© 2003 PeaceHealth Using Practice Teams to Improve Efficiency and Quality of Care for Older Adults...

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© 2003 PeaceHealth Using Practice Teams to Improve Efficiency and Quality of Care for Older Adults Ron Stock MD MA The Gerontology Institute PeaceHealth Oregon Region [email protected]

Transcript of © 2003 PeaceHealth Using Practice Teams to Improve Efficiency and Quality of Care for Older Adults...

Page 1: © 2003 PeaceHealth Using Practice Teams to Improve Efficiency and Quality of Care for Older Adults Ron Stock MD MA The Gerontology Institute PeaceHealth.

© 2003 PeaceHealth

Using Practice Teams to Improve Efficiency and Quality of Care for Older Adults

Ron Stock MD MAThe Gerontology InstitutePeaceHealth Oregon [email protected]

Page 2: © 2003 PeaceHealth Using Practice Teams to Improve Efficiency and Quality of Care for Older Adults Ron Stock MD MA The Gerontology Institute PeaceHealth.

© 2003 PeaceHealth

Learning Objectives

1) Understand the key attributes of a practice team and how to develop a team in practice.

2) Describe the team-based practice changes that lead to improved efficiency and quality of care.

Page 3: © 2003 PeaceHealth Using Practice Teams to Improve Efficiency and Quality of Care for Older Adults Ron Stock MD MA The Gerontology Institute PeaceHealth.

© 2003 PeaceHealth

Acknowledgements

• PeaceHealth Oregon Region Leadership, Eugene, OR• PeaceHealth Clinical & Operational Improvement

Division, Bellevue, WA• John A. Hartford Foundation, Geriatric

Interdisciplinary Teams in Practice Initiative• AHRQ Patient Safety Implementation Challenge Grant

Page 4: © 2003 PeaceHealth Using Practice Teams to Improve Efficiency and Quality of Care for Older Adults Ron Stock MD MA The Gerontology Institute PeaceHealth.

© 2003 PeaceHealth

Page 5: © 2003 PeaceHealth Using Practice Teams to Improve Efficiency and Quality of Care for Older Adults Ron Stock MD MA The Gerontology Institute PeaceHealth.
Page 6: © 2003 PeaceHealth Using Practice Teams to Improve Efficiency and Quality of Care for Older Adults Ron Stock MD MA The Gerontology Institute PeaceHealth.

Mission Statement:

"To seek to understand and meet the health, sociological,psychological, and functional needs of the aging population

through research, quality clinical care, education, andcommunity collaboration."

Research

Clinical Care

Education

Community Collaboration

Health Services Research *- Applied Geriatric Care- Transitional Care- Chronic Care

University of Oregon/Oregon Health Science University(OHSU) Collaboration *

Federal Demonstration Projects Pharmaceutical Drug Trials

Senior Health & Wellness Center(SHWC) *- Primary Care- Consultations

Regional Consultation Collaborative *- Inpatient- Outpatient

Geriatric Community Health CareServices (SNF, RCF, ALF) *

Inpatient Acute Care of the Elderly(ACE) Unit

OHSU Medical School Collaboration *

OHSU Nursing School Collaboration *

Teams in Healthcare Consultations *

Portland State University (PSU)SW Department

Advanced Training Program (ATP) inApplied Outpatient Care of older adults

Clinical Pastoral Education

OASIS *

HeartLine/Lifeline *

Chronic Disease Self ManagementProgram (CDSMP) *

Alzheimer's Association *

Senior & Disabled Services (AAA) *

Civic engagement

* current expertise/relationship

Eugene, Oregon

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© 2003 PeaceHealth

Care Model Influences

•The “Senior Health Clinic” movement•Lean Thinking; “Voice of the Customer”• Institute for Healthcare Improvement (IHI) Breakthrough Series on the Chronic Care Model

• IHI Idealized Design of Clinic Office Practice

Page 8: © 2003 PeaceHealth Using Practice Teams to Improve Efficiency and Quality of Care for Older Adults Ron Stock MD MA The Gerontology Institute PeaceHealth.

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

Improved Outcomes

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community

Health Care Organization

Chronic Care Model

Page 9: © 2003 PeaceHealth Using Practice Teams to Improve Efficiency and Quality of Care for Older Adults Ron Stock MD MA The Gerontology Institute PeaceHealth.

