SLIMNetwork:SharingBetterIdeas

AlbertYu,MD,MPH,MBA Director,SFDPHChinatownPublicHealthCenter ClinicalProfessor,UCSFDepartmentofFamily&CommunityMedicine (415)3647909orAlbert.Yu@ucsf.edu

EXPANDINGCAPACITY:MANAGINGSUPPLYANDDEMAND

ChinatownPublicHealthCenter
PartoftheSFCommunityHealthNetwork,hasbeenservingChineseimmigrants,vulnerableresidentsand thosewithlimitedEnglishproficiencysince1929. OurTEAMMD(2.45clinicalFTE),NP(2.55),RN(4.0),MEA(3.0),HW(2.8),EW(4.5),clerk(1.0),medrecord (1.0),nutritionist(1.0),healthed(0.9),MSW(1.0),psychiatrist(0.2),DDS(1.1),dentalaide(1.8),podiatrist (0.1),PharmD(0.2) Servicesinadditiontoprimarycare:publichealthnutrition,medicalnutritiontherapy,communityhealth educationandoutreach,pediatricdentistryandaudiology,podiatry,dementiascreeningandassessmentby UCSFMemoryCenter,EyeVan,Disability&Autismclinicforchildren,WIC,refugeeasyleenewcomers programandmental/behavioralhealth Clients84%speakChinese,65%female,allagegroups,insurance(HSF27%,MediCalFFS&Cap32%,CHN Capitated29%,Medicare5%,uninsured6%) Productivityandutilizationactivepatientpanel(about5K),averagepanelperclinicalFTE(MD:1,380,NP: 1,120),annualPCmedicalvisits(13K)&allvisits(22K),averagevisitsperhour(MD:2.5,NP:1.9),averageno showrate:10%anddailycapacity89%

DemandModerationandSupplyEnhancementChangeStrategies
1) PilotSMARTClinic(SamedayMedicalAttentionResponseTeam)dailyafternoonclinicsstaffedby designatedteamlet(PCP/RN/MEA)anddesignedto:a)addresstheneedsofpatientswhoneedtimely medicalattentionwithorwithoutanappt,b)facilitatepanelmanagementandcommunicationwithin teamlet,andc)promoteMEAidentificationofoverdueclinicalpreventiveservicesfornextdaypatients. 2) InitiatebriefRNvisitsforBPcheckand/orpanelmanagementrelatedactionsaspartoftheSMARTpilot. 3) PilotbrieffocusedinterventiontelephonevisitsbetweenPCPandprescheduledpts. 4) ImplementOrientationClinica2hourintroductoryvisitwithaRNandaMSWinagroupsetting,designed fornewCantonesespeakingptsasawayto:a)introducethemtoservicesavailableatCPHCandSFGH,b) reviewmedicationlabelsandrefillprocedures,c)highlightinsurancecoverage,d)explorethebenefitsofa proactivevisit,ande)completestandingordersforrecommendedclinicalpreventiveservicesand laboratorystudiesbeforetheinitialvisitwithPCP. 5) Offergroupmedicalvisitsforpatientswithdiabetesand/orcoronaryheartdisease a) POGMA(PlannedOnestopGroupMedicalAccess)aplannedmonthlymultidisciplinaryclinicstaffed byaMD,PharmD,RN,MEAandMSW,designedtoprovideALLevidencebasedservicesinone3hour visittoptsathighriskfordevelopingcomplicationsorfornotadheringtorecommendedtreatments b) ABCD(A1C,BP,Cholesterol,DoNotSmoke)isaplannedmonthlyclinicstaffedbyMDandhealth educator,designedto:a)educateptsabouttheharmfromtobaccouse,b)helpptssetactionplansto stopsmoking,c)reviewABCtreatmentgoalsandactualtestvaluesandd)reconcileandadjust medicationstoensureattendeesaretakingAspirin,StatinandACEI/ARB. 6) Expandnursingrolesthroughtrainingandmentoringto: a) Motivateptsthroughcoachingandsettingactionplans(RN,MEA,HW,PCP) b) Identifyduerecommendedclinicalpreventiveservicesusingstandingorders(MEA) c) Completediabetesrelatedmedicationreconciliationandlimitedadjustmentbasedondecisionsupport algorithms(RN) 7) EnsurediabeticptsgetnecessarybloodtestsbeforemedicalappointmentwithPCP. 8) Makecontinuityapriority a) CleanupthePCPdesignationfieldinEHR(LCR)bymatchingptvisitpatterntoPCPassignment b) ScheduleptswiththeirownPCPwheneverpossible c) Combineseveralparttimeclinicianpositionsintoonefulltimefamilyphysicianhire

9) Enhanceofficeflowthroughdeliberatedesign a) Bringallservicestopts(inroomintake,PCPvisitanddischarge) b) Conductpreclinichuddlestoensureclinicstartsontime c) Introduceteamletpatientcareteamstoinclude2PCPS,1RNand1MEA/HW d) Standardizesuppliesandreferralformsineachexamroom e) Redesignacentralspaceforteamhuddles,chartpreparation,ptordersandeasysurveyingofclinicflow 10) Engageclinicianstorethinkapptintervals 11) Enforcelatearrivalandfrequentnoshowpolicies

