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Saginaw (655) PACT Orientation

PACT Session 1 (Virtual) presentation, current as of 5-14-2012.
by

Aron Pollock

on 31 January 2014

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Transcript of Saginaw (655) PACT Orientation

Transformation #1: circa 1990-1999
Visionary: Ken Kizer MD, Undersecretary transforms VA Health Care
Change from Specialty focus to Primary Care-based
Every patient assigned a PCP to assure continuity
Multi-disciplinary teams to provide comprehensive care
New Electronic Medical Record: Unveils CPRS
Performance Monitoring and External Peer Review Program (EPRP) Transformation #2: circa 2010-2015
Visionary: Robert Petzel MD, Undersecretary
Patient centered
Engage Veterans in care
Team-based care
Coordinated care
Same day access for face-to-face and non face-to-face care PACT
Care is determined by a proactive plan to meet patient needs without visits

A prepared team of professionals coordinates all patients’ care

Acute care is delivered by open access and non-visit contacts

We track tests & consultations, and follow-up after ED & hospital

A multidisciplinary team works at the top of our licenses to serve patients Joint Principles of the Patient Aligned Care Team 2007 survey of fourth-year students, planned adult primary care careers.

American College of Physicians (2006): “primary care, the backbone of the nation’s health care system, is at .” The Lone Doctor Model is in Crisis in Adult Primary Care Reasons for lack of interest in primary care careers
PCPs earn on average 54% less than specialists
More importantly, work life of the lone PCP has become less fulfilling:
“Am I making a difference?” Lone Doctor Effect on Patients Access: 73% of adults surveyed reported difficulty getting a prompt appointment, getting phone advice, or getting care nights/weekends without going to the ED Public views of US health system organization, Commonwealth Fund, 2008. Gandhi et al. J Gen Internal Med 2000;15:626. Commonwealth Fund, National Scorecard, 2008. A study of 264 visits to primary care physicians using audiotapes:
Patients making an initial statement of their problem were interrupted by the physician after an average of

In of visits the physician never asked the patient for his/her concerns at all [Marvel et al. JAMA 1999;281:283] primary care burnout "Like everybody else who practices primary care, I feel like I'm running from when I get there to when I leave and take work home." From to :
From a sole focus on individual patients to a concern for the team’s entire panel Funny things providers write in their charts
when they are working like hamsters: “She is numb from her toes... “Patient has
two teenage children
but no other abnormalities.” “While in ER she was examined, “87 year old woman

completely dead is

here for follow-up” 1990 2015 1999 2010 Primary Care Projected Generalist Supply
vs Pop Growth + Aging Introduction Why PACT? Patient Aligned Care Team Taking Primary Care to the Next Level Teams and Teamwork Background PACT Care Tools VA excellence in the 21st century

will be driven by how well

VA employees learn to work within and across teams

as they deliver services and care

to our Veterans and their families. VA Transformation and Working in Teams For PACT Teams to reach and sustain success,
team members need to work on both
relationships and functions: Unexpected or new situations
can impact a team’s
relationships and functioning Secure Messaging Protocols Pre-Visit Planning Huddles and Team Meetings Group Clinics (Scrubbing) Roles and Responsibilities Care Management & Care Coordination 1. PACT Teamlet RN
2. Generalist
3. All PACT patients on panel
4. Continuous
5. Intensity varies
6. May delegate to another team member 1. RN or MSW
2. Specialist
3. More complex PACT patients
4. Duration varies as needed
5. Intensity varies
6. Does not delegate but reports back to teamlet care manager on a regular basis CaRe Manager CaSe Manager R S National tools
VHA Service Support Center (VSSC): PRIMARY CARE ALMANAC
Site specific tools
Registry reports
Data Warehouse reports
Check with your primary care leader to see what tools are available at your site Tools for Identifying Patients by Risk Available to Primary Care Provider
Panel Summary
Patient lists by condition with drill down to more information
Needs set-up by your CAC/clinical informatics expert,
New: PACT Compass metrics available at provider level Primary Care Almanac How Do PACT Teams Gauge Progress? Pact Compass metrics at National, VISN, Facility, Division level are available on VSSC web site http://klfmenu.med.va.gov/

