How To Improve Patient-Centered Primary Care This document contains a portfolio of resources to aide primary care practices in their efforts to improve the quality of care and experience their patients receive. Version 1.0 January 2012
Developed by: Kyrsten Chambers Access HealthColumbus Staff Kim Raderstorf Access HealthColumbus Consultant
For any questions regarding this document please contact: Jeff Biehl, President, Access HealthColumbus: jbiehl@accesshealthcolumbus.org Kyrsten Chambers, Project Coordinator, Access HealthColumbus: kyrsten@accesshealthcolumbus.org
TABLE OF CONTENTS
I. Introduction and Overview
Pages: 1-6
II. Access and Continuity of Care
Pages: 7-9
III. Care Coordination
Pages:10-12
IV. Patient and Family Engagement
Pages:13-15
V. Patient Self-Health Management
Pages: 16-18
Version 1.0 (DRAFT) November 2011
How To Improve Patient-Centered Primary Care
The purpose of this ini a ve is to provide primary care prac ces with the tools and knowledge needed to learn “how to” improve the value of pa ent‐centered services for pa ents/consumers based on na onal standards and best prac ces.
Why are We Supporting Primary Care Improvement? The current national focus is targeted at promoting primary care improvement by supporting comprehensive primary care to create better health, better care and lower costs. In alignment with this national trend, Access HealthColumbus created a “How To“ portfolio to provide the information needed for patient-centered primary care practices to implement practice improvement projects in the following four areas:
Con nuous Primary Care Improvement
Access and Continuity of Care Care Coordination Patient and Family Engagement Patient Self-Health Management
Each of the four improvement areas has an introduction that outlines the necessary key project steps and processes recommended for practices to learn “How To” improve patient-centered services. Tools and resources included in this “How To” portfolio are based on national standards and best practices. The following four definitions outline the purpose of each project improvement area.
Improvement Project Areas of Focus Access & Con nuity of Care
Care Coordina on Pa ent and Family Engagement
To enhance access to care and con nuity through improved systems/procedures, such as open scheduling, expanded hours and new op ons for communica on between pa ents, their personal provider, and prac ce staff. (Derived from the PCMH Joint Principals. Sourced from the PCPCC: h p://www.pcpcc.net/content/joint‐principles‐pa ent‐ centered‐medical‐home)
To improve care coordina on and integra on across all elements of the complex health care system and the pa ent’s community. (Derived from the PCMH Joint Principals. Sourced from the PCPCC: h p://www.pcpcc.net/content/joint‐principles‐pa ent‐ centered‐medical‐home)
To redefine pa ent‐provider rela onships in primary care by using an approach to plan, deliver and evaluate care grounded in mutually beneficial partnerships among providers, pa ents and families. (Derived from the Planetree Defini on. Sourced from the PCPCC: h p://www.pcpcc.net/files/ pcpcc_cce_consumer_views_of_pcc_7‐29‐11.pdf)
Pa ent Self‐Health Management
To ins ll the knowledge, skills and confidence integral for pa ents to manage their overall health or chronic condi on, and engage in disease preven on efforts. (Derived from Pa ent Ac va on Management Survey sourced from www.insigniahealth.com)
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PROCESS FOR “HOW TO” IMPROVE YOUR PRIMARY CARE PRACTICE
The following key project steps outline the process needed to start an improvement project initiative at your primary care practice. We have provided a step by step process to get you started on the pathway to improving primary care for your patients. In addition, we have included team planning worksheets to provide your practice improvement team with a good place to start.
KEY PROJECT STEPS Step 1: Hold Practice Shared Learning Session w/Staff
Review the Primary Care Practice Improvement Portfolio and Overview
Identify Practice Improvement Team Members
Create Improvement Team Expectations and Roles (See Goal Setting Worksheet example on page 3)
Develop Shared Purpose Statement
“Why are we doing this? And ”What is our end goal?”
Step 2: Perform Discovery Assessment
Hold Team Meeting to Answer Overall Discovery Assessment Questions
What are your needs and expectations for your improvement project?
