Phase 3. Redesign Care and Business Systems
Key Change 3.1. Organize Your Care Team
Team care is at the heart of improvement and presents one of the biggest opportunities to
improve practice efficiency. There are four key goals in rethinking primary care teams:
- Ensure all of the needs are met in caring for the chronically ill.
- Use the least expensive & best trained staff to perform each task.
- Maximize patient and staff satisfaction and retention.
- Standardize care, improving both quality and efficiency.
To achieve team-based care, an organization needs strong leaders willing to break down
professional silos and clinicians willing to delegate tasks and assign roles and responsibilities
for patient care to others on the team. Every staff person must be involved in the team and
perceive their duties as improving the patient's experience of care.
Tom Bodenheimer, M.D., notes that physicians often try to perform all the clinical and self-management
support functions necessary for effective patient care but are unable to do so as
the burden of chronic illness increases. Bodenheimer emphasizes the need to delegate work
to all staff, clinical and nonclinical. Nonphysician staff are more likely to adhere to protocols
than physicians and therefore should be asked to engage in more of those care processes.
Increasing staff involvement in patient care and creating a more cohesive care team increases
both patient and team satisfaction, improving patient and employee retention.
One of the more efficient ways to begin developing a team is to:
- Map out the existing care process for a specific clinical change (e.g. annual foot
exams for patients with diabetes).
- Determine which tasks aren't being completed or can be moved from "swamped"
personnel to those more appropriate for the task.
- Test how the new process works with the next patient scheduled.
Team members should be trained as needed. In addition, regular meetings are critical to
solidify the team. These can be early morning huddles or scheduled time during the week to
review cases, evaluate outcomes of ideas being tested, and modify roles and responsibilities.
Track 2. All finance tracks will want to organize the care team for efficiency,
but track 2 will want to ensure that every visit has a physician involved.
Track 3. Track 3 can further optimize efficiency by using ancillary staff
to conduct prework.
Hint: Standing orders can empower medical assistants and other ancillary staff to ensure
that appropriate tests are conducted and available before a planned visit.
|Acquaint yourself with the concept of
optimizing the care team.
||High functioning clinical teams are extremely efficient (presentation)29
|Decide where to start.
||Project Planning Form (worksheet)30
|Based on the key areas for improvement identified above, use process mapping to understand how care is delivered.
||Primary Care Practice High Level Flowchart (worksheet)31
|Clearly assign roles and responsibilities to staff
based on their capacities and licensure.
||Converting Guidelines to Practice (guide)32
|Use PDSA cycles to generate and implement
ideas on improved flow.
||Plan Do Study Act Worksheet33
Plan Do Study Act Self-Management Support Example34
|Conduct cross-training for staff where necessary/appropriate.
||Cross Train Staff (guide)35
|Evaluate team function.
||Team Effectiveness Exercise (survey)36
- Improving Primary Care by Thomas Bodenheimer and Kevin Grumbach
Chapter 9: Health Care Teams in Primary Care.
- Online training on improvement teams is available at http://www.improvementskills.org.
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Key Change 3.2. Clearly Define Patient Panels
Understanding your patient population is essential. If your practice does not have all patients
paneled in some kind of electronic system, this will be your next major task. Creating patient
panels helps to establish a linkage between a specific provider and his or her patients, a
necessary prerequisite for quality measurement and improvement and many pay-for-performance
programs. In addition, it enables the practice to assess the balance between
patient demand and capacity.
Patient panels can help capture efficiency gains, especially if supply and demand are not
properly matched. For example, once you can identify all your patients, you can begin to look
at how the practice operates on a daily, weekly, and monthly basis. Knowing when you are
likely to have heavy loads of chronically ill patients presenting or walk-ins allows you to
schedule for these peak times.
- Some practices already have this in hand, but if not, panel assignment is
an essential first step.
- Practices overwhelmed by demand should consider strategies for aligning supply
and demand, first by maximally using the existing team. If this is insufficient,
ensuring that all providers have reasonable panels by adding additional clinical
staff may be indicated.
- As you match patients and providers, ensure that you have up-to-date patient contact
information. This will make it easier to contact patients for planned care visits
described in section 3.4 below.
|Optimize the care team by assigning a panel of patients for
each provider and manage panel size and scope of practice.
||Panels and Panel Equity (guide)37
|Assess supply and demand to further optimize
your team and ensure appropriate panel sizes.
||Practice Supply worksheet38
Daily Demand (guide)39
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Key Change 3.3. Create Infrastructure To Support Patients at Every Visit
The ultimate goal of care that follows the Chronic Care Model is for every interaction
between the patient and the medical team to be productive. Whether the visit is acute or
planned, the care for every patient needs to change if we hope to improve health outcomes.