(“Clinical Care “ panel then select “Primary Care” then select “PACT Compass”) PACT Compass PACT the right care
in the right place
at the right time
by the right person Collaborative Website:
https://srd.vssc.med.va.gov/Collaboratives/Active/Pages/default.aspx

PACT Sharepoint Site:
http://vaww.infoshare.va.gov/sites/primarycare/mh/pcmhinfo/
default.aspx

ProClarity, PACT Compass & VSSC Training:
http://training.vssc.med.va.gov/Pages/Default.aspx

The Chronic Care Model
http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2 Helpful Websites [Hauer et al, JAMA 2008;300:1154] X-rated,

and sent home.” down.” A high performing team needs to be both an engaged and effective team.

High performing teams meet regularly to review their team engagement and their team effectiveness Interpersonal effectiveness alone will NOT fix ineffective processes and business practices “Process solutions” will NOT fix “relationship” issues that get in the way of providing quality service Function (Effective): approach to work & processes and business practices

Relationship (Engaged): how team approaches each other Engaged, Effective Teams Applying the VA Team Model 23 seconds 25% Why the rushed primary care visit? 7% grave risk of collapse trust the team To become a national leader in the transformation of primary care services to a model of health care delivery that improves patient and staff satisfaction, clinical quality, safety and efficiencies. Before PACT
Care is determined by today’s problem and time available today

Patients are responsible for coordinating their own care

Acute care is delivered in the next available appointment and walk-ins

It’s up to the patient to tell us what happened to them

Clinic operations center on meeting the doctor’s needs 1. Detailed descriptions of steps taken to deliver care based on evidence based practice

2. A framework with criteria for a specific aspect of patient care*

3. Less flexible than a guideline* Protocols are: Protocols at your facility Protocols at your facility Protocols at your facility Patients NOT billed

Patients don’t need travel

Captures workload for PACT

Influences Veteran Equitable Resource Allocation (VERA) – funding from VA for patient care

Shows the true picture for patient care in PACT

Supported by VHA as an appropriate and accepted method of delivering care to veterans. Benefits of Telephone Care in PACT Relationship is already established

Physical exam not needed

Test result notification

Chronic care and preventative management

Inpatient discharge and ED follow up

Medication management

Pre-visit work When to use telephone care in PACT 30-39% patient care can be done by Telephone

Telephone care by all team members needs to be legitimized, formalized and accepted.

Scheduled time on appointment grid.

Documentation of Telephone care via telephone stop codes, telephone clinics, coding/encounters and progress notes supports VERA allocation and workload Health Promotion/Disease Prevention

Routine Care of Chronic Conditions

Follow up Care: Using the telephone to effectively manage care after a face to face visit provides continuity with the PACT staff.
Clinics' check out options should include a system to schedule a patient in a telephone clinic within a specified timeframe. Most telephone episodic care is managed in an unscheduled manner. A group of primary care providers are assigned scheduled telephone clinic time to cover the clinic day (i.e. Dr X from 8-10 am, NP Y from 10-12, etc).

Call Center RN triage nurses provide initial telephone assessment and determine if provider level care is needed.

Patients requiring provider intervention are scheduled into a provider telephone clinic appointment. The provider calls the patient, evaluates, intervenes and determines the next steps in medical care and follow-up Per VHA Directive 2006-026:
A telephone contact between a practitioner and a patient is only considered an encounter if:
the telephone contact is documented
AND that documentation includes the appropriate elements of a face-to-face encounter, namely history and medical decision-making. “Historical” designated telephone notes (non count for workload) may be necessary and also add value to the patient experience and care delivered.

