Jessilyn Prichard’s Summer 2021 Dupper Internship
My Experience
Highlights
Obstacles
Breast Cancer Screening Project
Introducing the Primary Care Medical Home Model to the Central Valley Network
Continuity – Coordination – Management
Stage 1: Recruitment and Assisting Readiness
Assess the practice’s readiness and ability to undertake the proposed improvement effort. Completing preliminary paperwork such as business associate agreements that will allow you to access clinical data for measuring and monitoring practice performance.
Orient practices to the concept of practice facilitation and what facilitators (your roles) do.
Identify an individual who might be developed as an “internal facilitator” whom you will train in core competencies of practice facilitation. Identifying this individual typically will take some time, but you should begin evaluating individuals in the practice for this role from day one.
Invite practices to participate in improvement work. Whenever possible, facilitators are also encouraged to invite experienced practice employees to co-teach specific modules and to discuss their “real world” experiences from working with practices.
Identify the champion for the improvement effort at the practice and begin to build a working relationship with him or her. This individual will help to promote the PCMH model and maintain team momentum during the transition process.
Identify other practice members who will be key participants in the improvement work.
Assess the needs of the patient population. Collect information on social determinants of health, such as: access to educational/economic/job opportunities; public safety; social support; food and housing insecurities; household/environmental risk factors; exposure to crime/violence/social disorder; socioeconomic conditions; and residential segregation.
Stage 2: Kickoff Meeting
Collaborate
Design and lead the meeting in partnership with each practice’s PCMH champions.
Define
Prepare explanations of the concepts associated with the PCMH model and define each facilitating team member's role.
Learn
If the improvement project involves implementation of new treatments or care processes, you may also include a physician academic detailer (a peer from another practice who shares experiences and effective strategies) in the meeting.
Envision
Conduct team building exercises in which practice leaders articulate their vision and goals for their individual PCMH transformation, as well as the culture of their individual practices.
Invite
Encourage patient involvement in the kickoff event. Inviting regular patients from the practices ensures that patients maintain an active role from the start and establishes positive community relationships/ awareness.
Stage 3: Assessment and Goal Setting
Work with the QI team to conduct an initial assessment of the practice in areas related to the improvement effort. You will help the team review and use the data to finalize their goals and performance indicators for the effort.
Select from among the thousands of changes possible those that are most likely to be “high yield” and lead to the greatest improvements. Focus on the most costly patients – those that are eligible for Medicaid/Medicare or both programs due to very low incomes or age.
Meet weekly to discuss progress in the practices, review literature and share PCMH tools/techniques/innovations, and engage in ongoing training in a collaborative learning environment. Each practice will be individualized, foster communication among facilitators and project leadership, and standardize our project’s overall approach across practices.
Twice-yearly focus groups with the entire facilitation team (moderated by the project’s evaluation lead) will add to our ability to explore how facilitation is progressing over time, and what changes needed to be made to our practice facilitation and project staff training plans.
Who will make up our new care teams?
By bringing in specialists who serve local practices on a rotating basis, we can reduce hiring costs and expand our patient services.
If members of these specialties are not available locally, we may consider expanding our team to include providers who are available virtually.
Health Coaches/Educators
Pharmacists
Nutritionists
Social Workers
Behavioral Health Counselors
Care Coordinators
Physical/Occupational Therapists
Stage 4: Active Facilitation
Help practices build their capacity to generate performance data on the metrics that matter to them and their patients.
Conduct monthly chart audits and other assessments and providing feedback to the QI team on the results.
Train staff and clinicians on key change concepts, provide support and training to staff to build skills and knowledge for assuming new roles or activities, and engage expert consultants and academic detailers to provide additional support, training, and mentoring when needed.
Work with the EHR and registry managers to create reporting systems designed to monitor performance in the targeted areas.
When you and the practice’s IT staff cannot produce the desired modifications, you will help the practice engage their vendor or will add facilitators with expertise in EHR optimization to your team. The additional facilitators can provide technical assistance to the practice in this area.
Much of your time will be spent helping practices understand and evaluate their existing workflows, and then helping them enhance or redesign their workflows to improve quality, efficiency, and incorporation of key elements of the PCMH. As such, you will need to become familiar with the key workflows for each of the practices you work with and knowledgeable about exemplary workflows you can use to help practices improve theirs.���Unless supported by a care team, physicians simply do not have the time to provide ideal care for all their patients, and many burn out trying. For example:��Most physicians only deliver 55 percent of recommended care and 42 percent report not having enough time with their patients (Bodenheimer, 2008).
