49

Shadowing Vulnerable Patients’

Encounters with Health Care

Background

On Tuesday, following the morning interviews, we will assemble at the OU Family

Medicine Center where we will participate in the patient care provided to patients with

substantial medical and social vulnerability. We will see how the community outreach

programs of the OU School of Community Medicine provide care to patients without

health insurance and how this experience teaches teamwork and systems-based practice

to medical, physician assistant, nursing, social work, and pharmacy students.

Summer Institute students will shadow patients through their medical encounters. They

will experience health care form the patient’s not the physician’s perspective. Each

student will map the patient experience as a way to shape a vision of current health care

and what is needed for a better future to emerge through us.

On Tuesday evening, half of the medical students will experience triage as if they were

patients seeking care from the Bedlam Free Clinic. They will then shadow third and

fourth year medical students in providing care for actual patients who are seeking care.

On Thursday evening, the other half of the medical students will have a similar

experience.

You will have many opportunities to learn the diagnosis and treatment of medical

conditions. During the Summer Institute, it is important for students to put themselves in

the patient’s shoes, understand their perspective, condition and needs.

Patient-Centered Medical Home

The attached essay describes the elements of the patient centered medical home. This is a

microsystem of medical care that provides first-contact, comprehensive, coordinated, and

continuing care for patients of a particular age group or for families. The goal of the

School of Community Medicine is to provide students with an opportunity to learn how

to provide care in a medical home and to understand the important role of attention to the

systems-based practice, regardless of which specialty the student ultimately pursues.

You are encouraged to read this essay and to use the analysis form during your visit to

get an idea of how the practice-based systems actually work. You will identify many

holes in the current system that will provide you with ideas of how you can contribute to

improving the care delivered.

50

Mapping Patient Experience with Health Care

You will experience the Bedlam clinics from both the patient and the medical student

perspective. When you arrive at the Bedlam Longitudinal clinic, you will have a brief

introduction to the system-based approach to care. You will experience the ―round-up‖

with a team.

You will then meet a patient in the lobby and introduce yourself, asking the patient

permission to follow them through their visit. You should engage in a dialogue with the

patient about their life situation and their expectations and needs for medical care. It will

be important for you to understand the barriers that the patient may have faced in getting

to the clinic for this appointment.

You will have time to spend with the patient and the family while the team is doing its

work. You may take notes for your journal during this visit. You may be interested in

noting the wait times for the patient and talk with the team about these so that we might

understand what this waiting is like for the patient.

You might be interested in drawing a map of the patient experience indicating the stops

that the patient must make during the visit and the time intervals between the stops.

Indicate on the map the various persons that the patient encountered, what they did, and

something about their attitude of helpfulness and clarity of information they gave to the

patient.

51

APPENDIX

Patient Centered Medical Home

Elements of a Practice Microsystem

An Introduction to Systems-Based Practice

This essay describes the structure of the Patient Centered Medical Home. It was written

to provide a background for novice health care professionals who are learning about the

structure of the systems and Microsystems that provide medical care. It is a doorway to

understanding how healthcare depends upon competent staff and clinicians working

within a well-organized front line systems designed to provide high quality care.

In 2002 the American College of Physicians, the American Academy of Family Practice,

the American Academy of Pediatrics, and the American Osteopathic Association jointly

defined the functional qualities of a patient-centered medical home. This model provides

novice health care professional students a map for finding their way through the complex

sites of care as they begin gaining competence in systems-based practice.

The model described in this paper merges a train of concepts into a unified picture of the

systems that result in health care. Figure 1 traces the origin of the model as it was built

upon the prior work of the Institute for Healthcare Improvement (IHI) idealized practice

project (Charles Kilo), the Wagner Chronic Care Model (IHI), the Institute of Medicine’s

Crossing the Quality Chasms paper on the elements of a quality health care system,

Batalden and Nelson’s Dartmouth model of the clinical microsystem, the National

Committee on Quality Assurance (NCQA) standards for recognition of a medical home

through the Physician Practice Connections award , and the American Board of Internal

Medicine’s (ABIM) Practice Improvement module practice system assessment. Like any

model, it is wrong but may be useful.

Several names are used throughout this paper for the practice organization we are

describing. ―Patient-Centered Medical Home‖ is used to describe the front-line

organization of people, site of care, and care processes experienced by the patient. This

is the place and the people the patient will contact first with any health related issues.

―Practice‖ is used more generically to describe this same organization. Probably the most

accurate term for what we are talking about is ―Clinical Microsystem.‖ This is the term

coined by Paul Batalden and Gene Nelson to describe the front line people and processes

that actually deliver care. A patient-centered medical home is a clinical microsystem.

Likewise, an emergency department, hospital inpatient unit, dialysis unit, or x-ray

department are all examples of other clinical Microsystems. A medical practice or a

patient centered medical home may have many Microsystems. A large health care

system is made up of multiple interdependent Microsystems.

52

Figure 1

Improved Outcomes

Informed,Activated

Patient

Productive

Interactions

Prepared,Proactive

Practice Team

Resources and Policies

Community

DeliverySystemDesign

Decision

Support

ClinicalInformation

Systems

Self-Management

Support

Health System

Health Care Organization

Idealized Design of

Clinical Office Practices

Chronic Care Model

ABIM Practice

System Model

Clinical Microsystem

Patients

with needs:

Acute,

Chronic, &

Prevention

care

Access to

Practice

Access to

PracticeDiagnostic

Work-up

Diagnostic

Work-up

Treatment &

Monitoring

Treatment &

Monitoring

Self-Care

Support

Self-Care

Support

Leadership/citizenship - Quality InnovationLeadership/citizenship - Quality Innovation

Clinical Information ManagementClinical Information Management

Teamwork – Care ManagementTeamwork – Care Management

Tests – Consults – Referrals - Rx

Patients

needs met:

Clinical,

Satisfaction,

Economic

Community

IOM Crossing the

Quality Chasm

Clinical Microsystems

Origin of SystemsOrigin of Systems--Based Practice ModelBased Practice Model

From Charles Kilo, MD, September 2006

The Black Box of Systems-Based Practice When we begin to think about health care practice systems they are at best a black box.

Patients with needs enter the black box and come out the other end with their needs meet.

It is easy to see that both the patients and the health care practice system come from the

same community. That means they tend to share other values, transactions, and

environment.

Figure 2

Patient-Centered Medical Home

Patients

with needs:

Acute,

Chronic, &

Prevention

care

Patients

needs met:

Clinical,

Satisfaction,

Economic

Community

Black Box of

Health Care

Practice

Systems

6-7-08 FDD

53

The Clinical Care Process When we look inside the black box, the first process we encounter is the clinical care

process. This process is obvious, but its elements are not simple. From the perspective of

a single doctor’s visit or a single episode of care the process is linear: diagnosis->

treatment-> recovery-> and follow-up. In a medical home, which provides continuous

health care for prevention, acute limited illnesses, and ongoing chronic care, the process

is a repeating cycle as shown in the diagram. Follow-up starts a new cycle of examination

and diagnosis followed by treatment, and so on.