ChangeProcess
1) ParticipatedintheKaiserCHNPHASE(PreventingHeartAttack&StokeEveryone)initiative a) Receivedtrainingonhealthcoaching,panelandmedicationmanagement b) Createdadiseaseregistryandperformancedashboardthatstaffreviewregularly c) Createdmanypointofcareenablingtools(progressnotes,standingorders,pteducationmaterials,etc.) d) SharedideaswithandlearnedfromchangeleaderswithinCHN e) HeldmonthlyCPHCPhaseteammeetingstoinclude:MD,RN,MEA,PSAandnursemanager f) Assignedpanelmanagementteamlets(PCP/RN/MEA) g) DelineatedandexpandednonPCPstaffrolesandresponsibilities 2) ParticipatedinthePCDCChangingTheWayWeCareRedesigninitiative a) Convenedachangeteamthatmeets2hrsweekly(MD,NP,RN,HW,principalclerk&nursemanager) b) SharedideasandlearnedfromotherchangeteamleadersfromotherCHNclinics c) ParticipatedinWebinarandperiodiclearningsessions d) Engagedentirestaffinthechangeprocess e) AppliedPDSArapidimprovementcycleprinciplesandtoolstotestchangeideas f) ReceivedfeedbackandcoachingfromPCDCandUCSFconsultants 3) Criticalfactorsthatpromotebuyin,spreadteststrategiesandsustainmomentum a) Articulateclearandcoherentclinicgoalsandstaffexpectations b) Eliminateinefficiencyinatransparentandmeaningfulway(removesomethingbeforeaddingnewtasks) c) Communicatesuccinctlyandregularlyaboutplannedactions,highlightingespeciallythepotential benefitsfromchangestrategiestostaffandpatients d) CreateenablingtoolstofacilitateworkIT,forms,physicalspaceandetc. e) Empowerstafftospeakwillinglyandproblemsolveactively f) Developinternalchangechampionstoserveasliaisontootherunitstaff g) Listenandappreciatestaffsinsightsandperspectives h) Understandexistingdatacapabilityandleveragethemfullytodesignandevaluatechangetactics i) Appreciatevariablecomputer/technologyfluencyamongstaff;andthatadoptionisslowandrequires experientiallearningandoftencoaching j) Bepreparedtodealwithresistanceanddonttakenoforananswer

OUTCOMES
Myriadnewmodelstocareforpts(neworPHASE)aresustainedwithpositivefeedbackfromstaffandpts Newpatientappointmentsareconsistentlywithin2weeksmoderateOrientationClinictomeetdemand o AveragepanelsizegrowthsinceJuly2008(MD:1,260to1,380andNP:1,090to1,120) Clinicflowenhancementtacticsarenowfullyspreadandpartofstandardclinicoperation o 75%ofvisitsarenowunderCycleTime(CT)goalof60minutes o AveragevisitCTarenowneargoalof60minutes(baseline:84minutes) o Patientvisitstopsdroppedfromanaverageof9.4pervisittoabout34stopspervisit PatientswithoutPCPassignmentover25%inAugust2007tolessthan5%inApril2009

SLIMNetwork:SharingBetterIdeas
AlbertYu,MD,MPH,MBA Director,SFDPHChinatownPublicHealthCenter ClinicalProfessor,UCSFDepartmentofFamily&CommunityMedicine (415)3647909orAlbert.Yu@ucsf.edu

EstablishingRightSizeProviderPanelstoOptimizeContinuityofCare

ChinatownPublicHealthCenter
PartoftheSFCommunityHealthNetwork,hasbeenservingChineseimmigrants,vulnerableresidentsand thosewithlimitedEnglishproficiencysince1929. OurTEAMMD(2.45clinicalFTE),NP(2.55),RN(4.0),MEA(3.0),HW(2.8),EW(4.5),clerk(1.0),medrecord (1.0),nutritionist(1.0),healthed(0.9),MSW(1.0),psychiatrist(0.2),DDS(1.1),dentalaide(1.8),podiatrist (0.1),PharmD(0.2) Servicesinadditiontoprimarycare:publichealthnutrition,medicalnutritiontherapy,communityhealth educationandoutreach,pediatricdentistryandaudiology,podiatry,dementiascreeningandassessmentby UCSFMemoryCenter,EyeVan,Disability&Autismclinicforchildren,WIC,refugeeasyleenewcomers programandmental/behavioralhealth Clients84%speakChinese,65%female,allagegroups,insurance(HSF27%,MediCalFFS&Cap32%,CHN Capitated29%,Medicare5%,uninsured6%) Productivityandutilizationactivepatientpanel(about5K),averagepanelperclinicalFTE(MD:1,380,NP: 1,120),annualPCmedicalvisits(13K)&allvisits(22K),averagevisitsperhour(MD:2.5,NP:1.9),averageno showrate:10%anddailycapacity89%

