Care Coordination Process

If available, review current data related to care coordination:

What is the current policy/process in place for care coordination?

Who are the current staff members whose job responsibility is care coordination?

What is/isn’t working?

Create a flow chart of the current process

Visualize positive changes to process and record on new flow chart

Determine staffing availability, experience and responsibility for recommended care coordination process

Step 3: Develop Skills and Materials to Support Care Coordination

Activity: Customize Materials for New Care Coordination Strategy

Propose tools and solutions to improve care coordination.

Care Coordination Action Plan Worksheet

http://www.intrahealth.org/tol/documents/actionplan.pdf

Care Coordination Team Huddles

http://www.ihi.org/knowledge/Pages/ChangesUseRegularHuddlesandStaffMeetingstoPlanProduction-andtoOptimizeTeamCommunication.aspx

http://www.ihi.org/knowledge/Knowledge%20Center%20Assets/Tools%20-%20Huddles_75bc6994-c794-432c-b7fc-739278dbdf0f/Huddles1.pdf

Care Coordination Referral Curriculum for Current Practice Staff

http://www.improvingchroniccare.org/downloads/5_referral_coordinator_curriculum.pdf

Care Coordination Tracking Referrals Overview and Worksheet

http://www.improvingchroniccare.org/downloads/3_referral_tracking_guide.pdf

Patient Responsibility Assessment Checklist

http://www.improvingchroniccare.org/downloads/6_patient_referral_checklist.pdf

Develop a Community Resource List for Patients

http://www.handsoncentralohio.org/ or call: 2-1-1

Create action plan that incorporates selected care coordination resources

Step 4: Specify Process to Assure Greater Patient Responsibility for Managing Care

Activity: Develop Patient Referral Process Self-Health Management Responsibilities

Create Patient Responsibility Checklist:

Patient Responsibility Checklist

http://www.improvingchroniccare.org/downloads/6_patient_referral_checklist.pdf

Create practice policy/process that assures follow-up before the referral appointment with the patient to ensure they have all of the necessary information needed for the appointment

Implement practice policies that support practice improvements

Step 5: Implement and Evaluate

Activity: Evaluate Progress Towards Improved Care Coordination

Develop at least two performance indicators for care coordination

Establish simple process for measuring progress towards care coordination

Track progress and performance

Discovery Assessment Worksheet Care Coordination

1. What are your needs and expectations for coordinating care for patients?

2. How do you know if you are doing a good job coordinating care for patients? (State ways (performance indicators) that show how you judge patient care coordination in your practice.)

3. Name 1 thing your practice could do better or differently related to care coordination?

PROCESSFOR“HOWTO”IMPROVEPATIENTANDFAMILYENGAGEMENT

The following key project steps outline the process needed to start an improvement project focused on redefining patient-provider relationships in primary care by using an approach to plan, deliver and evaluate care grounded in mutually beneficial partnerships among providers, patients and families.

KEY PROJECT STEPS

Step 1: Complete Discovery Assessment

Activity: Answer “Patient and Family Engagement” Discovery Assessment Questions

What are your needs and expectations for patient and family engagement?

How do you know if you are doing a good job engaging patients? (State ways (performance indicators) that show how you judge the quality of relationship with your patients.)

Name 1 thing your primary care practice could do better, differently or change related to patient engagement?

Explore and discuss “Discovery Assessment” results

Review existing patient and family engagement policies at the practice

Identify how the practice wants to communicate better with practices

Brainstorm and create action plan for engagement activities staff would like to work on

Step 2: Develop Practice Specific Patient and Family Engagement Materials

Activity: Develop Patient and Family Engagement Materials

Decide what media practice would like to use to share important information and engage patients and family with the practice and staff:

Patient and Family Engagement Brochure and Guide

http://www.pcpcc.net/files/gruman_et-al_creating-patient-guide-for-medical-home-physician-practice.pdf

Patient and Family Engagement Guide

http://www.pcpcc.net/files/Supporting_Engagement_PCMH.pdf

Determine what information the practice would like to include in handouts

Create patient and family engagement materials

Develop process/goals for creating and distributing these materials

Step 3: Develop Materials to Identify Patient and Family Roles in the Primary Care Practice