Figure 3

The Clinical Care Process

Patients

with needs:

Acute,

Chronic, &

Prevention

care

Recovery,

Rehab, Pt

Self-Care

Recovery,

Rehab, Pt

Self-Care

Patients

needs met:

Clinical,

Satisfaction,

Economic

Community

Screening &

Diagnostic

Work-up

Screening &

Diagnostic

Work-up

Treatment

Intervention

Treatment

Intervention

Monitor &

Follow-up

Monitor &

Follow-up

6-7-08 FDD

The yellow boxes in Figure 3 describe four stages of the clinical care process: 1)

Screening and Diagnostic Work-Up, 2) Treatment Intervention, 3) Recovery,

Rehabilitation, Patient Self-Care, and 4) Monitoring and Follow-up. We will describe

each of these processes and the elements which comprise them.

Screening and Diagnostic Work-UP This process includes taking a history of the present illness, past medical history,

medication history, and screening family, personal risk, and social history to identify

present and future risks. It also includes performing a problem and age-appropriate

physical examination, ordering screening tests, and making specific diagnoses in the

context of the patient's comprehensive health care needs. The medical record of this

process includes a history and physical examination, a problem list of health problems,

diagnoses, and risk factors (including psychosocial risks) to be managed, and an

assessment of the patient’s current overall health and prognosis for future health. The

following value added elements to the screening and diagnostic work-up process that

have been identified by Michael Porter in his book Redefining Health Care: Creating

Value-Based Competition on Results:17

17

Porter ME, Teisberg EO. Redefining Health Care: Creating Value-Based Competition on Results. 2006

Harvard Business School Press, Boston, MA.

54

Medical History – Taking a medical history is the core patient care competence

developed my medical and physicians assistant students. The process can be streamlined

by using patient questionnaires, assigning the registration clerk duties to administer

screening questions, and assigning rooming staff responsibility for routinely collecting

specific information.

Screening – Patient questionnaires standardize the screening history during the check-in

process for a medical visit, the registration staff can follow a screening decision

algorithm and alert office staff to take action on performing additional testing for

screening.

Identifying risk factors – An age-appropriate questionnaire combined with a decision

algorithm that can permit registration and rooming or nursing staff to identify risk factors

(e.g. smoking, sedentary lifestyle, medical illiteracy, psychosocial stress, etc.) for each

individual patient and for specific populations of patients using the medical home.

Specifying & organizing tests – Physicians, physicians assistants, and nurse clinicians

learn how to frame clinical problems, develop a differential diagnosis, and specify the

diagnostic tests that will confirm the correct diagnosis and rule out competing

possibilities. Decision support tools such as diagnostic criteria templates serve as useful

reminders to assure standardization of the common work-ups performed in the practice.

Nursing staff can organize the results of the diagnostic work-up and the reports from

consultants that permit the clinician to make the diagnosis and design an appropriate

therapeutic plan.

Interpreting Data (Making a Diagnosis and Prognosis) – Arguably the most important

value added process in the clinical method is making an accurate diagnosis based on the

clinical history, physical examination, and laboratory data. Physicians have the authority

to make a diagnosis and to supervise the diagnostic process of physicians assistants and

other midlevel clinicians. The diagnosis involves selecting the ICD-9 code that best fits

the physician’s interpretation of the information, explaining the illness according to

pathophysiologic theories, and assessing the prognosis of the condition for the patient’s

immediate and long-term health status.

Consulting with Specialists to Determine the Treatment Plan – For many problems,

the clinicians in a medical home will need to consult with medical and surgical specialists

to determine the most effective treatment for the patient’s condition. This process

involves framing the treatment questions for the consultant, making the referral for some

treatments, transferring the needed clinical information, and developing a personal

relationship with the consultant to determine the human and interpersonal factors that

may be important in coordinating the care in a patient-centered manner for each

individual patient.

Developing a Prevention Programs – Most routine risk factor reduction and prevention

programs for otherwise healthy individuals can be standardized and built into the routine

processes of the practice. The routine prevention programs can be initiated by the

55

nursing staff of the practice. For the patients with complex chronic conditions, the

clinicians in the practice must design an individualized prevention program. Patients

who have already suffered loss of health need to prevent further loss in order to retain a

high quality of life. Both the routine and customized prevention programs involve

coordinating community services for providing patient self-care support.

Treatment Intervention

The second clinical care process is treatment intervention. The physician or team

develops a health management plan for the treatment of diagnoses, diagnostic plan for

problems, and counseling or treatment to mitigate health risks. In a medical home, all of

the undiagnosed problems and risks factors are addressed in the treatment plan. The

record of the treatment intervention is a medication list, treatment plan (or orders sheet),

written patient instructions, prescriptions, and order forms for diagnostic tests,

consultations, or referrals. The value-added elements to the treatment Intervention

process are the responsibility of the clinicians in the practice, and include the following:

Ordering & administering drug therapy – The most common and arguably the most

treatment intervention is prescribing a specific medication, does, frequency, number or

volume to be dispensed, and number of refills authorized. An electronic prescription

writer and electronic prescription decision support tools make the process more accurate.

As will be described below, the use of clinical information management will make this

proc is the ordering and prescribing drug therapy.

Performing procedures – Clinicians perform both diagnostic and therapeutic procedures

in the medical practice. These include surgery, biopsy, needle injections and aspirations.

Medical and physicians assistants students learn simple procedures such as passing tubes

per os, drawing venous blood, giving intravenous infusions, administering inhalation

therapy, performing injections and needle aspirations, and suturing simple skin

lacerations. Competence in performing more advanced office or hospital procedures are

learned during residency training or on the job under direct supervision.

Performing counseling therapy – Basic competence in communication and

interpersonal skills includes conducting diagnostic and therapeutic conversations with

patients and their families. Making shared therapeutic decisions in which the patient’s

values are taken into consideration when planning the therapeutic intervention is an

essential value-added skill for this process. Additionally, physicians develop competence

in motivational interviewing to encourage patients to take self-care actions or to pursue

complex or even risky procedures that are likely to help them achieve their health goals.

Counseling also involves developing the therapeutic relationship that permits reduction in

suffering from fear and anxiety, supporting patients during grief, and helping others gain

insight and coping skills in dealing with the health problems they face. These advanced

skills are learned in the context of the specific problems managed during residency

training.

Hospitalization – In a sense, a hospitalization is a complex therapeutic intervention. It is

a form of a health care ―Visit,‖ but it is also a standardized approach to diagnosis and

56

treatment of particular problems that require an organized system of staff and specialist

physicians using specialized technology to treat a problem. Medical students and other

student clinicians learn the hospital systems-based practice during school and during

specialized training. Coordination of admission to the hospital and following

hospitalization are essential elements of the therapeutic intervention process.

