Roadmap to Team Based Care

KEY ELEMENTS IN OPERATIONALIZING TEAM BASED CARE IN HEALTH CENTERS

OCTOBER 7, 2015 Debra McGrathHIT Director

and

Suzanne CohenDirector of Member Services

Agenda Overview and Background Best Practices for Team-Based Care Obstacles and Solutions First Steps Toward Change

ObjectivesUpon completion of this session, the participants will be able to:

◦ Evaluate the capability of their organization to adopt team based care◦ Identify potential barriers to team based care◦ Articulate different models and key elements of team based care◦ Develop an action plan to implement team based care

Components of a High Performing Medical Practice

Prompt Access to Care Coordination of Care

Patient – Team Partnership Population Management Continuity of Care

Data Driven Improvement Empanelment Team-Based Care

Engaged Leadership/Executive Sponsorship

Adapted from Safety Net Medical Home Initiative, Ed Wagner

State of Primary Care in 2015

Panel Management

Chronic Disease Management

Health Maintenance

Medication Reconciliation

Meaningful Use

PCMH

Patient Education

results follow up

Transitions in Care

patient engagement

insurance Evidence-based practice

Coding/ICD-10

productivity

Guiding Principles of Team Based Care

1. Facilitate all members of the team functioning at the highest level of their capability.

2. Eliminate those things that waste everyone’s time, so that you and the entire team can have more time to do the important things that really determine patient outcomes

Why Team Based Care - Time Significant impact on quality and outcomes Providers need time to

◦ Listen◦ Examine◦ Think◦ Explain◦ Operate◦ Interpret◦ Comfort

Lack of time contributes to job dissatisfaction and burn out

Why Team Based Care - Time Stealers Documenting Care Finding diagnostic study results and reports from specialists Waiting for delays in patient flow Justifying care/medical necessity Authorizations Prescription and referral renewals

How Team Based Care: Core Principles

Provider-MA Dyad Teamlets supported by a broader team Providers as the CEO of the team Risk stratification Care Coordination/Management Empanelment

Provider-MA Dyad is the

Teaming of one provider (or one FTE provider) with a medical assistant Responsible for the care provided to a panel of patients at the point of care as well as follow up care outside the visit including:◦ Following up on lab and diagnostic testing results◦ Following up on consults with referred to providers◦ Medication management◦ Managing health maintenance and health promotion activities◦ Following up with internal referrals to behavioral health, nutrition, social services◦ Co-managing chronic diseases with specialists and other members of the care team

Why are stable MA/provider dyads so important?

The heart of the team Huge gain in efficiency Patients recognize the MA as a stable part of the team MA’s take accountability for “their” patients More familiarity and trust leads to the MA doing more and the providers spending their time doing what only a provider can do.

Ideal Team Model

Shared Support Team(RN, LSW, pharmacist, attorney, health coach, care manager,

panel manager)

Clinician/MA Dyad

Patient Panel

Empowered Front Desk in Expanded Role

Phone Operator or Call Center

Clinician/MA Dyad

Clinician/MA Dyad

Patient Panel Patient Panel

Adapted from Willard, R and Bodenheimer, T. (2012) The Building Blocks of High-Performing Primary Care: Lessons from the Field. Prepared for California Healthcare Foundation

Providers are the CEO of the Team*

Provides clear direction for the team Leads team to proactively solve problems Builds the team Coaches team Manages stakeholder relationships

◦ *Even thought they don’t directly supervise most team members!

Importance of Risk Stratification In most health centers 80% of the care team’s effort is being spent on 20% of the patients

Critical Success Factors◦ Identify the patients requiring intensive care management and coordination◦ Assign these patients to care management/care coordination

Organizations are using the following criteria for risk stratification◦ Polypharmacy◦ 3 or more chronic diseases◦ Poor control of a critical chronic disease such as diabetes or hypertension◦ Chronic no shows or resistance to care or medication adherence◦ Behavioral health diagnoses

Importance of care management Has to be staffed - once you risk stratify, have to have someone to manage the high risk patients

Care transitions Increasingly, there is some reimbursement available for care management◦ New Medicare codes◦ Likelihood of enhanced PMPM in Medicaid

Importance of EmpanelmentPrompt Access to Care Coordination of Care

Patient – Team Partnership Population Management Continuity of Care

Data Driven Improvement Empanelment Team-Based Care

Engaged Leadership/Executive Sponsorship

Adapted from Safety Net Medical Home Initiative, Ed Wagoner

Empanelment Deliberate attempt to identify the group of patients for whom a care team is responsible.

