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Copy of SHARED PACT Session 4 v2

Version 2 (5/30/13), major changes noted in comments

Aron Pollock

on 23 July 2013

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Transcript of Copy of SHARED PACT Session 4 v2

Patient Aligned Care Team
Taking Primary Care to the Next Level
Transformation to Integrated Healthcare
Why Transform?
“The disease-driven approach to care has resulted in spiraling costs as well as a fragmented health system that is reactive and episodic as well as inefficient and impersonal
The Institute of Medicine (IOM) Summit on Integrative Medicine and the Health of the Public, Feb 2009

Redesign VHA Healthcare Delivery!
VHA’s Universal Health Care Services Plan, April 2009

Session 4
Information Management-Mission Critical
Prevention Strategies
Prevention Strategies
Prevention Strategies
Comprehensive health promotion and disease management by population
ALL patients including those who do not appear for routine care
Improve prevention and chronic care management effectiveness
Supported by organizational level
Transformation occurs at the practice level
Technologies - CAN Score, Almanac & Compass, Telehealth, MHV
Funding - Office of Telehealth, Rural Health
Extended Team Members - Pharm. D., Dieticians, Behavioral Coach
Policy - with the input of PC to ensure effectiveness
Mindset of Patient and Team
Cohesive Teamwork
Practice at the highest level of licensure
Population Management utilizes external factors to better service the population
Increase the size and scope of telehealth usage in VA to expand access to care and offer more timely care to Veteran patients. Providing the right care in the right place at the right time!

- Home Telehealth (HT)

- Store and Forward Telehealth (SFT)
Telederm Teleretinal Imaging Teleradiology

- Clinical Video Telehealth (CVT)
Patient-Centered Alternatives to
Institutional Extended Care
Provide innovative pilots of patient-centered non-institutional long term care (NILTC), and disseminate successful models broadly throughout the VHA.

Enhance options for Veterans choosing to receive extended care in the home and community rather than in an institution.

These models reflect how we will provide care to Veterans in the future!
End homelessness among
Veterans within 5 years

Identify & assist every eligible homeless and at risk for homeless veteran
Help Veterans acquire
Safe housing
Needed treatment services
Opportunities to return to employment
Benefits assistance
Highly engaged workgroups are*:
44% higher retention
56% higher in customer loyalty
50% more productive
33% more profitable

*Information form The Right Group and Manpower (2002)
Teams who proactively work on both team engagement and team effectiveness become high-performing teams.
Cullen Jones
Michael Phelps
Ryan Lochte
Psychological Safety
Each team member knows what expectations and tasks are envisioned for the whole team and for one another. 
Innovation and continuous improvement hinges on a work environment that is psychologically safe
Engaged Teams
Team members show basic courtesy toward each other, and all with whom they come in contact, while performing their duties in alignment with the team’s purpose and methods

Civility is the foundation to all relationships.  
Part of becoming a team is the commitment to regular reviews of team and team member functions. 
Team Effectiveness
Best illustrated by the practice of shared decision making, which contributes to the positive outcomes of team productivity,
team member satisfaction, and a safe work environment. 
Awareness of team priorities,
understanding of both short and long term goals and,
most importantly, how their team goal is aligned
with the global mission statement of the larger organization.
Team members show that they value the inherent worth in one another.

Teams who have learned to hold each other accountable for civil behavior can readily move toward a work environment that demonstrates and promotes respect for one another. 
Working well together, team cohesiveness is a sense of oneness or that we are ‘all in it together’.

Individual team members emphasizing team over personal goals and accomplishments.    
How team members
approach each other
on the job and
is seen and heard by those in and around the team.
How team members approach their tasks at work
Purpose & Method
Role Clarity
Awareness &
Nathan Adrian
High-performing teams enjoy better outcomes than ineffective teams
Team Effectiveness
What does

Patient Centered

mean to YOU?

Whole Health Care
Patient Centered Care & Cultural Transformation’s Mission
The Values and Culture of Veterans

MISSION: You commit to goals and outcomes with tremendous self-discipline and self-sacrifice.