Recovery, Rehabilitation, and Patient Self-Care

The third clinical care process is recovery, rehabilitation and patient self-care. This

process is most easily seen to be a discrete form of care following a surgical procedure or

a course of chemotherapy. For patients with chronic illness or ongoing disability, this

process is part of the continuous cycle of clinical care in which self-care becomes an

essential skill. For all patients self-care is an important in changing health habits. The

medical record for this process is additional assessments of patient needs, plans for

intervention and progress notes for patient self-care instruction.

The value-added elements of the Recovery, Rehabilitation and Patient Self-Care process

are frequently given short shrift in medical student and even residency education. The

nursing profession focuses most on this stage of care both in hospital and ambulatory care.

Home health nursing is the profession most intimately focusing care on the rehabilitation

and recovery stage of illness.

Porter identifies some elements of this process and I have added others related to the

activation of patients in self-care, home-health coordination, and community resource

coordination. The physician specialties of Geriatrics and Physical Medicine and

Rehabilitation focus on this process of the clinical care method, but most others do not.

Inpatient recovery – Recovery from a surgical procedure or a serious medical illness is a

complex bio-psycho-social-spiritual process. There is the biological process of wound

and tissue repair, regeneration, and scarring. There is also the psychological

readjustment to pain, bodily dysfunction, and temporary or perhaps permanent disability.

All serious illness disrupts a patient’s social structure creating a period of vulnerability

and lost of role function and social status. All illness, particularly serious illness, calls

into question the meaning of life and the spiritual dimensions of our personhood.

Although these aspects of recovery often occur in the hospital, they continue following

discharge and must be handed-off to the medical home for seamless transfer of the

recovery and adaptation process. Nursing

Inpatient & outpatient rehabilitation – The value-added element of recovery is often

overlooked by the primary care medical home clinicians as well as specialty care

clinicians. It is even undervalued by hospital services. Nursing professionals perform this

process and in particular, cases such as stroke, amputation, or spine care by rehabilitation

specialist physicians. Handoff problems and coordination of care problems are

particularly problematic for the medical home, which may be less involved in this type of

care. It is important for a medical home to keep a registry of patients receiving

rehabilitation care to assure that case management is being provided.

57

Therapy fine-tuning – During the recovery and rehabilitation, process of clinical care

initial therapy must be repeatedly adjusted as the body heals. Doses of medications may

need to be changed or discontinued. Medical education programs are beginning to focus

on the importance of the hand-off of responsibility for this process of care. The

specialists often perform fine-tuning during this phase of care – but failure to coordinate

these changes in the treatment between the medical home and the specialists creates

confusion about who has the responsibility for these changes and communicating the

changes to others involved in the care.

Discharge plan – Following hospitalization or completion of treatment by a specialist the

discharge plan is the instrument for hand-off of responsibilities for care and coordinating

the information needed for the medical home to assume responsibility for care. This is a

complex process involving coordination of nursing, physician, pharmacy, home-health,

patient education, follow-up visit scheduling and transportation. Nursing services have

been assigned responsibility for the execution of the process following the physician’s

order to discharge the patient. What is often missing is the clear communication with the

medical home about the plans for follow-up and instructions for actions to be taken next.

As will be described below, systems for managing this transition must be developed to

assure safety and effectiveness of the transfer. Moreover, the engaging of the patient,

family and community agencies are essential to making sure that the hand-off form

nearly total care in the hospital system to the somewhat chaotic and uncoordinated

ambulatory setting is effective. The more complex the hand off the more important it is

for the medical home to have a complex case manager responsibility for receiving the

hand-off.

Activation and education in self-care – The chronic care model describes the

importance of having a prepared patient to engage in their own care.18

The patient, his or

her family, and possibly other caregivers are involved in the recovery and rehabilitation

process following an acute or serious episode of illness. Whether this involves a

hospitalization or is limited to coordinated ambulatory care for a serious illness, this

function is essential. The value-added element of patient activation and education in self-

care is best performed by medical home nursing and social work staff.

Home-health coordination – The nursing staff of the medical home and the nursing staff

of home health services and community nursing services add value to this process by

coordinating their efforts in accordance with the treatment plan. Unfortunately the home

health agencies have become separated from primary care medical homes; and except in

some cases in geriatrics care or in other special needs care, the coordination of these

services is haphazard, inefficiently, and ineffective.

Community agency service coordination – Most medical homes do not have social

work staff to perform this function. It is particularly important for obtaining reduced rate

18

Reference: Chronic Care Model: Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients

with chronic illness: the chronic care model, II. JAMA. 2002;288:1909-1914.

58

medications, obtaining mental health, legal, and social support services, and finding

financial aid. Although nursing home health services and some experience with this

function, they are usually exceeding the scope of their education. The medical home,

particularly those that serve poor and underserved populations or populations of patients

with chronic conditions can add substantial value to the clinical care process by adding

these social services.

Monitoring and Follow-up The fourth process in clinical care is monitoring and follow-up. It involves teamwork to

review laboratory results, consultation reports, revise the patient’s health assessment,

problem list, and modify the treatment plan and self-care plan. This process can occur in

a follow-up visit if it is important to perform monitoring physical examinations or to have

a face-to-face conversation with the patient. Otherwise, in the medical home much of the

follow-up or inter-visit care can be performed by the health care tem with telephone, e-

mail, and other non-visit engagement with the patient. The medical record of this process

is the monitoring flow sheet, the patient care registry for prevention and chronic illness

care, phone notes, and changes in prescriptions, medication lists, and progress notes.

The value-added elements to the Monitoring and Follow-up process of clinical care is

one of the most important yet poorly recognized functions. I have combined Porter’s

functions of ―Preparing‖ and ―Monitoring‖ into a single function that is conducted by

physicians and the medical home staff. It is in conducting this process of clinical care

that the medical home demonstrates its effectiveness in coordinating care and managing

the multiple resources necessary for high quality care.

Monitoring patient’s health condition – The medical home staff develops a plan for

monitoring the patients’ acute, chronic and preventive conditions. Patient registries make

tracking the schedule for when services are due efficient. Effective monitoring involves

pro-active contacting patients to make certain that they receive follow-up laboratory

testing, physical examinations, and other services recommended for the treatment of their

condition.

Monitoring complications with therapy – Guidelines for therapy usually include the

frequency and type of laboratory or clinical monitoring that should be done to recognize

complications early or to prevent them. Anticoagulation clinics have demonstrated their

effectiveness in preventing complications of therapy and more rapidly achieving desired

levels of anticoagulation. Most practices rely on the patient’s own interest and initiative

to arrange follow-up. Practices that have adopted pro-active monitoring not only

improve their performance measures, but also improve their patient satisfaction with the

service. ,

Monitoring lifestyle modification – Making lifestyle habit modifications is difficult and

regular and frequent monitoring provides the sort of accountability that most patients

need to stick to a change in lifestyle. A preventive care registry used by patient education

and self-care training nursing staff enhances the effectiveness of the medical home.