StrategiestoOptimizeContinuityofCare
1) 2) 3) 4) 5) 6) 7) 8) 9) 10) CleanupthePCPfieldinelectronichealthrecordbymatchingpatient(pt)visitspatterntoPCPassignment ProducemonthlypanelsizereportsforPCPsandusethedatatoinformdecisionsaboutpanelclosure Engagesystemwidediscussionsaroundpanelsizestandardsandcalculationmethodology ScheduleptswiththeirownPCPwheneverpossible Combineseveralparttimeclinicianpositionsintoonefulltimefamilyphysicianhire Cutappointment(appt)typesfromover15to5(new,return,urgent,gynandprocedure)andcombine returnoptionwithallotherapptstooptimizedailycapacityandtopromoteschedulingwithassignedPCP EducatenewCantonesespeakingpts,duringOrientationClinics,aboutthemeaningofprimarycare providerandthebenefitsofcarecontinuity Createteamlets(PCP/RN/MEA)tofacilitatepanelmanagementandplannedvisits PilotbrieffocusedinterventiontelephonevisitsbetweenPCPandassignedptswhodonotneedfaceto faceencountersbutwhodoneedcorrespondencebeforetypical36monthsfollowupintervals PilotSMARTClinic(SamedayMedicalAttentionResponseTeam)dailyafternoonclinicsstaffedby designatedteamlet(PCP/RN/MEA)anddesignedto:a)addresstheneedsofpatientswhoneedtimely medicalattentionwithorwithoutanappt,b)facilitatepanelmanagementandcommunicationwithin teamlet,andc)promoteMEAidentificationofoverdueclinicalpreventiveservicesfornextdaypatients IntroducegroupmedicalvisitstopatientwithDMand/orCHDathighriskforcomplications MatchknowledgeandskillstotaskrequirementsinordertoincreasePCPproductivity a) PilotbriefRNvisitsforBPcheckand/orplannedactivitiestoreducetheneedtoseePCP b) TrainMEA/HW/RNtomotivateptsthroughcoachingandsettingactionplans c) TrainMEAtoidentifyduerecommendedclinicalpreventiveservicesusingstandingorders d) TrainRNtocompletediabetesrelatedmedicationreconciliationandlimitedadjustmentbasedon decisionsupportalgorithms Engageclinicianstorethinkapptintervalstocreatecapacityformanageassignedpanelofpts

11) 12)

13)

ChangeProcess
1) ParticipatedintheKaiserCHNPHASE(PreventingHeartAttack&StokeEveryone)initiative a) Receivedtrainingonhealthcoaching,panelandmedicationmanagement b) Createdadiseaseregistrytosupportplanningforgroupmedicalvisits

c) SharedideaswithandlearnedfromchangeleaderswithinCHN d) Assignedpanelmanagementteamlets(PCP/RN/MEA) e) DelineatedandexpandednonPCPstaffrolesandresponsibilities 2) ParticipatedinthePCDCChangingTheWayWeCareRedesigninitiative a) Engagedentirestaffinthechangeprocess b) AppliedPDSArapidimprovementcycleprinciplesandtoolstotestchangeideas c) Testedcapacityenhancementanddemandmoderationstrategies 3) Persistedinpushingsystemwidediscussionsaroundrightsizingpanels 4) Criticalfactorsthatpromotebuyin,spreadteststrategiesandsustainmomentum a) HireafulltimefamilyphysicianeliminatedproviderhoppingamongptswhohadnoidentifiedPCP b) Recognizethateveryone,especiallyfrontdeskandPCPs,wantscontinuity c) CoachfrontdeskstafftoverifyPCPassignmentinEHRbeforeschedulingappts d) Createacultureandsupportiveenvironmentwherestaffcanspeakfreely,sharetheirinsights,problem solve,thinkteamandfeelappreciated e) EngagestaffinregularPDSArapidcycleimprovementactivitiesduringweeklyclinicmeetings f) Articulateclearandcoherentclinicgoalsandstaffexpectations g) Eliminateinefficiencyinatransparentandmeaningfulway(removesomethingbeforeaddingnewtasks) h) Communicatesuccinctlyandregularlyaboutplannedactions,highlightingespeciallythepotential benefitsfromchangestrategiestostaffandpatients i) Developinternalchangechampionstoserveasliaisontootherunitstaff j) Bepreparedtodealwithresistanceanddonttakenoforananswer

OUTCOMES
Newpatientappointmentsareconsistentlywithin2weeksmoderateOrientationClinictomeetdemand o AveragepanelsizegrowthsinceJuly2008(MD:1,260to1,380andNP:1,090to1,120) Clinicflowenhancementtacticsarenowfullyspreadandpartofstandardclinicoperation o 75%ofvisitsarenowunderCycleTime(CT)goalof60minutes o AveragevisitCTarenowneargoalof60minutes(baseline:84minutes) o Noshowrateissustainedat10% o Dailycapacityissustainedatabout90% PatientswithoutPCPassignmentdroppedfromover25%(August2007)tolessthan5%(April2009) Myriadnewmodelstocareforpts(neworPHASE)aresustainedwithpositivefeedbackfromstaffandpts