PLAN: You wouldn’t fight a war or go into battle without one.

TRAINING: You wouldn’t send your troops in without training and skill building.

TEAM, TRUST, AND SUPPORT: You rely on your team and live or die by your fellow Soldiers, Sailors, Airmen and Marines.
Components of
Proactive Health & Well-Being
“Meeting the Veteran where he/she is” on the continuum of life and health through the construct of Mission, Plan, Training, and Support. “
Veteran Centered Care
“We need to start not by asking ‘What is the matter with you?’
We need to start by asking
‘What matters to you?’"
Maureen Bisognano,
President &CEO, IHI
Anyone you can add?
HPDP Program Manager
– New T21 position

Health Behavior Coordinator
– New T21 position

Veterans Health Education Coordinator

MOVE! Coordinator

HPDP Program Committee
- Representatives from multiple
programs, services
Extended Team Assistance:
The Captain = Veteran
The Journey to lifelong heath and well-being is a team sport.
The Veteran is the Captain of the team
and healthcare professionals are some of the invited players.
The Veteran’s Life Choices
How do I…
Population Management
Population Management Concept
The CAN report utilizes multiple variables for the Model including:
Patient characteristics
Demographics – age, priority level
Coexisting conditions, severity of illness
Vital signs
Utilization – inpatient and outpatient
Lab values
Top 10
VHA Discharge Diagnoses 2008
Population Based Healthcare at the Point of Care?
Population Health Management
Reflects estimated probability of admission or death within a specified time period (90 days or 1 year)

Expressed as a percentile, ranging from 0 (lowest risk) to 99 (highest risk)
Special emphasis is given to high risk patients.
Patient Care Assessment System (PCAS)
Figure Source: Practice-Based Population Health: Information Technology to Support Transformation to Proactive Primary Care. AHRQ.
Select CAN Timeframe
CAN Risk Level (1-99)
Spectrum of Population Health
Step 1: Identify Populations
Step 5: Make Data Available
Step 4: Track Performance
Step 3: Create Triggers
Reducing exposure or risk factor levels
Reduce or eliminate causative risk factors
Prevent occurrence of disease of injury
Smoking Cessation Classes
Coaching/Motivation Interviewing
Home BP Monitor
Medication - HTN
Clinical Reminders
PAP Smear
Specialist Consult
Pharm.D. Appt.
& Treatment
Identify and control disease processes (early stages)
Restoring optimal level of functioning
after a disease
or injury
Prevent disability
Collective PC Practice
Community Health Dept.
Larger Healthcare Unit
5. Error-Proof
1. What are We Sustaining?
Be clear on what is being sustained
Be clear on who “owns” the responsibility
Build sustainability in from the start
Understand critical failure points
Design SMART processes
Measure and Adapt (PDSA)
Building Reliable and Sustainable Processes: 8 Principles
The goal is to spread sustainable change
Share advice and recognize good work.

This type of giving not only inspires others to return the favor, but it creates an infectious feeling of goodwill around you. People are attracted to positive vibes.

Another person’s success does nothing to detract from yours and frequently enhances it.
Steal Shamelessly
Find Friends Along the Way
“Sustain” Means…..
Sustaining change takes intentional effort on multiple levels
It is important to make and carry out a specific plan for each change
Standardization is our friend
Ongoing measurement is key to sustainability
If you can do something for long enough it becomes easier to maintain the habit than break it.
Create Self-Reinforcing Habits
Average Daily % of ED stat orders (Order to Verify)
returned within 60 minutes through April, 2006
To keep in existence; maintain.

To supply with necessities or nourishment; provide for.

To support from below; keep from falling or sinking.

Continue to function, hold in place, or keep going.

Don’t fall back!
Make measurement part of the work
Utilize available resources
Create your own data collection
8. Measure
Healthcare Examples
Intent to follow process or guideline
Common equipment
Standard order sheets
Written policies/procedures/protocols

Awareness and training

Feedback on compliance

Hard work
4: Standardize
Starts during testing
Perform robust testing
Test over a wide range of conditions
Builds during implementation
Build reliable processes
Use change management strategies
Continues after implementation
3. Build Reliability in
From the Start
Every key process has an “owner”

Ownership means this person is responsible to make sure the process WORKS, and when the process doesn’t work, fixed it or improved it.