For example, calling a patient to discuss test results associated with an office visit would be non count, but it is valuable in terms of patient care. Making time for telephone care Scheduled Telephone Care Unscheduled (Episodic) Telephone Care Hybrid Model -- Scheduled Telephone Care for Episodic Clinical Needs Documenting and Coding a Telephone Encounter Non-Count Telephone Encounters This model enables triage nurse staff to schedule telephone appointments with primary care providers for patients presenting with an acute/episodic complaint. IMPORTANT:
A telephone note must include

1) history, evaluation & plan

AND

2) documentation of time spent in delivering care on the telephone. The patient calls the clinic about a clinical need. The resulting patient interaction is documented by entering a new telephone note in a telephone clinic (previously set up) and appropriately documenting and coding the care delivered. A notification is made to the PCP or RN either electronically or hard copy. How Will PACT Help Me? Patient
Actively engaged in plan of care
Notify team of communication preference (mail, email, phone etc.)
Utilize MyHealtheVet
Complete the health risk assessment
Provide input in committees, patient advisory groups, surveys and task forces Provider
Hands on, focusing on higher level, complex patients
Utilizes motivational interviewing to guide patients to establish goals
Performs final medication reconciliation
Ensures appropriateness of CCHT, HBPC, etc
Complete clinical reminders (pertinent) MD, NP, PA Clinical Associate
Uses motivational interviewing and health coaching to guide patients
Reviews daily schedules for patient care needs (pre-visit planning/scrubbing)
Assists with medication reconciliation
Assists with orientation: PACT patient orientation and new staff/affiliate orientation
Ensures visit closure
Secure Messaging
Practices per protocols LPN, LVN, NA, MA, HT Clerical Associate
Initial point of contact (first impression)
Assists with daily schedule review
Data entry and retrieval
Data collection from registries
Obtains medical records and test results from non-VA providers
Coordinate information exchange for dual care
Pre-visit patient reminder calls (coordinated with Teamlet)
MyHealtheVet enrollment and in-person authentication
Specialty consult and encounter completion tracking MSA, PSA RN Care Manager
Support self-management, prevention, and wellness, based on patient’s goals
Uses Motivational Interviewing to guide patients to establish goals
Smoothes transitions by collaborating with multidisciplinary services, internal and external to the VA
Identifies high risk populations/chronic disease tracking
Place orders according to protocol
Promotes access with non face-to-face visits when appropriate
Collaborates with key members of expanded team SMA Team
Nurse: Documenter:
Behaviorist: Provider:
 
ID: |PATIENT AGE| year old |PATIENT SEX|
 
MEDS:
|ACTIVE MEDS COMBINED|
 
Vitals: (BP/P/R/T)
BP |BLOOD PRESSURE| P |PULSE| R |RESPIRATION| T |TEMPERATURE|
WT |PATIENT WEIGHT| HT |PATIENT HEIGHT| General: Well-nourished, well-developed |PATIENT SEX| in no distress

Lungs: Clear to auscultation bilaterally, no crackles or wheezes

Heart: Regular rate and rhythm without murmurs, no S3 or S4

Extremity: No cyanosis or edema Labs:
|LR HEMOGLOBIN A1C(LAB)1YR|
|LR CHOLESTEROL(5Y)|
|LR LDL CHOLESTEROL(5Y)|
|LR HDL CHOLESTEROL(5Y)|
|LR TRIGLYCERIDE|
|LR TSH|
|LR PSA| Xrays:

Assessment/Plan:
 
|FUTURE APPOINTMENT|
|GIM RECALL DATE|
 
RTC Sample SMA Note Template Planning Ahead
to Run Your Clinic “Working together with each Veteran to provide the right care at the right time” The idea arose from the need to improve efficiency and clinic flow.


Shift actions to be proactive instead of reactive What's the point? Increased efficiency in mere minutes a day! Pre-Visit Planning
(aka "Scrubbing the Schedule") 3 to 7 Day Look Ahead

Pre-Visit Telephone Call

Teamlet huddle New Patient
Reminders
Obtain outside records and labs
Medication review
Visit instructions
Pre-visit lab work or other tests
Remind patient to bring in Home BP log, BS log, medication list, meds, etc. New Patient or Follow up Appointment? Follow-up
Reason for Visit
ED or recent hospitalization?
Outside hospitalization
Discharge Summary
PCP following up on recent intervention? Routine exam? Lab status
Pending
Needed

