Circles of Care:A Transition to

Patient Care Teams Story

PresentersLaurel Domanski Diaz, MNO, Director of

Business OperationsDan Gauntner, CNP, Director of Clinical

OperationsMarianella Napolitano, RN, MBA, Clinical

Quality Coordinator

ObjectivesParticipants will understand how safety

net practices can implement a systematic approach to caring for their communities

Participants will learn how to organize a practice to allow staff members to work at the top of their licenses.

Participants will become familiar with how implementing care teams can improve the quality of care.

NFP BackgroundA Federally Qualified Community Health

Center founded in 1980Last year served 13,400 patients on the near

west side of Cleveland17 Providers on staff--8 Family Practice MDs,

6 Family Practice CNPs, 3 Certified Nurse Midwives

Focus on the medically underservedServe a large Hispanic population

Partnering with the community for everyone’s best healthNFP has always believed that partnering with a

patient is the best way to achieve healthy outcomes.

NFP sees that the services provided to patients are each just one stop in a constant continuum of care that envelopes every patient into their own medical home.

NFP developed a model, Circles of Care, to transform our Community Health Center into a Care Team and EMR driven practice focused on Patient Centered Care.

Redesign ActivitiesCare Teams EMROptimizationContinuous Improvement Processes

Why Care Teams?Working from NFP’s 2009-2011 Strategic Plan,

NFP identified the following areas to be addressed:Improvement of patient’s health and safetyImprovement in NFP’s financial performanceIncreased provider, staff and patient satisfactionBecoming an NCQA Patient Centered Medical Home

Care TeamsA Care Team has been defined as: A panel of

patients who usually see or choose a particular group of providers for their care AND the group of staff who generally work together for the care of that panel of patients.

NFP Circles of Care

Patient

Contract IT Staff

OCHIN/ Epic

InformationTechnology

NFP IT Staff & Medical Records

Nurses, MAs, Patient Advocates

Clinical

Providers & Behavioral Health

Community Agencies

Front Office

Billing & PBS

Administrative

Management & Executive Leadership

Care Team CompositionThree Providers—combination of Family MDs,

Family CNPs, (one team’s providers consists of 3 Certified Nurse Midwives)

One to two RNsOne to two Patient AdvocatesMedical Assistant for each ProviderFront Office representative at each team

meeting

Care TeamsDeveloping new procedures around scheduling,

registering patients & directing phone calls to teams

Conducting training activities to facilitate team communication, structure and creating ongoing team meetings

Redesigning of nursing staff structure to provide individual nurses to care teams.

Organizing providers and support staff into integrated care teams.

Adding a Patient Advocate to each team

Team TrainingPromoting the idea of team across the

organizationTeam formation activities prior to implementationTeam trainings help decrease hierarchical

systems (TEAMSTEPPS, Practice Coaching)Practice Coaching and facilitation

Team MeetingsGoal: Improve communication and increase

efficiency across all disciplinesCommitment from the leadershipFinancial investmentMore frequently initiallyOutside facilitator present at the beginningInternal staff facilitates meetings

Team HuddlesDaily meetings at the beginning of the

morning, may include the entire team, Provider and MA

Approximately 10 minutesProvides MA with clear path of what needs to

be done to prepare for the Providers entrance in the exam room

Patient Service Representative RoleAccurate team schedulingDirecting of patient inquiries (phone and in-

person) to the appropriate team Reinforcing PCMH message: scheduling with

PCP, we do not operate as an urgent careServes as a member of the Care Team for

Team meetings

Patient AdvocatesInitially grant fundedStarted with a focus on specific populationsOur Patient Advocates range from recent college grads

to members of our community who have a background in activism or social work

Use of standing orders and protocols allow PAs to unload the provider and nursing workload

Each PA has a specialized area—Hispanic patients, women’s health, refugees, computer expertise

Increase patient’s access to the Care Teams by helping with patient communication and correspondence

Patient Advocate Role

Paperwork• Processing requests for disability, physical forms, utilities,

faxing, copying, mailing forms, letter processing.

Population Management• DM,HTN,WCC, Hospital follow up, Hunt groups 2005,

2000 coverage, Nurse messages

Case Management• Meeting with patients at provider request, community

resource coordination, making appointments for urgent referrals, Huddle participation, No-Show follow up coordination

Referrals• X-rays, ultrasounds, specialists and DME, some urgent—

nothing requiring prior authorization

Other Responsibilities• Interpreting, Coordination of Centering, Coordination of

Refugee Clinic, grant funded responsibilities, PDSA activities

Order Entry• DX--DM, HTN, Adult Physical, Hypothyroidism,

Hyperlipidemia, heart issues. Entering standard orders routine labs, immunizations, referrals.

Nurse Role

Care Team Support• Preparing forms for provider signature, calling in Rx,

calling patients with lab or test results

Patient Triage• Speaking with patients on the phone about their

symptoms and concerns, triaging patients in the waiting room that may need to be seen immediately or may need to be overbooked.

Patient Visits• Seeing patients in the health center for

immunizations, INR, something that is not a new concern.

Patient Education• Educating patients with diabetes and hypertension,

answering questions about medications, done on the phone or in person.

Medical Assistant RoleRooming Patients• Taking Vitals, entering in chart: medications, chief

complaint, review allergies, PHQ scores, complete tobacco, substance, sexual abuse history, enter diagnosis, check for Pharmacy, goal sheets.

Maintain Provider Rooms• Keep rooms stocked with appropriate supplies, tests, do

inventory every 2 weeks

Back Office Labs• Order and Result back office labs--UA, Strep, INR,

Glucose, Hemoglobin, HbA1c, iconImmunizations• Complete immunization consent forms, Review past

immunizations given, Print out IMPACT sheet to review what is needed , Review old chart, Order and pend immunizations needed- provider to review and sign, Enter into IMPACT, Historical immunizations must be entered into EPIC Order Entry & Release

• Female Physicals—order mammogram, Fit Test—women and men over 50, WCC—lead and HGb for 1 to 6 YO, DM—foot exam, last eye exam, enter referral, HTN—do EKG, Others--PAP, Urine culture, Chlamydia/ Gonorrhea

Ancillary Support ServicesAvailable In-Office Support includes:

On-site Behavioral Health On-site Clinical PharmacistRNs provided by insurance companiesWellness CoordinatorMedication Assistance ProgramDiabetes Educational Sessions

provided by local Diabetic Assoc.

OptimizationEnabling Providers to practice at highest scopeProfessionals will work at the top of their

licenses if:They have people they can delegate to. At NFP

this was done by increasing the skill set of: Medical Assistants Patient Advocates

There are effective communication methods In-basket messages within the EMR to make clinical

communication efficient Team meetings for peer and cross professional feedback

Optimization (cont.)Patient Advocates

Use evidence based protocols to address health disparities

Use registries to identify gaps in healthcare Identify high risk patients for case management by

nursesTracking and monitoring goals of the Health Center

Operational Clinical

Developing policies and procedures for EMR system and Care Teams at NFP

Outcomes of the Circles of Care ProjectNFP achieved Level 3 NCQA PCMH

Accreditation with a score of 99%In a Medicare Pilot Program on PCMH, NFP

was the top scoring FQHC in the country. Improved communicationIncreased coordinationImproved quality of care for our patients

Patient Satisfaction – Decreasing wait time

Continued Wait Time Improvement

Financial Performance Improvement

HbA1c less than 8• Increased from 48% to 62%

BP control in DM patientsIncreased from 72% to 79%

DM patients who had a Foot ExamChallenges tracking this information Increase coordination and communication with all team members

Questions?