NCA TBC Session 5 March 15 2017

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Advanced Team Based Care (TBC) Learning Collaborative

Welcome to Session 5March 15, 20173:00 - 4:30 EST

Developing core and extended team capabilities for implementing an advanced team based care model.

Introductions

TBC Collaborative Design, Facilitation, Faculty Ann Marie R Hess ANP, MS

National Cooperative Agreement Anna Rogers, Director Reema Mistry, Program Coordinator

Mentors , Coaching Faculty Deborah Ward, RN Kasey Harding

Evaluation Faculty Kathleen Thies, PhD, RN

Improvement Science Faculty Patti Feeney Mark Splaine, MD Grace Capreol

Objectives Session 5

Summarize Action Period 4 Milestones (6 weeks)

Discuss lessons learned from a panel of leaders

Learn from teams who are spreading standards using evidence from PDSAs and SDSAs

Provide a path forward and assignments for Action Period 5

Mentor Name of FQHC State Coach Team Members Team

Kasey Avenal Community Health Center CA John Kalfayan

Frances Silva, Behavioral HealthVivian Stafford, Physician

Khuong Phui, Medical directorBetty Mora, MA

Christina Castaneda, Receptionist

1 BH, 1 Physician, 1 MA, 1 Medical Director, 1 Front Desk

Deb Carolina Family Health Centers , Inc. NC Mary Williams

Amparito Fiallo, MDAl Abaya, NP

Lisa Vinson, LPNBernadette Mangum, LPN

Cheyenne Robbins, Care CoordinatorBetty Lucas, Front Desk

Zenaida Aguilar, InterpreterRaquel Milbourne, CNA

Sandra Botello, Referral Specialist

1 MD, 1 NP, 2 LPN, 1 Care Coordinator, 1 Front Desk, 1 Interpretor, 1 CAN, 1

Referral Sepcialist

Deb Educational Health Center of Wyoming WY Pamela Oiler

Donna Romain, RNLaDonna Whittaker, Radiologic TechLiz Bravo-Alcon, Executive Assistant

Stephanie Schneider, MAPatrick Monahan, Clinical Manager

Marianne Ploucha, Business Office ManagerKimberly Broomfield, Faculty Physician

Jennifer Walsh, MAChristie Novy, MA

Evan Norby, Clinical Team LeadMonette McKee, RN

Thanh-Nga Nguyen, Faculty Pharm D.Pamela Oiler, Faculty LCSW

1 Provider, 2 RN, 1 Radiologic Technologist, 1 EMR Manager, 3 MA, 1

Clinical Manager, 1 Pharmacist, 1 LCSW


Kasey El Rio Santa Cruz AZ Josh Carzoli

Crystal Chavira, MAYomaira Preciado, RNJennifer Stivers, LPN

Rajiv Modak, PhysicianStephanie Pinedo, Reception

Linda Beauchesne, Medical Informatics SupervisorSonia Reidy, Physician

1 MA, 1 RN, 1 BH, 1 Chief Clinical Officer, 1 LPN, 2 Physician, 1 Front

Desk, 1 COO, 3 RN Clinic Manager, 1 IT

Deb Healthcare for the Homeless TX Carlie Brown

The core team: Henry Siem, MDLuis Huerta, MA

Krissy Joubert, MA – Intake/Registration Unfilled RN Position

Extended team: Cidney Aae, Case Manager

Joseph Benson, Community Health Worker

Need new team

Kasey Holyoke Health Center MAMegan T.

Wechsler, Rosie Romero

Core Team:Dr. Kefah Al-Ramahi, Internal Medicine, MD

Karen Horgan, RNNatalie Alicea, MA

Juan Acevedo-Behavioral Health Integration Program Manager

Mariluz Vargas, Front DeskExtended Team:

Dr. Alejandro Esparza, CMOMartha Fisk, Director of Quality and Compliance

1 Director of Quality and Compliance, 1 Physician, 3 RN, 1 MA, 1 Front Desk

Deb Johnson City Community Health Center TN Flo Weierbach

Martiza Ramirez, Front DeskRebecca Morrison, PNPAmy Mclaughlin, LCSW

Mae Crestinger, RNLaura Gentles Gonzales, Interpreter

1 Dfront Desk, 1 PNP, 1 LCSW, 1 RN, 1 Interpreter


Kasey Peach Tree Healthcare CA Ruben Ruiz

Core Team: Margarita Cuevas, MA

Rene Minnaar, NPJose Alvarado, MA

Kathleen Hawes, Site ManagerAlex Castro, Customer Service Specialist

Tang Yang, Operations SpecialistTameka Frank, Quality Coordinator

Hakeem Adeniyi, Chief Medical OfficerRuben Ruiz, Quality Coordinator

Sheila Arnold, Clinical Support Services ManagerOther Team Members in Monthly Meetings:Michelle Woodard, Director of Operations

Mary Renner, Director of HRDalip Rai, Data Analyst

1 Chief Quality Officer, 1 Quality Coordinator, 1 Director of

Operations, 1 Site Manager, 1 Director of HR, 1 NP, 3 MA, 1 Data Analyst, 1 Operations

Specialist, 1 Clinical Support Services Manager

Deb Sumter Family Health Center SC Sandra Sturkie

Core Team:Linda Brice, Adult Health Clinical Manger

Dr. Etheridge, Adult Health MDPorcelyn Scarborough, MA

Ebony Singleton, Call Center/RegistrationSondra Richardson, Referrals Manager

Extended Team:Kitty Kulungowski, RN Behavioral Health

Wendy Bonds- Chapman, Case ManagementMary Byrd, Case Management

Tina Thompson, Behav Health RNJolie Costello, Dental Services CoordinatorJoyce Bair, Patient Financial Coordinator

Marti Martin, Clinical IT/EMRMelvina Chappell, Pharmacist

1 Director of Patient Services, 1 Clinical Manager, 1 BH Clinical

Manager, 1 BH RN, 1 Physician, 2 Case Managers, 1 MA, 1

Dental Services Coordinator, 1 Patient Financial Coordinator, 1 Clinical IT, 1 Pharmacist, 1 Call

Center Rep, 1 Referrals Manager


Deb Syracuse Community Health Center, Inc. NY Cathy Brigden

Dr. Roy Smith, Physician Ms. Zarina Smith, FNP

Ms. Stephanie Green, LPNMs. Rebecca Wright, RNMs. Shanieka Smith, MA

Ms. Tania Guntin-Bernal, MAMs. Tiffany Senke, MA

Ms. Stephanie Montgomery, Office ManagerMs. Verna Griffith Payne, RN

1 Physician, 1 FNP, 1 LPN, 2 RN, 3 MA, 1 Office Manager

Kasey The Children’s Clinic CA Karla RodriguezDr. Shea Suskin, Provider

Joana Rios, MAElizabeth Castruita, LVN

Angela Moreno, Clinic Manager1 Provider, 1 MA, 1 Care Team Rep

Deb Tyler Family Circle of Care TX Sherri Gould

Carolyn Risinger, CMOLinda Isabell, COO

Nadra Miller, Lead LVNJuana Crespin, OARobin Hogue, PNP

Vanessa Vela, Process Improvement Manager

1 CMO, 1 COO, 1 LVN, 1 OA, 1 PNP, 1 Process Improvement Manager

Kasey Via Care Community Health Center CA Lourdes Olivares

Agustin Jaime Lara, CMOAnamaria Lopez-Chavelas, MSW

Ema Hernandez, LVNLaura Andrade, MA

Julio Arellano, EnrollerMaria Valdez, Director of Operations

Maricela Romero, MA/Front Desk leadVictoria Moreno, RN

1 FNP, 1 MA, 1 Outreach & Enrollment Specialist, 1 MSW, 1 Front Office Lead

MA

Define Core and Extended Team

Achieve multiple TBC specific aims

Standardize (SDSAs) roles and key processes (Playbook, Spread Plan)

Improve team and coach skills (improvement science, team work, coaching)

