Office Redesign: The Planned Care Model

1
Office RedesignThe Planned Care Model

• Dave Eitrheim MD
• Red Cedar Medical Center-
• Mayo Health System
• Menomonie, WI
• eitrheim.david_at_mayo.edu

2
Red Cedar Medical CenterProviders are busy, but
not seeing more patients
3
(No Transcript)
4
The 15 minute office visit

• Nurse tasks in rooming a patient 21 years ago
• 1) Weight.
• 2) Blood pressure.
• 3) Chief complaint.

5
The 15 minute office visit

• Nurse tasks when rooming a diabetic patient
  today
• Weigh patient.
• Take and record BP, pulse, temperature if needed,
  O2 sat if needed, LMP if applicable.
• Record tobacco use and offer cessation
  counseling.
• Review and update all allergies and medications
  listed on the Current Medication List and see if
  refills are needed.
• Counsel preventative services and give
  appropriate immunizations, help schedule pap,
  mammogram, lipid testing, and colonoscopy.
• Diabetic care includes doing annual diabetic foot
  exam and recording information that is used by
  our diabetic registry. Review diabetic knowledge
  assessment worksheet and provide education or
  make needed referrals to the dietician or
  diabetic educator.
• Provide and review patient education materials.

6
Planned Care Visits

• Most chronic care visits are not preplanned.
• Provider lacks necessary information.
• Patient has different expectations for visit.
• Staff isnt fully utilized.
• EMR can make the situation worse if more tasks
  and clicks are put on to the provider.
• Systems are perfectly designed to get the
  results they receive. Dr. Don Berwick

7
Physicians are doing nursing tasks

• Patient satisfaction is heavily determined by the
  patients interaction with their provider.
• Set an agenda Providers should maximize the
  time spent on the patients reason for the visit.
  
• DMS, accreditation standards, EMRs and increasing
  documentation have led to appointments where the
  provider is handling the patients medical
  concerns plus many other tasks that take time
  away from the primary purpose of the visit.
• Each part of the office visit should be done by
  the most appropriate employee. Nurses should be
  empowered to work to the fullest level of their
  abilities and training. Minimize physician tasks
  that are in the skill set of others.

8
Preplanned Chronic Care

• Patients want to discuss and ask questions about
  labwork and test results at their clinic visit.
• Physicians are more efficient when they have all
  the info that they need at a visit.
• Preplanning the next chronic care visit prevents
  rework before the next visit.
• Techniques such as goal-setting and
  motivational interviewing lead to
  better outcomes.
• It doesnt take a village,
  but it takes a team.

9
(No Transcript)
10
Planned Care Model
Planned Care Visit Physician-Nurse Team

• Preplanning
• Patient
• self management data
• Preplanned Care Coordinator
• contacts patient to pre-plan appointment
• Registry
• database shows most recent patient data and
  trends

• Post Planning
• Nurse
• patient education/coaching
• Appointments
• next planned care visit setup with pre-labs
• Community Resource
• communication to nursing homes, caregivers,
  home health nurses
• Registry
• database updated

Nurse -chart prep -reconcile current medicine and
allergy list -tobacco use -preventative medicine
measures -additional tasks determined by team
Physician -SOAP -focus on patients reason for
visit -access to evidence-based guidelines -goal
setting -preplan next visit -post-planning
11
PreplanningPatient Responsibilities

• Work on goals established at last visit
• Bring self-management data to visit and act on
  data that is out of range (blood pressure, blood
  glucose, peak flows, diet and exercise, etc.)

12
PreplanningPreplan Care Coordinator

• Letter or phone call to patient instructing
  patient to
• Update current medication list
• Pre-labs Preorder labs to be done right before
  clinic visit per protocol (if not already
  ordered)
• Self management data Bring home BPs, glucose,
  weight, exercise log, peak flows,etc. to
  appointment

13
(No Transcript)
14

•     3.         PSA
•                  a .  All men age 50-70 should
  have screening PSA
•                   b.  Men with history of PSAs
  elevated above normal (or 4.0) should have a Free
  Total PSA
•                   c.  Men with history of
  prostatectomy, brachytherapy, or radiation
  therapy as treatment for prostate
  cancer now have very lowPSAs and should have a
  diagnostice PSA
•        4.         Diabetic Flow Sheet Labs
  Indicated for
• Diagnosis Diabetes Mellitus
  I and II
• If on these Medications
•                         Insulin                   
         Oral Agents
•                         Humalog                  
                   Glypizide
•                         Novolog                  
                   Glyburide        
•                         Lantus                   
                     Glimepiride (Amaryl)
•                         Levemir                  
                    Metformin
•                         Humulin                  
                    Pioglitozone (Actos)
•                         Novolin                  
                    Rosiglitazone (Avandia)
•         
•                   a.  Annual labs include
  Glucose, Creatinine, Urine Microalbumin,
  Lipid Profile (Glucose and
• creatinine are
  included in fasting basic profile if on
  hypertension meds noted above)
•                 b. HgbA1c every 6 months

15
PreplanningRegistry

• Searchable database
• Most recent data
• Trends in data
• Improves population care
• Motivational tool

16
Planned Care VisitProvider/Nurse Team
17
Planned Care VisitNurse

• Chart prep (EMR included)
• Reconcile current medication and allergy list
• Tobacco use discussed and counseling offered
• Preventative medicine measures counseled and
  ordered
• Mammography, pap, colon CA screens
• Immunizations
• Additional tasks determined by team

