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NFP Care Team Patient AdvocateNew Roles, New Possibilities

Do you have what it takes to be aNFP Patient Advocate?

We are looking for 6 people who: Can be an active member of the NFP CareTeam, supporting the providers and nurses with patient management and administrative tasks

Can organize and utilize social services and linkages for patients and their families

Is committed to improving:Access to CareQuality of CarePatient OutcomesWhat does a Patient Advocate do?Patient Advocates make sure patients are aware of and can access available services and are not lost to follow-up by eliminating the following barriers: Financial barriers (including uninsured and underinsured) Communication barriers (such as lack of understanding, language/cultural) Medical system barriers (fragmented medical system, missed appointments, lost results) Psychological barriers (such as fear and distrust) Other barriers (such as transportation and need for child care)

Philosophy Behind the JobIncrease access to careIdentify changes needed to decrease barriers to care Enhance access to services and quality of care for all populations Improve the quality of careImprove coordination of high-quality, compassionate careIncrease patient satisfactionImprove outcomes Increase retention and use of preventive careIncrease positive outcomes in DM, HTN and other chronic diseases

New Roles, New ResponsibilitiesMeet the requirements of NCQA PCMH Accreditation, as well as other PCMH demonstration projects and pilotsStandardize responsibilities across all Patient AdvocatesCo-locate Patient Advocates with TeamsTrain Advocates and other staff on new rolesMonitor Job Performance

Standard Patient Advocate DutiesCoordination of Team HuddlesForm PreparationReferral AssistancePatient EngagementEnabling VisitsPatient Resource ManagementPartnering with MA, Nurse and Providers

Coordination of Team HuddlesPull together team each morning to review days scheduleProvide input into areas where PA can be helpfulBe the Time KeeperEnsure that huddle remains 15 minutes or less

Form PreparationPrepare forms for provider signaturesThese forms may include:DisabilityWork/school physical formsMed certsgas or electricHEAP

Referral AssistanceInternal vs. External ReferralsReferral completion trackingObtaining specialists reportsAssist patient in obtaining appointments for referrals when complex or when patients face barriers.

Patient EngagementMaintain patient/family engagement through proactive methods of communication: Conducting reminder phone calls for well child checks, past due chronic disease management visits for diabetes and hypertension Contacting patients that no-show for appointments.Calling patients in advance of appointments with patient specific reminders (if needed):DMbring glucometer numbers, meds, questions for providerHTNmeds, questions for providerFollow-up calls to patients that have been hospitalized

Conducting Phone CallsMonthlyreminder phone calls for WCC, DM & HTN (telephone encounter)Dailycalls to no-shows (use no-show tool), hospitalized patients (telephone encounter), review next days schedule for HTN and DM (add to appt. notesPA DM Prep, PA HTN Prep)

11Enabling Visits (face to face)Provide enabling visits to patients of NFP. This involves:Assessment of non-medical needs, Linkage to internal or external resources, Ongoing follow up to resolve issues and/or referral to appropriate level of care (whether behavioral or medical).

Patient Resource ManagementMaintain a resource list to provide patients with the external resources they may need in relation to both medical and non-medical needs including: food, shelter, clothing, utilities, etc.Utilize the online 211 tool Share resources with each other, Alison will maintain database of resources.Partner with the Care TeamCommunicate, work together as a Team within the Care Team, the Provider office and within the Patient Advocate Department

GuidanceWhat can a Patient Advocate advise on?Medical Advice vs. Orders

A question of EPIC proportionsInterim Notes-when patient is in the clinic, but is not part of the provider visitTelephone EncountersPatient Advocacy, Patient Education, reminder calls, med refills, patient messagesOffice Visit/Addendumspatient advocacy is related to Provider visit, preferably document in visit note

You expect me to do all that?????

August 22nd..Prepare formsConduct reminder phone calls for well child checks, past due chronic disease management visits for diabetes and hypertension and contacting patients that no-show for appointments, hospitalized patients.Call patients in advance of visit with patient-specific reminders if necessaryEnabling Visits & Community Resource provisionTeam Work Weekly Meeting

And down the roadAdditional TrainingTeam HuddlesReferral Follow-up and processingAdditional Patient Engagement ActivitiesAdditional Care Management Support ActivitiesPublic program understanding

Questions and Open Discussion