Move Practice Assessment Data toward Level A

Develop a post collaborative team action plan

TBC Learning Collaborative

90 minLearningSessions

Between Session Action Periods (6 weeks)Complete AssignmentsWeekly Team Meetings , Daily Huddles Monthly ReportingShare Your Work – TBC Website (Moodle)

Developing Effective Meeting and Improvement SkillsImplementing Team Based Care – Small Tests of ChangeLearning from Each Other

Action Period 4

Core (POD) and Extended Team Adjustments, Spread

TBC Webinars (1-6) Onboarding, Spread

Weekly Team Meetings and Daily Huddles (92%)

Readiness Survey (N=83)Progress Check List (5)

Role Activity and Cycle Time Data - deeper

Specific Aims (small, measures) • Fishbone Diagram• Process Map• Data driven

PDSAs – tests of changeSDSAs – protocols, check lists , standing orders

Playbooks

Between Session Coach Mentoring (weekly – attend 2-4/mo)Faculty SupportMoodle Resources and Discussion Board

7

Sept 21 Dec 14 Jan 25 Mar 15 Apr 26 June 14Nov 2

Agenda3:00 5 min Welcome and Introductions

Improvement Road Map

3:05 10 min Action Period 4 Milestones and ChallengesSummary : Specific Aims , PDSAs, SDSAs

3:15 20 min Leadership Panel (5 min each specific examples of how they are helping teams succeed)

El Rio Santa Cruz Dr Rajiv Modak, Team Leader

Via Care Community Health CenterDr Agustin J. Lara , CMO

Sumter Family Health CenterAllison Shuler, RN, MSN Director of Patient

Services Sumter

3:35 15 min Theory Burst: Standardizing and Spread Concepts

3:50 30 min Team SDSA and Spread Topics (5 min, 2 min Q and A)Homeless | Sumter | Via Care | HolyokeWhat did you standardize and how did you spread

(review SDSA Worksheet)What were your lessons learned?

4:15 15 min Path Forward and Progress Check List Action Period 5 Assignments

Improvement Science Theory Bursts (10 min)Developing Capacity for Implementing Advanced TBC Model

Session 1 : Sept 21st o Running effective team meetings using toolso Developing and using a cause and effect diagram to inform PDSAso Writing a global and specific aim statement

Session 2 : Nov 2nd

o Developing a process map or current state workflow o Applying PDSA methodology for improvement

Session 3 : Dec 14th o Using data for improvement (run charts, bar graphs, sampling)

Session 4 : Jan 25th o Standardizing (SDSAs) and Process Reliability

Session 5 : March 15th o Spreading Change

Session 6 : April 26th

o Gantt Charting : 3-6 month Core Team improvement plan (progress check list)Session 7 : June 14th

Improvement Ramp for Implementing TBC

1

Action Period 6

4-5

2-3

Action Periods 4, 5, 6

Role OptimizationEfficiencyAccessTeam Based Care

Aims and Measures, Small Tests of Change (PDSAs)

Daily Huddle Implementation and Role Optimization MA Led Huddles Behavioral Health Integration Closing Care Gaps

Prevention Screening MA Protocols Pre visit planning workflows

Access and Efficiency | Patient Satisfaction (Reduce Wait Times, Duplication, Phone Calls)

Med Refills Process Appointment Scheduling Guidelines Rooming Standards Eliminate Paper and Duplication Role Activity |Documentation Patient Portal Activation

Care Coordination Lab Result Tracking and Follow Up Referral Process

Pre Visit Planning Pre Registration Phone Calls Closing Clinical Quality Gaps

Chronic Care Management RN managing more challenging, complex patients

Evidence of New Team Skills? Effectively Meetings, Daily Huddles, Improvement

Evidence of TBC Transformation?

The physician on our team no longer dominates the daily huddles Our MA is usually very quite but now finding her voice as a team member Our team members are growing in their inter professional roles There are team changes during our meetings in body posturing to more engaged,

particularly our MA who is coming of her ‘shell’ When we included our behavioral health specialist in our huddles, the energy and

engagement changed for the better We have seen transformation in some of the MAs and Nurses as they display

increased leadership skills in their team to roll out our PDSAs. Team loves seeing data that they have been personally collecting Working with our RN to help manage more complicated patients, I feel like a

burden has been lifted and patients are getting better care. As the physician, I used to manage all of these things myself (not very efficiently)

“PCMH implies : major changes in the ways individuals and groups within practices view their roles, and the ways they work together”.