Represents a shift from the care of patients in the context of an encounter to the proactive, planned care of a population of patients

Goes beyond disease-specific interventions to address preventive, chronic and acute patient needs

Allows the practice to manage supply and demand as an information/data driven process

Barriers to Team Based CareNo Time for:

HuddlesTeam Meetings

part – time providers

staff are not capable

Incongruent with Organizational Chart

Providers work 10 hours, MA’s work 8 hours

not enough staff

providers don’t trust staff

Difficult to incorporate Care Managers, Front Desk, BHC’s ….

no funding for care coordinator positions

Overcoming barriers and getting started

Scheduling ideas Team role analysis tool Cambridge Model Enabling Technology Tools Training Be proactive about new funding/reimbursement possibilities

Scheduling ideas Evaluate provider staffing in terms of FTE Consider assigning 2 or more providers to a team to create one FTE Consider moving to a consistent staffing model where MA’s and providers are working similar hours

Assign responsibilities to teams when providers are not present actively seeing patients

Try to keep providers/MA’s at one location

Getting Started: Team Analysis Tool

Developed by Qualis

Designed to identify which team member is responsible for each role and function and help with staffing ratios

Compare what you’re doing now to where you would like to be – create a roadmap

Team Role Analysis

Cambridge Model Adopted by and designed for safety net providers What is a Team

◦ Session Team◦ Patient’s Planned Care Team◦ Coverage Team◦ Complex Care Team

When/how often should teams meet◦ Daily for a huddle focused on individual patients◦ Weekly, biweekly or monthly focused on the panel and QI measures

Cambridge Model• Track high risk patients• Collaborate with the Planned Care

Team as needed

• Patient's "Go To" Team and each patient is assigned to one.

• Consists of stable Provider-MA dyads, Clerk Assistant, Back-desk

MA, BHC, RN

• Provides a structure to improve access while maintaining

continuity

• Ideally = Planned Care Team• Team of record for the encounter

and participates in the huddle• Communicates with the Planned

Care Team if indicated

Complex Care

Management Team

Planned Care Team

Coverage Team

Session Team

Cambridge ModelSession Team Responsible for the patient’s care on the day of the encounter

Participates in the daily huddle Ideally is the same as the Patient’s Care Team

Patient’s Care Team “Go To” Team Accountable to and for a panel of patients

Regularly evaluated for:◦ Total number of patients in the panel◦ Average number of visits/patient◦ Total number seen >3 times annually◦ Total number of patients with more than

3 chronic illnesses

Cambridge ModelCoverage Team Supports a higher level of access Consists of 2-3 Planned Care Teams

Responsible to communicate among Planned Care Teams

Complex Care Management Team At least one care manager (team leader, ideally an RN), a social worker and/or case manager, community health worker(s), pharmacist, nutrition coach or dietician.

Supports 2 -3 Planned Care Teams Responsible to and for the high risk/high utilizer patients

Collaborates with the Planned Care Teams

Health Information Technology

Optimize HIT to support the team – e.g. enhanced MA intake, care management forms

Consider i2i Tracks or other Population Health Management tools Consider purchasing enabling tools e.g. Phreesia, bi-directional interfaces, bi-directional HIE tools, automated patient contact tools, etc.

Ensure HIT is functioning as well as possible from a performance perspective e.g. hour-glassing, wireless access etc.

Training Evaluate training needs for providers and staff based on their role in the team.

Motivational Interviewing - everyone Clinical Skills Training – MA’s Leadership Training – providers Standardized use of technology tools - everyone