© 2003 PeaceHealth

Senior Health & Wellness Center

Aim: To develop a comprehensive senior healthcare practice through an interdisciplinary team approach

Page 10: © 2003 PeaceHealth Using Practice Teams to Improve Efficiency and Quality of Care for Older Adults Ron Stock MD MA The Gerontology Institute PeaceHealth.

© 2003 PeaceHealth

SHWC Interdisciplinary Team

• Geriatrician• Gerontological Nurse Practitioner (GNP)• Team Nursing• Medical Social Worker/Care Coordinator• Pharmacist• Dietician• Physical Therapist• Chaplain• Home Health Coordinator• Health Information Librarian

Page 11: © 2003 PeaceHealth Using Practice Teams to Improve Efficiency and Quality of Care for Older Adults Ron Stock MD MA The Gerontology Institute PeaceHealth.

© 2003 PeaceHealth

Senior Health Center Care Model• Geriatric expertise• Prepared, proactive interdisciplinary care team• Planned, coordinated, protocol-driven care• Informed, activated patients• Senior sensitivity trained staff• Community collaboration

Model description in:Stock RD, Reece D, Cesario L. Developing a Comprehensive

Interdisciplinary Senior Healthcare Practice. JAGS 52:2128-2133, Dec 2004.

Page 12: © 2003 PeaceHealth Using Practice Teams to Improve Efficiency and Quality of Care for Older Adults Ron Stock MD MA The Gerontology Institute PeaceHealth.

© 2003 PeaceHealth

Hartford Senior Health Clinic Study

• “Does an interdisciplinary team (and Chronic Care Model) approach improve health/org outcomes for older adults?”

• 3 groups; n=1309; 30 month study• Results:

– Take less meds– Higher immunization rate– Fall less– Despite physical decline maintain quality of life– Depression scores improve – Pt Satisfaction unchanged– Lower Medicare costs

Page 13: © 2003 PeaceHealth Using Practice Teams to Improve Efficiency and Quality of Care for Older Adults Ron Stock MD MA The Gerontology Institute PeaceHealth.

© 2003 PeaceHealth

Page 14: © 2003 PeaceHealth Using Practice Teams to Improve Efficiency and Quality of Care for Older Adults Ron Stock MD MA The Gerontology Institute PeaceHealth.

© 2003 PeaceHealth

Page 15: © 2003 PeaceHealth Using Practice Teams to Improve Efficiency and Quality of Care for Older Adults Ron Stock MD MA The Gerontology Institute PeaceHealth.

© 2003 PeaceHealth

Why “team” care?

•Changing healthcare models and environment, regulatory and training requirements

•Clinical outcomes better•Safer, more reliable care•Happier patients•Happier staff

Page 16: © 2003 PeaceHealth Using Practice Teams to Improve Efficiency and Quality of Care for Older Adults Ron Stock MD MA The Gerontology Institute PeaceHealth.

© 2003 PeaceHealth

Challenges to Developing Effective Teams

•Different disciplines•Not trained together•Hierarchy•Asynchronous care•Lack of continuity•Culture slow to change

Page 17: © 2003 PeaceHealth Using Practice Teams to Improve Efficiency and Quality of Care for Older Adults Ron Stock MD MA The Gerontology Institute PeaceHealth.

© 2003 PeaceHealth

What is a “team”?

Work Group

Ad hoc committee

“Unit”

Clinic

“Practice”

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© 2003 PeaceHealth

What is a team?

Multidisciplinary Interdisciplinary

Interdependent

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© 2003 PeaceHealth

What is a Team?

•Task-oriented vs relationship-oriented•Membership defined by healthcare vs. patient/family

•Teams develop around the core principle of “trust”

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© 2003 PeaceHealth

“…two or more individuals who have specific roles, perform interdependent tasks, are adaptable, and share a common goal. Moreover, members of teams must possess specific knowledge, skills, and attitudes (KSAs), such as the ability to exchange information, which enable individual team members to coordinate.”

Baker et al. The Role of Teamwork in the Professional Education of Physicians. Jt Comm J Qual Saf 31(4): 185-202, April 2005.

Page 21: © 2003 PeaceHealth Using Practice Teams to Improve Efficiency and Quality of Care for Older Adults Ron Stock MD MA The Gerontology Institute PeaceHealth.