Paul Nutting et .al Transforming Physician Practices to PCMH

HealthCare for the Homeless

How are you identifying teams within your health center, and to help patients?*Scrub colors, wall colors, door colors, badges, business cards, pictures?

Core and Extended Team : Structure, Definitions , Standards and Protocols

Sustaining Weekly CORE TEAM Meetings : Team Must Meet

Differentiating between meeting leader and the team leader Transitioning the role of coach (meeting roles) to team. Inviting leaders to meetings to understand their work together Onboarding new staff (using webinars, team members) Developing more effective Ground Rules : Say “in the weeds”

when getting off topic or too much detail. Make sure everyone contributes by asking if they have anything to add.

Seeing more engagement from all team members

How do you keep teams engaged?

How would you rate team engagement , scale of 1 (not at all ) – 10 (very engaged) Ranged from 5 to 10

Coach Polling : Team Engagement?

Ratings of 10 : o leadership engagement, team member is a strong ‘project lead’ or ‘team leader’

Agenda Session3:00 5 min Welcome and Introductions






Sumter Family Health CenterAllison Shuler, RN, MSN Director of Patient

Services Sumter





Leadership Panel

The objective is to learn from examples of how leaders are:

Supporting teams |coaches in implementing team based care Committing time for sessions, meetings and huddles Implementing of core and extended team structure and

roles Testing change ideas (PDSAs) Standardizing and spreading change

Closing readiness for change gaps identified by the ORIC survey

Readiness for Change – how are leaders closing gaps?

Leadership Panel5 min each : supporting teams, addressing challenges

Agustin J. Lara, MD CMO Via Care Rajiv Modak, MD Team Physician El RioAllison Shuler, RN, MSN Dir Patient Services

Sumter

Dr. Modak El Rio

Sumter Family Health CenterHelping the Team Succeed

• The "Perfect Storm" - New MD started with PCMH background / New EMR / Increased staff - experienced RNs / Project Leader (Allison) in position for 3 years – ideal fit for project lead

• Weekly meetings (stay engaged and informed)• One Drive with all documents (easy access)• Executive Leadership involvement• Dedicated admin staff (allows members to focus)• Engage all team members for input on new processes /

feedback on challenges• Praise efforts (lunch, treats, brag about them to ELT)

Agenda Session 5 (3:00-4:30)3:00 5 min Welcome and Introductions






Sumter Family Health CenterAlison Shuler, RN, MSN Director of Patient

Services Sumter





Theory Burst Using CHC Example

From Standardizing to Spread

Kasey HardingGrace Capreol

Via Care Community Health Center

Standardizing and SpreadingDaily Huddles

Huddle Card

Healthcare for the Homeless

Standardizing and SpreadingReferral Process

Caroline Street Clinic

CORE TEAMPOD

CORE TEAMPOD

CORE TEAMPOD

Community Health Worker (CHW)

CHW

Case Manager

BHC

CORE TEAM: PCP (MD/NP)/MA

IN-CLINIC EXTENDED TEAM: COMMUNITY HEALTH WORKERS (CHW)

CASE MANAGEMENT

BEHAVIORAL HEALTH CONSULTANT (BHC)

There are 3-4 “core team” primary care teamlets who may produce internal referrals to one or more in-clinic “extended team” members.

Standardizing the Process of Internal Referrals Between Core and Extended

TeamPrevious method: “Warm Handoffs”; No formal internal referral systemGoals of standardizing process (in no specific order):

• Improve fidelity of post-visit tasks including extended team member referrals and other tasks that need to be performed by MA’s

• Improve patient access to extended team member referrals• Decrease provider time looking for BHC, CHW, RN, CM, MA

to allow more time seeing patients (efficiency/cycle time, practicing at the top of your license)

• Maintain ability to do “Warm Handoffs” between provider and BHC, CHW, RN, CM, if needed

Logistics• Created a “Routing Sheet” to:

• Help efficiently direct patients to necessary extended team members• Track % of successful internal referrals from core to extended team – Did

the patient make it to where they needed to be? How efficient was the process?

