This webinar explored the benefits of teamwork in allowing staff to more effectively deliver preventive services and manage chronic illness. It built on the content from previous webinars to describe how to optimize the core team to provide population management, self-management support and planned care. Infrastructure considerations to improve team-based care were also discussed including training, career ladders, and communication management. This webinar was present April 21, 2016 3:00 PM.

1. Welcome
The National Cooperative Agreement on
Advancing Team-Based Care
WEBINAR 5: A Team Approach to Prevention and Chronic Illness
Management
April 21st, 2016
Presented by the
the Community Health Center, Inc.
& the MacColl Center for Health Care Innovation

2. Speakers
From MacColl Center for Health Care Innovation, Group Health Research Institute:
Ed Wagner, MD, MPH, Director Emeritus
Brian Austin, Deputy Director
Katie Coleman, MSPH, Research Associate
From Community Health Center, Inc.:
Margaret Flinter, APRN, PhD, Senior Vice President & Clinical Director
Kerry Bamrick, MBA, Senior Program Manager
Mary Blankson, DNP, APRN, FNP-C, Chief Nursing Officer
From Cambridge Health Alliance:
Kirsten Meisinger, MD, Regional Medical Director

3. Community Health Center, Inc.
Foundational Pillars
1. Clinical Excellence- fully Integrated teams, fully
integrated EMR, PCMH Level 3
2. Research & Development- CHC’s Weitzman Institute is
the home of formal research, quality improvement, and R&D
3. Training the Next Generation: Postgraduate training
programs for nurse practitioners and postdoctoral clinical
psychologists as well as training for all health professions
students
CHC Profile:
•Founding Year - 1972
•200+ delivery sites
•130k patients

4. The Community Health Center, Inc. and its Weitzman Institute will provide
education, information, and training to interested health centers in:
Transforming Teams
• National Webinars on advancing team based care
• Invited participation in Learning Collaboratives to advance team based care at
your health center
Training the Next Generation
• Two National Webinar series on developing Nurse Practitioner and Clinical
Psychology residency programs and successfully hosting health professions
students within health centers
• Invited participation in Learning Collaboratives to implement these programs at
your health center
Email your contact information to nca@chc1.com and visit www.chc1.com/NCA.

5. Learning Objectives:
1. Participants will understand how the core team can share responsibilities to
reliably deliver population health, planned care and self-management
support.
2. Participants will be able to describe two ways practices build trust by
developing shared competency and training protocols.
3. Participants will be able to identify two innovative practices used to train
and retain high-quality staff by creating career-ladders.

6. Get the Most Out of Your Zoom Experience
• Send your questions using Q&A function in Zoom
• Look for our polling questions
• Live tweet us at @CHCworkforceNCA and #primarycareteams and #HRSAnca
• Recording and slides are available after the presentation on our website within one week
• CME approved activity; requires survey completion
• Upcoming webinars: Register at www.chc1.com/nca

7. A Team Approach to Prevention and
Chronic Illness Management
Learning from Effective Ambulatory Practices
MacColl Center for Health Care Innovation
Group Health Research Institute
April 21, 2016
Ed Wagner, Director Emeritus
Katie Coleman, Research Associate | Brian Austin, Deputy Director

8. How Do Teams Enable Practices To Achieve
Benchmark Preventive Care?
By using their teams to effectively
perform key primary care functions.

9. The Key Functions Of Excellent Primary Care

10. Providing planned,
evidence-based care
to patients presenting
for care—PLANNED
CARE
Need to access care
gap data by
individual patients
(e.g., tomorrow’s
appointments)
Searching for and reaching
out to patients needing
care—POPULATION
MANAGEMENT
Need to access care gap
data by population (e.g.,
patients with type 2
diabetes).
What leads to benchmark clinical
performance?