59

Pro-active preparation & coordination of resources – The medical home employs a

nursing and medical assistant staff that stays in contact with patients, consultants, and

vendor services to assure that the diagnostic and therapeutic plan is executed. The staff

pro-actively stays in contact with hospitalized patients and their caregivers and is

prepared to receive the hand-off upon discharge. Additionally, a patient-centered medical

home staff prepares for a patient visit to assure that services recommended by guidelines

are provided and that the results of tests and consultations are available for review with

the patient during the visit. Such pro-active planning requires tracking and monitoring

systems, case management for complex patients, and dividing the roles and

responsibilities so that anticipated patient care needs can be met in a timely manner.

Network of Service Vendors and Consultants The next process in the integrated system of health care is the connection between the

black box of the Medical Home and a network of Clinical Service Vendors and

Consultants needed to provide myriad medical, psychiatric, and social service patient

needs. These services include laboratory-testing, consultations, referrals, admissions to

hospitals or emergency departments, and medications dispensed by pharmacies. In the

diagram, this network of usually independent service providers is shown in the blue oval

at the bottom and outside the box of the medical home but within the community. One

of the most important functions of a patient-centered medical home is the building,

coordination, and management of this service network. Coordination is facilitated by

personal human interactions and contracted agreements, as well as effective information

tools for timely and accurate transfer of necessary information.

Figure 4

Clinical Service Vendors & Consultants

Patients

with needs:

Acute,

Chronic, &

Prevention

care

Recovery,

Rehab, Pt

Self-Care

Recovery,

Rehab, Pt

Self-Care

Patients

needs met:

Clinical,

Satisfaction,

Economic

Community

Screening &

Diagnostic

Work-up

Screening &

Diagnostic

Work-up

Treatment

Intervention

Treatment

Intervention

Monitor &

Follow-up

Monitor &

Follow-up

Tests – Consults – Referrals - Admits - Rx

60

The following elements shape and maintain the clinical service vendor and consultant

network. This list was developed at the ABIM Foundation’s Stepping Up to the Plate

conference held in Washington, DC, March 2007.19

Lab & Imaging Test Ordering & Tracking - Medical homes establish vendor contracts

with laboratory and imaging services. Within these contracts are the agreements for how

the order for the tests will be communicated to the vendor, who will draw blood and

transport it, and how the reports will be returned to the medical home. Electronic

transmission of the order to the laboratory and of the report to the medical home with a

computer application that tracks that status of the request permits careful monitoring of

the service according to the agreement.

Service Agreements and Referral Contracts – Agreements between medical homes

and specialty consultants have been introduced into the VA system, other integrated

health care systems, and some practicing communities. In these the primary care

physicians and the specialist physicians develop compact specifying expectations in

referral for services. The compact includes the aim for ―respecting‖ the coordinator of

the care which should be the primary care physician. It includes clear lines of

responsibility and accountability for the care of the patient and the expectation that all

members of the team will be informed of the actions of others. The compact is based on

the idea that each patient has an integrated management plan.

Integrated Treatment Plan, Fax-Back Reports, and Referral Database – The medical

home develops an integrated treatment plan for patients who are being co-managed with

specialist physicians. The practice sets up a system for receiving reports from the

specialist consults either in the form of fax-back reports or other electronically

transmitted information. Lastly the medical home keeps a referral database tracking the

service and quality performance of the consultants and referral specialists so that the

network may be refined and feedback may be provided to the network participants to

improve the services. Currently this practice is more theoretical than used in practice.

The Doc2Doc referral system being studied in the School of Community Medicine is an

early example of this process.

Referral & Consultation Request and Tracking - Medical Homes need a process for

standardizing the referral and consultation requesting process and tracking the progress of

the request until it is completed. The American Academy of Family Practice has

developed the Chronic Care Record (CCR) which is an HL-7 technology for transmitting

the core data needed for coordination of care between a consultant and a medical home.

Except in integrated health care systems this capability is not often available. The OU

School of Community Medicine is currently working on ways to implement this process

within its clinical services.

Nurse Care Management, Discharge Summary Fax Backs, & Medication

Reconciliation – Medical homes assign a nurse care manager to receive the hand-off

from hospitalization to the medical home. In addition to identifying the personnel to

19

http://www.abimfoundation.org/quality/suttp.shtm accessed July 5, 2008.

61

receive the handoff, the practice must establish a process for receiving discharge

summaries by fax and conduct a post-hospitalization medication reconciliation with the

pre-hospitalization medical home medications. This coordination of care activities

clarifies the delegation of responsibility for follow-up and continuing care.

Prescription Management Process – The medical home establishes vendor

relationships with pharmacies that will fill patient prescriptions. Faxing or e-transmitting

prescriptions directly to the pharmacy are highly desirable. Protocols for nursing staff to

authorize chronic medications can be instituted. Decision support for checking

medications for errors and identifying drug-drug interactions are also important safety

checks. (Revised April 25, 2007)

Practice Microsystem Support Processes Returning to the inside of the clinical care microsystem of the patient-centered medical

home, we will explore five practice processes that make up the microsystem of the

medical home. The first of these is the process for access and arranging care from the

medical home.

Access & Arranging Care Medical practices have a filtering process that assures that the practice is equipped to

provide the services patient’s need. One of the characteristics of a medical home is that it

provides the initial assessment and triage service for undifferentiated patient problems

within the population served.

Figure 5

Access & Arranging Care

Patients

with needs:

Acute,

Chronic, &

Prevention

care

Recovery,

Rehab, Pt

Self-Care

Recovery,

Rehab, Pt

Self-Care

Patients

needs met:

Clinical,

Satisfaction,

Economic

Community

Screening &

Diagnostic

Work-up

Screening &

Diagnostic

Work-up

Treatment

Intervention

Treatment

Intervention

Monitor &

Follow-up

Monitor &

Follow-up

Tests – Consults – Referrals - Admits - Rx

Access & Arranging CareAccess & Arranging Care

The value-added elements of the access & arranging support process include methods for

patients to contact the practice, scheduling patients with particular providers and

scheduling visits with consultants and other clinical services.

62

Assignment to Primary Provider or Team – The medical home has a standardized

process that registration staff follows to make certain that every patient in the medical

home is assigned to a primary clinician and/or practice team. The practice establishes

policies and procedures for transferring patients to other primary providers, and has a

system for back up when the primary provider is unavailable. The practice has written

policies for provider assignment and uses measures to determine the degree of

compliance with its policies.

Routine- & After-hours Contact for Information – The medical home establishes

policies and processes to permit patients 24/7 telephone (or e-mail) access to a nurse or

clinician in the practice who has access to the patient’s medical record, integrated

treatment plan, and can answer medical questions or process questions about obtaining

services. The medical home has an agreement for the coordination of urgent visits within

24 hours for its patients. It also has an agreement with an emergency department for

coordination of emergency care for its patients and for the follow-up of that care in the

medical home. The medical home has policies guiding these processes and measures of

the effectiveness of the processes in adhering to the policies.