Pending consults

Preventative Health
Cancer screening
Mammogram
Diabetic foot exam RN and LVN work together to look for areas that may be taken care of pre-visit or even diverted to a different type of appt. (phone, RN or LVN etc)

Consult with PCP. They may have a plan. Review Data with Team Work Together! 5 minute stand-up meeting
Beginning of Shift/Clinic--Quick review of day
End of shift/clinic to plan for the next day Staffing- anyone sick or need to leave early
are you covering for anyone?
Anticipated issues/problems
Pt takes a lot of time?
Open slots or potentials
When/where & chronic no-shows Daily Huddle - What to Cover? How to: Daily Huddle Optional Mid-shift huddle
Changes to schedule
Updates on any pt care issues provider needs to address
Update on new calls/request Define responsibilities for each team member
Protected time in schedule for huddles
Isolate the teamlet
Arrange time to huddle with multiple providers Overcoming Huddle Hurdles Secure, encrypted online communication
Patient access through My HealtheVet
For non-urgent issue
Asynchronous
Resolve within 3 business days
Can triage messages within a team
Can save messages to CPRS Associate Model: Clerical or Clinical Associate review, resolve or assign to appropriate staff.

Nursing Triage Model: LPN or RN or NCM review, resolve or assign to appropriate staff.

No Triage Model: The provider reviews and completes all messages. 1. Rescheduling or requesting an appointment
2. Renewal of a medication
3. Instructions or directions to a clinic or test Examples of Messages Not Needing to be Save to CPRS Destination Establish your aim or goal?
For clarity,
describe the aim in ~3-4 detailed sentences. A good aim statement should be
“SMART” It is common for teams to repeatedly clarify and refine their aims until they become operational… or specific and clear enough to measure through short cycles of testing. S Specific
M Measurable
A Attainable
R Relevant
T Time-bound S Specific
What are you trying to achieve?
(Improve timeliness? Decrease errors? Increase revenue?) M Measurable
How will you know you are making progress?
(i.e., How much time? How many incidents? How much money?) A Attainable
Set goals that are aggressive yet realistic.
(i.e., 95% success with timeliness, decrease errors by 99%, decrease waste by 75%) R Relevant
Align your aims with the broader mission of the organization.
Does your project relate to patient care, staff satisfaction, or key organizational goals? T Time-bound
When will your testing be complete?
Cycles of projects should be brief and not expected to take a year or more. Patient Centeredness Peripheral Monitoring Devices (wired/wireless)
BP Monitor
Weight Scale
Pulse Oximeter
Glucose Monitor E-Consults Establishes a new approach to specialty care, providing consultation without face-to-face contact Circumvents barriers and challenges of traditional consultation methods... PCP, Veteran, and Specialist must agree to an E Consult (opt in or opt out) Specialist completes and enters consult report in the electronic medical record. ... eliminating the need for both the specialist
to travel to the CBOC or the Veteran to the larger VA facility Attempts to increase the access to Specialty Care groups in “real time” via a VISN on-call system Increased access to Specialty Care
Decrease travel for Veterans and reduction of travel cost for the VISN Home TeleHealth Specialty Care Access Networks –


Extension for Community Healthcare Outcomes Access Improved provider and staff satisfaction
Improved patient satisfaction and health
Improved access to care Increase satisfaction with medical care
Closer relationship with teamlet
Increased personal touch
Ownership of healthcare Increased control of your schedule
More time with patients
Less time with clerical and paperwork tasks
Decreased number of surprises
Closer working relationship with teamlet Patients Provider Increased patient satisfaction
Improved coordination of care
Decreased number of surprises
Increased involvement in patient care and education
Increased autonomy
  RN Care Manager Increased patient satisfaction
Closer working relationship with teamlet
Closer relationship with patients
Acknowledgement of value to the team Increased patient satisfaction
Closer working relationship with teamlet
Closer relationship with patients
Increase involvement and responsibilities in direct patient care
Increase involvement in patient education Clinical Associate Clerical Associate From to :
From the lone doctor with “helpers” to the high-functioning team

From my patients to our patients I We The Paradigm Shift He/She They Will patients accept team care? Patients may initially object since they want to see their provider

