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VISN 11 PACT COE Combined Session 1 & 2

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Aron Pollock

on 28 November 2014

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Transcript of VISN 11 PACT COE Combined Session 1 & 2

Radiating Possibilities
PACT Care Tools
Care Management
Patient Aligned Care Team
Combined Session 1 & 2
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.
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
Non-Traditional Care
Unique patients assigned to provider
# of PC Tele Encts + PC Group Enc +
Incoming & Outgoing Sec. Messages
Post-Discharge Contact
# VHA inpatient discharges from any VAMC of assigned PC pts
# of discharges with f/u contact by a member of the assigned PACT team w/in 2 business days of discharge
Completed PC appts
w/in 7 days of Desired Date
# of completed PC appts for new and established pts
# of completed F2F PC appts which took place w/in (= / <) 7 days of desired date
92 %
Same-Day Appts w/ PCP
# 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 or day after appt request/desired date
Primary Care Provider Continuity
Tot # of encounters for assigned PC pts.
# of PC Encounters While on Panel w/ pt's 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)
PACT Metrics
Non-Traditional Care...................20%
Completed PC Appts. w/in
7 Days of Desired Date.....................92%

Same Day Appts. w/ PCP..................70%
2 Day Post-Discharge Contact.........75%

What Does Patient Centered Care mean to
Empathy: The Human Connection to Patient Care
Dir. Office of Patient Centered Care & Cultural Transformation
Dr. Tracy Gaudet
Teams and Teamwork
If you are a
If you're working with a
, consider:
Developing more comfort with emotionally charged situations
Learning to value informal interactions with others
Adjusting standards to the needs of the environment
Approaching in a straightforward manner – stick to business
Building credibility by offering pros and cons to suggestions
Doing what you say you will do
Presenting an implementation plan with timetables
Assuring no surprises
If agreeing, provide follow-through
If disagreeing, make an organized presentation
Giving time to verify reliability of actions
If you're working with a
, consider:
If you are a
Learning to handle change better
Becoming more assertive
Increasing comfort with open conflict
Varying routines occasionally
Speaking up when concerned or bothered
Starting however briefly, with a personal comment
Patiently draw out personal goals
Listening – Be responsive
Presenting information in a non-threatening manner
Watching for areas of possible disagreement – flight rather than fight
If disagreeing – watch for hurt feelings
Clearly defining individual contributions (preferably in writing)
Providing guarantees that decisions will minimize risks
Personality Styles
Team Building
If you're working with a
, consider:
If You are a
Being more objective in making decisions
Developing more organized, systematic approaches to tasks
Improving follow-through by attending to key details
Learning to be more direct
Having better control over use of time
Planning interactions which support interaction
Allowing time for relating/socializing
Talking about people and their goals
Tasks/assignments are followed –up best when in writing
Asking for opinions/ideas
Providing approaches to implementing actions
Providing testimonials from people seen as important or prominent
Offer special, immediate and extra incentives for willingness to participate
If you are a
If you're a Red, consider:
Developing more patience with other people
Learning to negotiate with others
Developing greater awareness of other people’s needs
Participating more with others
Being clear, specific, brief, to the point
Sticking to business
Coming prepared – requirements, objectives, support material
Presenting material in a logical format
Providing alternatives/choices for making “their” decision
If disagreeing, take issue with facts not people
Supporting rather than directing or ordering
Departing graciously
If you're working with a
, consider:
National Center for Organization Development
Each team member knows the expectations and tasks for the whole team and for one another. 
Innovation and continuous improvement
hinges on a work environment
that is psychologically safe
Engaged Teams
Part of becoming a team
is the commitment to
regular checkups and maintenance
Team Effectiveness
Awareness of team priorities, goals, and the global mission statement.
Team members show that they value each other.

"Respect for ourselves guides our morals, respect for others guides our manners."
~ Laurence Sterne
Working well together:
a sense of oneness or that we are ‘all in it together’.