• Facilitate each team member to practice at the top of their license

• Routing sheets color coded according to associated pod/”teamlet” • Once seen by the PCP, if in-clinic referral to extended team

member(s) need to be made: • MA places the color coded Routing Sheet in the centrally located hanging

bin • Extended team members can visible see that there is a referral waiting for

them and in what pod/teamlet the patient is waiting in/coming from

Patient has primary care visit – with core teamlet

Patient needs internal referral to extended

team

Core team places color coded routing sheet in

centralized bin

CHWs and BHCs: Patient waits in exam room CM: Patient waits in

small waiting area by lab

Once patient is seen by extended team member,

Task Done

Smoking cessation consult

Needs to get I.D.; Housing/shelter resources

Lessons Learned• Initially, the routing sheet was passed from team member to

team member, which was not successful in improving efficiency because providers were still having to spend time looking for each other. The centralized hanging bin was a game changer!

• The routing sheet has worked very well in terms increasing access and decreasing wait times for extended team

• Extended team members are able to better serve patients because they have more information/context about what other needs have come up for the patient that day. Also helps with efficiency of visit.

• Patients are better assisted because now all team members they see that day are better informed about the other services they have/are receiving.

Holyoke Health Center

Standardizing and SpreadingPaperless Workflows

SumterFamily Health Center

Standardizing and SpreadingPre Registration Using Pre Visiting Planning Standards

Plan:Decrease cycle time

Do:Increase # of Pts who

are preregistered

Study:Gather baseline data

Act:Gather monthly data; repeat cycle analysis;

dedicate staff; targeted pt. group

Allison Shuler, RN, MSN Dir Patient Services Sumter

3:00 5 min Welcome and IntroductionsImprovement Road Map





Sumter Family Health CenterAlison Shuler, RN, MSN Director of Patient

Services Sumter





Action Period 5 Assignments

1. Improve ‘effectiveness’ of your weekly meetings2. Improve ‘quality’ of daily huddles and roles, measure

some impact3. Achieve 1-2 Specific Aims by implementing multiple

PDSAs 4. Collect and Track Data – weekly feedback5. Implement SDSAs (standards) – evaluate , playbook6. Spread a Standard to another POD if ready, track how

it is working (consider skills set)7. Improve Communication - leaders and managers

8. Complete Progress Check List

Action Period 5 Assignments

5. Post your assignments on Moodle Learning Network site https://moodle.weitzmaninstitute.org/login/index.php

Progress Check List Readiness Survey PDSA Worksheets : Disciplined Approach (Aims,

Measures, Tests of Change) SDSA Worksheets : Are standards working? What is the

evidence? Spread ? Monthly Reports : March Due Now Playbooks : Spread Support Core and Extended Team Structures : Role Descriptions

https://moodle.weitzmaninstitute.org/login/index.php



Improvingprimarycare.org

Engaging Teams Pre Registration Self Management Tools Care Coordination Identifying PODs

Webinars

Do you have the resourcesyou need?

What are some discussion topics you would like to see?

Next Session (s) April 26

Submit Your Team’s Work to Share

Improvement Stories: from Global Aim to Specific Aims to PDSAs to SDSAs to Spread. Playbooks.

Core and Extended Team Structures and Role Definitions. Pilot to Practice.

Theory Burst : Tools for developing your post collaborative team improvement plan (using progress check list)

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Nov 09 Dec 09 Jan 10 Feb 10 March 10 April 10 May 10 June 10 July 10 Aug 10 Sept 10 Oct 10

% Pts w/ Up-to-Date A1C Testing

UW Health Trained Microsystem Team Pilot Teams

Registry management and standardized lab ordering per protocol

UW.hess.2011Ihi.org

Higher Performing PODS : investing in a culture of continuous improvement

Top Down Projects

Business as usual

High Performing POD

Thank You All

Survey Post Session

Thank you for your participation today and feedback : Session Evaluation