Practices can start by treating the next patient that comes through their door as a partner
for whom the clinic is organized to support. Some elements of Chronic Care Model-based care
that should be present at every visit—planned or acute—should be:
- A deliberate focus on understanding and meeting patients' needs, including
taking into account their treatment priorities. This can be accomplished through
the creation and integration of a care plan.
- An explicit effort to enhance patient's health literacy. This can be accomplished using
teach-back techniques to ensure that patients understand what you have told them.
- A perspective that any single interaction with a patient is part of an ongoing set of
productive interactions where all of the patient's needs are being met. This can be
accomplished by using each visit as an opportunity to engage the patient around the
full array of medical needs including multimorbidities and depression, encouraging
them to return for a planned visit when time is short.
All three financial tracks benefit from productive patient—provider interactions. This
interaction is, after all, the source of all value in the health care system. Practices that
ensure that patients truly understand their medication regimen, for example, greatly reduce
errors and the resulting rework and poor outcomes associated with them.
When providers manage the total breadth of their patient's needs, rather than creating more
work, efficiencies can be gained.
Track 3. Specifically, good integration of depression screening and management can
directly increase revenues for track 3 practices, while dramatically freeing up time for
primary care providers.
Track 1, Track 2, Track 3. Good mental health management can ensure that "15-minute visits don't turn into disorganized 45-minute visits," (Ann Lewis, CEO CareSouth
Carolina, Curing the System May 2002). Such practices can dramatically improve efficiency for
all three tracks. The CareSouth Carolina Story in the "Stories From The Field" section
provides more details about their mental health work. In addition, the integration of case
management activities into each visit increases the complexity of visits, increasing
|Create a patient care plan that captures
the needs of the whole patient.
||Shared Care Plan (patient material)40
|Reduce the health literacy demands
made on patients.
||Health Literacy and Patient Safety: Manual for Clinicians (guide)41 go to pages 18-40
Helping Patients Manage Their Chronic Conditions (online)42 go to pages 8-15
|Utilize depression screening and care
management to engage the whole patient.
||Depression Management Tool Kit43 go to Appendix I, p. 17 (online)
Spanish PHQ-9 (survey)44
- The Center for Health Care Strategies has put together a set of fact sheets on
health literacy that you may find interesting. They are available at http://www.chcs.org.
- In addition to their Health Literacy manual, the American Medical Association
has a number of other good health literacy tools, including a video available on
their Web site: http://www.ama-assn.org.
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Key Change 3.4. Plan Care
Now that you have some of the fundamental building blocks of Chronic Care Model-based
care in place, you are ready to try delivering planned care. A planned visit is an interaction
with a patient designed and organized to ensure that the care is consistent with guidelines.
Prenatal and well-child visits are examples already in use. Planned visits are proactive,
not patient initiated.
Many health care providers believe themselves to already be doing "planned" visits. They
note that their patients with chronic conditions come back at defined intervals. Upon closer
inspection, however, these visits may look a lot like acute care. The provider might lack
necessary information about the patient's care needs; provider and patient might have
different expectations for the visit; and staff may not be fully used to help with the
organization of the visit and delivery of care. These "check-back" visits, while scheduled
in advance, are often not efficient or productive for the provider and patient.
Finance tracks need to look closely at how proactive clinical care can improve business
practices. For example, while a team member is ensuring that labs and screenings are up
to date, they or others can verify coverage or eligibility for supplemental programs.
Track 2, Track 3. For fee-for-service tracks 2 and 3 with onsite labs, ensuring that all
patients receive the recommended number of tests can dramatically increase revenue. The
Mercy Clinic and the Point of Care A1c Testing stories in the "Stories from the Field" section
demonstrate how real clinics used this concept to increase revenue.
In addition, the more complex and comprehensive nature of planned care visits enables sites
to qualify for more robust evaluation and management (E&M) codes when they integrate the
educational and counseling elements of the Chronic Care Model into practice. The Greenfield
Clinic story illuminates this point.
Finally, once you have worked out how your team can best deliver planned care to individual
patients, consider including group visits as part of your practice. Group visits benefit patients
clinically and can benefit your center financially.
