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February 22 2018 team based care webinar 2

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February 22 2018 team based care webinar 2

  1. 1. The National Cooperative Agreement on Clinical Workforce Development Advancing Team-Based Care WEBINAR 2 : Advancing the Practice of RNs and Behavioral Health Providers February 22, 2018 Presented by the the Community Health Center, Inc.
  2. 2. Get the Most Out of Your Zoom Experience • Use the Q&A Button to submit questions! • Live tweet us at @CHCworkforceNCA and #primarycareteams • Recording and slides are available after the presentation on our website within one week • CME approved activity; requires survey completion • Upcoming webinars: Register at www.chc1.com/nca Q&A
  3. 3. Learning Objectives 1. Participants will be able to identify three elements of complex care coordination that are key to improving patient outcomes. 2. Participants will be able to list three types of independent nurse visits that might be carried out by the RN on the primary care team. 3. Participants will be able to describe a team-based approach to screening for behavioral health disorders with timely follow-up intervention. 4. Participants will be able to identify a core set of standing group therapy options that a health center might offer.
  4. 4. Advancing Team-Based Care: 1. Advancing Team-Based Care: Building Your Primary Care Team to Transform Your Practice 2. Enhancing the Role of the Medical Assistant 3. The Emerging Role of Nurses in Primary Care 4. Data Driven Dashboards to Support Team-Based Care 5. A Team Approach to Prevention and Chronic Illness Management 6. Complex Care Management in Primary Care 7. Achieving Full Integration of Behavioral Health and Primary Care 8. Dissolving the Walls: Clinic Community ConnectionsTransforming TeamsPlease visit www.CHC1.com/NCA to access NCA webinar recordings, presentations and resources
  5. 5. Expanded Roles for RNs 2.22.18 Malia Davis, NP Director of Nursing Services and Clinical Team Development Robert Wood Johnson Executive Nurse Fellow 2014-2017 Community commitment. Uncompromising care.
  6. 6. Why RNs ? IOM Future of Nursing 2010 • Who is the best person on our care team to serve you today? • Maximize nurse skill set / work at top of scope • Provide direct patient care • Triage, intake, medication reconciliation, patient education, culturally responsive care to patient population, schedule management, nursing assessment skills, care planning, and on and on and on…. Community commitment. Uncompromising care.
  7. 7. Why RNs? Community commitment. Uncompromising care.
  8. 8. Why RNs? Community commitment. Uncompromising care.
  9. 9. RN role expansion •Complex Care Management •Active schedule management •Data •Co-visits
  10. 10. CCM Complex Care Management • High risk/high cost patients • Directed and lead by RN • Involve PCP/BHP in care planning and service provision • Developing goal-oriented shared care plan Care coordination • Available to all patients • Provided by the Case Manager • Supports complex care management activities as directed by the PCP, RN, BHP • Connecting patient to appropriate tools and resources
  11. 11. Complex Care Management Shared Care Plan Care Team Mtg w/o Pt
  12. 12. Active schedule management
  13. 13. Data
  14. 14. Nurse Visit Types: - INR visits up at all sites 0 20 40 60 80 100 120 Pecos NV by Type INR Wound Other 0 10 20 30 40 50 60 70 80 90 100 Thornton NV by Type INR Wound Other 0 5 10 15 20 25 30 35 40 45 50 Westminster NV by Type INR Wound Other 0 10 20 30 40 50 60 Peoples NV by Type INR Wound Other 0 10 20 30 40 50 60 70 80 Lafayette NV by Type INR Wound Other
  15. 15. Co-Visits  Improve patient access to same day care  More appointments available every day  Expand nursing role at Clinica  Eliminate double booking providers to decrease provider pressure and stress  Improve patient care and education  Decrease telephone triage and electronic tasking  Improve team-based care and communication between care team and patient Enhancing the Role of the Nurse in Primary Care: The RN Co-Visit Model . Karen A. Funk, MD, MPP and Malia Davis, MSN, ANP-CClinica Family Health, Lafayette, CO, USA. Journal of General Internal Medicine DOI: 10.1007/s11606-015- 3456-6© The Author(s) 2015.