Ownership means measurement

Ownership is built into job descriptions, training, resourcing
2. Ownership
Inevitably there will be failures and set backs. In these times it’s important to understand that every failure is a success.

Each failure means that you stepped out of hiding and took a risk — something most people never dare to do.
Go Easy On Yourself
Time Bound
Forward thinking will help you form a
long term vision that is sustainable.
Set Attainable and Realistic Long term Goals
Failure modes and effects analysis (FMEA)
What could go/went wrong?
What would cause(d) it?
What are the consequences?
What can we do?
Contingency planning
6. Understand Critical Failures
You Want to Be Here
Develop improved practice
Relationship between collaboration and Improvement
The “Work Harder” Loop
Woodward-Hagg, H., El-Harit, J., Vanni, C., Scott, P., (2007). Application of Lean Six Sigma Techniques to Reduce Workload Impact During Implementation of Patient Care Bundles within Critical Care – A Case Study. Proceedings of the 2007 American Society for Engineering Education Indiana/Illinois Section Conference, Indianapolis, IN, March 2007.
Unreliable Process
Unreliable Process
Erosion in Reliability
Investment in Reliability
Process Reliability
* Repenning, N. and J. Sterman (2001). Nobody Ever Gets Credit for Fixing Defects that Didn't Happen:
Creating and Sustaining Process Improvement, California Management Review, 43, 4: 64-88
Quality Improvement Model
Poka Yoke: Error-Proofing
An environment that encourages and supports their members to ask questions, seek clarity, ask for help, and share concerns regarding the team’s performance. 
High-performing teams increase their performance by continuously assessing their purpose and methods, role clarity, communication, and business practices. 
The quality, type, and amount of communication
is impacted by the level of psychological safety.
Mutual support and respect for each team member’s role is paramount
Teams who agree on their purpose and methods are better positioned to achieve success.
As a TEAM –
Discuss the questions and your associated responses.
Know Your Process
CCA Implementation Steps (Cont)
Consensus is reached among PC and SC providers for CCA content, scheduling process, and audit criteria
Agreement is formally adopted by medical executive committee
Measures assessed periodically and discussed in face-to-face meeting of PC and SC providers
Ideas for improvement considered and adopted as needed

Without trust, collaboration is merely
cooperation, which fails to achieve the
benefits and possibilities.

(Covey & Merrill, 2006)
Better Working relationships between PC & SC
Faster response to PC consults
Reduced demand on SC
Less work on the part of PC staff
Less denied consults
Fewer visits for patient