© 2003 PeaceHealth

Teamwork Model (Baker et al, 2005)

Organization

Team

Individual

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© 2003 PeaceHealth

Team Structure

1. Core Team

2. Coordinating Team

3. Contingency Team

- TeamSTEPPS

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© 2003 PeaceHealth

The Team “Bundle” Intervention•Leadership Commitment

– Practice/Unit level– Organization

•The Team Development Measure– Feedback to team with discussion– Target improvements

• Intra-staff communication skills training•Patient/case-focused care conferences or “huddles”

Page 24: © 2003 PeaceHealth Using Practice Teams to Improve Efficiency and Quality of Care for Older Adults Ron Stock MD MA The Gerontology Institute PeaceHealth.

© 2003 PeaceHealth

How will you know whether you’re a team…. or not?

The Team Development Measure (TDM)www.teammeasure.org

31 Items

Rasch survey measurement methodology

Psychometric testing:

250 teams; n=956

Mplus factor analysis= 4 factors best sol’n

Cronbach’s alpha=0.90

Page 25: © 2003 PeaceHealth Using Practice Teams to Improve Efficiency and Quality of Care for Older Adults Ron Stock MD MA The Gerontology Institute PeaceHealth.

The Team Development Measure (TDM)

Cohesion

Communication

Roles Clarity

Goals Clarity

“…the social glue that binds the team members as a unit.”

Team members…. Say what they feel and think; are truthful, respectful and positive; address conflict maturely

Clearly defined roles and expectations. Accomplishments of the team are placed above individuals

Clearly defined team goals and the means to reach these goals.

Building

PreTeam

Stage 1

Fully Developed

Stage 8

Stage 7

Stage 6

Stage 5

Stage 4

Stage 3

Stage 2

Established

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Typical 1st Assessment Results

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© 2003 PeaceHealth

Same Team 4 Months Later

Page 28: © 2003 PeaceHealth Using Practice Teams to Improve Efficiency and Quality of Care for Older Adults Ron Stock MD MA The Gerontology Institute PeaceHealth.

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What have we learned about teams?

• Teams don’t just happen, formalized training is necessary• Requires ongoing maintenance • Use the Team Measure to inform and improve• Weekly Care Conference/huddle helps the team

“practice” • Teams are a prerequisite for sustainable quality

improvement• Clinical outcomes are better• Organizational health improves

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© 2003 PeaceHealth

Team Practice Interventions That Make a Difference

• Practice re-design• Protocol-Driven Standardized Processes • Care Management Services• Managing “Transitions”• Engagement of Patients and Families

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© 2003 PeaceHealth

Practice Re-Design

•One-stop shop•Nursing care teams•Advance Practice Nurses

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© 2003 PeaceHealth

Protocol-Driven Standardized Processes

•Very Important Papers (VIP) process• Immunizations•Medication Management•Disease-specific management

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© 2003 PeaceHealth

Immunization Pearls

•Agree on immunization protocol•Educate all staff•Provide standing orders •Assign the role of immunization management to a staff nurse and provide appropriate training and resources

•Measure and have a process for follow-up

Page 33: © 2003 PeaceHealth Using Practice Teams to Improve Efficiency and Quality of Care for Older Adults Ron Stock MD MA The Gerontology Institute PeaceHealth.

© 2003 PeaceHealth

Pneumovax and influenza vaccination rates are significantly higher in the Intervention Group, the Senior Health & Wellness Center (SHWC) model.

Baseline 6 Months 18 Months 30 MonthsWave

828384858687888990919293949596

Per

cen

t

Care Model

Intervention

Comparison 1

Comparison 2

Percent Patients Having Pnuemonia Vaccination by Wave by Care Model

Page 34: © 2003 PeaceHealth Using Practice Teams to Improve Efficiency and Quality of Care for Older Adults Ron Stock MD MA The Gerontology Institute PeaceHealth.

© 2003 PeaceHealth

Medication Management Pearls

•Agree and educate on “bad” drugs•Screen for patients on >4 meds•Referral to geriatric pharmacist for med review if on >4 drugs (standing order)

•Standardize process components of med reconciliation in ambulatory setting

Page 35: © 2003 PeaceHealth Using Practice Teams to Improve Efficiency and Quality of Care for Older Adults Ron Stock MD MA The Gerontology Institute PeaceHealth.