18
Planned Care VisitPhysician

• Focus on patients agenda or reason for visit
• Access to evidence-based guidelines
• Goal-setting with motivational interviewing
• Set up post-planning including preplanning next
  visit

19
Post-planningPhysician

• Additional orders Labs can
  usually be added to blood drawn
  before planned care visit
  (lab stores blood for 6 days)
• Follow-Up Planner Order Sheet
• Preplan next visit with pre-labs ordered

20
Post-planningNurse

• Patient education or coaching
• Teach off of patient education handouts or
  websites
• Patient education materials dont need to be
  physician driven (ex) pedometer program
• Diabetes knowledge worksheet used to make
  dietician and diabetic educator referrals

21
Post-planningAppointments or scheduling

• Follow-Up Planner Order Sheet
• Sets up
• Next planned care visit with any prelabs or x-ray
  (appointment set up or reminder letter sent)
• Referral visits to other clinic physicians,
  dietician, diabetic educator, PT/OT/ST, nurse
• Referral visits to outside specialists done by
  routing order sheet to specialty care coordinator

22
(No Transcript)
23
Dear _______________________,This is to inform
you that your next physical exam with lab work is
due soon. It works well if you can have your
blood drawn a few days before your exam so that
you and your provider can discuss the results at
your visit. Since most tests require 12 hours of
fasting, please do not eat or drink for 12 hours
(except for water) before coming. Ideally, you
should do this no more than 3 days prior to your
physical exam appointment. An order has been
sent to the lab for you.Lab hoursMonday 6
a.m. 8 p.m.Tuesday through Thursday 6 a.m. 6
p.m.Friday 6 a.m. 5 p.m.Saturday and Sunday 9
a.m. 3 p.m.Report to the Urgent Care
registration desk for your lab work.Please call
715-233-7777 to schedule an appointment for your
physical exam.Thanks you,
24
Post-planningRegistry

• Database updated for next planned care visit
• Patient notified if next planned care appointment
  is missed or labs not done
• Providers receive monthly reports that shows
  their own population data compared to other
  providers and benchmarks
  (unblinded)

25
Post-planningCommunity Resources

• Good communication to home health nurses,
  nursing homes and caregivers
• Referrals to community health programs
• Department of Human Services Birth to 3, WIC,
  County Office on Aging
• Know community resources and provide info on them

26
Planned Care Model
Planned Care Visit Physician-Nurse Team

• Preplanning
• Patient
• self management data
• Preplanned Care Coordinator
• contacts patient to pre-plan appointment
• Registry
• database shows most recent patient data and
  trends

• Post Planning
• Nurse
• patient education/coaching
• Appointments
• next planned care visit setup with pre-labs
• Community Resource
• communication to nursing homes, caregivers,
  home health nurses
• Registry
• database updated

Nurse -chart prep -reconcile current medicine and
allergy list -tobacco use -preventative medicine
measures -additional tasks determined by team
Physician -SOAP -focus on patients reason for
visit -access to evidence-based guidelines -goal
setting -preplan next visit -post-planning
27
Pursuing Ideal

• Through Frontline Solutions

28
Frontline Solutions is a simplifying, enabling
methodology based on the Toyota Production System
that gets the patient exactly what they need at
continually lower costs.
29
Toyota Production System Principles

• Problem recognition and understanding begins with
  direct observation.
• Problems are best solved by those actually
  involved in the work, with assistance from
  management/leadership.
• Everyone is responsible for problem
  identification and solution.

30
Comments about Frontline Solutions

• This is changing the culture one problem at a
  time (Learning Line Trainer)
• Its more efficient within a couple of days of
  identifying a problem, a solution is available to
  try (office nurse)
• I am constantly thinking how we can do things
  better for our patients or how we can do things
  more efficiently for our Dr./Nurse teams The
  great thing is that these are often things that
  we can change immediately and we do not have to
  wait weeks or even months to get approval from
  someone.
• The nice thing is that the people who are doing
  the work are actually finding the solutions to
  problems.

31
Many healthcare systems and processes are so
complex that top-down design will inevitably lead
to defects, breakdowns, and work-arounds.--------
----------------------------------Frontline
Solutions is a methodology that can address these
breakdowns with frontline level problem solving.
32
How Does Frontline Solutions Actually Work?

• Direct observation as the method of problem
  identification
• Involve frontline staff in problem identification
  and solution as a Learning Line with assistance
  from LLTs and management
• The rules in use

33
Problem Solving with Frontline SolutionsThe A3

• Frame the Problem in the Context of Ideal Patient
  Care
• Map the Current Condition
• Find the Root Cause(s)

• Propose a Solution (Target Condition)
• List the Steps Needed (Counter-Measures). Who
  does What, When, etc.?
• How do you know if the counter-measure failed
  (Test)?

34
(No Transcript)
35
How is this different?

• Not just another improvement tool
• A different way of thinking and acting
• A Culture shift

36
Additional Resources Frontline Solutions

• Designed to Adapt Leading Healthcare in
  Challenging Times John Kenagy, M.D.
• Jim Haemmerle, M.D. Red Cedar Medical
  Center-Mayo Health System haemmerle.james_at_mayo.ed
  u
• Rule 4 Consulting www.rule4consulting.com