Benefits of Care Coordination Agreements (CCA’s)
Method(s) of Consultation
Face-to-face visit
Just-in-time telephone consultation
Shared Medical Appointment / Group visit
Telehealth visit
Care Coordination Agreements (CCA)
Understanding or agreement between any 2 parties
(who send work to each other)
governing the work flow rules
Quality Care
Quality, effectiveness, and safety in health care are dependent on the interrelationship between the Patient, Primary Care, Specialty Care and Surgical Services.
A Look through Different Eyes
Arrangements between Parties
Define time expectations
Referring provider/PACT team members
Specialist in urgent referral situations
Define specific directions for contacting specialist / PACT team
Include specific duties for specific roles
For changes in diagnosis, testing, procedures, referrals, follow-up, etc
Point of Contact (and back-up POC)
Phone / pager / Blackberry numbers (and alternate)
CCA Implementation Steps
1. Volume, reason, and source of existing referrals are measured and shared
2. Face-to-face discussion between PC/Specialists occurs
Discuss current data
Discuss referral process
Small group tasked to work out agreement
3. Simple CCA is drafted and tested
Decide on Participants/Stakeholders
Done in conjunction with flow map
Uncover all of the steps in flow order
Identify stakeholders
Primary Care
Specialty Care
Others- Facilitator, Systems Redesign, IT/CAC, leaders
Specify Referral Relationship Type(s)
Consultative (evaluate and advise)
Co-management with shared care
Co-management with principal care
Full responsibility for all patient care
Shared Care Platform - multiple specialists with PC (e.g., lung nodule clinic with CT surgery, Heme-Onc, Radiology, SW)
1. Discuss what needs to happen to ensure that the patient arrives ready for the consult.
PACT staff & SC Handoff
An 82 yo Veteran with suspected dementia who lives alone is referred to Geriatrics for evaluation. Labs and a CT scan have been ordered
Mike Davies, MD FACP
Ntl. Dir. Systems Redesign
PACT: How to Do
Arrangements between Parties
Specify how to handle secondary referrals or need to amend referral
Clarify inpatient processes
Include communication regarding notification of admissions, secondary referrals, data exchange, and transitions into and out of a VAMC.
Describe contingency plans to manage emergencies and other circumstances .
Remember our ladder
Limited communication
Provider focused
Win-Win for all
Sometimes limited benefit
Sometimes one-sided
New name
Old name
Work my body?
Rest, recharge?
Fuel myself with food/drink?
Work and enjoy my mind?
Satisfy the needs of spirit and soul?
Choose surroundings that support and sustain?
Develop myself personally/professionally?
Form and sustain nourishing relationships with family, friends and co-workers?
Lifelong Health and Well-Being
of the Game
Healthcare professionals
- Prevention and intervention
- Conventional and Complementary Approaches
Athlete, Coaches, Teams
Pastor, Priest, Rabbi
Family, Friends, Bosses, Co-workers
Players on the Team
Leverage use of Tele-health and other technologies to deliver care without requiring face-to-face visit:

- electronic and phone consults
- telemedicine

Expand Specialty Care Collaborative to improve and maximize access
Patient Aligned Care Teams
Transform the episodic primary care model to a longitudinal, relationship based model, where PACT team fully participates and contributes to the care of the panel of patients.
Patient Centered Care
& Cultural Transformation Mission
VHA must change the way health care is delivered by moving from the current system which is problem-based…
Primary Care-Mental Health
Integration (PC-MHI) Mission
Integrate care for Veterans’ physical and mental health conditions, improve access and quality of care across the spectrum of illness.

Assist in treatment of mental disorders in primary care, either on site or through telehealth.

PC-MHI programs provide evidence-based mental healthcare, focusing on health behaviors.

Offer education and training for other PACT staff.
Population Explosion
Source: Women’s Health Evaluation Initiative (WHEI) and the Women Veterans Health Strategic Health Care Group; SourceBook: Women Veterans in the Veterans Health Administration V1: Sociodemographic Characteristics and Use of VHA Care, 2011.
Women VA Patients: Three Peaks
Older women (largest sub population of female VA users)
Menopausal needs
Geriatric Care
Inpatient/extended stays
Influx of younger women
Maternity care
Service-connected disabilities
Privacy, safety, convenience
Women’s Health
Achieve INTEGRATED patient centered comprehensive primary care for women Veterans.

Recognize unique needs of female Veterans to individualize care

Provide services in a sensitive and safe environment
Specialty Care
Transform Specialty Care into a Veteran-centric system

Interface with PACT teams to provide coordinated team-based care

Focus on the Veterans experience & shared decision-making

Maximize access to all services
All Transformational Initiatives
Common Threads
Clear vision / purpose
Patient centered
Strive to improve Access
Offer Training
Provide resources & tools to support change
Evidence based
Mental Health
Women's Health
personalized, proactive, and patient driven.
to one that is…..
“find it, fix it,”
Virtual Medicine
Secure Messaging (SM) provides a virtual technology alternative to patient face-to-face encounters with their PACT and Specialty Care teams.