Activity: Define Patient and Family Roles and Develop Supporting Materials

Determine what the practice sees as the patient’s role

Develop checklist to communicate patient’s role

Patient Responsibility Checklist

http://www.pcpcc.net/files/pcmhpatientchecklist_0.pdf

Create and implement policy to distribute checklists and follow-up

Step 4: Create Practice Patient-Provider Advisory Council

Activity: Work Towards Establishing Patient-Provider Advisory Council (PPAC)

Define the purpose and scope of practice PPAC

Patient-Provider Advisory Council Best Practices Articles

http://www.ipfcc.org/advance/Advisory_Councils.pdf

http://www.ahrq.gov/qual/advisorycouncil/adcouncil3.htm

Create criteria for PPAC participation

Develop action plan and objectives to create PPAC and invite patients to be involved

Patient-Provider Advisory Council Objectives and Goals

http://www.ahrq.gov/qual/advisorycouncil/adcouncilapa.htm

Carry out PPAC action plan

Step 5: Implement and Evaluate

Activity: Evaluate Progress Towards Improving Patient and Family Engagement and Establishing a PPAC

Develop at least two performance indicators for patient and family engagement, including the PPAC

Establish simple process for measuring progress towards establishing a successful PPAC

Track progress and performance

Discovery Assessment Worksheet Patient and Family Engagement

1. What are your needs and expectations for patient and family engagement?

2. How do you know if you are doing a good job engaging patients? (State ways (performance indicators) that show how you judge the quality of relationship with your patients.)

3. Name 1 thing your primary care practice could do better, differently or change related to patient and family engagement?

PROCESSFOR“HOWTO”IMPROVEPATIENTSELF‐HEALTHMANAGEMENT

The following key project steps outline the process needed to improve patient self-health management. This improvement project area focuses on empowering patients with the knowledge, skills and confidence integral to manage their overall health or chronic condition, and engage in disease prevention efforts, by creating health action plans and .

KEY PROJECT STEPS Step 1: Complete Discovery Assessment

Activity: Answer “Patient Self-Health Management” Discovery Assessment Worksheet

What are your needs and expectations for empowering patients to care for their own health?

How do you know if you are doing a good job empowering patients? (State ways (performance indicators) that show how you judge the patient self-health management quality of your practice.)

Name 1 thing your practice could do better, differently or change to empower patients to play an active role in their care?

Explore and discuss “Discovery Assessment” results

Review existing patient self-health management policies at the practice

Review current patient charts/information to determine percentage of patients who receive patient self-health management education or coaching

Brainstorm patient health-management of care activities staff would like to work on

Step 2: Develop Self-Health Management Process Flow Chart

Activity: Visualize Self-Health Management Process

Review data from chart review. Set new goal for number of patients that receive self-health management counseling

Create flow chart of current process

Visualize positive changes to process. Record on new flow chart

Create action plan for team to implement flow chart

Step 3: Develop Materials to Support Patient Self-Health Management

Activity: Develop Skills and Materials Needed to Support Self-Health Management

Focus on improving patient and provider communication

Review motivational interviewing strategies to discuss methods to better engage patients about their health care and communicate health care prevention/management education effectively

Motivational Interviewing Best Practices Article

http://www.nova.edu/gsc/forms/mi_rationale_techniques.pdf

Customize goal setting and tracking sheets to be used with patients

Asthma Action Plan

http://www.nhlbi.nih.gov/health/public/lung/asthma/asthma_actplan.pdf

Diabetes Action Plan

https://www.harvardpilgrim.org/pls/portal/docs/PAGE/PROVIDERS/PATIENT/HANDOUTS/DIABETES_ACTION_PLAN_6.11.PDF

Step 4: Implement, track and evaluate.

Activity: Evaluate Progress Towards Improving Self-Health Management

Assure that goal-setting sheet and tracking tools are being used by staff while coaching patients

State at least two performance indicators for self-health management

Establish simple process for measuring progress towards self-health management

Create action plan for team to implement practice scheduling solutions

Discovery Assessment Worksheet Patient Self-Health Management

1. What are your needs and expectations for empowering patients to care for their own health?

2. How do you know if you are doing a good job empowering patients? (State ways (performance indicators) that show how you judge the patient self-health management quality of your practice.)

3. Name 1 thing your practice could do better, differently or change to empower patients to play an active role in their care?