Track 2, Track 3. Fee-for-service tracks 2 and 3 can benefit by including a medical
exam component and billing for each patient in the group.
Track 1. Track 1 can use nurses to conduct group visits as an alternative to phone or
individual office consultations.
Additional Ideas to Help Make Efficient Planned Care a Reality
- Use registry and guidelines as the informational basis for your planned care visit.
- Integrate case management to improve efficiency and patient outcomes.
- Fully use the team you developed as part of key change 3.1.
|Use planned interactions to support evidence-based
care for individuals.
||Organizing the Planned Visit (guide)45
System Changes and Interventions: Planned Care (presentation)46
|Conduct visit preparation to ensure labs and screenings are
up to date, & referral/specialty care information is available.
||Diabetes Standing Orders (worksheet)47
|Patient priorities are elicited & available.
||Open Access—Open Office (patient material)48
Shared Care Plan (patient material)49 go to page 3
|Patient eligibility & insurance information is up-to-date.
||Front Desk Collections Flow Chart (guide)50
|Teams have all the information they
need at the time of the visit.
||Huddle Sheet (worksheet)51
|Ensure that this more complex visit is being
||Getting Paid: Maximizing
|Try group visits.
||Group Visit Starter Kit (guide)53
Group Visit Financials (worksheet)54
- Planned Care (streaming media), available at http://www.improvingchroniccare.org. This video was produced by Improving Chronic Illness Care and demonstrates how planned
care occurs within the context of a busy office.
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Key Change 3.5. Assure Support for Self-management
To cope with their illness, patients living with chronic conditions must carry out complex
treatment regimens, adjust everyday life tasks to accommodate their physical capacities, and
deal with emotional responses to illness and loss. Because patients and families carry out
much of the management of chronic illness, collaborative self-management support with
patients is key to any effort to improve health outcomes. This effort can be seen both as a set
of techniques useful in partnering with patients and as a cultural shift in the delivery of health
care that places patients' goals, beliefs, preferences, and capacities at the center of care.
Creating informed, activated patients is particularly helpful when those patients have
more than one chronic condition. When patients are informed and participate as partners in
their care, they can provide valuable information to help their clinical team prioritize issues.
Knowing patient preferences enables teams to have a realistic conversation about what self-care
actions may best meet the patient's multiple needs. Other strategies the clinical teams
can use to effectively partner with multimorbid patients include:
- Helping all patients to engage in general preventive care, such as exercising, eating
well, and quitting smoking.
- Seeking out clinical "two-fers," where synergistically managing related chronic
diseases results in positive outcomes for both, particularly in managing depression.
Providing necessary information, responding to patients' goals, and problem solving with
patients to support continued improvement are central to self-management and can be part
of every interaction between patients and the care team.
Track 1. Self-management is important for patient improvement in all three financial
tracks. For practices in track 1, good support for self-management support can keep patients
healthy, reducing their demand for frequent, low-intensity visits. Self-management support
in conjunction with planned care also reduces costly emergency department visits, a key
financial lever in integrated delivery networks.
Track 2, Track 3. Track 2 and 3 practices benefit because when patients do come in
for a planned visit, that visit is often more complex.
Track 3. For those in track 3, self-management support by professionals such as Licensed
Clinical Social Workers or Certified Diabetes Educators may be reimbursable.
|Empower patients to be responsible for their health.
||Helping Patients Manage their Chronic Conditions (online)55
|Use the care team to work with patients collaboratively to:
||Understanding Goal Setting & Action Planning (guide)56
||Action Plan (guide)57
- Follow up regularly to problem solve barriers
and set new goals.
|Agenda Setting Tool: Bubble Diagram (patient material)58
- Share easy-to-read, culturally and linguistically
relevant information with patients.
|World Education (online)59
|Explore resources in the community to support
||Diabetes Initiative (online)60
- The "5 A's" Behavior Change Model, a useful framework for organizing the
infrastructure of self-management support. Check out the model by Glasgow
et al and Whitlock et al.61
- New Health Partnerships, http://www.newhealthpartnerships.org , for those interested
in self-management support. They are also developing a business case for self-management
- Techniques for Patient Self-Management, available from the California Health
Care Foundation at http://www.chcf.org. This video provides an overview of how to
- Improving Primary Care by Thomas Bodenheimer Chapter 5: Self-Management
Support for People With Chronic Illness.
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