Over time, if they get good care from all team members, they begin to Telephone Care Leverages Telehealth (clinical videoconferencing technology) to:

allow Specialists (from tertiary medical centers) the opportunity to provide support to providers in less complex facilities or rural areas Purpose & Intended Outcomes Implementation SCAN Centers established to serve VHA facilities (CBOCs and Medical Centers)
Initial SCAN clinics will focus on 4 diseases / conditions
Diabetes, Pain Management, Hepatitis C, Cardiology
Additional SCAN “clinics” will be added based on the availability of funds, expertise of Specialists at the SCAN Centers, interest among PCPs, success of the initial clinics, and program refinements VA SCAN-ECHO Centers VA Connecticut Health Care System (V1)
Richmond VAMC (V6)
Cleveland VAMC (V10)*
VA Ann Arbor Health Care System (V11)*
VA New Mexico Health Care System (V18)*
VA Eastern Colorado Health Care System (V19)*
VA Greater Los Angeles Health Care System / San Diego VAMC (V22)* Roles and Responsibilities Teams to develop SOPs for each disease and/or condition
Training will be provided by staff from University of New Mexico – Project ECHO
Educational modules will be developed in collaboration with National Program Directors & Specialists
Evaluation components are under development in partnership with HSR&D and Office of System Redesign/VERC * Participating in Cardiology SCAN / ECHO Reduced referral fee costs
More efficient use of Specialists time Improved communication between Specialist and PCP
Improved Veteran and provider satisfaction Intended Outcomes SCAN /
ECHO Know your processes Promoting access through improved processes for clinic and non-clinic visits Patient Centered Access Providing Same-Day Availability Objective List the benefits of same-day access
compare it to carve-out, denial, and saturated models of providing access to care
Measure, analyze, and balance supply of appointments with the demand for care
List the steps to achieve and maintain same-day access Access Models Old New Access: OLD Access: NEW Continuity: Every patient sees their own provider/team member
Capacity: Future schedule is truly open
Backlog has been eliminated
Increase non-appointment care
Increase shared medical appointments
Right team member engaged with right patient’s needs (RN, Pharm. D., Nutritionist)
Right needs addressed by right tool (phone, email) Why is it so hard to do? Failure to understand the basic supply and demand dynamic 1. Know, Understand
& Balance
Supply and Demand 2. Reduce the Backlog Backlog is defined as…
Measured by….
Created when…. What is BACKLOG? Erlang's Law Reduce the BACKLOG Measure
Communicate within the teamlet
Standardize and right-size supply
Add temporary supply
Pull increasing amounts of work into today
Use tools to reduce demand
Protect providers who decreased backlog Utilize Appropriate Appointment Types and Times Use the smallest number of appointment types and lengths
Assure appointment interval is correct length
Utilization Telephone Visits
Utilization of Shared Medical Appointments Saturated schedules
Triage and rework often with high intensity resource
Multiple appointment types
Needs for “urgent”, “routine” and intermediate not met
Getting capacity: overbook or send “over there”
Continuity: Fine if you can wait Creating Schedule Space Work Smarter = reduce provider demand
Improve continuity
Reduce no show/fail to keep rate
Extend return visit interval
Schedule phone visits
Use secure messaging
Delegate tasks to others
Use group visits
Increase self care
Is Face-to-Face necessary Where is my practice data? What if...? VISITS VISITS VISITS Email Phones Ongoing relationship with personal teamlet
Whole person orientation
Enhanced access to care
Coordinated care across the health system
Quality and safety T21 People Centric Results Driven Forward Looking Improve Quality and Access... Increase Veteran client Satisfaction... Raise Readiness... Improve Internal Customer Satisfaction... Goals Principles Make it easier to receive the right benefits Educate and empower veterans and their families Build our internal capacity to serve Design a Veteran Centric Health Care Model Develop a PACT with the Veteran... to provide the
BEST CARE anywhere Re-engineer our Primary care to:

provide "Patient Aligned Care Teams"
offer first contact, comprehensive, coordinated care. Promotion of Disease Prevention Ensure timely,
appropriate access to care. Increase useage
of the
PACT team design Enhance useage
of
non-hospitalized care Create a culture of patient centered care 8. Enhance the veteran's experience and access 1. Eliminate Veterans Homelessness