How would you know if you were doing a good job? (State ways (performance indicators) that show how you judge the quality of your practice.)
What goals do you have?
Name 1 thing your team could do better, differently, or change?
Step 3: Choose Improvement Project and Track Progress
Determine Improvement Project Action Plan and Process
Set Goals and Timeline
Develop and Set Team Member Responsibilities
Track Improvement Project Success
Step 4: Review Improvement Project Progress and Determine Next Steps
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Discovery Assessment Worksheet-Overall
1.
What are your needs and expectations for your improvement project?
2. How would you know if you were doing a good job? (State ways (performance indicators) that show how you judge the quality of your practice.)
3. What goals do you have?
4. Name 1 thing your team could do better, differently, or change?
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Goal Planning Sheet Target Date Champion Goal
Step Number
Action
Measures of Progress
l ----- l ----- l ----- l ----- l -----l ----- l ----- l ----- l ----- l ----- l ----- l 0%
Start Date
10%
20%
30%
40%
4
50%
Who
Date Completed
60% 70% 80% 90% 100%
Goal Tracking How to Measure Goal Achievement Step 1 ________________________________________________10% Is the goal well-defined? Has a champion been assigned? Have basic steps and timing been estimated? Step 2________________________________________________30% Have the means for achieving the goal been identified? Have equipment, material, staffing and methods been initially approved? Have all the necessary resources been acquired? Step 3________________________________________________40% Has a detailed action plan been developed? Step 4________________________________________________50% Means of achieving the goal are fully designed, developed and ready for implementation. Have all final approvals been received? Step 5________________________________________________90% All action steps have been implemented to achieve the goal. Step 6________________________________________________100% We need to assess the effectiveness and degree of success. Performance indicators have been discussed and the team is satisfied. Has the implementation also passed the test of time?
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Goal Planning Sheet (Sample) Completion Date 1/12/2012 Champion Smith Goal Customize goal setting and tracking sheets to be used with patients for self-health coaching. Step Number 1. 2.
3.
4.
Action Read CHAP – Take Action (insert link) Have Team write an action plan for chronic problem in their life. They can utilize the Asthma and Diabetes Action Plans as a template. Team asks self – How sure are you that you can follow your action plan? Who can help? What barriers will prevent action? Team discusses answers to these questions. Team monitors and charts progress towards goal on run chart.
Start Date 1/3/12 1/3/12
Who
1/3/12
Team
1/3 – 1/10/12
Team
Team Smith and team
5.
Team reconvenes to discuss experience. Led by Smith, team now customizes action plans and run charts to meet patient needs.
1/10/12
Smith and team
6.
Team distributes customized sheets to assigned providers. Provides training as needed on the spot. Describes how progress towards self-health coaching will be monitored (e.g. patient count). After conversation, team member checks off provider’s name on VMS (Visible Measurement System-like a poster) as trained in coaching methods and documents. Each team member recycles this conversation on a weekly basis with assigned providers to encourage coaching.
1/12/12
Team
Ongoing
Team
Ongoing
Team
7.
8.
Measures of Progress
Date Completed
l ----- l ----- l ----- l ----- l -----l ----- l ----- l ----- l ----- l ----- l ----- l 0%
10%
20%
30%
40%
6
50%
60% 70% 80% 90% 100%
PROCESS FOR “HOW TO” IMPROVE PATIENT ACCESS AND CONTINUITY OF CARE The following key project steps outline the process needed to start an improvement project focused on improving patient access and continuity of care with their assigned or preferred primary care provider. This improvement project area focuses on enhancing access to care and continuity through improved systems/procedures, such as open scheduling, expanded hours and new options for communication between patients, their personal provider, and practice staff. KEY PROJECT STEPS Step 1: Complete Discovery Assessment Activity: Answer “Access and Continuity of Care” Discovery Assessment Worksheet
What are your needs and expectations for creating better access for patients?
How do you know if you are doing a good job creating access for patients? (State ways (performance indicators) that show how you judge the access of your practice.)
Name 1 thing your medical practice could do better, differently or change to give patients better access?