Emphasizing team over personal goals
and accomplishments.
How team members
treat each other
on the job
is noticed by others around them.
Understanding how
what we do is connected
Role Clarity
Awareness &
An environment that encourages and supports their members to:
ask questions
seek clarity
ask for help
share concerns regarding the team’s performance
The quality, type, and amount of communication
is impacted by the level of psychological safety.
Having mutual understanding and respect
for each team member’s role
Civility is the foundation
of all relationships.
Basic courtesies
Just a little bit
Just a little bit
"Goals must never be from your ego,
but problems that cry for a solution."
“The single biggest problem with communication
is the illusion that it has taken place.”
~ George Bernard Shaw
Shared decision making can improve:
team productivity
team member satisfaction
work environment safety
Secure Messaging
What is Secure Messaging?
Secure, encrypted online communication
Patient access through My HealtheVet
For non-urgent issue
Resolve within 3 business days
Can triage messages within a team
Can save messages to CPRS
Message Triage Set-Up (MHV Coordinator)
Associate Triage Model: Clinical or Clerical Asssoc. triage all messages for resolution or re-assignment
Nurse Triage Model: RN or LPN to triage all messages for resolution or re-assignment
Provider Triage Model: Provider reviews all messages for resolution or re-assignment
Team Specific: Team designates triaging team member(s)
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
Examples of Messages NOT needing to be saved to CPRS
1. Rescheduling or requesting an appointment
2. Renewal of a medication
3. Instructions or directions to a clinic or test

Benefits of Telephone Care
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.
Making Time for Telephone Care
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.
Like every appointment - Documentation, Documentation, Documentaiton!
The Appropriate Elements are:
documentation of time
Telephone encounters must be associated with a clinic that is assigned one of the DSS Identifier telephone codes and are to be designated as count clinics for workload collection
Huddles and Team Meetings
5-10 minutes stand-up meeting
Beginning of Shift/Clinic--Quick review of day
End of shift/clinic to plan for the next day
Mid-Day - focusing on afternoon appointments
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
Define responsibilities for each team member
Protected time in schedule for huddles
Isolate the teamlet
Arrange time to huddle
Overcoming Huddle Hurdles
The Football Huddle
A quick huddle can ensure that everyone is on the same page
aka "Scrubbing the Schedule"
What is it?
3 to 7 Day Look Ahead at the current schedule to determine readiness and appropriate level of visit
The purpose:
improve efficiency of daily clinic flow
Shift actions to PRO-ACTIVE not REACTIVE
Better address the needs of the patient with the resources available
How its done:
Team members work together to address:
issues that can be taken care of pre-visit
Redirect patient to appropriate level of care (RN/LVN clinic, phone care...)
Open communication between team members
What To Do:
Established Patient
Reason for visit
ED or recent hospitalization updates
Lab or Consult status
When to Use Telephone Care
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
To Assist in a SMA
Utilize entire team
Seek out extended team members
Clinical Pharmicist
Health Behavior Coach
Health Promotion/Disease Prevention Coordinator
Remember the 50% Rule ~ roughly 50% of those you ask will accept the offer
Seek out templates for documentation

Peripheral Monitoring Devices (wired/wireless)
BP Monitor
Weight Scale
Pulse Oximeter
Glucose Monitor
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:
Results lead to a reduction in:
Bed Days Of Care (BDOC)
ER Visits
Triage calls
Timely completion of prevention screens (clinical reminders)
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
Using HT Messaging Devices in Veteran's Homes
for Health Information
Benefits to PACT Teamlets:
Chronic Diseases currently monitored:
Weight loss
Home Telehealth Overview
It's not about the technology...
...it's about the connection with the veteran
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
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
HT focuses on these Veteran Populations
Chronic Care
Acute Care
Maternity Care*
Smoking Cessation*
*Site Specific
>11 S/E Centers
>25 Conditions
And Growing
Specialty Care Access Network /
Extension for Community Healthcare Outcomes
Purpose & Intended Outcomes
Leverages Telehealth (clinical videoconferencing technology) to allow Specialists from tertiary medical centers the opportunity to provide support/transfer knowledge & skills to Primary Care Providers in less complex facilities or rural areas
Intended Outcomes:
-Improve Access
-Reduce Fee and Travel Costs
-Improve Veteran and Provider Satisfaction
Initiated in June 2011
Modeled after Univ. of New Mexico's Project ECHO
Case based learning between Specialist Teams & PACT Teams (no patient present)
As of FY14
>600 CBOCs have participated
3,600 consults have been placed
Plans for FY15
further expansion of SCAN-ECHO participation in non-hub networks
collaborations with the Office of Mental Health for Substance Abuse
Geriatrics and Extended Care Services (GECS) for Palliative Care.
What Are Protocols:
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 at your facility
Protocols at your facility
Primary Care Provider Continuity....77%
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)
Primary Care Provider Continuity