�Clinicians spend 13 percent of their day on care coordination activities and only half of their time on activities using their medical knowledge (Loudin, et al., 2011). ��Increasing availability at practices will improve patient satisfaction and enable healthcare providers to serve more patients. To do this, the practices may consider instituting open-access scheduling, keeping a few reserved walk-in/same-day appointment slots open for patients, or maintaining monthly weekend hours for patients in rural areas.
Stage Five: Holding the Gains
ONCE A PRACTICE HAS ACHIEVED ITS DESIRED CHANGES, ATTENTION WILL DRIFT TO OTHER ISSUES. YOUR JOB IN STAGE 5 WILL BE TO ASSIST THE QI TEAM AND PRACTICE LEADERSHIP TO MAINTAIN THEIR GAINS BY CREATING THE CONDITIONS NEEDED TO SUSTAIN THE CHANGES LONG TERM.
HELP THEM CONTINUE PERFORMANCE MONITORING AND DETERMINE HOW THE PERFORMANCE DATA WILL BE USED TO ENSURE THAT THE CHANGES ARE SUSTAINED. SEEK REGULAR FEEDBACK FROM PATIENTS USING SURVEYING SYSTEMS ALREADY SET UP BY ADVENTIST HEALTH.
WORK WITH THEM TO INCORPORATE THE CHANGES INTO THE PRACTICE’S OR ORGANIZATION’S POLICIES AND PROCEDURES, JOB DESCRIPTIONS AND EVALUATIONS, AND STAFF ORIENTATION AND TRAINING.
Both patient education and SMS are necessary.��Some aspects of patient education work well, some do not. Information is necessary and skills must be taught.��Knowledge does not create behavior change, and compliance is not a useful goal.
Patient Education
Self-Management Support
Information and skills are taught
Usually disease-specific
Assumes that knowledge creates behavior change
Goal is compliance
Healthcare professionals are the teachers
Skills to solve patient-identified problems are taught
Skills are generalizable
Assumes that confidence yields better outcomes
Goal is increased self-efficacy
Teachers can be professionals or peers
Implement the 5 A's into Care
ASSESS�Beliefs, Behavior, Knowlege
ADVISE�Provide Specific Information about Health Risks and Benefits of Change
AGREE�Collaboratively Set Goals Based on Patient's Interest and Confidence in their Ability to Change the Behavior
ASSIST�Identify Personal Barriers, Strategies, Problem-Solving Techniques, and Social/Environmental Support
ARRANGE�Follow-Up (Visits, Phone Calls, Mailed Reminders, etc.)
Stage Six: Completion and Transition to Maintenance
The practice has access to all the resources and tools engaged to support the improvement work.
In an ideal scenario, you will have had a chance to provide sufficient training to the “internal facilitators” so that you can step back and allow them to facilitate these discussions and decisionmaking processes for the QI team with support from you only as needed.
The practice develops a clear and empowering narrative or “story” about the improvement effort that it can incorporate into its history and organizational memory.
The QI team and practice at large have an opportunity to reflect on and react to this story.
Check in once every 3 to 4 months.
Send periodic emails to the QI team, or if appropriate, engage them to participate as academic detailers or “exemplars” to another practice that is in active facilitation.
Action Items for the CVN
Establish a 24/7 call line.
Formulate an ideal composition for interdisciplinary teams.
Begin recruiting staff and establishing new roles to compliment the services we currently offer.
Establish a method of documenting patient collaboration with their interdisciplinary teams in treatment records, as well as their self-management goals and progress towards them.
Create an assessment to screen patients' communication needs prior to their appointment (glasses, hearing aids, etc.). Choose an assessment of their health literacy needs (functional, interactive, critical) from the examples given by Joint Commission.
Measure coordinated continuity of care.
Draft a survey that measures patient's peception of the three components of PCMH care.
Create a new system of financing the PCMH model, as traditional payment plans do not apply under most conditions.
Extend clinic hours to include breast cancer screening days once a month on Saturdays. Consider including vaccination scheduling in these events.