SC PA Best Practice Sharing
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Transcript of SC PA Best Practice Sharing
SC PA Best Practice Sharing
Practice 1PDSA’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
APRILMAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
JANUARY**
FEBRUARY
MARCH
0%
10%
20%
30%
40%
50%
60%
70%
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90%
100%
HEDIS GOAL74.7%
HbA1c <8%
APRILMAY
JUNE
JULY
AUGUST
SEPTEMBER
OCTOBER
NOVEMBER
DECEMBER
JANUARY**
FEBRUARY
MARCH
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
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