Scheduling Contact with the Primary Provider – Medical Home practices make every

effort to connect patients with their primary clinician or primary team. The practice

measures its compliance with its policies for continuity of care and reports its

performance in adhering to the policies while also providing urgent (24-hour) visit

availability to patients when needed. When someone other than the patient’s primary

clinician conducts a patient visit, the medical home has a process for assuring that the

primary clinician is informed of the actions taken in the visit conducted for him or her.

Coordinating Contact with Other Providers – Medical Home practices arrange the

visits with other primary providers in the absence of the patient’s assigned clinician.

They also arrange the visits with specialists and consultants. A patient case manager is

assigned to the coordination of multiple visits for high utilization patients.

Patient Education and Self-Care Support The second support process, shown in figure 6, is the organization of the staff and

resources to provide Patient Education and Self-Care Support. Medical and physicians

assistant students learn to perform some of this function in providing patient self-care

instruction, but most of the value-added elements of this process are provided by practice

nursing and social work staff.20

20

Pare G, Jaana M, Sicotte C. Systematic Review of Home Telemonitoring for Chronic Diseases: The Evidence Base.

Journal of the American Medical Informatics Association Volume 14 Number 3 May / June 2007.

63

Figure 7

Patient Education – Self-Care Support

Patients

with needs:

Acute,

Chronic, &

Prevention

care

Recovery,

Rehab, Pt

Self-Care

Recovery,

Rehab, Pt

Self-Care

Patients

needs met:

Clinical,

Satisfaction,

Economic

Community

Screening &

Diagnostic

Work-up

Screening &

Diagnostic

Work-up

Treatment

Intervention

Treatment

Intervention

Monitor &

Follow-up

Monitor &

Follow-up

Tests – Consults – Referrals - Admits - Rx

Access & Arranging CareAccess & Arranging Care

Patient Education - Self-Care SupportPatient Education - Self-Care Support

The nursing and social work professional staff of the medical home have the greatest

expertise in developing and executing this process. In the OU School of Community

Medicine novice professional students learn the value of teamwork in providing the

patient-self care needed for managing complex chronic illness.

New Patient Information about Medical Home Procedure – Practices provide written

and/or web-based information about the procedures, services, and processes for accessing

the staff and clinicians in the medical home. Some of this information may be tied to a

patient portal that gives patients access to their medical records as well as access to the

scheduling system for making their own appointments. The information is provided to

patients in a language and literacy level that is appropriate for the majority of the

population. The administration and nursing staff of the practice usually take primary

responsibility for developing these materials.

Identify special communication needs (language, etc.) – The medical home uses a

screening tool for identifying communication needs of its patients. It identifies the

patient’s primary language and their language of choice. It identifies difficulties with

literacy, vision, and hearing. This information is clearly identified on the medical record.

The practice has procedures and processes in place for responding to the communication

needs of patients. This includes making translation services available.

Patient Self-Care Needs Assessment – The nursing and social work staff of the medical

home identifies the patient education needs, resources, and social support that will add to

the improvement in health status. The needs assessment is translated into a self-care plan

that is incorporated into the integrated treatment plan. Patients with chronic illnesses and

those who can benefit from reducing health risks receive one-on-one or group patient

education support.

Patient Education Materials at Appropriate Language Level – The medical home

provides written, web-based, or other formats for patient education. These are written in

the patient-appropriate language at a sufficiently low literacy level to meet the practice

population’s needs. The practice has an educational resource storage and replacement

64

process. The nursing staff of the practice manages the patient education resources in the

practice.

Patient Self-Monitoring Training and Use of Logs for Reporting – A medical home

teaches to perform self-monitoring of their progress in making lifestyle changes to

improve health and to monitor blood sugars in diabetes and blood pressure in

hypertension and congestive heart failure. Patient with asthma monitor their peak flows

and patients with arthritis and pain syndromes may keep logs of their pain and response

to treatment. Staff instructs patients in the proper monitoring technique and how to keep

the records of the results in logs or graphs. Technologically advanced practices provide

patients with monitoring and reporting tools that transmit data electronically to the

medical home.

Referral to Community education & support programs for self-care – The nursing

and social work staff accumulate the community education and support programs for

patient self-care support. Mental health groups, groups focused on learning coping skills,

disease peer support groups, web discussion groups, and behavioral therapy groups

augment the patient education provided in the medical home. Community-based care

management programs and case management can be very helpful. Medical Home

practices participate in the community services that support patient self-care.

Teamwork and Proactive Care Management At the heart of the patient-centered medical home is the interdisciplinary teamwork. The

model highlights the importance of a team of talented professionals each bringing their

expertise to the care, rather than a staff that assists the clinicians in their work. Everyone

functions at the top of their license.

Figure 8

Teamwork – Proactive Care Management

Patients

with needs:

Acute,

Chronic, &

Prevention

care

Recovery,

Rehab, Pt

Self-Care

Recovery,

Rehab, Pt

Self-Care

Patients

needs met:

Clinical,

Satisfaction,

Economic

Community

Screening &

Diagnostic

Work-up

Screening &

Diagnostic

Work-up

Treatment

Intervention

Treatment

Intervention

Monitor &

Follow-up

Monitor &

Follow-up

Tests – Consults – Referrals - Admits - Rx

Access & Arranging CareAccess & Arranging Care

Patient Education - Self-Care SupportPatient Education - Self-Care Support

Teamwork – Proactive Care ManagementTeamwork – Proactive Care Management

65

Pro-active care management is best performed by nursing and social work staff whose

professional education prepares them for coordination of services and integrating health

care plans into the patient’s daily life. The pro-active care management provides

anticipatory continuing care to patients with chronic conditions and provides preventive

services for screening and behavior change. Usually the care manager is a nurse or nurse

practitioner who is responsible for a number of patients with a common chronic illness or

for patients who are high utilizes of health care services, such as those with heart failure

or multiple chronic conditions. The value-added elements of the Teamwork and Proactive

Care Management process include:

Use Pro-Active Patient Contact and Follow-Up – Instead of relying on patient initiated

visits for care, the medical home’s care management team uses a care management

registry to plan contacts with patients to determine their progress and initiate the next

visit. They call the patient after the visit checking on how they are doing. They

coordinate community outreach, sending patient reminders for services that are due, and

coordinating the various components of the overall management plan. The Care

Management may be done within the office or may be delegated to services outside.

Regardless of the method used for delivering the services, the comprehensive care system

coordinates the services. It was not until the health plans organized external care or case

management organizations of services that this function became a structured entity. It

had formerly been a component of the basic clinical method for patients with chronic

disease. It was the failure of many practices to provide this service effectively and their

absence of the necessary data and information management infrastructure that led to data

rich health plans to organize nurse-hired and directed case management services. These

can be returned to the office system with the addition of advanced information

management and delegation of roles and responsibilities among the staff.