11. What is a Care Gap?
A care gap is a health problem or service need that
requires attention from the practice team:
• An uncontrolled chronic condition --e.g., type 2 diabetes
with HbA1c >9% without a recent visit.
• An overdue evidence-based service –e.g., mammogram,
diabetic foot exam, flu shot
• An abnormal lab result
• A failed referral—e.g., appointment not made, consultant
note not returned
• A high risk situation—e.g., multiple ER user, opioid
abuse,

12. Population Management/Planned Care
Key Changes
Link each patient to a specific team and provider
Decide which patient populations and which data elements to track
Create consensus to follow selected evidence based guidelines
Develop criteria that specify who/when/how to take action
Enable EMR to provide actionable care gap data on individual patients
and populations
Select and train population management staff
Use data to plan visits and reach out to patients needing care

13. Create Consensus on Evidence Based Guidelines
to Use
Must make guidelines
actionable by
embedding them in
team work flows for
population and panel
management
Selecting & developing
consensus on the
guidelines is
responsibility of
clinicians

14. Population Management
There are four overarching key principles for population management
1. Population-Based Care: Focus on caring for the whole population
you are serving, not just the individuals actively seeking care.
2. Data-Driven Care: Utilize data and analytics in order to make
informed decisions to serve those in your population who most
need care.
3. Evidence-Based Care: Make use of the best available evidence to
guide treatment decisions and delivery of care.
4. Care Management: Engage in actionable care management for
the population you serve.

15. Select and train population
management staff
• In most LEAP practices, population
management is shared among staff;
 Front desk or panel managers review care gaps
requiring appointments to be made
 Team RN reviews chronically ill out of control
patients.
 RN care managers review recent hospital
discharges

16. Steps for planned care
16
Assign the
delivery of key
services to
specific staff and
train them.
Use protocols
and standing
orders to allow
staff to act
independently.
Efficiently
generate patient-
specific care gap
data on patients
to be seen.
HUDDLE the
core team and
organize visits to
close care gaps.

17. Cambridge Health Alliance
Integrating Population Health into
every day care

18. Kirsten Meisinger, MD Rachelle Jean Amberly Ticotsky , RN

19. Central Concepts
• Every interaction with a patient represents an
opportunity to help that patient come closer
to health
• Outreach – go looking for trouble
– Registries are the key tool
• In-reach - every patient, every time, no
excuses
– Lists are the key tool

20. MA and LPN roles on the team
• Flow, warm handoffs to RN, pharmacy and psych
especially important
• Labs, vaccines
• Patient education and reinforcement of team
messages
• Coordination of care – make appts, direct pt to
referral coordinator etc.
• Pharmacy calls and clarifications
• Outreach for selected population health categories

21. Redesigning Care Delivery:
Care is no longer based primarily on visits
Previsit
The time of recognized
need or risk by system
or time of patient
contact to check-in
Care team plans for the
encounter
Visit
Time of check-in to
departure from health
center
Patient’s encounter
with clinician and
care team
Post-visit
Departure to
completion of visit
plans/actions
Between visit
Completion of visit
plans/actions to
previsit
Care management

22. The Clinical Encounter – Pre-visit work
• LPN reviews all appointments for the week on and starts
the documentation, specifically with any immunizations
due
• Format is:
– Provider:
– MA:
– LPN:
– RN:
– timestamp
• MA and MD and RN all do the same (usually the night
before)
• Any team member who sees it is not done yet will start
the process – especially for same day appointments

23. The Clinical Encounter - Huddle
• 2-3 minutes with MA and provider present as a
minimum, co-location means that more often than
not, the RN is also present
• Teams use the “rolling huddle” approach – frequent
check ins with each other to see how things are
going
• RNs focus on tel. management of pts who do not
need an appointment and those who are post-
hospitalization, rising risk etc.
• LPN does ER follow up letters, calls and
appointments and sends to the team

24. The Clinical Encounter – Post visit
• Patient chart is in a folder with a routing slip that serves as the
guide to all post provider stops (lab, referrals, imaging)
• All screening papers arrive in the folder but stay with the
team (if leave in the folder get caught at check out)
• Pt goes to check out and is tracked through labs, referrals etc
by check out on lists (safety concerns addressed and better
flow)
• Advanced Access means usually no follow up appointment
booked
– pt put on a list specifying need for follow up (either for
chronic disease or a recall list)

25. Outreach
• PCM Objective: provide care at a panel level
• Meetings are meant to review a panel of patients, not 1-2 patients
• Coordinated development of action plans by care teams for targeted patient
cohorts; some actions include:
– Send a staff message to remind a team member to schedule a visit with PCP, PA,
RN, BH, Pharmacy, LPN, etc.
– Phone call to update PHQ-9, care plan, ADHD check-in
– Perform a change in medications
– Update HM, problem list, etc.
– Perform a referral to CCM, Specialty, community resources, etc.
– Other…
• Recommended PCMs typically occur weekly and last 30 mins.
25
Week 1 Week 2 Week 3 Week 4
Cancer Screening &
Follow Up
Diabetes &
Hypertension
Depression Complex Care

