Sustaining the Vision - Massachusetts League of Community Health

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Sustaining the Vision November 19, 2013

SOUTH BOSTON COMMUNITY HEALTH CENTER

PCMH: CORE COMPETENCIES

Kathleen Civiello, RN

Katy Short

Elizabeth Staunton, RN

Disclosures

We have no financial disclosures.

About SBCHC  South Boston Community Health Center is the only provider of primary

health care in South Boston

 South Boston Community Health Center provides 57,000 visits per year  57% of Patients are from South Boston  South Boston Community Health Center provides an additional 22,700

visits for Lab and WIC

 South Boston Community Health Center employs 124 FTEs.  NCQA Level 3 PCMH (2008 Guidelines)

Our Mission: We will provide accessible, high quality care to all patients, regardless of status and ability to pay.

MLCHC LEAN PIP Training SBCHC sent a group to MLCHC’s Lean Performance Improvement Practioner (PIP) Training in June 2012. PIP Training gave us the tools to work with the key Change Concepts of PMCH implementation via a systematic LEAN approach. LEAN thinking introduced…      

Standardization Efficiency Waste Elimination Getting the voice of the costumer Having a set process Visual Management

while PCMH had us focusing on… • • • • • • • •

Engaged Leadership Quality Improvement Strategy Empanelment Continuous & Team-Based Healing Relationships Organized, Evidence-Based Care Patient-Centered Interactions Enhanced Access Care Coordination

Let’s take a closer look at our project \

http://www.safetynetmedicalhome.org/change-concepts

Empanelment

After some marriage-counseling from our couch, Joanna Kreil… we focused our LEAN initiative on Empanelment. Our thought was… Empanelment  Stronger Continuity & ultimately Improved Health Outcomes In 5 months time…

Define  Measure & Analyze  Improve  Sustain  Report Out

Project Charter for: SBCHC Empanelment Project  Problem Statement: There is currently no sustainable process for staff to assign new patients to  existing panels. This creates frustration and inefficiencies between  providers, staff and patients. As a result, South Boston Community Health  Center does not develop optimal patient care team relationships.    Aim Statement: To have a sustainable empanelment process for new patients which will  ultimately lead to continuity of care.  Measures of Success: • A staff survey that measures their knowledge of the empanelment process  for new patients as well as make appointments for existing PT.  • A report that measures the quality of the empanelment process for a new  patients against provider’s panel size to whom they were assigned. Scope: • Out of scope :  Adjusting panels based on the patient’s problem list.  Dental, Eye, Non‐South Boston Patients or Established Patients seen  initially for sick or walk‐in visits.  • In scope: New Patients to whom we provide primary care. Boundaries: FTE neutral

Sponsor  Approval & Date

Sponsor Approval & Date

Start Date: 6/7/2012 Planned End Date: 11/8/2012  Sponsor: Virginia Fitzgerald, MD Facilitator(s) / Practitioner(s): • Laurie Laporte • Katy Short • Kathleen Civiello, RN • Elizabeth Staunton, RN Coach: Joanna Kreil Team Members: • Front Desk Staff • Karen Richardson • Shawn Martin • Taylor Duross • Dotty Parker • Tatiana McQueen • Kinena Dent‐Smith • Wanda Soto • Elizabeth Alves

Sponsor  Approval & Date

The Outcome

 Communication Board  Scheduling Cheat Sheet  Follow-Up Appointment Guide  Written Instructions & Visual

Workflow  Case Studies

New Patient Appointments     1st

FAMILY

Team 1 F – A. Williams  F – Wlaskiuk Team 2 F ‐ Gray F ‐ Toledo Team 3 F ‐ Amos F ‐ Beauchamp Team 4 F ‐ Johnson F ‐ Liff