Use Standardized Health Assessment Questionnaire, History & PE form – The

medical home designs a standardized health assessment questionnaire and standardized

templates for history and physical examination. The staff team can participates in the

completion of the standardized health assessment by filling in cells of the templates.

Patients can complete a pre-visit questionnaire to provide screening health information.

Use Problem and Risk Factor List – The clinicians in the medical home generate a

comprehensive problem and risk factor list which contains diagnoses, undiagnosed

problems, and risks for future illness. The problem list is updated periodically and serves

as an index to the patient’s medical record.

Use Medication & Allergy List – A medication list and an allergy list are generated and

updated at nearly every visit. Reconciliation of the medication list should occur

following any hospitalization or consultation.

Use Integrated Care Management Plan – The clinicians, nursing staff and social work

staff operate from the same integrated care management plan. This plan indicates the

goals for therapy, the medications and other treatments, social services, patient education

and self-care support, patient home monitoring, and follow-up testing and intervals. The

66

integrated care management plan is a ―play book‖ guiding everyone’s participation in the

patient’s care.

Use Care Management Flow Sheets (Patient Registry) – Within the patient’s

individual medical record flow sheets contains the symptoms, physical examination

findings, and laboratory tests that are used to monitor the progress of the treatment and

recovery. At each visit the data is recorded in the flow sheet so that progress may be

tracked over time, trends detected, and variations from the expected easily visualized. A

patient registry electronically tracks measures of services due for preventive care and for

chronic illness care and permits notification of patients. The registry also provides

guidance for planning a visit. Finally the registry can calculate quality measures for

certain diseases and preventive services.

Clinical Information Management The fourth support process is Clinical Information Management which includes the

methods and technology to document clinical care and transmit information in a feed-

forward and feed-back way to all elements of the medical home and to the network of

vendor and consultant services. Information management enables coordination of care

through sharing and timely transfer of information.

Figure 9

Clinical Information Management

Patients

with needs:

Acute,

Chronic, &

Prevention

care

Recovery,

Rehab, Pt

Self-Care

Recovery,

Rehab, Pt

Self-Care

Patients

needs met:

Clinical,

Satisfaction,

Economic

Community

Screening &

Diagnostic

Work-up

Screening &

Diagnostic

Work-up

Treatment

Intervention

Treatment

Intervention

Monitor &

Follow-up

Monitor &

Follow-up

Tests – Consults – Referrals - Admits - Rx

Access & Arranging CareAccess & Arranging Care

Patient Education - Self-Care SupportPatient Education - Self-Care Support

Teamwork – Proactive Care ManagementTeamwork – Proactive Care Management

Clinical Information ManagementClinical Information Management

The value-added elements of the Clinical Information Management process are show

in the general order in which they are adopted by practices. As vendors release integrated

systems, the order of adoption may change.

Novice healthcare professional students learn how to use these information management

tools and their processes during clinical rotations. Each microsystem in the overall health

care systems modifies information management processes to meet their individual needs.

On of the challenges over the next decade will be the standardization and integration of

67

clinical information management processes. A new medical specialty of Medical

Informatics has emerged to tackle this problem.

Practice management system – an electronic system which tracks patient registration

demographics, billing information, ICD-9 and CPT codes used for submitting insurance

claims and bills has been adopted by nearly every practice. The more sophisticated

practice management systems generate financial reports for planning and projecting

revenues. Some systems also track office purchases, expenses, personnel records, payroll,

and other business operations of the practice.

Patient Visit Scheduling – the first addition to most practice management systems is

usually a visit scheduling program which permits scheduling multiple clinicians in the

practice with varying lengths of appointment times for patients.

Phone Message Management Systems – include automated answering, routing

algorithms, and voice mail. More advanced systems track efficiency of calls. Some

sophisticated systems provide call logs and branching call-triage systems. As of 2008,

most practices use a paper record of telephone messages, and rely on pagers, cell-phones,

and answering services for after hours calls.

Medical Record & Document file, fax and scan system – Paper medical records are

kept in a record file system. The individual patient record holds all of the clinical

documents about the patient’s care. The greatest advantage of the electronic medical

record is reducing the physical space and time required for filing and locating missing

records and handing the stacks of paper that must be filed into the record. Unfortunately,

until all reports are received electronically, it will be necessary to track and scan into the

EMR a large number of documents that are still mailed and faxed to offices.

Consult and Referral Tracking Process– Medical homes track the status of the consults

and referrals to other physicians. In most practices the tracking is performed manually by

nurses who keep a paper record or tickler file of important pending consultations that

may require a call to the consultant to follow-up when an expected call or report has not

been received in a timely manner. Safety-net health care systems have a particularly

difficult time tracking consultation because the network of referring physicians and

consultants has not been established.

Test Tracking Process – Almost all practices order a large number of laboratory tests for

diagnosis and follow-up monitoring of treatment. As test ordering and reporting systems

become automated, the tracking becomes less important. In patient-centered medical

homes the practices critical laboratory testing reports to assure that they have been

completed, and the results have been reported back to the patient.

Image Tracking System – As x-rays, scans, ultrasounds, ECG’s and other imaging

examinations become digitized they can be transmitted, retrieved, and stored

electronically. Patient-Centered Medical Homes use a process for tracking the critical

68

imaging requests. The most sophisticated integrated systems permit the clinician to

access the actual image electronically.

Care Management Registry – As stated above, the single most important tool for

providing pro-active care management for a Patient-Centered Medical Home is the care

management registry. This is a paper or electronic tool that keeps a record of all of the

patients with a particular chronic condition or a particular risk category for prevention

services. There are three types of care management registries: high risk patient registry

(these are the patients who have frequent hospital admissions or ER visits and whose care

can benefit from aggressive care management); prevention registry (this is particularly

useful for assuring that the well-child screening and adult preventive services are

provided to patients according to a specified schedule); and a chronic care registry (for

patients with chronic conditions, e.g. diabetes, asthma, CKD, etc. who require close

follow-up monitoring for quality care). Registries perform three functions: 1) visit

planning – providing a list of the services that a patient is due to receive at a particular

visit, 2) patient reminder lists of services for which the patient should be notified to make

an appointment to receive, and 3) the next element – providing quality measure reports of

practice performance.

Reports for Clinical and Financial Practice Improvement – Improvement in the

efficiency and effectiveness of the practice requires receiving performance measurement

reports. The care management registry and practice management system can feed data

into a process that calculates performance measures and provides the leadership of the

practice with a management dashboard of quality metrics. The calculation of quality and

financially performance measures does not happen automatically, and even when

integrated electronic records deliver these reports, the practice must build a Quality

Improvement process into the practice. That Patient Centered Medical Home process

will be discussed in the next section.

