One Best Practice Change

1
One Best Practice Change

• First Up
• Bala Cynwyd Medical Associates

2
The One Best Practice Change Bala Cynwyd
Medical Associates

• Attitude towards patients
• Patient as team member
• Medicine is a team sport. Until the
  collaborative I never viewed the patient as a
  member of the team. Now I realize the patient is
  the most important member of our team
• Resulting Positive Impact/Outcomes
• Retention of patients who were thinking of
  leaving the practice
• Better outcomes
• Better staff satisfaction

3
The One Best Practice Change Project Salud

• Major change
• Change of diabetes self-management tool and
  consistent use of the tool
• Self-management tool had been in English and
  could not be applied to the majority of our
  population
• New self-management tool includes multiple
  pictures so that patients with low literacy level
  can understand the tool
• Resulting Positive Impact/Outcomes
• Patients begin thinking about an area they would
  like to improve on and can discuss with the
  provider prior to the provider entering the room
  
• Patients get to take the self management tool
  home with them to have visual reinforcement of
  self-management goals

4
The One Best Practice Change Crozer Medical
Associates

• Major change
• Pre-Visit Planning
• 30 Day Appointment List with Deficiencies
• Contact patient to arrange blood tests prior to
  visit
• Resulting Positive Impact/Outcomes
• Patients arrive at appointments with up to date
  labs
• Providers have necessary data to make decisions
• In the initial stages of rolling out to network
  practices

5
The One Best Practice Change Medical Group at
Marple Commons

• Major change
• We use a disease registry
• For the first time, the doctors and MAs can
  track individual diabetic patients and our entire
  population.
• MAs are more involved in patient care
• Resulting Positive Impact/Outcomes
• Patients are more involved in their care
• More individual self-management support.
• We have overcome clinical inertia for a number of
  measures.
• Improvement in almost all tracked measures

6
Childrens Health Center of VNA Community
Services

• Major change
• Utilization of an Asthma Visit Form
• An Asthma Visit Form was developed which included
  data fields, components of disease management and
  the NAEPP guidelines.
• Resulting Positive Impact/Outcomes
• The visit ran smoother.
• All data fields were completed ensuring key
  components in asthma care were addressed.
• NAEPP guidelines were followed.
• Asthma visit forms are utilized on all asthma
  patients regardless of the reason for the visit.

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The One Best Practice Change Buckingham Family
Medicine

• Major change
• Implementation of EMR
• We now do all of our charting on an electronic
  medical record. All labs, letters and reports
  are imported or scanned into the system. Health
  maintenance rules allow us to track vaccines,
  cancer screening and disease specific testing
  needed.
• Resulting Positive Impact/Outcomes
• Tracking needed tests/visits
• Prescription management
• Access to medical record when off site
• Searchable database

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The One Best Practice ChangeAbbottsford/Falls

• Major change
• Initiated Diabetic Group Visits with use of
  Conversation Maps
• Gather 6-10 patients to share and exchange
  information
• Discuss action before motivation
• Patients help motivate each other to help
  control BSs
• Resulting Positive Impact/Outcomes
• Decline in A1Cs
• Patients are taking BSs and recording them more
  consistently
• One patient started her own support group in her
  apartment complex.
• Greater patient empowerment and confidence in
  their ability to manage a chronic illness.
• Greater compliance with medication regimen
• More family involvement as a support system to
  patient.

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The One Best Practice Change Crozer Keystone
Center for Family Health

• Major change
• Developed Diabetic Report Card
• Created a letter to communicate results and
  interpretation of diabetic testing to patients
  that is written at a 6th grade reading level that
  is populated with data from our EMR
• Resulting Positive Impact/Outcomes
• Positive patient feedback
• Now printed prior to visits to help guide MAs
  and providers determine services that need to be
  provided to patients
• Prompts providers to address diabetes even when
  that is not the primary purpose for the visit
• DM report card has been shared with and adopted
  by several practices in the Collaborative

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The One Best Practice Change PHMC Health
Connection

• Major change
• Social Worker will track referrals to increase
  attendance at specialist appointments
• Make appointment
• Call to remind of appointment
• Check if appointment kept
• If appointment is missed, call and reschedule
• - repeat, as above
• Resulting Positive Impact/Outcomes
• More appointments kept
• More reports received

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The One Best Practice ChangeJefferson Family
Medical Associates

• Expanding the role of our medical assistants to
  fill out diabetes flow-sheets and perform
  monofilament exams
• Resulting Positive Impact/Outcomes
• Involving medical assistants in patient care has
  been enjoyable for the medical assistants and for
  patients
• Reviewing flow-sheets allows patients to be more
  involved in their care
• Flow-sheets have helped PCPs to identify goals
  of care, deficiencies in care, and overcome
  clinical inertia

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The One Best Practice Change Rising Sun Health
Center

• Major change
• Replicating immunization follow-up for Diabetes
• At time of visit - file in tickler file for one
  week before the next clinic
  visit
• An addressed postcard reminder
• If appointment is missed call and reschedule
• Resulting Positive Impact/Outcomes
• More appointments kept for follow-up

13
The One Best Practice Change Kids First High
Point

• Major change
• Patient Panel review with PCP and RN prior to
  start of office hours
• Takes lt 5 minutes
• Significantly includes the nurse in patient care
  and decisions
• Prepares for Asthma planned visit
• Resulting Positive Impact/Outcomes
• Have improved daily schedule
• Allot enough time per visit
• Have all pertinent records available prior to pt
  arrival
• Better compliance completing ACT and Asthma
  Intake Hx
• More comprehensive visit -- Feels Good!