  16. 16. Co-Visits • Approximately half of triage calls during a measured time frame were converted to Co-Visits. In many cases, this means patients were able to avoid visits to urgent care or emergency departments. • Feedback so far indicates patients, providers, and nurses are satisfied with the model. • Average time for co-visit for provider is 7-10 minutes and charting is completed by nurse. Provider must review and edit, but overall time for visit is short and there is a reduced electronic work load for provider. • There is a significant increase in value- added time for patient as they have a nurse with them for most of this visit….this is reflected in our patient satisfaction data
  17. 17. Co-Visits Defined • Co-visits are visits shared between a nurse and a provider that enable our patients to be seen the same day (increase access) • Co-visits were designed as a new model to help increase patient access to care and to improve staff satisfaction Community commitment. Uncompromising care. Provider Nurse
  18. 18. Who Schedules Co-Visits • Co-visit appointments are scheduled by the communication center. They can also be scheduled by other team members (typically triage nurse) • Co-visit appointments can occur almost anywhere within a Provider’s schedule Community commitment. Uncompromising care.
  19. 19. Co-Visit Visit Types Typically minor acute visit type requesting same day appointment • UTI/dysuria • Ear Pain • Any nurse protocol visit • Lice • Thrush • Emergency contraception and birth control • INR / lab follow up • Conjunctivitis • Rash • Newborn bilirubin • Cold and cough / flu • Sore throat • Fever • Cast removal • ER follow up • Wound care • Breast feeding support Community commitment. Uncompromising care.
  20. 20. Documentation requirements: • Nurse note • Provider note • Face to face (in the presence of the patient) • Scribe box on E and M (see example later) • Chart review from the provider • Billing and coding • **it is your responsibility to research your billing and coding requirements in relation to your electronic record to meet your compliance standards** Community commitment. Uncompromising care.
  21. 21. Nurse Responsibilities Responsible for obtaining and documenting Subjective / HPI Scribes for provider for the rest of the patient visit (physical exam, plan) Reviews Assessment and Plan with patient Appropriate patient ed reviewed with patient Patient plan given to patient Maintain communication with provider about co-visit schedule, changes of schedule, Provider Responsibilities Responsible for Assessment, and Plan. This includes medical decision making (MDM) and coding. Make necessary changes to the HPI if needed Perform physical exam on patient. Assessment and plan of care thoroughly reviewed with nurse Verbal orders for labs, written orders meds and diagnostics as needed for this acute visit
  22. 22. Provider Billing Documentation Community commitment. Uncompromising care.
  23. 23. Time On average: • Face to face patient time with nurse 20-30 minutes • Provider time 7-10 minutes • Charting completed by nurse • Sign off review by provider Community commitment. Uncompromising care.
  24. 24. Measures Triage volume: baseline 30-100 calls/wk = decrease by 2/3rds Total visits : goal 2-3 per provider per session = 1.5 * Nurse utilization: (Co-visits) 40-60 week Patient satisfaction: peaked at 97% Staff satisfaction: goal 80% we made 79% Access: TT3rd goal 3, achieved 2 in one month Continuity: PCP goal 70 =67% Team goal 90 = 87% Cycle time: no change *no show rate / 1 vs 3 pod data Community commitment. Uncompromising care.
  25. 25. CHC Profile Founding year: 1972 Primary care hubs: 14; 204 sites Staff: 1,000 Patients/year: 100,000 Specialties: onsite psychiatry, podiatry, chiropractic Specialty access by e-Consult Elements of Model Fully Integrated teams and data Integration of key populations into primary care Data driven performance “Wherever You Are” approach Weitzman Institute QI experts; national coaches Project ECHO®— special populations Formal research and R&D Clinical workforce development CHC Locations in Connecticut
  26. 26. • POD design  2 Medical Providers  1 Registered Nurse  2 Medical Assistants  1 Behavioral Health Clinician  Additional members: podiatrist, dietician, Pharm-D, chiropractor, CDE  Student/Trainees The Interdisciplinary Team
  27. 27. Shared Communication Among the Team 2017
  28. 28. Care that is Comprehensive: IPCP Team Additional on-site specialties Nutrition Diabetes education Chiropractic Podiatry Retinal screening PATIENT Medical BH Nursing Pharmac y Prenata l Dental
  29. 29. Essential member of the primary care team and inter-professional activities (1) RN supports (2) primary care providers/panels Key functional activities:  Patient education and treatment within provider visits  Independent Nurse Visits under standing orders  Delegated provider follow up visits using order sets  Self management goal setting and care management  Complex Care Management; coordination and planning  Telephonic Advice and Triage via dedicated triage line  Quality improvement leaders, coaches, and participants  Leaders and participants in research  Clinical mentoring of RN students; Supervision and mentoring of Medical Assistants Domains of RN Nursing Practice at CHC, Inc.