Explore and discuss “Discovery Assessment” results
Review existing access and continuity of care policies at the practice
Brainstorm access and continuity of care activities staff would like to work on
Step 2: Solve Problems Related to Appointment Scheduling Activity: Review Current Practice Policies Related to Appointment Scheduling
Review data related to scheduling:
Do we know how long patient wait times are at our practice?
Do we know how large our practice schedules patient backlog is?
List and review current scheduling practices
Propose tools and solutions to reduce backlog and other issues using proposed resources:
Backlog Reduction Worksheet:
http://www.ihi.org/knowledge/Pages/Tools/BacklogReductionWorksheet.aspx
Third Next Available Appointment Process and Example
http://www.ihi.org/knowledge/Pages/Measures/ThirdNextAvailableAppointment.aspx
Appointment Sequencing Worksheet
http://www.ihi.org/knowledge/Pages/Tools/BacklogReductionWorksheet.aspx
Group Visits
http://www.aafp.org/online/etc/medialib/aafp_org/documents/clinical/pub_health/aim/ groupvisits.Par.0001.File.tmp/GroupVisitAIM.pdf
After-Hours and Email Access
http://www.aafp.org/online/en/home/policy/policies/e/evisits.html
http://www.qhmedicalhome.org/safety-net/upload/EnhancedAccess_ImpGuide.pdf (pg.13)
Create action plan for team to implement practice scheduling solutions
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Step 3: Specify Process to Assure Greater Patient Responsibility for Managing Care Activity: Develop Patient Responsibility Checklist for Appointments
Create Patient Responsibility Checklist
Patient Responsibility Appointment Checklist
http://www.pcpcc.net/files/pcmhpatientchecklist_0.pdf
Create reminder policy and process to ensure patients bring checklist to appointment
Create action plan that assures follow-up before the appointment with the patient to ensure they have all of the necessary information needed for the appointment.
Utilize team huddles to determine what each patient will need for their appointment and confer with patient checklist to prep patients efficiently before their appointment
Team Huddles
http://www.ihi.org/knowledge/Pages/Changes/ UseRegularHuddlesandStaffMeetingstoPlanProductionandtoOptimizeTeamCommunication.aspx
Step 3: Implement and Evaluate Activity: Evaluate Progress Towards Improved Access and Continuity of Care
Develop at least two performance indicators for improving access and continuity of care
Establish simple process for measuring progress towards access and continuity of care improvement
Track progress and performance
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Discovery Assessment Worksheet Access and Continuity of Care
1. What are your needs and expectations for creating better access for patients?
2. How do you know if you are doing a good job creating access for patients? (State ways (performance indicators) that show how you judge the access of your practice.)
3. Name 1 thing your medical practice could do better, differently or change to give patients better access?
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PROCESS FOR “HOW TO” IMPROVE CARE COORDINATION The following key project steps outline the process needed to start an improvement project focused on improving care coordination and integration across all elements of the complex health care system and the patient’s healthcare community. This improvement project area focuses on better coordinating patient’s care across their primary care practice through improved systems/procedures, implementing referral tracking processes and developing patient follow-up policies, working towards enhancing communication between patients, their personal provider, practice staff and other members of the patient’s healthcare community. KEY PROJECT STEPS Step 1: Complete Discovery Assessment Activity: Answer “Care Coordination” Discovery Assessment Worksheet
What are your needs and expectations for coordinating care for patients?
How do you know if you are doing a good job coordinating care for patients? (State ways (performance indicators) that show how you judge patient care coordination in your practice.)
Name 1 thing your practice could do better or differently related to care coordination?
Explore and discuss “Discovery Assessment” results
Review existing care coordination policies at the practice
Brainstorm care coordination activities staff would like to work on
Step 2: Develop Staffing Model to Support Care Coordination Activity: Visualize Care Coordination Process
If available, review current data related to care coordination:
What is the current policy/process in place for care coordination?
Who are the current staff members whose job responsibility is care coordination?
What is/isn’t working?
Create a flow chart of the current process
Visualize positive changes to process and record on new flow chart
Determine staffing availability, experience and responsibility for recommended care coordination process
Step 3: Develop Skills and Materials to Support Care Coordination Activity: Customize Materials for New Care Coordination Strategy
Propose tools and solutions to improve care coordination.