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The One Practice Change Health Annex

• Major change
• --Dedicated 2 new staff members to work
  exclusively with diabetic patients.
• --RN and CDE dietitian conduct one on one
  education and intensive case management total 106
  visits over 3 months.
• Positive Impact/Outcomes
• -- More glucometer use and testing
• -- 56 Podiatry visits were scheduled by RN
• -- Patients are seeing behavioral health
  therapist at time of visit.
• -- Building trust, confidence and empowerment

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The One Best Practice Change Mt. Airy Family
Practice

• A paradigm shift from I tell the patients and it
  is up to them to follow my advice. to How can I
  empower patients to manage their diabetes?
• Causes of this changed attitude
• NCQA certification process/ Medical Home
• SEPA CCC educational process and program
• RMD Registry
• Impact for patients and the practice
• Higher level of accountability on both sides
• Improved satisfaction and outcomes of care

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The One Best Practice Change Holland Medical
Associates

• Major change
• Institution of Case Management
• CRNP and RN
• Focused Case Management
• Resulting Positive Impact/Outcomes
• Patient Empowerment
• Lower A1cs
• Increase in Compliance

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The One Best Practice Change North Willow
Grove Pediatrics, PC

• Major Change
• Implemented new asthma visit template that
  incorporates evidence based guidelines.
• All providers involved in Asthma Chronic Care
  Model.
• Documentation now matches care of patients!
• Resulting Positive Impact/Outcomes
• Efficiency!!
• Implementing our new asthma template has
  increased our goal percentages.
• Each provider can follow previous providers plan
  of care.
• Has spread to other chronic diseases/diagnoses
  now have templates for ADHD, injuries, newborn
  weight checks.

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The One Best Practice Change Greenhouse
Internists

• Major change
• Implementing SMS
• New staff/staff roles
• Enhanced educational resources
• Patient outreach and follow up
• Planned visits
• Resulting Positive Impact/Outcomes
• Appreciative patients
• Empowered and accountable patients
• Healthy behavior changes
• Engaged staff

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The One Best Practice Change Lower Bucks
Pediatrics, P.C.

• Major change
• Asthma Nurse
• Educator
• Case Management
• Action Plan
• Triage
• Medication Management
• Resulting Positive Impact/Outcomes
• Better Understanding of Disease
• Self Management
• Fewer ER visits, hospitalization

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The One Best Practice Change Mary Howard
Health Center

• Major change
• Starting of open access last calendar year.
• Resulting Positive Impact/Outcomes
• Patients are seen same day.
• Patients are aware of process, so no one is
  turned away
• No more long lines of patients waiting to be
  seen.

21
The One Best Practice Change Founders Medical
Practice

• Institution of Self-management Education for all
  DM patients
• Stratification of DM pts
• Staff initiates SM education for all DM pts
• High and medium risk patients referred for direct
  SM education by CRNP
• Staff provided additional education
• Resulting Positive Impact/Outcomes
• Improvement in SM goals for all DM Pts
• Improved referrals for podiatry, eye exams
• Closer to goals for HgA1c results

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The One Best Practice ChangeNinth Street
Internal Medicine

• Major Change
• Adoption of the PDSA Process as a Change Agent
• - Impetus/focus for weekly meetings
• - Smooth transitions to new protocols
• - Gave permission to take chances and try
  new things
• Resulting Positive Impact/Outcomes
• Development and Use of Innovative tools
• Implemented Pre-Visit Planning
• Improved Preventive Care
• Increased Accuracy of Medication Lists
• Standardized Data
• Increased Patient Involvement in Self-
  Management
• Strengthened Team Concept

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The One Best Practice Change Kids First
Chestnut Hill

• Major change
• Blending of PNPs into the CCI project within
  our site
• Descriptor
• Initially attempted to utilize traditional
  management and clinical support staff conclusion
  was that initial development and implementation
  required a higher level of clinical and
  operational training and experience
• Currently have 32/hrs per week of PNP carved out
  and funded time allocated to the collaborative
  project, who are higher level clinicians in terms
  of training and experience
• Develop, implement and support CCI goals
  throughout entire three year program on a daily
  and consistent basis
• Provide leadership, education and resource roles
  to all staff
• Resource to newly named team champions and care
  coordinator
• Resulting Positive Impact/Outcomes
• Incorporated evidence based practices within all
  clinical decisions
• Developed an infrastructure that imbeds clinical
  goals into workflow and is sustainable
• Developed workflows that are efficient and
  fiscally sound
• Professional development of all staff members
• Generalization (Halo Effect) to other processes
  within the office
• Best Practice Model for other sites in our
  network

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The One Best Practice Change 11t Street Family
Health Services

• Ophthalmology Clinic Developed
• Access to on site retinal exams
• Planned visits pts called from registry
• Captured patients seen by PCP and LCSW also
• Positive Outcomes
• We overcame our fear of planned visits damaging
  OPEN ACCESS appt scheduling
• We obtained care for the uninsured, underinsured
  and non compliant patient reducing barriers
• From this we modeled our Friday AM Intense
  focus group visits targeting lowering BP first!