  30. 30.  Uncomplicated UTI  Vulvovaginal candidiasis  Comprehensive diabetes visit with retinal screening  Pupil dilation  Titration of basal insulin  Pedi & adult vaccines  TB DOT  Bronchodilator testing in spirometry  Tobacco cessation  Emergency contraception  Pregnancy testing  Orders for emergency situations Nursing Standing Orders
  31. 31. Independent Nursing Visits 1/1/17 to 12/31/17 13,123 9,366 1,648 2,341 880 1,480 0 2,000 4,000 6,000 8,000 10,000 12,000 14,000 Immunization, Screening & Health Promotion Chronic Illness Care & Care Management Contraceptive Support & Family Planning Recurring Medication Administration: (ie. progesterone administration and monitoring for prevention of pre-term birth) Anticoagulation Management Nursing visits for Standing or Delegated Orders (Acute) Total Visits: 28,839
  32. 32. Substance Abuse, 27.7% Diabetes, 22.4% HTN, 12.8% BH, 10.0% Chronic Pain, 4.3% Obesity, 2.7% HCV/HBV/HIV, 2.5% Asthma/COPD, 1.9% Other, 15.7% Chronic Illness Care
  33. 33. Templated Nursing Visits
  34. 34. Order Sets
  35. 35. Complex Care Management Dashboard: Eligible Patients
  36. 36. Complex Care Management Dashboard: Enrolled Patients
  37. 37. Training primary care RNs to a new model Project ECHO: RN complex care Management: RNs participate bi-weekly for two hours of didactic, plus case presentation and feedback
  38. 38. Integrating Nursing into Behavioral Health & Dental
  39. 39. Integrating Nursing into Behavioral Health & Dental
  40. 40. • Exam rooms and therapy rooms • Reducing stigma of seeing behavioral health provider – no longer sent “over there” • Seamless transition between medical and behavioral health Facilities: One Corridor Care
  41. 41. Behavioral Health Integration Systems & Technology Integrated EHR • Up-to-date patient medical and behavioral health information available. • Pain scores and access to other data – bi-directional information sharing • Shared Care Plans • Electronic referral and recall process • Collaborative Care Dashboard
  42. 42. • Rethinking the warm hand-off process: Proactive vs Reactive 05/14/2014 42 Processes • Medical initiated warm hand-off and behavioral health initiated warm hand-off • Staggered vs. consecutive visits – make our presence known • Criteria: • No BH services and PHQ above 15 • No BH services and BH Diagnosis • No BH services and chronic pain patient
  43. 43. Screening in Medical Visits There are many pathways to Behavioral Health care, one of the most robust and reliable is regular screening by nurses and MA’s in Medical visits. Nurses and MA’s can screen for multiple conditions including • Substance abuse (DAST, AUDIT) • Depression (PHQ-9) • Domestic Violence (HITS and HARK) • and more as required by grants, outside agency, or quality initiatives All of these identify patients in need of support from Behavioral Health
  44. 44. • Seamless Scheduling Processes
  45. 45. Systems and Technology Integrated Scheduling System • Call any CHC number and connected to same scheduling agent • Medical, dental, therapy and psychiatry services all scheduled through one system • All Recalls visible at all points of contact
  46. 46. Systems and Technology and Process Collaborative Care Dashboard  Planned Care in Behavioral Health  Delivery of Integrated Services
  47. 47. Group therapy offers additional services to patients who may have common needs. While those common needs can be things like depression or trauma, often identified in behavioral health care, but they might also be problems commonly identified in medical visits. • Smoking cessation • Chronic pain • Suboxone groups as a part of integrated Medication Assisted Treatment • Insomnia • Weight loss Group Therapy and Medical Integration All of these and more can create referrals for in house services and serve to better integrated care between medical and behavioral health.
  48. 48. Integrated Care Meetings • A case review meeting conducted at each site facilitated by a BHCC. Patients are selected from a risk stratified list and have chronic disease as well as a BH condition. • Goal of the meeting is to close care gaps and to reduce preventable ER utilization • Participants include the PCP, MA, RN, BH Clinician, and ATC • Seven to ten cases are discussed per session • Cases are presented by team members who have reviewed the record respective to their role • Documentation in the health record is completed. (Global Alert). Recommendations for follow up is noted in TE’s or Action items.
  49. 49. Questions
  50. 50. Upcoming Webinars • Beyond the Walls: Effectively Utilizing Community Health Workers and Clinical Home Visitors as Part of the Team March 1, 2018 | 3 p.m. EST • Caring for Patients with Pain is a Team Sport March 8, 2018 | 3 p.m. EST Register at www.chc1.com/NCA