ADULT Team 1 F ‐ SLOAN

Team 2 M ‐ BAKSHI Team 3 F ‐ MISELIS Team 4 x

2nd

PEDIATRICS Pedi Team F ‐ Renzi F – M. Lee

Team 2 M – Long F ‐ Gryczynski F ‐ Meyer M ‐ Toraldo

FAMILY Team 1 F ‐ Dietrich Team 2 F ‐ Poluin F ‐ GOLDMAN Team 3 F ‐ Dallman

Team 3 F ‐ Leszczynski M – B. Chang 

Team 4 F ‐ Tulshian

Team 4 F ‐ Chiang M ‐ Pravodelov

FAMILY Team 1 F ‐ CHIAKPO F ‐ REGAN, NP 

Communication Board MARCH 2013

ADULT Team 1 x Team 2 M ‐ MEHSSEN

Team 1 x

Team 1 x

PEDIATRICS

3rd

Pedi Team M ‐ Gianferante F ‐ MARSHALL, NP 

Team 2 M ‐ Lee F ‐ Wang F ‐ LIN Team 3 M ‐ McGlynn Team 4 M ‐ Chakan

FAMILY

PEDIATRICS Pedi Team F ‐ REGAN, NP M ‐ SCHUCH

ADULT

ADULT Team 1 F ‐ CATTEL

Team 2

PEDIATRICS Pedi Team F ‐ FITZGERALD F ‐ THAKRAR

Team 2

x

x

Team 3 x

Team 3 M ‐ HINES

Team 3 F ‐ MARSHALL, NP  M ‐ REINHOLD

Team 4 F ‐ DALEY, NP

Team 4 M ‐ KALIGIAN

Team 4 M ‐ SAXENA

Last Resort

Helpful Key:   F – Female Provider  M – Male Provider  NP – Nurse Practitioner  Italics – Resident  BOLD – PCP Provider

Scheduling Cheat Sheet

Appointment Types:  Walk In • •

Want to be seen today, BUT NOT SICK  DO NOT schedule >24 hours in advance

Follow Up

Responsible Provider (RP): • • • •

Appointments should be scheduled with patients RP If RP isn’t available schedule with provider from the same team If team provider isn’t available schedule in the same department If nothing available in dept. and patient would like to be seen  – If patient is on the phone  send  phone note to dept. RN  – If patient is here  RN TRIAGE SHEET and send to dept.  

General Rules: 

• • • •

Any ongoing issue/disease pt. has previously been seen for  (ER visit/hospital discharge, Diabetes, HTN, fractures, ongoing rash, abnormal labs)  Schedule with provider pt. has seen for this issue DO NOT schedule new patient as F/U

Sick   • •

Pt. is sick and needs to be seen within 24‐ 48 hours (fevers, ear infections, cough & cold, UTI, GI) DO NOT schedule >48 hours in advance

Physicals (PE)

• •

NEVER schedule an appointment for a time that has already past  (If it is 4:02 pm you cannot schedule a 3:50 pm appointment)

• • •



PAP is to be scheduled as a PHYSICAL with RP 

Required PE Schedule 



Pediatrics  – No patients >22 years old – No Pregnant patients  – If  > 18 years and graduated from Pedi dept. (transitioned to AM or FM) DO  NOT schedule in PEDI – Call/Flag Pediatrics to schedule Dr. Kate Knutson, Child Psychiatrist 



NEWBORNS ‐within 3 days of birth/hospital dc or sooner if parent requests. 

• • • • • • • • • • • • • •

2 weeks    *(schedule as F/U)      1 month  2 months   4 months 6 months  9 months 1 year old (this appt. must be on or after child’s 1st birthday) 15 months 18 months 2 years old ½ years old  years old years old (this appt. must be on or after child’s 4th birthday) years old 



• • •

• •

Family Medicine – All Pregnant Patients  – FM COLPO ‐ pt. received letter saying need a colposcopy (letter will be in pts.  EMR) – FM WALK IN ‐ NO OB PATIENTS, can see FM patients for W/I, F/U, SICK  – OB/GYN ‐ Schedule with appropriate provider Prenatal Intakes ‐ schedule when 8 weeks pregnant If nothing available can schedule when 7‐9 weeks pregnant If no appt. available schedule with Nancy Regan, NP in FM DEPT ONLY! – SOCIAL WORK ‐ To schedule with Kate Lufkin, LICSW call x7482 or x7565 or  send Flag 

