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February 15 2018 NCA Team Based Care Webiner


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February 15 2018 NCA Team Based Care Webiner

  1. 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. 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 Q&A
  3. 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. 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 to access NCA webinar recordings, presentations and resources
  5. 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. 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
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  8. 8. Where to find help to build your team February 21, 2018
  9. 9. At the center is the Teamlet February 21, 2018
  10. 10. At the center is the Teamlet February 21, 2018 J Am Board Fam Med January-February 2016 29:135-138.
  11. 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. 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. 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. 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. 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. 16. Shared Communication Among the Team 2017
  17. 17.  Planned Care  Delegated Ordering  Scanning/Faxing/handling of incoming faxes  Panel Management  QI/Microsystem Participants The Role of the Medical Assistant
  18. 18. Split Screen: PCD and EHR ID ID Provider Name Provider Name Patient Name
  19. 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 00/00/00 22 What is MA Panel Management?
  20. 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 00/00/00 23 Goals & Outcomes of MA Panel Management
  21. 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. 22. Team Based Care: the visit
  23. 23. 00/00/00 26
  24. 24. 27 Use of Data to Support Team Based Care at Community Health Center, Inc.
  25. 25. 28 Open Planned Care Dashboard & Select Provider Select Provider
  26. 26. 00/00/00 29 Structured Fields and/or Templates
  27. 27. Tool for PCD: Mammograms
  28. 28. Planned Care Dashboard Display
  29. 29. • Used the following week to identify opportunities to reach back out to patients 00/00/00 32 Missed Opportunities
  30. 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. 31. Panel Management: Diabetes and Hypertension Control 00/00/00 34
  32. 32. 00/00/00 35
  33. 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 00/00/00 36 Key Elements of Success
  34. 34. 00/00/00 37 Questions?
  35. 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