# of PC Tele Enc + PC Group Enc + Incoming & Outgoing Sec. Messages

Panel Unique Patients assigned to the Provider

Non-Traditional Encounters
Completed PC appts
w/in 7 days of Desired Date
# of completed F2F PC appts which took place w/in (= / <) 7 days of desired date
# of completed PC appts for new and established pts
# of completed PC appts for new and established pts
# F2F appts completed on day of or day after same-day appt req.

# of completed F2F appts w/ PCP or assoc. Prov where desired appt date is same as appt creation date
Critical Care Transitions
Specialty Care
Importance of Transitions of Care
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
Ineffective Transitions = Poor Outcomes

Delay in diagnosis

Wrong treatment

Severe adverse events

Patient complaints

Increased length of stay

Increased health care costs
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
Medication Management / Reconciliation
Transition Planning
Patient and Family Engagement/Education
Information Transfer
Follow Up Care
Healthcare Provider Engagement
Shared Accountability
7 Elements of Safe Transitions
Community Based


RVI - A Closer Look
Non-VA Provider Care
Care Management
Greater Than Just
VA Resources

Goal for Care Management??
Address Moderate Care Patients
keep from creeping to High Risk
move to Lower Risk
Get the Unknown patients to Lower Risk
PC Almanac
Key to Panel Information
PC Compass
Performance Data
PACT Tool Kit
Re-Admission Calculator
We recommend the use of four symbols to create process flow diagrams:
Beginning or
End processing step or event
Flow Chart Shapes
Flowcharting Example - Changing
Systems Redesign

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.
"Because we've always done it that way" steps.
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.
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
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
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…
Create a Flow
Completing the Puzzle of Access
PACT Tools Utilization
Any Others
Spaghetti Mapping
A foot path of a person or trail of a paper
1. Easy/Major
2. Easy/Minor
3. Difficult/Major
4. Difficult/Minor
Focus on the ideas that are
easy to implement
and have a major impact
Systems Redesign
Brain Storming/PDSA

What is Brainstorming?
a group
technique that
involves the
of ideas from


members of the group
Why Brainstorm?
1. Great way to come up with ideas
2. Leverage Collective Think
- building on others ideas
3. Increase activity in the Generative
part of your brain and
decrease activity in the
evaluative part.
Are there Rules to Brainstorming
A few:
There are NO bad ideas
There no Feedback OR
There are no limits
What Constitutes a Telephone Encounter?
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
*VHA Directive 2009-002 Patient Care Data Capture
What To Do: New Patient:
Obtain Outside Records
Medication Review
Visit Instructions
~Pre-visit lab requirements
~please bring....
...are clinical consultations entered into CPRS that can be resolved without a face-to-face encounter.
NEW - Team Approach
Traditional Provider Face-to-Face Visits
Nurse Visits
both RN and LPN/LVN dependent on need
Extended Team Visit
Clinical Pharmacist
Phone Visits
Group Visits
"It doesn't happen all at once. There is no instant pudding."
W. Edwards Deming
Father of Process Improvement
The result of long term relationships is better and better quality.
W. Edwards Deming
Father of Process Improvement
A few final thoughts
Establishes a new approach to specialty care,
providing consultation

without face-to-face contact
What were perceived as barriers
Veteran Having to Travel
Specialist Having to Travel
Are removed leaving PACT Teams with
Ability to respond faster to patient needs

Additional knowledge to
address similar cases
Anecdotally: e-Consults have a turn around time of
24-48 hours.
Active Link to the Systems Redesign Toolkit:
Active Link to VSSC - Location of the Compass and Almanac:
Full transcript