Medical Specialties  Appointments to be scheduled in MS dept.  x 7583 and x 7523

Limited to one per year for all persons 3 years and older (yearly check up, well child check, Pap)  Schedule with RP Check when the last PE was, are they due for PE? (See attached insurance grid)



If unavailable dept RN 

Sibling Physicals  – – – –

Find appt. time that does not have PE right before or right after, schedule first PE then force  book the sibling into spot directly after / back to back appt. slots  DO NOT schedule sibling PE’s with available appt. slots in between siblings  No more than 2 siblings together unless ok’d by provider  DO NOT schedule Sibling PE’s with 2 different providers for the same day

Assigning New Patients to a Provider Panel  How to add a new patient (patient that is establishing primary‐care at SBCHC) to a provider’s panel: ‐ Check/Ask patient who his/her PCP (Primary Care Provider) is. This information is available on the patient’s insurance card ‐ Find PCP’s team  Now look to see which residents are on the PCP’s team.  ‐ GOAL: Assign new patients to residents if possible or providers that are growing their panel of patients ‐ This will allow for the patient to have better access to the provider chosen, which in turn will allow for better  care and attention for the patient. ‐ Assign patient to a resident in the green section of the PCPs team (see Communication Board) ‐ On the registration tab, enter the chosen provider under “Responsible Provider”. This is the provider that the patient  will see on a regular basis at the health center. ‐ Now, enter the PCP listed on the insurance card under “Primary Care Provider” on the registration tab. This is the  provider that we bill the visit under.

“SBCHC is a Patient‐Centered Medical Home (PCMH), which means that we provide team‐based  care that puts the patient first.  The PCP you chose has limited availability, so I put you  with another provider on his/her care‐team. Our goal is to have all our patients assigned to a provider  that will be able to see them, so that the patient can build a continuous relationship with that provider.  The care‐team model supports this approach. In the future, if your regular provider, RP (aka  responsible provider), is not available, then our goal is that a team member (that includes your PCP)  who is familiar with your care will see you.” “Team‐based care is a new model that focuses on providing the right care for each patient at the right time in order to maximize health outcomes. Preventative care is a large part of the  PCMH model, so rather than wait until you are feeling ill your provider or his/her care‐team will reach  out to you when you are due for routine health maintenance care.”

Follow‐up Appointment Guide Adult Medicine Department

Family Medicine Department

Team 1

Pediatrics Department

Team 1

Medical Specialties Department

Pediatric Team

Cardiology

Cattel, Pamela MD

F

Chiakpo, Evelyne MD

F

Fitzgerald, Virginia MD

F

Sloan, Sarah MD

F

Regan, Nancy NP

F

Thakrar, Nisha MD

F

Wlaskiuk, Lidya MD PGY‐1

F

Marshall, Alison NP

F

Dietrich, Gretchen MD PGY‐2

F

Schuch, Thomas MD

M

Regan, Nancy NP

F

Renzi, Cathleen DO  PGY‐1

F

Team 2 Mehssen, M. Azzam MD

M

Lin, Suru MD

F

Toraldo, Gianluca MD PGY‐1 

M

Wang, Ke MD PGY‐2

F

Gryczynski, Gabriela MD (Kuo) PGY‐1 F Meyer, Kari MD PGY‐1 

F

Williams, Aimee MD (Isakova) PGY‐1 F Team 2

Gianferante, Matt MD PGY‐2 M

Goldman, Laura MD

F

Bakshi, Munish MD

M

Gray, Jessica MD  PGY‐1

F

Lee, Steve MD PGY‐2

M

Poulin, Shayne MD PGY‐2

F

Long, Paul MD (Kim) PGY‐1 

M

Toledo, Anne MD (Lara)  PGY‐1

F

Lee, Monica MD (Kumar) 