2. Enable 21st century benefits delivery and services

3. Automate GI bill benefits

4. Create Virtual lifetime electronic record

5. Improve Veterans mental health

6. Build Veteran Relations Management capability (VRM) for seamless interactions 7. Design a veteran centric health care model

8. Enhance the Veterans experience and access to health care

9. Ensure preparedness to meet emergent national needs

10. Develop systems to drive performance and outcomes

11. Establish VA management infrastructure an integrated operating model 12. Transform human capital management

13.Perform research and development to enhance the long term health and well-being of Veterans

14.Optimize the utilization of VA’s Capitol portfolio by implementing and executing the strategic capital investment planning process

15.Health care efficiency: improve the quality of health care while reducing cost

16.Transform health care delivery through health informatics. Share one point in the video that stuck out to you How will you put this into practice? Point that Stuck Out to you Chronic Diseases currently monitored:
CHF
COPD
Hypertension
Depression
Diabetes Home TeleHealth provides close monitoring of Veterans, at home, who have chronic diseases

Gives Veterans a monitor to use at home that they log into daily Home Telehealth Overview Access to care in their home
Improved Healthcare Outcomes for chronic disease
Increased care between Primary Care visits
More timely clinical interventions:
medical changes identified quickly
changes in care plan completed sooner and often without an appointment
continuous preventive health education Benefits to Veterans: Benefits to PACT Teamlets: Results lead to a reduction in:
Bed Days Of Care (BDOC)
ER Visits
Triage calls
Timely completion of prevention screens (clinical reminders) Increased primary care between visits
Resource for closer monitoring and accurate assessment of chronic diseases patients
Continuous health status updates with real time critical values Improves Care Management & Coordination Focuses on comprehensive health promotion and disease management daily
Activates and engages patients in self management through ongoing education in their home
Reinforces patient’s self-care skills
Provides Caregiver burden screening and support
Provides communication and feedback with PACT Teamlet HT Serves These Veteran Populations: Non-Institutional Care (NIC)
Chronic Care Management (CCM)
Acute Care
Health Promotion/Disease Prevention Frequent Users/Frequent Callers?
Limited in their ability to access Care?
Living in remote, rural or urban areas where travel to the clinic is often difficult and unreliable?
Without adequate caregiver support?
At risk for nursing home placement?
High risk and high cost to the system? Do you have patients who are.. If you answered "YES" to any of these, then Home Telehealth may be the right choice for your Veterans and their caregivers Using HT Messaging Devices in Veteran's Homes for Health Information Consult submitted by PACT teamlet for HT; in some cases this may also be driven by facility policy/protocol

Plan of care is developed by HT Care Coordinator aligned with goals & targets identified by the Veteran and the PACT teamlet. HT Process of Care And so much more!

Do You Have Success Stories from HT? George Susan Roy It's Not About the Technology... It's About Making the Connection with Patients “Being on this program has saved my life”

“I feel more secure knowing you folks are there to watch over me” The Voice of the Veteran “This program has saved me time”

“My patients are very satisfied with the Home Telehealth program.” The Voice of the Providers “The quickness of this program in getting me what I need always amazes me”

“I got to see my platoon buddies because this program made me well enough to travel, you can’t put a price tag on something like that” “My patients seem to be able to follow their treatment regimen better when enrolled in HT”