Electronic Health Record – Coded Clinical Data – We have not discussed the

electronic medical record (EMR) or electronic health record (HER) before now, because

many electronic medical records are simple word processors which permit the

documentation of large volumes of text data and eliminate the need for paper storage

cabinets. The real strength in the EHR is the collection of clinical data in coded,

electronically retrievable form. Data must be recorded as codes in templates rather than

as text. Moreover, these templates must use standardized codes so that the data can be

transmitted to other clinicians’ EHRs and may be used to calculate the measures and

actions needed for the care management registry and even the practice management

system.

Patient Portal – As more patients use the internet for communication, they also wish to

communicate with their medical home through e-mail. A patient portal permits two-way

communication between the patient and the staff or clinician in the medical home. Some

practices provide electronic visits through the patient portal (DocVia and RelayHealth).

Some portals permit patients to select appointment times on the internet; others collect

69

registration and even clinical data through the portal. Some patient portals provide nurse

consultations, patient education, and prescription refill services.

E-Prescription Management – Probably the most timesaving information management

process is an electronic prescription management system, which include prescription

writer that is tied to drug prescribing information databases with or without clinical

decision support tools. The most efficient models are actually tied to the patients’

demographic and clinical data so that specific decision support may be provided for drug

interactions and potential adverse events. When the prescription management system is

tied to the patient’s health plan formulary specific medications can be selected at the time

of prescription and when these formularies change, the changes can be automatically

updated in the patient’s care process. In addition to having a printed prescription at the

time of the visit, some prescription management systems are connected to the patient’s

pharmacy and the transmission of the prescription information is completely automated

electronically.

Leadership/citizenship in Quality Innovation The fifth support process in the Medical Home is shown as the gold box in Figure 10. It

is labeled Leadership/citizenship in Quality Innovation. This process guides and changes

the clinical care process in response to measured patient needs, innovations in medical

science and practice, and measures of practice performance. The leadership in quality

improvement process is the ―brain‖ of the patient-centered medical home that scans the

environment for innovations and learns new knowledge about its own processes through

measurement of performance in practice and determining the effect on the practice of

making rapid-cycle tests of change.

Figure 10

Leadership/Citizenship – Quality Innovation

Patients

with needs:

Acute,

Chronic, &

Prevention

care

Recovery,

Rehab, Pt

Self-Care

Recovery,

Rehab, Pt

Self-Care

Patients

needs met:

Clinical,

Satisfaction,

Economic

Community

Screening &

Diagnostic

Work-up

Screening &

Diagnostic

Work-up

Treatment

Intervention

Treatment

Intervention

Monitor &

Follow-up

Monitor &

Follow-up

Tests – Consults – Referrals - Admits - Rx

Access & Arranging CareAccess & Arranging Care

Patient Education - Self-Care SupportPatient Education - Self-Care Support

Teamwork – Proactive Care ManagementTeamwork – Proactive Care Management

Clinical Information ManagementClinical Information Management

Leadership/citizenship - Quality InnovationLeadership/citizenship - Quality Innovation

This process is labeled ―Leadership & citizenship in Quality Innovation‖ because it

involves leadership in setting the tone and aims for agenda of quality in the practice; it

70

also involves citizenship of every staff and clinician member of the medical home in

doing their part to value and embrace continuous improvement of the quality of care

provided in the practice. Such citizenship requires both knowledge and instrumental skills

in using measurement data, testing change ideas in rapid-cycle tests of change, and

selecting those proved to be improvements for implementation across the medical home.

The name Quality Innovation was inspired by the concept of permanent innovation.21

This concept of innovation includes not only improvement, but also life-long learning,

creativity, and remaining economic viable to one’s clients or customers. What is most

important here is that both leadership and citizenship in quality innovation are essential

elements of a clinical microsystem. The value-added element s of the

Leadership/citizenship in Quality Innovation process includes:

Identified Clinical Quality and Resource Management Roles – High quality medical

practices identify persons with specific roles and responsibilities for the clinical quality

and resource management of the practice. Although everyone one the team has specified

roles and responsibilities for teamwork, one person is identified with the role and

responsibility for the overall performance of the team. This person helps the team set the

aims for quality and safety, motivates the team, counsels and support team activity and

facilities the resolution of conflicts within the team. Likewise the well functioning team

has an identified person with the role and responsibility for assuring that the resources

needed by the team, including the personnel, are available for the team to do its work.

The resource leader also has responsibility for assuring the financial viability of the

practice.

Quality Aim & Objectives for a Culture of Safety – The aim of the patient-centered

medical home is to improve the quality of care as defined by the Institute of Medicine’s

construct for a quality system: patient-centeredness, efficiency, effectiveness, equity,

timeliness and safety.22

One of the leadership responsibilities is to set the theme for

improvement in the medical home. The specific aim that the practice is tackling will

change from time to time. As one aim is achieved and maintained another is tackled.

This continuous cycle of improvement energizes the practice and joy to the clinicians and

staff. Another task of the leader is to build a culture of safety in which mistakes and

errors are seen as opportunities to explore the root cause and to build a fail-safe system.

Such a culture looks for system failures rather than blaming the last person who touched

a process before it failed.

Quality Measure Dashboard & Control Charts – The quality improvement process

relies on measures of the microsystem’s performance. These measure can be the

reliability of the care processes (e.g. the percentage of hyperlimidemic patients who have

had an LDL cholesterol measured within the past year). Or they may be outcome

measures (e.g. the percentage of patients with diabetes who have an A1c less than 7.0%).

21

Morris L. Permanent Innovation: The Definitive Guide to the Principles, Strategies and Methods of

Successful Innovators. 2006. http://www.permanentinnovation.com/downloads.html accesses July 5, 2008. 22

Institute of Medicine: Crossing the Quality Chasm. 2002 National Academy of Sciences Press,

Washington, DC.

71

Measures of practice timeliness (e.g. availability of the third next new patient visit) or

patient-centeredness (e.g. time to return patient phone calls) are also necessary. Once the

practice has determined the spectrum of measures it will track, these should be displayed

in a prominent place in the practice as a dashboard of microsystem performance. This

dashboard stimulates everyone to take the actions within their license to improve

performance.

Rapid-cycle Tests of Change Improvement & Innovation teams – Change won’t

happen only through the good intentions of the staff, practice processes will need to be

engineered and re-engineered to accomplish the aims of the practice. Novice health

professional students will learn how to apply the quality Improvement methods of rapid-

cycle tests of change in learning how to improve the system of care. This disciplined

approach makes certain that good ideas are tested in small steps and shown to be

improvements. The opposite approach of imposing a good idea without testing more

often than not disrupts other aspects of the system or doesn’t work as intended. Making

changes without testing them first threatens safety, creates chaos and staff stress and

dissatisfaction.

Spread of Innovation – Once the team has demonstrated that the rapid-cycle test of

change has resulted in an improvement, the team sets out to engage all of the other

members of the practice in learning how to adopt the process change into their practice.

