SC PA Best Practice Sharing

Practice 1

PDSA’s Included: Identifying DM patients prior to and/or at time of visits

Identify who needs Urine Micro Albumin and Eye Exams Prior to visits Shoes/Socks off at visit, Monofilaments completed if due

How did these Impact the Staff/Work Flow: Secretaries assisted in placing “Prep Sheets” with Encounters when registering

All MA’s trained in Monofilament exams Referral MA ran reports and placed calls to diabetics to get eye exam info.

Diabetic PatientsPA Spread REMINDERS

•HPI entered “Pt. is a Diabetic”

•Have patient take shoes and socks off at every routine visit!!!

•Monofilament Foot exam completed within the last year??? If no, PERFORM exam today!!!

•Urine Microalbumin done within the last year??? If no, COLLECT urine sample and send!!!

•Retinal Eye Exam done within the last year??? If no, enter REFERRAL for diabetic eye exam!!!!

Practice 1

Moving Forward…

Pre-Visit Chart Preps Daily Huddles (Providers, MA, etc…The whole team!)

RN Care Coordination for patients who need “extra care” “High Risk” Meetings for Complex Patient Care Plans Expanding the PCMH Module to other Diagnoses and

eventually “All Patients”

MAJOR CHANGE Implementation of EMR •All charts are now electronic with PMR scanned and saved to appropriate folders. All labs, orders, medications, letters and communication notes are in the EMR.

OUTCOME•Improved continuity of care with greater access for all providers•Easier tracking and searching for test/results• Ability to set Protocol Template allowing quick look for gaps in care

Practice 2

Practice 2

MAJOR CHANGE Pre Visit Chart Preparation•Health Coach uses EMR to Plan upcoming patient visit. Focus on Diabetic patients.•Uses a Needs List Worksheet & completes with Gaps in Care identified. •Worksheet is given to MA for review with patient at visit & standing orders to be completed. Physician to be made aware of other orders needed to complete Gaps in Care.

OUTCOMES• Microalbumin testing increased by 9% • A1C Trending down • More staff engaging w/pt visit

Practice 2

MAJOR CHANGE PCMH Health Coach • Pt is referred to Health Coach at time of visit or referral made for teaching which could include diet, exercise and/or insulin titration to target based on standing orders. • Continued point of contact for pt. & f/u calls made by PCMH Team.• Recognize when further needs or Recourses are needed & assist w/referral.

OUTCOMES• 70 y/o w/history of DM, HTN, OBESITY and Hyperlipidemia Meet w/health coach, titrated insulin via phone calls & standing orders Date: A1C LDL TRIGLYCERIDES WEIGHT 7/10/12 8.5 127 276 307 LBS

3/01/13 6.5 63 132 291 LBS

Practice 2 MOVING FORWARD:

• Begin work on Self-management goals. Patient will be given handout that list several types of goals (healthy diet, exercise etc.) and asked to pick one realistic goal for them.

• High Risk Management: RN Care Coordinator will contact patient to assist with any transitions of care.

• Regular communication with physicians regarding care of High Risk to include regular meetings for management strategies.

Practice 3Major Change

• Pre-visit Planning – Huddle

• Developed a Standard Protocol • EMR Monthly Reports

• HgbA1c > 9.0• LDL > 100

• Medication Adherence Hgba1c > 11.0• In House Lab Testing

APRILM

AY

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HEDIS GOAL74.7%

HbA1c <8%

APRILM

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JULY

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HEDIS GOAL76.70%

Blood Pressure < 140/90

Best Practice ChangesPractice 4

• Formed a Quality Management Team with a Quality Management Supervisor.– One of the responsibilities is coordinating and

performing Pre-Visit Preparations• Consists of a check list of orders, reminders,

immunizations, results, etc. required to be in the chart based on age, gender and chronic conditions.

• Pre-Visit Preparations are conducted 24-48 hours prior to all previously scheduled appointments

Best Practice ChangesPractice 5

• Care Guide implementation for chronic conditions– Tool allowing provider to document care plan, goals,

self-management abilities, educational material, etc.• Diabetes, Asthma, Smoking

• Patient Recall Registry– Report generated from EHR data indicating patients

in need of tests, procedures, immunizations, etc.– Outreach is performed to ensure patient receives

appropriate care.

Best Practice ChangesPractice 6

• Created a Patient Navigator Position– Helps complete Pre-Visit Preparation– Reviews Quality Measures

• Care Guide implementation for chronic conditions

• Implemented Auto-Fax– Inbound faxing ability– Eliminates the need to scan paper faxes

Best Practice ChangesPractice 7

• Care Guide implementation for chronic conditions

• Transition of Care (TOC) follow-up– Made/making arrangements with hospital systems

to notify site(s) of patient discharge– Implemented TOC Nurse and Office Visit Note

• Provides structured documentation for nurse phone outreach after discharge and provider office visit follow-up

Best Practice ChangesPractice 8

• Patient Registry– Identified patients with elevated A1C and over due for

DM office visit• Used this information to outreach to patients via 3 phone

calls• If no response sent series of 2 letters

– Statistics– 32 patients were sent letters, 15 patients scheduled due to receiving

the letter(s)» 47% success rate

• Care Guide implementation for chronic conditions

Best Practice ChangesPractice 9

• Pre-Visit Preparation– Enters reoccurring Reminders for routine and

preventative testing• Learning how to address the Reminders and over due Orders

at time of visit

• Nurses perform DM Foot Exams– Nurse practitioner worked with nursing staff to teach

proper foot exam technique – Nurse enters result into EHR

• Ensures proper documentation within EHR for reporting purposes

Best Practice ChangesPAL-Eastbrook Family Health Center

• Implemented the use of Standing Orders– Protocol for Strep screening– Protocol for A1C blood draw– Protocol for Lipid screening

• Care Guide implementation for chronic conditions

• Pre-visit Preparations

Best Practice ChangesPractice 10

• Pre-Visit Preparations by the Quality Management Team– Enters Reminders and Orders to make the most of

each visit• Quality Team meetings to discuss what is

working for each individual site• Transition of Care follow-up

Best Practice ChangesPractice 11

• Patient Registry– Outreach to identified patients has evolved into

case management• Coordinated diabetic learning sessions at

Millersville University• Involvement with PA SPREAD has prepared the

site(s) for PCMH

Example MaterialsPre-Visit Prep Check List

Example MaterialsCare Guides—Diabetic Care Guide

Example MaterialsPatient Registry for Diabetic Management

Example MaterialsTransition of Care Nurse Note

Example MaterialsTransition of Care Office Visit Note