1. Chris Shea
Practicum Presentation
12-14-2012

2. The Problem
 Patients with chronic conditions often must undergo
substantial behavior change to perform self-care
activities effectively
 National efforts aim to improve care for patients by
supporting their self-care activities
 Patient Centered Medical Home (PCMH)

3. Scope and Goals of the Practicum
 Setting: Carolina Advanced Health (CAH)
 Overall Goal: To achieve PCMH recognition
 Requires use of EHR to document the following for 50% of
patients in diabetes, hypertension, or depression registry:
 Goal setting with patients
 Patient education materials
 Self-management tools
 Counseling (i.e., nutritional and behavioral).
 My goal was to engage staff who are involved with
completion of the PCMH-related activities to participate in
planning for the change and to adopt new workflows

4. Carolina Advanced Health
 A partnership between UNC Health Care System
(HCS) and Blue Cross Blue Shield of North Carolina
 An innovative patient-centered primary care model
 longer patient visits (i.e., 40 minutes)
 onsite pharmacy, nutrition, and behavior specialists

5. Approach
 The PCMH change effort was embedded within the CAH’s
quality-improvement (QI) approach
 The QI team dedicated to this effort consisted of
representatives from each role directly involved with the
care processes
 The CAH QI specialist worked with developers to modify
the EHR
 The aims were to
1. Modify the EHR to capture necessary data for PCMH
2. Optimize EHR usability and workflows related to the
PCMH activities
3. Monitor the performance of the clinic in these areas.

6. Methods for Change Management
 Initial interviews and follow-up discussions with 6
CAH representatives to identify current and desired
future processes for PCMH-required activities
 Weekly QI meetings to
1. Make decisions about EHR design modifications
2. Formalize related workflows
3. Review data on the clinic’s performance on PCMH-
related care processes

7. Education, Counseling, Self-Monitoring

8. Education, Counseling, Monitoring #2

9. Education, Counseling, Monitoring #3

10. Education, Counseling, Monitoring #4

11. Process Diagram: Educational Materials

12. Initial Results
Denominator Numerator % of Denominator
PCMH Requirement August November August November August November
Education Provided 154 168 49 106 31.82% 63.10%
Has Goal or Plan 154 168 54 85 35.06% 50.60%
Self-Mgt Tool Provided 154 168 21 76 13.64% 45.24%
Counseling Provided 154 168 14 112 9.09% 66.67%
Note:
Denominator = patients verified in diabetes, hypertension or depression registry
Numerator = patients who received education, set goal/plan, received self-monitoring tool or received counseling

13. Lessons Learned
 Embedding this type of change within a QI framework
helps ensure successful completion
 As with most process-oriented requirements, there is a
need to assess whether the “spirit” of the requirement
is being achieved over time.
 Are patients receiving educational materials that are
appropriate?
 Are patients being overloaded with information?
 Do they use each source of information provided (e.g.,
educational materials and self-monitoring tools)? For what
purposes?