Care Coordination Action Plan Worksheet
http://www.intrahealth.org/tol/documents/actionplan.pdf
Care Coordination Team Huddles
http://www.ihi.org/knowledge/Pages/ ChangesUseRegularHuddlesandStaffMeetingstoPlanProductionandtoOptimizeTeamCommunication.aspx
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http://www.ihi.org/knowledge/Knowledge%20Center%20Assets/Tools%20-% 20Huddles_75bc6994-c794-432c-b7fc-739278dbdf0f/Huddles1.pdf
Care Coordination Referral Curriculum for Current Practice Staff
http://www.improvingchroniccare.org/ downloads/5_referral_coordinator_curriculum.pdf
Care Coordination Tracking Referrals Overview and Worksheet
http://www.improvingchroniccare.org/downloads/3_referral_tracking_guide.pdf
Patient Responsibility Assessment Checklist
http://www.improvingchroniccare.org/downloads/6_patient_referral_checklist.pdf
Develop a Community Resource List for Patients
http://www.handsoncentralohio.org/ or call: 2-1-1
Create action plan that incorporates selected care coordination resources
Step 4: Specify Process to Assure Greater Patient Responsibility for Managing Care Activity: Develop Patient Referral Process Self-Health Management Responsibilities
Create Patient Responsibility Checklist:
Patient Responsibility Checklist
http://www.improvingchroniccare.org/downloads/6_patient_referral_checklist.pdf
Create practice policy/process that assures follow-up before the referral appointment with the patient to ensure they have all of the necessary information needed for the appointment
Implement practice policies that support practice improvements
Step 5: Implement and Evaluate Activity: Evaluate Progress Towards Improved Care Coordination
Develop at least two performance indicators for care coordination
Establish simple process for measuring progress towards care coordination
Track progress and performance
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Discovery Assessment Worksheet Care Coordination
1. What are your needs and expectations for coordinating care for patients?
2. How do you know if you are doing a good job coordinating care for patients? (State ways (performance indicators) that show how you judge patient care coordination in your practice.)
3. Name 1 thing your practice could do better or differently related to care coordination?
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PROCESS FOR “HOW TO” IMPROVE PATIENT AND FAMILY ENGAGEMENT The following key project steps outline the process needed to start an improvement project focused on redefining patient-provider relationships in primary care by using an approach to plan, deliver and evaluate care grounded in mutually beneficial partnerships among providers, patients and families. KEY PROJECT STEPS Step 1: Complete Discovery Assessment Activity: Answer “Patient and Family Engagement” Discovery Assessment Questions
What are your needs and expectations for patient and family engagement?
How do you know if you are doing a good job engaging patients? (State ways (performance indicators) that show how you judge the quality of relationship with your patients.)
Name 1 thing your primary care practice could do better, differently or change related to patient engagement?
Explore and discuss “Discovery Assessment” results
Review existing patient and family engagement policies at the practice
Identify how the practice wants to communicate better with practices
Brainstorm and create action plan for engagement activities staff would like to work on
Step 2: Develop Practice Specific Patient and Family Engagement Materials Activity: Develop Patient and Family Engagement Materials
Decide what media practice would like to use to share important information and engage patients and family with the practice and staff:
Patient and Family Engagement Brochure and Guide
http://www.pcpcc.net/files/gruman_et-al_creating-patient-guide-for-medical-homephysician-practice.pdf
Patient and Family Engagement Guide
http://www.pcpcc.net/files/Supporting_Engagement_PCMH.pdf
Determine what information the practice would like to include in handouts
Create patient and family engagement materials
Develop process/goals for creating and distributing these materials
Step 3: Develop Materials to Identify Patient and Family Roles in the Primary Care Practice Activity: Define Patient and Family Roles and Develop Supporting Materials
Determine what the practice sees as the patient’s role
Develop checklist to communicate patient’s role
Patient Responsibility Checklist
http://www.pcpcc.net/files/pcmhpatientchecklist_0.pdf
Create and implement policy to distribute checklists and follow-up
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Step 4: Create Practice Patient-Provider Advisory Council Activity: Work Towards Establishing Patient-Provider Advisory Council (PPAC)
Define the purpose and scope of practice PPAC
Patient-Provider Advisory Council Best Practices Articles
http://www.ipfcc.org/advance/Advisory_Councils.pdf
http://www.ahrq.gov/qual/advisorycouncil/adcouncil3.htm
Create criteria for PPAC participation
Develop action plan and objectives to create PPAC and invite patients to be involved
Patient-Provider Advisory Council Objectives and Goals
http://www.ahrq.gov/qual/advisorycouncil/adcouncilapa.htm
Carry out PPAC action plan
Step 5: Implement and Evaluate Activity: Evaluate Progress Towards Improving Patient and Family Engagement and Establishing a PPAC
Develop at least two performance indicators for patient and family engagement, including the PPAC
Establish simple process for measuring progress towards establishing a successful PPAC
Track progress and performance
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Discovery Assessment Worksheet Patient and Family Engagement
