lecture lessons learned - pcmh presentation (2)

PCMH Train-the-Trainer

Lessons Learned

Greenville Health System

Greenville, South Carolina

April 2, 2014

Center For Pediatric Medicine’s Quest for

PCMH Recognition

Katy Smathers, Practice Manager V

Tammy Gladson, Clinical Manager

THE CAMDEN GROUP | 2/26/2014 2

Pediatric primary care – a.k.a. “The Peds Clinic”

Physician providers (7), Mid-level providers (4), Residents (48) &

Faculty/Attending Physicians (25)

3 locations

Center for Pediatric Medicine – 20 Medical Ridge Drive

Pediatric Rapid Access – 57 Cross Park Court

North Greenville Outpatient Center – 807 N. Main St, Travelers Rest

QTIP Practice (Quality through Technology and Innovation in

Pediatrics) – CHIPRA Demonstration Grant (SCDHHS & SC AAP

partnership) focus – implementing quality measures in the primary care

pediatric office

Who is the Center for Pediatric Medicine?


Approximately 19,000 active patients

Approximately 40% Hispanic

96% patients Medicaid eligible

Annual Visits – 52,000ish

(combined 3 locations)

Patient Population


Respiratory Therapy/Asthma Educator

Social Work

RN Case Management (Care Coordination)

Lactation support

Medicaid eligibility worker on site

Interpreters

Ancillary Resources Available at CPM


Primary care – well

visits/acute care

ADHD subspecialty

clinic

Adolescent subspecialty

clinic

Centering Parenting

Psychiatric care clinic

Asthma subspecialty

clinic

Newborn clinic

High Risk/NICU

clinic

Foster Care clinic

Scope of Services


Purchased a multi-site PCMH application April 2013

Corporate tool submitted April 2013

Center for Pediatric Medicine site-specific tool submitted August

2013

CPM Level 3 Recognition

awarded November 2013!

Rapid Access & North Greenville site-specific tools to be

submitted this month

Recognition Achieved – Partially….


Piqued our interest in 2007 – attended NCQA training (2008

PCMH Standards)

These were things we were already doing, but needed to

engrain into the clinic culture. PCMH standards aligned with

CPM’s patient centered mission.

Elements/Factors aligned with several other ongoing projects

Carrots & Sticks

Carrot – potential for enhanced reimbursement

Stick – Dr. Schmidt (if anything less than level 3 was achieved)

Why Become a Recognized Patient Centered Medical Home?


Focuses on making QUALITY the forefront of everyday

operations

Preparation for changing reimbursement methodologies

Importance of exposing residents to the Medical Home model

of care

Why PCMH?

Systematic approach to coordinated care

Encourage the concept of a “Care Team”

Become a true “Medical Home”


Project team formation

Doreen Patterson, MD, Provider/Faculty

Katy Smathers, Practice Manager

Tammy Gladson, Clinical Manager

Kristi Caballero, Office Supervisor

Sabrena O’Connor, Physician Practice Specialist

Cindy Garnett, EHR Technical Specialist

Cheri Yeargin, Office Coordinator

Established weekly meeting time

Began our assessment – What were we doing? What

documentation existed?

Preparation


We had to change our approach – looking at all the

standards at one time became confusing and overwhelming!

Made the decision to work on each standard until completed

before moving to the next

After participation in NCQA multi-site call, decided to focus

on Corporate elements

Developed Sharepoint site & completion status grid to track

each factors completion status

Each meeting began with updating completion grid/ended

with assignment of new tasks

How Do You Eat an Elephant?


Element C – Electronic Access

Patient portal is not available for majority of our population,

required website tweaks including building contact forms

for secure electronic requests of prescription refills,

referrals, test results, appointments & clinical advice.

Development of a process for distribution/handling these

requests was also necessary.

Element G – Practice Team

Determining how team members fulfilled the specific

functions of a patient centered medical home (i.e. who

does what?)

PCMH STANDARD 1 - CHALLENGES


14


Element A – Implement Evidence Based Guidelines

Wasted time and frustration would have been avoided had we

looked ahead to the other elements in Standard 3 – and how the

important conditions were to be used later.

Element B – Identify High-Risk Patient

How do you define “high risk patients” when all of your patients are

high risk?

Process of identification not previously documented; required

involvement of other practice staff.

Element C & D – Care Management/Medication Management

Documentation of care plans for patients with ADHD required hand

mining and a definition of what meet criteria for a “care plan”.

Structured data fields would have been helpful.



Element A – Support Self-Care Process

Defining what documentation met the intent of the factor (Record

Review Workbook). Having a physician involved during this step

was crucial! Templates would have been helpful.

Record review workbook instructions were confusing – pay close

attention to the inclusion of high risk patients in record review (lost

points for CPM).

We had difficulty enlisting physicians to assist with record review.

Element B – Provide Referrals to Community Resources

This is something we all do regularly – but is it documented?

Referral tracking process developed & implemented to meet

documentation requirements– included social work, case

management.



Community Resource Referral Log


Element A – Test Tracking and Follow Up

Cleaning up the multitudes of duplicate outstanding labs in eCW

Element B – Referral Tracking and Follow Up

Defining our process highlighted organizational issues with referrals

(i.e. sending/receiving appointment dates/times and consult notes,

definition of “outgoing” and “incoming” referrals, once addressed –

difficult to track)

Element C – Coordinate with Facilities and Manage Care Transitions

We could not have done this without DMCN!

Did not get credit for this element – reviewer felt our documentation

did not demonstrate the intent of the element, only “spoke to the

intent” because the lack of a “step-by-step process”.



Element A – Measure Performance

Determining what data was available through eCW – What

were we measuring that met the requirements?

Element B – Measure Patient/Family Experience

Patient satisfaction survey did not identify the provider –

required change in the process.



Element C/D – Implement Continuous Quality Improvement

PDSA cycles a must!

Reviewer did not feel that adolescent depression screening

addressed services for a vulnerable population.

Measurement over time and the creation of run charts to

demonstrate achieved performance.

Element E – Report Performance

Developed a QI bulletin board “Hall of Fame” to share results

throughout the practice

Posted QI results in waiting room to share with patients

Challenges sharing results by clinician due to multiple

providers



PCMH recognition and the process changed the way we care

for patients

Increased awareness of the QI process & how the results of our

efforts benefit our patients – continuous quality improvement!

Helped to define and organize care processes

Increased structure of patient centered care

Proactive care vs. reactive care

Strengthened team approach & reduced silos

Outcomes


Templates, templates and more templates! Build in prompts to

ease workflow change implementation.

Include entire staff from the beginning to improve buy-in –

“What is PCMH?”

Title all of your documents appropriately. Any data must

include a date range.

Store and organize your documents in one place (i.e.

Sharepoint).

Tips/Lessons Learned


Use techniques such as GE Healthcare CAP/Workout to

facilitate change management

Establish a multidisciplinary QI team Advantage – breadth of knowledge

Disadvantage – many opinions/interpretations

Measure continuously

Submit as many points as you can – just in case

Use text boxes and highlights to point the reviewer to the

specific areas of a document that meets the intent of the

factor – they will not dig

Tips/Lessons Learned


Q&A

lecture lessons learned - pcmh presentation (2)

Health & Medicine