26. Team meetings
• PCP panel is the unit of work
• 30 minutes once a week, everyone present
• Division of work with increasing panels now
spread across multiple team members, not
just the core team of
MD/MA/RN/Receptionist
• PA and MD cover each other when the other is
away, ensuring the work gets addressed
seamlessly

28. Operational Strategy:
Deploy & monitor
planned care actions
Operational Strategy:
Agree on care actions for
patients in need
1 2 3
PCM Sample Workflow: Hypertension
28
At PCM After PCMBefore PCM
• MAs identify/review
patients who need a BP
test
• RNs identify/review
patients with high BP
• Care team meets to
review HTN patients
• Team agrees on patients
who require outreach for
tests, BP follow ups, or
other
• Snapshot, HM, etc.
updated as needed
• Team reviews quality
dashboard
• Teams deploy actions
agreed during PCM
o Schedule a visit
o Phone encounter to
update a care plan, PHQ-
9, etc.
o Change medications
o Process referrals
o Etc.
• PCC monitors and
supports team
Epic Report Used:
My Loc Pts w/
Hypertension

29. www.improvingprimarycare.org

30. Resource Spotlight #1

31. Resource Spotlight #2

32. How Do Teams Enable Practices To Achieve
Benchmark Chronic Care?
By using their teams to effectively
perform key primary care functions.

33. The Key Functions Of Excellent Primary Care

34. What do Patients with Chronic Illness Need
to Optimize Outcomes
• Drug therapy and medication management that gets them
safely to therapeutic goals.
• Effective self-management support so that they can manage
their illness competently.
• Preventive interventions at recommended times.
• Evidence-based monitoring and self-monitoring to detect
exacerbations and complications early.
• Follow-up tailored to severity, and more intensive
management for those at high risk.
• Timely, well-coordinated services from medical specialists and
other community resources.

35. Skilled and Well-organized Care Teams
• Team involvement in the care of chronically ill folks is the
single most powerful intervention.
• Involvement of non-physician care team members in care has
been associated with a 0.75% reduction in HbA1c and a 13
mmHg reduction in BP.

36. How do effective practices implement self-
management support
36
• linkages with self-management programs in the
community.
Forge
• team members to provide basic self-management
support.
Organize & train
• self-management support into every interaction.Build
• self-management goals and their attainment in
the patient’s record.
Document

37. How do effective practices manage
medications?
• Protocol-based prescribing and monitoring of adherence and
outcomes is routine.
• Medication reconciliation is viewed as a critical intervention
for both patient and practice. MAs collect important
information on drug use.
• Pharmacists and RNs play important roles in complex med.
rec., titrating medications, and addressing non-adherence and
other drug problems.
37

38. How do effective practices deliver planned follow-
up and Care Management (outside of visits)
• Follow-up can range in intensity from periodic status checks
by telephone or e-mail (MA) to active care management (RN).
• LEAP practices have tended to move routine chronic illness
follow-up care to team RNS.
• Follow-up/care management are core functions of the
practice team.
• Higher risk patients (poor disease control, frailty, etc.) receive
regular follow-up (monitoring) AND active care management
by RN care managers.

39. Relationship between care coordination, follow-
up & care management activities
39
Care Management
Logistical
Logistical
Logistical Clinical Monitoring
Care Coordination
Clinical Follow-up
Medication management
Self-management Support
Clinical Monitoring
Administrative
staff
Medical
Assistant
Registered
Nurse
(team)

40. LEAP Innovations in Chronic Care
• Use of trained MA or lay health coaches to
provide routine self-management support.
• Independent or conjoint RN visits for routine
chronic care follow-up.
• RN titration of anti-hypertensive,
hypoglycemic, anti-cholesterol drugs using
delegated order sets.

41. Cambridge Health Alliance
Implementing Chronic Illness Care
into everyday practice

42. CHA Chronic Illness Strategy
RN role transformed into the team
member primarily responsible for
patients with chronic diseases who are
not at goal
Education, empathy and patient
centeredness are hallmarks of excellent
nursing education – use them!

