Promoting Team Based

Care

DC Primary Care AssociationOctober 27, 2015

Mary Blankson DNP, APRN, FNP-C Chief Nursing Officer

Our Vision: Since 1972, Community Health Center, Inc. has been building a world-class primary health care system committed to caring for underserved and uninsured populations and focused on improving health outcomes, as well as building healthy communities. CHC Inc. Profile:•Founding Year - 1972•Primary Care Hubs – 13 ; 218 sites•Organization Staff – 650; active patients: 130k•Disciplines: Medical, Behavioral Health, Dental•Specialties: CDE, Nutritionist, Podiatry, Chiropractic Care•Specialty access by eConsultsTop Chronic Diseases

Cardiovascular Disease Obesity/Overweight

Diabetes Chronic Pain

Asthma Depression

Three Foundational Pillars Clinical Excellence

Research & Development Training the Next Generation

Elements of Model

• Integrated primary care teams/pods• Integrated medical, dental, BH EMR• PCMH Level 3• TJC Patient Home• School Based Health Centers across CT• “Wherever You Are” HCH program

Innovations• Postgraduate Training Programs • Weitzman Institute • Project ECHO –CT (pain, opioid addiction, QI)

• Specialty access by eConsults

CHC’s Educational, Technical & Innovation Projects

Facilities and Physical Model

• Interdisciplinary Pods that Promote Team-Based Care• Open office structure• Collaboration throughout the workday

6

• Exam rooms and therapy rooms

• Reducing stigma of seeing other disciplines

• Seamless transition between Disciplines

05/14/2014

Facilities: One Corridor Care

What does an Integrated Record Look Like?

800/00/00

Data Driven: the Right Data at the Right Time

EHR

ETL Process

Data WarehouseStructured Data Pulls

Dashboards

Scorecards

Additional on-site specialties

Nutrition Diabetes

education Chiropractic Podiatry Retinal screening

Care that is Comprehensive: IPCP Team

PATIENT

Medical

BH

Nursing

Pharmacy

Prenatal

Dental

4 Clinical Chief positions: Chief Medical Officer Chief Nursing Officer Chief of Behavioral Health Chief Dental Officer

Leadership Support Executive Mentoring Interdisciplinary Chief Meetings Leadership Meetings

Collaboration/Integration among departments QI Projects/Microsystem work Clinical Initiatives/Policies

MU2/PCMH/UDS

Interdisciplinary Leadership

Onsite Clinical Directors OSMD Nursing Managers OSBHD OSDD

Collaboration/Integration among departments Integrated Microsystems Integrated Care Meetings Clinical/Pod “Huddles”

Leadership Support Leadership Skills Training Leadership Meetings

Interdisciplinary Leading

Interdisciplinary Care“Every CHC Patient has Team!”

Initiative BH Medical

Nursing

Dental

Integrated Care Meetings r r r

Recalls r r r r

BH Groups r r

Shared Medical Visits r r r

Warm Hand-Offs r r r

Prenatal-Dental Project r r r

Shared Care Plans r r r

Complex Care Management

r r r

Trauma Screening & TFCBT

r r

Standing Orders r r

Fluoride Varnish r r r

SBIRT r r r

BH Dashboard r r r r

Appointment Allocation r r r r

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Interdisciplinary Care Initiatives

Figure 1. Diabetes Dashboard by Provider

Team-Based Care: Tele-Ophthalmology

• Rooms Patient• Collects Vitals• Captures Images

MA

• Diabetes Education• Self-Management

Goal Setting

Nurse

• Reviews Results• Creates a Referral

when needed

PCP

Collaboration/Integration among departments Training/Competencies Program Oversight Developing Standing Orders Chair of the Pharmacy & Therapeutics Committee MU2 Implementation PCMH, UDS Reporting & TJC MA/RN recruitment Nursing Informatics Promotion of Research & Translation Mentor/Coach to the Nurse Managers Relationships with Professional Schools

Leadership for RNs and MAs: The Role of the CNO in Team-Based Care

POD design 2 Medical Providers 1 Registered Nurse 2 Medical Assistants 1 Behavioral Health Clinician Additional members: podiatrist, dietician, Pharm-D,

chiropractor, CDE Student/Trainees

The Interdisciplinary Team

Essential member of the primary care team and interprofessional activities

(1) RN supports (2) primary care providers/panelsKey functional activities:

Patient education and treatment within provider visits Independent Nurse Visits under standing orders Delegated provider follow up visits using order sets Self management goal setting and care management Complex Care Management; coordination and planning Telephonic Advice and Triage via dedicated triage line Quality improvement leaders, coaches, and participants Leaders and participants in research Clinical mentoring of RN students; Supervision and mentoring of Medical Assistants

Domains of RN Nursing Practice at CHC, Inc.

Uncomplicated UTI Vulvovaginal candidiasis Comprehensive diabetes visit with retinal screening Pupil dilation Titration of basal insulin Pedi & adult vaccines TB DOT Bronchodilator testing in spirometry Tobacco cessation Emergency contraception Pregnancy testing Orders for emergency situations

Nursing Standing Orders

Independent Nursing Visits

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000 12,870

4,2285,444

736 1,4222,952

766

Total Visits: 20,717, Total Services Delivered: 28,418

Total Visits: 20,717, Total Services Delivered: 28,418

Hypertension; 41.9%

Diabetes Man-agement; 25.3%

BH; 10.6%

Asthma/COPD; 7.9%

HCV/HIV; 2.2%

Obesity; 1.6%CAD; 1.0% Hyperlipidemia;

0.7%

Other; 8.8%Chronic Illness Care

National Advisory Council on Nurse Education and Practice

Competency Fairs Leadership Conferences Facilitation Training Comprehensive didactics for Complex Care Management

• Transition Care• Medication Reconciliation• CHF• DM• Asthma• COPD• Psych• MI/SMG

Training

4-day comprehensive didactics for Care Coordination Transition Care, Medication Reconciliation, CHF, DM,

Pediatric Asthma, COPD, Psych, Motivational Interviewing, Self Management Goal Setting

Supervision Case Reviews via videoconference EHR Templates

Structured Intakes/Follow up Nursing Informatics/Outcome Measures Dashboards (Population Management)

Community Engagement Open House Data Sharing

RN Complex Care Management

Reason for Complex Care Management

Consider Possible Data Sources

Customizing the Sort

Additional Actionable Data

29

Complex Care Management Scorecard

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Complex Care Management Scorecard

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Planned Care Delegated Ordering Panel Management Scanning/Faxing/handling of incoming faxes Retinal Camera Operation QI/Microsystem Participants

Role of the Medical Assistant

Planned Care Dashboard

33

11/1/2014

36.5%

2/1/2015

41.5%

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PCD—Birth Cohort HCV Screening

Added to the PCD

Baseline Screening

Rates

Final Data Collection Completed

New Screening

Rate

As initiatives/responsibilities are added, redefining ratios

Refining workflows with EHR limitations

Recruiting RNs with ambulatory care experience

Training to our model of care

Working toward full MA certification

Challenges

Additional standing orders

Improve data driven performance appraisals for MA/RN teams

Improve structured data entry for team members (Informatics) to better document the impact of various care team members

Increasing the use of automated workflows

Continue to enhance front-line involvement and leading in initiatives

Future Directions

Contact Information

National Advisory Council on Nurse Education and Practice

Mary Blankson, DNP, APRN, FNP-C Chief Nursing Officer(860) 852-0851 office(860) 227-5432 cell

Mary@chc1.com