1.
Welcome
The National Cooperative Agreement on
Advancing Team-Based Care
WEBINAR 1: Taking Team-Based Care to the Next Level
February 15, 2018
Presented by the
the Community Health Center, Inc.

2.
Get the Most Out of Your Zoom Experience
• Use the Q&A Button to submit questions!
• Live tweet us at @CHCworkforceNCA and #primarycareteams
• 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
Q&A

3.
Learning Objectives
1. Participants will be able to describe the core concepts of team-
based care
2. Participants will be able to describe the roles and functions of the
primary care teamlet.
3. Participants will identify 3 additional roles beyond the core team.
Complete the survey at the end of the webinar to receive CME
credits!

4.
Advancing Team-Based Care:
1. Advancing Team-Based Care: Building Your Primary Care Team
to Transform Your Practice
2. Enhancing the Role of the Medical Assistant
3. The Emerging Role of Nurses in Primary Care
4. Data Driven Dashboards to Support Team-Based Care
5. A Team Approach to Prevention and Chronic Illness
Management
6. Complex Care Management in Primary Care
7. Achieving Full Integration of Behavioral Health and Primary
Care
8. Dissolving the Walls: Clinic Community ConnectionsTransforming
TeamsPlease visit www.CHC1.com/NCA to access
NCA webinar recordings, presentations and resources

5.
Upcoming Webinars
• Taking Team-Based Care to the Next Level
February 15, 2018 | 3 p.m. EST
• Advancing the Practice of RNs and Behavioral Health Providers
February 22, 2018 | 3 p.m. EST
• Beyond the Walls: Effectively Utilizing Community Health
Workers and Clinical Home Visitors as Part of the Team
March 1, 2018 | 3 p.m. EST
• Caring for Patients with Pain is a Team Sport
March 8, 2018 | 3 p.m. EST

6.
CHC Profile
Founding year: 1972
Primary care hubs: 14; 204 sites
Staff: 1,000
Patients/year: 100,000
Specialties: onsite psychiatry, podiatry,
chiropractic
Specialty access by e-Consult
Elements of Model
Fully Integrated teams and data
Integration of key populations into primary care
Data driven performance
“Wherever You Are” approach
Weitzman Institute
QI experts; national coaches
Project ECHO®— special populations
Formal research and R&D
Clinical workforce development
CHC Locations in Connecticut

7.
www.improvingprimarycare.org

8.
Where to find help to build your team
February 21, 2018

9.
At the center is the Teamlet
February 21, 2018

10.
At the center is the Teamlet
February 21, 2018
J Am Board Fam Med January-February 2016 29:135-138.

11.
“Core” and “Extended” team members
•Core = full-time (or close to full-time) individuals
on a team that works with specific PCPs caring for a
defined population of patients (a panel).
•Extended = practice staff who have an ongoing
professional relationship with the core team and
who provide services to any patient of the practice
or specific sub-populations.

12.
Primary Care Team
February 21, 2018
CentCore
Team
Provider
-MA
Teamlet
Provider
-MA
Teamlet
Provider
-MA
Teamlet
Extended Care
Team
• Receptionist
• Team RN
• Health Coach
• Panel Manager
• RN Care Managers
• Lay Caregivers
• Pharmacists
• Behavioral Health
Specialists
• Administrative Staff

13.
Team Structure:
Major Findings From Site Visits
February 21, 2018
Medical assistants, receptionists, and
lay-persons play key patient care roles .
Roles are expanded. All staff work at the
top of their license and skillsets.
All core teams supported by RN care
managers, behavioral health specialists,
pharmacists, etc.
Providers and their panels supported by
Core teams consisting of MAs, front desk,
and others.

14.
Care that is Comprehensive: IPCP Team
Additional on-site specialties
Nutrition
Diabetes education
Chiropractic
Podiatry
Retinal screening
PATIENT
Medical
BH
Nursing
Pharmac
y
Prenata
l
Dental

15.
• POD design
 2 Medical Providers
 1 Registered Nurse
 2 Medical Assistants
 1 Behavioral Health Clinician
 Additional members: podiatrist,
dietician, Pharm-D, chiropractor, CDE
 Student/Trainees
The Interdisciplinary Team

16.
Shared Communication Among the Team
2017

17.
 Planned Care
 Delegated Ordering
 Scanning/Faxing/handling of incoming faxes
 Panel Management
 QI/Microsystem Participants
The Role of the Medical Assistant

18.
Split Screen: PCD and EHR
ID
ID
Provider Name
Provider Name
Patient Name

19.
• Recurring biweekly (40 min) dedicated time will be scheduled
for Panel Management activities
• Medical Assistant Reviews:
• Diabetes Dashboard
• HTN Dashboard
• Opioid Dashboard
• Missed Opportunities Dashboard
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What is MA Panel Management?

20.
• The goal of MA Panel Management is to:
• Re-connect patients who are overdue
• Ensure that uncontrolled patients are adhering to
defined treatment plans
• Ensure all planned care associated with HTN, DM and
chronic Opioid treatment have been completed
• The expected outcome of MA Panel Management is to:
• Improved rates of HTN & DM control
• Improved rates of Planned Care completion
• Improved adherence to defined treatment plans
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Goals & Outcomes of MA Panel Management

21.
The Role of the Provider
• Clinical Leader/Responsible
• Clinical Management
• Support planned care
• Evidence based care delivery
• Care coordinate with team
• Empower the Team
• Leverage the Team
• Engage in the Team

22.
Team Based Care: the visit

23.
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24.
27
Use of Data to Support Team Based
Care at
Community Health Center, Inc.

25.
28
Open Planned Care Dashboard & Select Provider
Select Provider

26.
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Structured Fields and/or Templates

27.
Tool for PCD: Mammograms

28.
Planned Care Dashboard Display

29.
• Used the following week to identify opportunities to reach
back out to patients
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Missed Opportunities

30.
Medical Assistant Performance Appraisal
• Annual process led by CNO and
site Nurse Managers
• In FY 2017, it included 18
measures for which the MA has
direct responsibility.

31.
Panel Management: Diabetes and Hypertension Control
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32.
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33.
• Defined and standardized documentation in the EHR
• Training existing and new staff to the standard
• EHR Registries, Clinical Alert, and/or BI
• Time given to teams
• Reasonable expectations
• Monitor and Support
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Key Elements of Success

34.
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Questions?

35.
Speakers
From MacColl Center for Health Care Innovation, Group Health
Research Institute:
Brian Austin, Deputy Director
From Community Health Center, Inc.:
Margaret Flinter, APRN, PhD, Senior Vice President & Clinical
Director
Veena Channamsetty, MD. Chief Medical Director
Aislinn Edwards, Senior Medical Assistant
Tierney Giannotti, MPA- Senior Quality Improvement Manager for
Population Health
Anna Rogers- Project Director