Promoting Team Based Care DC Primary Care Association

Promoting Team Based Care DC Primary Care Association October 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: 130 k • Disciplines: Medical, Behavioral Health, Dental • Specialties: CDE, Nutritionist, Podiatry, Chiropractic Care • Specialty access by e. Consults Top Chronic Diseases Cardiovascular Disease Obesity/Overweight Diabetes Chronic Pain Asthma Depression

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 e. Consults Three Foundational Pillars Clinical Excellence Research & Development Training the Next Generation

CHC’s Educational, Technical & Innovation Projects

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

Facilities: One Corridor Care • Exam rooms and therapy rooms • Reducing stigma of seeing other disciplines • Seamless transition between Disciplines 05/14/2014 6

What does an Integrated Record Look Like?

Data Driven: the Right Data at the Right Time EHR ETL Process Data Warehouse 00/00/00 Scorecards Dashboards Structured Data Pulls 8

Care that is Comprehensive: IPCP Team Medical Dental BH PATIEN T Nursing Prenatal Pharmacy Additional on-site specialties § Nutrition § Diabetes education § Chiropractic § Podiatry § Retinal screening

Interdisciplinary Leadership 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 MU 2/PCMH/UDS

Interdisciplinary Leading 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 Care “Every CHC Patient has Team!”

Interdisciplinary Care Initiatives Initiative BH Medical Nursing Integrated Care Meetings r r r Recalls r r r BH Groups r r Shared Medical Visits r r r Warm Hand-Offs r r r Prenatal-Dental Project Shared Care Plans r r r Complex Care Management r r r Trauma Screening & TFCBT r Dental r r r Standing Orders r r Fluoride Varnish r r r SBIRT r r r BH Dashboard r r Appointment Allocation r r 00/00/00

Figure 1. Diabetes Dashboard by Provider

Team-Based Care: Tele-Ophthalmology Nurse • Rooms Patient • Collects Vitals • Captures Images MA • Diabetes Education • Self-Management Goal Setting • Reviews Images • Sends Diagnosis & Recommendations Electronically Specialist Ameri. Corps Member • Sends results to PCP through EHR • Sets Recall for Future Visit • Reviews Results • Creates a Referral when needed PCP

Leadership for RNs and MAs: The Role of the CNO in Team-Based Care § § § Collaboration/Integration among departments Training/Competencies Program Oversight Developing Standing Orders Chair of the Pharmacy & Therapeutics Committee MU 2 Implementation PCMH, UDS Reporting & TJC MA/RN recruitment Nursing Informatics Promotion of Research & Translation Mentor/Coach to the Nurse Managers Relationships with Professional Schools

The Interdisciplinary Team 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

Domains of RN Nursing Practice at CHC, Inc. Essential member of the primary care team and interprofessional activities (1) RN supports (2) primary care providers/panels Key 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

Nursing Standing Orders § § § 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

Independent Nursing Visits Total Visits: 20, 717, Total Services Delivered: 28, 418 14, 000 12, 870 12, 000 10, 000 8, 000 6, 000 4, 000 2, 000 0 4, 228 5, 444 2, 952 736 Immunization and Chronic Illness Care Chronic Pain Recurring Screening & Care Support: follow up Medication Management & assessment Administration: (ie. progesterone administration and monitoring for prevention of preterm birth) 1, 422 Anticoagulation Management 766 Nursing visits for Smoking Cessation Standing or visits Delegated Orders Total Visits: 20, 717, Total Services Delivered: 28, 418

Chronic Illness Care CAD; 1. 0% Obesity; 1. 6% Hyperlipidemia; Other; 8. 8% 0. 7% HCV/HIV; 2. 2% Asthma/COPD; 7. 9% Hypertension; 41. 9% BH; 10. 6% Diabetes Management; 25. 3%

Training § § Competency Fairs Leadership Conferences Facilitation Training Comprehensive didactics for Complex Care Management • Transition Care • Medication Reconciliation • CHF • DM • Asthma • COPD • Psych • MI/SMG

RN Complex Care Management Ø 4 -day comprehensive didactics for Care Coordination Ø Transition Care, Medication Reconciliation, CHF, DM, Pediatric Asthma, COPD, Psych, Motivational Interviewing, Self Management Goal Setting Ø Supervision Case Reviews via videoconference Ø EHR Templates Ø Structured Intakes/Follow up Ø Nursing Informatics/Outcome Measures Ø Dashboards (Population Management) Ø Community Engagement Ø Open House Ø Data Sharing

Reason for Complex Care Management

Consider Possible Data Sources

Customizing the Sort

Additional Actionable Data

Complex Care Management Scorecard 00/00/00 29

Complex Care Management Scorecard 00/00/00 30

Role of the Medical Assistant § § § Planned Care Delegated Ordering Panel Management Scanning/Faxing/handling of incoming faxes Retinal Camera Operation QI/Microsystem Participants

Planned Care Dashboard

PCD—Birth Cohort HCV Screening Added to the PCD 11/1/2014 00/00/00 Baseline Screening Rates 36. 5% Final Data Collection Completed 2/1/2015 New Screening Rate 41. 5% 33

Challenges § 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

Future Directions § 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

Contact Information Mary Blankson, DNP, APRN, FNP-C Chief Nursing Officer (860) 852 -0851 office (860) 227 -5432 cell Mary@chc 1. com National Advisory Council on Nurse Education and Practice