“I have been able to extend the amount of time between clinic visits because of the HT team” ? s Health Promotion Disease Prevention
Promotes evidence-based patient-driven care in Health Promotion and Disease Prevention (HPDP).
Collaborates training in health coaching, Self-management support, motivational interviewing
Develops relationships with external stakeholders and agencies to enhance and support HPDP programs and services and healthy behavior adoption among Veterans. Health Behavior Coordinator
Performs health psychology assessment/intervention (e.g., pre-bariatric surgery, Veterans with unique or complex problems impacting self-management plans).
Leads and coordinates training and ongoing coaching for PACT staff in:
Patient-centered communication
Health behavior change coaching
Self-management support strategies, including TEACH for Success and Motivational Interviewing Registered Dietitian
Create individually tailored nutrition strategies
Provide nutritional intervention at desired time of service
Screen for potential nutrition risk factors
Counsel to motivate/inspire healthy behavior changes
Provide follow-up to help Veterans meet their healthy nutrition goals
Implement Medical Nutrition Therapy Clinical Pharmacy Specialist
Pharmacist visits for medication management,
Same day access for complex medication issues
Medication Reconciliation prior to 1st PC visit for newly enrolled
Management of treatment resistant patients or patients with compliance issues
Chronic Disease Registry review for medication optimization
Post Discharge Follow-up and High Risk identification Social Work Case Management
Support PACT Team members with challenging patient-care situations Collaborate
Assist Veterans and their families/caregivers in resolving psychosocial, emotional and economic barriers to health and well-being
Interface with other Specialty Case management Programs
Identify high risk cohorts to prevent inpatient stays due to psychosocial issues
Collaborate with inpatient SW in discharge planning for pts at high risk for re-admission due to psychosocial or environmental Primary Care-Mental Health Integration
Evaluation and brief treatment for mental health and behavioral conditions that do not require Specialty Mental Health services

Facilitate transfer of care to Specialty Mental Health services if needed

Early identification, education, and intervention for behavioral, psychiatric and/or emotional issues Characteristics of Expanded Teams Completed PC appts
w/in 7 days of Desired Date Same-Day Appts w/ PCP Primary Care Provider Continuity Telephone Utilization Post-Discharge Contact # of completed PC appts for new and established pts # of completed F2F PC appts which took place w/in (= / <) 7 days of desired date # of completed F2F appts w/ PCP or assoc. Prov where desired appt date is same as appt creation date # F2F appts completed on day of or day after same-day appt req. Tot # of encounters
for assigned PC pts. # of PC Encounters While on Panel w/ pts assigned PCP (or assoc) Includes: Encounters in PC w/ assigned PCP (or assoc) AND VHA ED/UC encounters AND PC Encounters w/ a prov. other than pts PCP (or assoc) # of PC encounters for prov./assoc prov. assigned PC panel # of PC tele encounters # VHA inpatient discharges from any VAMC of assigned PC pts # of discharges with f/u contact with VA PC at any VAMC w/in 2 business days of discharge. PACT
Recognition program PACT
Recognition program PACT
Recognition program PACT
Recognition program Washington Post, Apr. 2010 Over 1.79 Million Registered Users
Over 30.5 Million Rx Refill Requests Processed via MHV
Averaging over 23,000 new Rx refill requests daily for FY 2012
More than 900 refill requests per hour for FY 2012
Over 350,000 VA Patients Opted In for Secure Messaging
Averaging 925 new patients daily in FY 2012
Over 750,000 Authenticated Patients
Averaging 8,466 authentications per week (FY 2012)
VISNs 20, 5, 21, 18 and 11 have Highest Percentage of their baseline
FY 2010 VA Patients Authenticated
VISNs 20, 7, 8, 16, and 6 with Highest Total Number of Authentications Importance of Transitions of Care Ineffective Transitions = Poor Outcomes

Delay in diagnosis

Wrong treatment

Severe adverse events

Patient complaints

Increased length of stay

Increased health care costs 7 Elements of Safe Transitions Medication Management / Reconciliation
Transition Planning
Patient and Family Engagement/Education
Information Transfer
Follow Up Care
Healthcare Provider Engagement
Shared Accountability Definition of Care Transitions
“The movement that patients make between healthcare practitioners and settings as their condition and care needs change during the course of a chronic or acute illness.”
California Health Care Foundation Critical Care Transitions Within Settings
Primary care  Specialty care
ICU  Ward
ED  Primary Care

Between Settings
Hospital  Sub-acute facility
Ambulatory clinic  Senior center
Hospital  Home