1. What are your needs and expectations for patient and family engagement?
2. How do you know if you are doing a good job engaging patients? (State ways (performance indicators) that show how you judge the quality of relationship with your patients.)
3. Name 1 thing your primary care practice could do better, differently or change related to patient and family engagement?
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PROCESS FOR “HOW TO” IMPROVE PATIENT SELF‐HEALTH MANAGEMENT The following key project steps outline the process needed to improve patient self-health management. This improvement project area focuses on empowering patients with the knowledge, skills and confidence integral to manage their overall health or chronic condition, and engage in disease prevention efforts, by creating health action plans and . KEY PROJECT STEPS Step 1: Complete Discovery Assessment Activity: Answer “Patient Self-Health Management” Discovery Assessment Worksheet
What are your needs and expectations for empowering patients to care for their own health?
How do you know if you are doing a good job empowering patients? (State ways (performance indicators) that show how you judge the patient self-health management quality of your practice.)
Name 1 thing your practice could do better, differently or change to empower patients to play an active role in their care?
Explore and discuss “Discovery Assessment” results
Review existing patient self-health management policies at the practice
Review current patient charts/information to determine percentage of patients who receive patient self-health management education or coaching
Brainstorm patient health-management of care activities staff would like to work on
Step 2: Develop Self-Health Management Process Flow Chart Activity: Visualize Self-Health Management Process
Review data from chart review. Set new goal for number of patients that receive self-health management counseling
Create flow chart of current process
Visualize positive changes to process. Record on new flow chart
Create action plan for team to implement flow chart
Step 3: Develop Materials to Support Patient Self-Health Management Activity: Develop Skills and Materials Needed to Support Self-Health Management
Focus on improving patient and provider communication
Review motivational interviewing strategies to discuss methods to better engage patients about their health care and communicate health care prevention/management education effectively
Motivational Interviewing Best Practices Article
http://www.nova.edu/gsc/forms/mi_rationale_techniques.pdf
Customize goal setting and tracking sheets to be used with patients
Asthma Action Plan
http://www.nhlbi.nih.gov/health/public/lung/asthma/asthma_actplan.pdf
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Diabetes Action Plan
https://www.harvardpilgrim.org/pls/portal/docs/PAGE/PROVIDERS/PATIENT/ HANDOUTS/DIABETES_ACTION_PLAN_6.11.PDF
Step 4: Implement, track and evaluate. Activity: Evaluate Progress Towards Improving Self-Health Management
Assure that goal-setting sheet and tracking tools are being used by staff while coaching patients
State at least two performance indicators for self-health management
Establish simple process for measuring progress towards self-health management
Create action plan for team to implement practice scheduling solutions
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Discovery Assessment Worksheet Patient Self-Health Management
1. What are your needs and expectations for empowering patients to care for their own health?
2. How do you know if you are doing a good job empowering patients? (State ways (performance indicators) that show how you judge the patient self-health management quality of your practice.)
3. Name 1 thing your practice could do better, differently or change to empower patients to play an active role in their care?
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