Incremental national rollout will eventually offer online access to portable health records, advanced information access and communication tools (e.g mobile devices, social networks, websites, chats)
Source data supplied 7/9/10 by the Office of the Actuary, Office of Policy and Planning, Department of Veterans Affairs
Download and Share Personal Health Record
Refill Prescriptions
View Appointments and Health Information
Communicate with Participating Patient Aligned Care Team Members
A personal MyHealtheVet account provides Veterans with 24/7 online access to a variety of tools to manage their health care.
Creating change that is sustained entails four steps:
4. Adopting practices
3. Action to change
2. Acceptance of responsibility for change
1. Awareness of
the need for change
Work Smarter
Work Harder
Time Spent Working
Pressure to Do Work
Desired Performance
Performance Gap
Actual Performance
Erosion in Reliability
Process Reliability
Investment in Reliability
Time Spent on Improvement
Pressure to Improve Capability
Actual Performance
Desired Performance
Systems Redesign Applications
aka: Work Smarter Loop
Maintain routine practice
Share practice
Work in isolation
“Motivation doesn’t last,
but neither does taking a bath. That’s why we recommend it DAILY.” - Zig Ziglar
We are what we repeatedly do.
Excellence then, is not an act, but a habit – Aristotle
Teamwork, measurement, feedback, critical path
Access, care management, improved workflow
Increased satisfaction, reduced hospitalizations, ED visits, etc.
and Alarms
sensory clues
to restrict or limit actions
color-coding, sizing, separation
7. Design Smart Processes
Further standardization of process
Decision tools/aids built into the system
Desired action the default
Error proofing (pokayoke)
Human factors considerations
Indicates how a given patient compares with other VA patients in terms of likelihood of hospitalization or death
Care Assessment Need (CAN) Score
Step 2: Examine Characteristics
Web based application
A Care Management & Tracking tool for PACT Teams
Patient Care Assessment System
Team Time
Population Management
Added January of 2013
Clinical Notes (progress Notes)
Active Problem List
Vitals and Readings
Radiology Reports
Electrocardiogram (EKG)
Demographics (past 3 years)
Additional Laboratory Results
Microbiology, Pathology,
Benjamin Zander
Patient Centered Care & Prevention
Welcome to Day 2 of the
PACT Session 4 Training
A team meeting is about to take place among a PACT Teamlet. Each member of the team is present, Provider, RN Care Manager, Clinical Associate and the Clerical Associate. In Session 2 of the PACT training, the team has agreed to work on establishing a Shared Medical Appointment (SMA). The meeting is called to discuss a few ideas and establish next steps.
Necessary steps- Establish tasks for members of the team:
•Determination of cohort
•Collection of possible patients
•Contact of patients
•Space allocation
•Extended teamlet member contact
•Appointment format (how will the medical appointment run)
Show the best known practice once a team figures one out!
Team members form a circle representing the steps in the process
1 person stands aside and observes/ records data (quality officer)
3 tennis ball
Stop watch or watch with second hand to measure time
Experiential Learning
What helped?
What got in our way?
Debrief our Experience
Do the exercise
in the smallest amount of time,
yet still follow the rules.
1. Standardize
2. Incremental
3. Innovation
3 Approaches to Improvement
Repeat as above with NEW TOYS
We have a change...
Integration of key data from multiple sources
Summary of patient risk factors
Task Lists and notifications
Multiple VAMCs & Community info
Ability to create a care plan and write it back to CPRS as a standardized note
Highly Desired Functionality
Name your successes (celebrate!)
What do you want to work on next?
What is the current situation?
What will improve it?
What steps will you take to make this change?
Draw Something!
Group Activity
Motivational Interviewing
Health Coaching
Personal Health Plan
Prevention Education
Dietary Management / Education
Disease Management / Education
Medication Management / Education
Patient Identification
Patient Education
Group Visits
Telephone Care
CAN Score
Medication Reconciliation
Caregiver Support
Population Management Responsibilities
Hypertension NOS
Hyperlipidemia NEC/NOS
Other Specified Counseling
Other Unspec. Counseling
Vaccine for Influenza
Esophogeal Reflux
Tobacco use disorder
Depressive disorder NEC
Full transcript