Communicating Effectively to Enhance Quality:

A Team-Based Approach

Bluestone Physician ServicesApril 3, 2018

Presented by: Annette Fagerlee, RN, Director of Care CoordinationNate Hunkins, MPH, Director of Population Health

Objectives

1. Provide strategies for communicating with all members of the patient’s care team to benefit the whole person and increase the quality of care.

2. Demonstrate how can help organizations understand and better serve complex patients.

3. Using IDT (interdisciplinary care teams) to collaborate and make positive change in people’s lives.

Presentation Outline

• Background• Communication strategies• Utilizing data• Organizing IDTs• Team based approach• Questions / Answers

Overview of Bluestone Physician Services

Bluestone’s Services Count

Geriatric Practice – FL, MN, WI 11,366

Integrated Care – currently MN only

611

Care Coordination - currently MN only

5,888

Geriatric patients enrolled in Chronic Care Management Program

8,513

Average # of chronic conditions per patient

7

• Geriatric On-site Primary CareProvider teams partner with Assisted Living and Memory Care communities to see patients in their homes.

•PsychiatricOn-site and telehealth visits.

• Integrated CareOn-site care for people with disabilities living in group homes.

• Care CoordinationRN and SW led preventative model under contract with MCO Special Needs Plans.

Care Coordination in MN

• Assisted Livings = 800• Group Homes = 600• Community = 4,300• Care Coordinators = 56• Care Coordinator Assistants = 15

Serving primarily Medicare, Medicaid and Dual eligible patients

Communicating with the Care Team

1. Define the care team:a. Identify the people on the teamb. How do people prefer to be contacted/informed?c. Define roles and responsibilities of team members

2. Who is your audience?a. When talking with outside agencies, what do people need to know to provide the

best care possible to the patient?

3. What is your desired outcome?a. When talking with people, know what you are trying to accomplish.b. What is valuable to them to do their job better?

Three strategies for successful team communication:

Who’s on the care team?

• Health plan care coordinator• Primary care provider• Waiver case manager• County financial worker• Clinic health care home coordinator• Home care providers• Specialty care providers• Family• Guardians• And don’t forget The Patient!

To name a few….

Conceptual Model of CC

Case Managers

Medical Providers

Financial Workers

Home Care

Services

Family / Guardians

PatientCare

Coordinator

Care Coordinator

Strategy #1: Define the care team

• The care team:– Identify the people on the team

• Gather information from patient, family, guardian, etc.– Define roles and responsibilities of team members

• Refer to handout

Strategy # 2: Build relationships with team

members

• Building Relationships:– Identify how people prefer to be contacted/informed

• Email, phone calls, face to face– How can we be of value to the team?– Communicating to medical providers

Strategy # 3: The right information to the right team member

• The Right Information– You know roles, responsibilities, how to communicate

• Now - what information does everyone need?

– What are the types of information to be distributed?• Medical, socio-economic, etc.

– Having the right information allows people on the team to do their job better

Communication & Quality

Can effective communication increase the likelihood of a desired health outcome for a patient

or population?

Communication & Quality

1. Bluestone Bridge

2. Concise and actionable data

3. Interdisciplinary team meetings

4. Post-visit care conference

Effective communication tools enhance quality for Bluestone’s patients….

1. Bluestone Bridge

• Secure, online platform links providers, community staff, families and partners

• Provides a record of communication for patient related action

• Request and receive orders online• Chronic disease monitoring- INR flowsheets• Most efficient way to communicate with providers teams

24/7Bluestone Bridge

Stakeholders use a common communication platform

2. Concise & Actionable Data

Cast & Crew• data analysts• health plans• quality directors• and everyone else with

access to data

“The Good, the Bad, and the Really Bad Data”

Concise and Actionable Data

COORDINATION RISKNumber of Members

Percent of Members

Average Spend perMember

Likely Care Coordination Issue 147 8% $36,250Possible Coordination Issue 100 5% $19,750Unlikely Coordination Issue 984 53% $8,890Grand Total 1856 100% $12,654

“The Good,”

Concise and Actionable Data

“the Bad,”

Enrollment0 85,745

Concise and Actionable Data

Patient Name

Location Measure Name

Performance

Bob Adams WhitePines

A1C Poor Control

Performance Met

Carrie Smith White Pines

A1C Poor Control

Performance Met

JasonJohnson

WhitesPines

A1C Poor Control

Performance not met

“the Really Bad,”

Concise & Actionable Data

Concise & Actionable Data

• Quality Work Plans sent to teams every 3-4 weeks.

– Work plans include only patients who are not passing the measures

– Clear and concise action statements (i.e. order A1c, falls risk assessment due)

– Sortable by location, measure, etc. to allow for prep work to be completed prior to visit

• Field/Territory Summary Reports:– Manger level reports gives a snapshot of their teams

– Easily identify improvement areas for every team within a territory

– Prioritize measures to focus on

3. IDT - Interdisciplinary Team Meetings

• Weekly team meetings to address the physical, emotional, psychological, and social needs of our complex/high risk patients. Team members include,

– Care Coordinator– Director, Manager Care Coordination– MD or advanced practice provider– Population Health team members– Chief Clinical Officer

Goal:

• Create tailored interventions for complex/high risk patients and members.

Post-Visit Care Conference

• Care coordinator & provider have a conversation to determine next steps

• Follow-ups are created as action items in the EHR

• Scheduling coordinator also included or looped into the discussion

Determining the next steps…

Making positive change in people’s lives

• It should be our common goal--to make people’s lives better

– How we get there may take different paths but our goal is the same

• Working together brings positive change– Communicate success stories with everyone in the organization!

Questions / Contact info

• Nate Hunkins, Director of Population Health, Bluestone Physician Services

– 612-916-4497– Nate.Hunkins@BluestoneMD.com

• Annette Fagerlee, Director of Care Coordination, Bluestone Physician Services

– 651-342-3045– Annette.Fagerlee@BluestoneMD.com