43. Site based or regional resources
(the Extended Team)
• Pharmacist – 40% time (direct pt visits for DM, HTN, Anti-
coagulation; not staffing a pharmacy)
• Referral Coordinator
• Nutrition
• Psychiatry/ On site behaviorist (integrated therapist)/On
site care partner (non-licensed BH)
• Social Work
• LPN (immunizations, ED follow up, managing the floor)
• Complex Care team
• Family Planning Counselor

44. RN Role on the team: what we do when we
come to work every day
• RNs co-manage multiple chronic diseases: depression,
diabetes, HTN, anxiety, abnormal cancer screening
• Monthly review of Rising Risk, depression, diabetes,
abnormal cancer screen lists at weekly team meetings
• Self structured review of lists in between to outreach to
patients
• Care coordination: are the glue for the patients with
chronic illness – they guide which team member will
see the patient next

45. RN Training
• CDE based training using our larger system and
specialty RN (endocrinology)
• Multi-disciplinary case conferences (pharmacy,
CDE, PCP, SW) at first; now they have their feet
wet and feel more independent
• Co-management and co-location with the
Providers and team engenders continual learning
in both directions
• Motivational Interviewing training
• Diabetes, HTN, CHF clinical updates

46. RN Visits
• Dedicated time for RN visits
• LPN hired to get them off the floor (shots, limited
triage, supplies and stocking, faxing!)
• Two RNs seeing visits all sessions, evenings busy with
floor and some visits
• Chronic Care visits 30/60 min and urgent care 15/30
min
• Dedicated time for outreach for depression patients
and the home bound

47. Typical ScheduleRN PCP

48. Role of the extended Team

49. Patient story
• New patient with new diabetes from Nepal, little English
• Presents with 6th nerve palsy from TB!
• Seen first day by MD who started medications for diabetes,
RN by warm hand off for teaching and labs and PHQ9
screening done by protocol by MA
• Pt screened positive for depression – unable to complete
school work due to double vision and afraid will lose his visa
• Nurse visit 5 days later – care plan completed, pt had not
picked up or started meds, did not understand them, very
depressed
– Pt declined depression meds but accepted counseling from team

50. Patient story (con’t)
• Telephone call 2 weeks later with RN, pt depressed and overwhelmed,
counseled by RN
• PCP visit soon after, sl better mood, added medicine for glucose control
• RN visit 2d later to confirm the plan
• Patient no shows to all appointments 3 months later
• Telephone call 2 weeks later – confused about medicines and not taking
them correctly, unable to make nutrition appt and not sure what to eat
– Same day nutrition appt made, patient seen
• Patient no shows to all appointments 3 months later
– Outreach by team MA results in patient coming back to care, agrees to appt with RN
RN appointment kept and detailed care plan done again, pt with much improved depression
and glycemic control

51. Did it work?
• A1c: originally (5/4/2013) 9.0; PHQ9 was 12
• Went to 6.1 by 7/31/2015; PHQ9 was 7
• Now (12/4/2015) 6.5; PHQ9 is now 6

52. Team Dynamic
• PCP saw patient for initial visit and largely prescribes
medications
• RN had next visit with patient to focus on chronic diseases of
diabetes and nutrition – is the center of the patient’s journey
into managing their new chronic disease
• RN developed the primary relationship with this patient
through longer appointments, motivational interviewing, and
follow up phone calls
• Population management was essential to keeping him on
track – if he had been allowed to no show, he would not have
gotten to goal!

53. Outcomes – the right away
• RNs have taken on direct patient education for
high risk patients, esp. diabetics
Hgba1c Avg
7.7
7.8
7.9
8
8.1
8.2
8.3
8.4
8.5
8.6
2011 2012
Hgba1c Avg
LDL Avg
96
98
100
102
104
106
108
110
2011 2012
LDL Avg

54. Diabetes “Perfect Care”
Outcomes – the long term
0
10
20
30
40
50
60
70
2008 2009 2010 2011 2012 2013 2014 2015
Perfect care

55. Union Square Staff

56. www.improvingprimarycare.org

57. Resource Spotlight #3
www.improvingprimarycare.org

58. Open Space for Discussion

59. Reminders
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Complex Care Management in Primary Care
Thursday May 5th, 3–4 p.m. EST
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