© 2003 PeaceHealth

Medications

SHWC participants (intervention group) were prescribed significantly less medications and use did not increase over time.

6 Months 18 Months 30 MonthsWave

3.6

3.7

3.8

3.9

4.0

4.1

4.2

4.3

4.4

Est

imat

ed M

arg

inal

Mea

ns

Estimated Marginal Means of Number of Prescription Medications by Wave by Care Model

Intervention

Comparison 1

Comparison 2

Page 36: © 2003 PeaceHealth Using Practice Teams to Improve Efficiency and Quality of Care for Older Adults Ron Stock MD MA The Gerontology Institute PeaceHealth.

© 2003 PeaceHealth

Care Management Services

•Primary care-based•RN/MSW•High intensity/low volume•Care Management Plus

Page 37: © 2003 PeaceHealth Using Practice Teams to Improve Efficiency and Quality of Care for Older Adults Ron Stock MD MA The Gerontology Institute PeaceHealth.

© 2003 PeaceHealth

Managing Care Transitions

•Develop services that address care across the care continuum

•Leverage EMR capabilities•www.caretransitions.org

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© 2003 PeaceHealth

Patient & Family Engagement

•Self-management support (Group visits; Chronic Disease Self-Management Program)

•Office practice volunteers•New patient and family orientation•Quality Improvement project participation•Patient Advisory Council

Page 39: © 2003 PeaceHealth Using Practice Teams to Improve Efficiency and Quality of Care for Older Adults Ron Stock MD MA The Gerontology Institute PeaceHealth.

© 2003 PeaceHealth

What have we learned?

• This model of care has features that produce better outcomes; Implement a “bundle” of improvement changes

• Interdisciplinary, Interdependent team approach• Planned, coordinated care• Protocol-driven processes (standardization)• Continually involve patients and caregivers;

Patients and families need to be “partners”, not just “consumers”

Page 40: © 2003 PeaceHealth Using Practice Teams to Improve Efficiency and Quality of Care for Older Adults Ron Stock MD MA The Gerontology Institute PeaceHealth.

© 2003 PeaceHealth

References• www.teammeasure.org• GITT program (www.gitt.org)• TeamSTEPPS http://www.ahrq.gov/qual/teamstepps• Drinka T and Clark PG. Health Care Teamwork:

Interdisciplinary Practice and Teaching. Westport, CT: Auburn House, 2000.

• Grumbach K and Bodenheimer T. Can Health Care Teams Improve Primary Care Practice? JAMA 2004;291(10):1246-1251.

• Baker et al. The Role of Teamwork in the Professional Education of Physicians. Jt Comm J Qual Saf 31(4): 185-202, April 2005.

• Pronovost P, Berenholtz S, et al. Improving communication in the ICU using daily goals. J Crit Care. June 2003; 18(2):71-75.

Page 41: © 2003 PeaceHealth Using Practice Teams to Improve Efficiency and Quality of Care for Older Adults Ron Stock MD MA The Gerontology Institute PeaceHealth.

© 2003 PeaceHealth

References• Singh H, et al. Medical errors involving trainees. Arch Intern

Med Oct 2007; 167(19):2030-2036.• Baker et al. The Role of Teamwork in the Professional

Education of Physicians. Jt Comm J Qual Saf 31(4): 185-202, April 2005.

• Cohen, S.G. and Bailey, D.E What makes teams work: Group effectiveness research from the shop floor to the executive suite. Journal of Management, 23, 1997, 239-290.

• Gaba et al. Simulation-based training in anesthesia crisis resource management (ACRM): A decade of experience. Simulation Gaming 2001; 32:175-193.

• Pizzi L, Goldfarb N, and Nash D. Chapter 44. Crew Resource Management and its Application in Medicine. http://www.ahrq.gov/clinic/ptsafety/chap44.htm

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© 2003 PeaceHealth

The Team Development Initiative

•Development of a comprehensive senior healthcare practice using the Chronic Care Model and IDT principles

•Funded by the Hartford Foundation Geriatric Interdisciplinary Teams in Practice (GIT-P) Initiative and subsequent 3-year Dissemination Project

•Spread: PeaceHealth; Group Health; Providence-Oregon; preliminary discussions with Kaiser