Bernard, Sheilah MD Dermatology Mansur, Claire MD

F

Pulmonary Berk, John MD

M

F Podiatry tbd Physiatry Manasian, Simona MD

Team 3

F

F

Team 3

Reinhold, Lars MD

M

Miselis, Heather MD

F

Marshall, Alison NP

F

Hines, Thomas MD

M

OB/GYN

Leszczynski, Anna MD PGY‐1

F

Amos, Meredith MD PGY‐1

F

Dangel, Alissia MD

F

McGlynn, Patrick MD PGY‐2

M

Dallman, Rebecca MD  PGY‐2

F

Harrison, David MD

M

Chang, Bailey (Lurie) MD PGY‐1

F

Beauchamp, Kate MD (Shertukde) 

F

Saxena, Sheel MD

M

Kaligian, Aram MD

M

Daley, Megan  NP

F

Skrekas, Jaime NP

F

Chiang, Kim MD PGY‐1 

F

Johnson, Michelle MD  PGY‐1

F

Chakan, Matthew MD PGY‐2

M

Tulshian, Priyanka MD PGY‐2

F

Pravodelov, Vassilili MD (Khemka)

M

Liff, Olivia MD (Strnad)  PGY‐1

F

Team 4

Team 4

The order of booking a f/u visit: 1. Responsible Provider 2. Team Provider (resident first) 3. Resident within Department 4. Other Provider within Department Providers that can be listed as a PCP with  Insurance Companies are highlighted in light blue.

Sustaining the Vision… So what has worked?

 Engaged Leadership, especially Departmental Leads 

Proactive departmental or projects managers are taking the lead on incorporating LEAN thinking into the SBCHC Medical Home culture.

 Introducing LEAN thinking to staff 

From Full Staff Meetings to Departmental gatherings and small projects, under the umbrella of PCMH, LEAN is on the agenda.

 Building and spreading a QI strategy that can be understood on all levels. 

We are bringing QI to the frontline staff to engage them in current initiatives and give them a voice in our proactive changing by supporting them with QI education and meetings geared toward QI.

 Thinking of the project as a marriage and not a wedding. 

We quickly learned that we need to take our time to work through each phase of the project so that we could address issues or concerns that could have faltered our sustainability.

Sustaining the Vision… What hasn’t worked?  Forgetting about the LEAN initiative 

LEAN is continuous. A project never really ends. In order to sustain the great work, it needs to be evaluated from time to time to make sure that things are going as planned.

 Believing that the Empanelment is done. 



This falls under the same notion as LEAN. Empanelment is always changing as new Providers come and go or schedules change. We are constantly communicating and updating the Communication Board for the call-center and registration. Looking to the future: 

 

How to adjust when a provider leaves  Residents  Unexpected departures

Reviewing panels at least annually Incorporating Provider and Team input at review

 Taking Joanna back to the Health Center to continue to counsel our

marriage. 

Joanna has another job at the MLCHC and, frankly, she charged to much. MLCHC and GE gave us the tools to bring LEAN into SBCHC and move forward on our own.

S.p.r.e.a.d.i.n.g. the Vision  What are we doing now?  Spreading our QI strategy and vision across departments  QI check-ins with Front Desk Manager  We are not perfect – it is hard work to keep on top of this  Giving the front line a voice  Taking criticisms  QI Boards within the departments – updated quarterly  Using our Empanelment work to guide us on implementing or improving upon other PCMH milestones.  Focusing on Training and Education around PCMH & LEAN.

Education & Training  LEAN Training & PCMH awareness  Full Staff Meetings or Departmental Meetings  Quality Improvement Bulletin Boards  Orientation Packet  Incorporating the Empanelment Project, PCMH education

Take-Aways REMEMBER: 

Plan for the marriage, not just the wedding ceremony



The focus is on sustainability



There is no “one and done” when it comes to LEAN.



No one said it is easy…



Slow down!



Assign responsibility for follow-through



You need a solid QI strategy to move forward with any change concept Hitting home that strong panels  better care coordination Keeping front line staff engaged – giving them a voice

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Sustaining the Vision - Massachusetts League of Community Health

Sustaining the Vision November 19, 2013 SOUTH BOSTON COMMUNITY HEALTH CENTER PCMH: CORE COMPETENCIES Kathleen Civiello, RN Katy Short Elizabeth S...

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