Across health states
Curative care  Palliative care/Hospice
Personal residence  Assisted living Transition of Care Samples Patient presenting with Uncontrolled DM in need of admission to a VA hospital Highly rural 92 Yr. Old patient with lung Ca, in need of admission to Non-VA hospital OEF/OIF Patient Presenting to VA ER needing referral to PACT Team Patient returning from Non-VA hospitalization due to stroke, following up with PACT team. Transitions High Risk: Management Elderly (frail or > 80)
Frequent Admissions/Re-adm.
Frequent ED visits
Complex patients with uncontrolled conditions
Poor Psychosocial support systems May benefit from case management
Some may benefit from frequent contact with RNCM
May benefit from Home Telehealth
May benefit from Community resources Moderate Risk: Management Those with one or more chronic disease health problems
Stable disease processes
Self Management skill development Alternative visits – nurse clinics, group visits, scheduled telephone clinic visits, discipline specific visits
Secure Messaging
Self Management skills
Tracking reports Low Risk: Management Time limited or uncomplicated health condition, but well-controlled
No active medical issues (mental or psychosocial) Proactive identification of preventive health screens & interventions
Facilitate MyHealtheVet and Secure Messaging use
HPDP (Health Promotion Disease Prevention Coordinator)
HBC (Health Behavior Coordinator) Unknown Risk: Management No shows
No recent encounters with a healthcare system (past 1-2 yrs)
Not seen by PCP – but has been seen by MH
No recent PC encounters but several ER visits Check demographics
Telephone visit to determine health care needs http://vhacinsql1.v10.med.va.gov We recommend the use of four symbols to create process flow diagrams: Beginning or
End processing step or event Flow Chart Shapes Square/Rectangle Diamond Kapowee Circle Flowcharting Example - Changing Mapping Can you recognize
waste? Steps for creating spaghetti diagrams: Find or create a diagram of the workspace.
Note the physical location of the worker at the beginning of the process.
Observe the process, drawing lines that follow the path that the worker takes as they complete the processing steps. Spaghetti Diagram 8 Flow Charting / Flow Mapping A picture of the process
Serves to identify a process clearly, clarifies the start, end, and key decision points for a process
Allows teams to agree on the process VA~TAMMCS
MAP Flow Charting Benefits Increase understanding of the overall process
Identify Improvement targets
Increase Teamlet awareness of how they fit into the overall process
Improve communication between people and service
Identify any discrepancies between policy and practice
Identify opportunities for improvement
Constructing Flow Chart
Check List Step 1: Determine the Boundaries (Start & End)
Step 2: List the Steps
Step 3: Sequence the Steps
Step 4: Draw Appropriate Symbols
Step 5: Check for Completeness
Step 6: Finalize the Flowchart The spaghetti diagram is used to examine the physical path that a patient takes through a treatment area or the path that a health care worker takes as they perform tasks associated with patient care. Spaghetti Diagram Lines may be numbered
to reflect the steps on
the process map. (Process Step) Events or processing steps that have a single possible outcome (Decision) Events or processing steps that have multiple possible outcomes. Events that occur resulting in an interruption to the processing flow, a.k.a. ‘Kapowees’ Hello! My name is Aiden
and I am just 1 year old.
I am a growing boy and I love to eat…
afterwards, my daddy Jake needs to do the unthinkable… Examples of Messages to Save to CPRS
1. Patient requesting and receiving more information about a health condition
2. Patient asking for and receiving test results
3. Reporting problems with a medication
4. New or worsening health-related issue
5. Information about care received outside of the VA
6. Status about a chronic condition, including improvement, worsening or status quo
7. Questions about a new condition or treatment or test Secure Messaging MHV Statistics Update
Thru June 2012 The Football Huddle
A quick huddle can ensure that everyone is on the same page
In every work environment, there are multiple opportunities for reducing non-value added activities that have, over time, become an ingrained part of our standard operating procedure. All things operate in a process A high number of process steps can cause waste, delays, and decreased reliability (quality)
Variations lead to an increase in process steps that often result in defects/errors
Key: make processes operate without waste and minimal variation Create a Flow
Map Patient Process Flow Map On your table you will find a large piece of flip chart paper and 4 different shapes of post-it notes.

As a team create a process flow map of a patient visiting your clinic. VA TAMMCS
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