This spread of the innovation is not simple. It takes time, education to help other

understand the basis for the change and how to adopt the habits and skills needed to

implement it. Change is difficult and teams often underestimate the resistance and even

sabotage that will occur when spreading innovations. Here is the role for leadership and

citizenship in helping everyone strive for the common aim of improved health care.

Financial Plan for Practice Viability – Although this is the last element described, it is

essential to staying in practice. Each microsystem must have a business or administrative

manager who looks after the financial and organizational health of the practice. Keeping

up with insurance and government regulations, accurately filing charges, tracking

supplies and getting the best price from vendors, and maintaining effective personnel

policies are all essential to maintaining the financial health and viability of the practice.

These are important aspects of the leadership role. The quality measure of efficiency

involves providing the highest quality of care while using the fewest resources to do so.

Measures of efficiency require the merging of quality and financial data.

72

Putting It All Together

Figure 11 is the complete model of the integrated practice unit which Batalden and

Nelson call a clinical microsystem. The NCQA Physician Practice Connections standards

are being used by the Center for Medicare and Medicaid Serves (CMS) to identify those

practices that are providing a patient-centered medical home. In the OU Tulsa School of

Community Medicine, we are using the model to help novice health care professional

students understand the curriculum in systems-based practice and to participate in the

continuing evolution and improvement of the Community Medicine clinical services.

Figure 11

Integrated Practice Unit

Patients

with needs:

Acute,

Chronic, &

Prevention

care

Recovery,

Rehab, Pt

Self-Care

Recovery,

Rehab, Pt

Self-Care

Patients

needs met:

Clinical,

Satisfaction,

Economic

Community

Screening &

Diagnostic

Work-up

Screening &

Diagnostic

Work-up

Treatment

Intervention

Treatment

Intervention

Monitor &

Follow-up

Monitor &

Follow-up

Tests – Consults – Referrals - Admits - Rx

Access & Arranging CareAccess & Arranging Care

Patient Education - Self-Care SupportPatient Education - Self-Care Support

Teamwork – Proactive Care ManagementTeamwork – Proactive Care Management

Clinical Information ManagementClinical Information Management

Leadership/citizenship - Quality InnovationLeadership/citizenship - Quality Innovation

6-6-08 FDD revision

During the Summer Institute, novice students will visit the Bedlam Longitudinal clinic

and the Bedlam Acute clinics. There they will compare this model with their experience.

They will be able to see many holes in the current system as compared with this idealized

model. Over the course of their medical education these students will have ample

opportunity to participate in the continuous improvement of the processes of care to

achieve greater quality and safety for our patients and greater satisfaction for the health

care professionals who work in these environments.

Summer Institute Students can use the attached table to identify the elements of the

clinical Microsystems they will visit (Bedlam Longitudinal – a medical home) and

Bedlam Evening Acute – a free clinic. By comparing the systems and the processes they

observe in these two different clinics, they may begin to appreciate the systems-based

practice competency needed by physicians. This will provide a 30,000 foot view of a

clinical operation as the students prepare to learn the theories and concepts that underlie

the core clinical skills of patient examination, diagnosis and treatment.

73

Analysis of a Medical Home

Systems-Based Practice in a Clinical Microsystem

Directions: As you shadow patients and medical students through the Bedlam Longitudinal and Bedlam

Acute Evening Clinics, use the following table to tabulate the processes that you observe. Place a check

beside each element of the clinical microsystem. ―+‖ = the element was present and seems to be

working well, ―-― = the element was absent or not observed to be working. ―?‖ means that you are

unsure whether the element was present or being used effectively. You may wish to make comments

about the process that were personally meaningful to you.

Student: Clinic: Date:

# Medical Home Process + - ? Comment Clinical Care Process

Does the medical home…

1 Identifies health care needs of community

2 Demonstrates that care needs have been met

3 Interacts actively with the community

Diagnostic (screening) work-up Did the team perform…

4 Medical History

5 Screening History - laboratory

6 Identifying risk factors

7 Specifying & Organizing tests

8 Interpreting data (making diagnosis

9 Consultation with specialists

10 Develop a prevention program

Treatment intervention Did the team…

11 Order (prescribe) drug therapy

12 Perform procedures

13 Perform counseling therapy

14 Hospitalize or refer to ER

Recovery, Rehabilitation, Self-Care Did the team…

15 Fine tune therapy in progress

16 Give patient self-care education

17 Coordinate home-health care

18 Coordinate community services

Follow-up monitoring

74

# Medical Home Process + - ? Comment Did the team…

19 Monitor patient’s health condition

20 Monitor complications of therapy

21 Monitor lifestyle modification

22 Pro-actively prepare for the visit and

coordinate follow-up care

Service Vendor & Consultant

Network Does the practice have…

23 Laboratory & Imaging providers

24 Service agreements/referral contracts with

consultants

25 Integrated treatment plan used by consultants

26 Referral/Consultation request tracking

27 Discharge summary, med reconciliation

process

28 Prescription management process in practice

Access & Arranging Care Does the practice…

29 Assign patient to a primary provider

30 Available for telephone contact 24/7

31 Schedule visits with primary provider as

much as possible

32 Coordinating contact with other providers for

the patient

Patient Education and Self-Care

Support Does the practice…

33 Provide new patients with information about

how the medical home works

34 Identify special communication needs such as

language of choice

35 Perform a patient self-care needs assessment

36 Provide written education materials in

appropriate language at all literacy levels

37 Provide home monitoring and reporting logs

38 Refer patients to community self-help and

self-care programs

Teamwork & Proactive Care

Management Does the practice…

38 Proactively contact patients when services are

Copyright © 2008. F. DANIEL DUFFY, M.D., THE UNIVERSITY OF OKLAHOMA-TULSA. All rights reserved. 75

# Medical Home Process + - ? Comment due and follow-up after visits

40 Use a standardized patient screening

questionnaire and H&P form

41 Use a problem (and risk factor) list

42 Use and update a medication & allergy list

43 Use an integrated care management plan

44 Use a care management flow sheet or patient

registry for proactive care management

Clinical Information Management Does the practice have…

45 Practice management (billing) system

46 Patient visit scheduling system

47 Phone message management system

48 Medical record, document file, fax, scan

system

49 Consult & referral tracking process from

order to receipt of report

50 Laboratory test tracking process from order to

receipt of report

51 Image tracking system from order to receipt

of report

52 Care management registry for most common

chronic diseases and risk factors

53 Reports for clinical & financial improvement

54 Electronic health record with coded clinical

data

55 Patient internet portal for secure e-mail with

patients

56 E-Prescription management system

Leadership/Citizenship in Quality

Improvement Does the practice have…

57 An identified leader for clinical quality

58 An identified leader for resource management

58 Quality aims, objectives, culture of safety

60 Quality measures, dashboard, control charts

61 Rapid-cycle test of change teams

62 Process for spreading innovation throughout

the practice

63 Financial plan for practice viability