Terry's Weblog

An Ideal Chronic Care Office Visit in the Transformed Healthcare System

Mon, 23 Jun 2003 20:48:04 GMT

We have been piloting group visits and creating new Shared Care Plans for our patients 65 and older with complex medical problems.

We have been updating existing Shared Care Plans in office visits.

We have assessed the amount of time needed for data entry of the Shared Care Plan to review all 7 tabs ~ adding new Care Team members, editing medications, adding new medications, and determining Goals and Next Steps.

In the new world, this would be an ideal scenario:

1. Do a mailing to the patient with a blank paper version of the electronic Shared Care Plan and include instructions from our patient guide.

2. Instruct the patient to fill it out as much as possible. If you had the capacity to mail them a list of their diagnoses and medications as well, that would be very useful. (This was feedback we received from patients).

3. For a patient to be able to enter this information electronically themselves they would have to be registered in order to create a new Shared Care Plan.

We would have to eliminate the face-to-face encounter in order to accomplish this. Hopefully, the clinics would “know” their patients and “whom” they were mailing it to. (The thought of lost mail or error in delivery may mean we should consider not sending their list of medications or diagnoses).

4. The patient would either mail it back to the clinic or they could bring it in at their next office visit.

5. This paper electronic version of the Shared Care Plan would be entered into the computer for all patients that needed assistance. “Who” would do this work would still need to be determined. Only if patients could be registered by the clinics prior to the mailing, could they then enter it themselves if they were capable and had computer access.

6. Schedule a 1 hour office visit with their Primary Care Clinician /ARNP/PA.

You will need ~ 30 minutes to edit and review an existing electronic Shared Care Plan and address any concerns. A one-hour visit is what it will take to do a history and physical examination, reconcile an accurate medication list, review and update an existing Shared Care Plan.

This would promote continuity of care, medication safety and accuracy, promote patient self-activation and management, and increase physician, staff, and patient satisfaction.

7. This would also promote open access to care when a patient wanted or needed an appointment as it has been proven that utilization decreases when a patient sees their own PCP /Specialist who is most familiar with them.

8. Reimbursement still needs to be worked out for this comprehensive visit.

Today’s office visits for chronic care that may have 15 minutes at some facilities to

address complex, multi-system failure concerns are not able to treat the patient as a whole and deliver patient –centered care. This is one reason why patients return frequently and subsequently create increased demand for care with diminished access.

It is time for a new world in healthcare – we need to do the work smarter not harder.

Group Visit for Heart Failure Patients Across Organizations

Wed, 11 Jun 2003 17:18:36 GMT

Kudos to Erin Baumgart and Roland Trenouth ~ true pioneers. They piloted the First Heart Failure Group Visit across organizations (CSH and NCC) and did a wonderful job - the patients loved it and want to come back again!

Carol Hanson, RN at CSH was very helpful in explaining the role of the nurse, when to call and what information would be most helpful.

Here is an overview of our pilot group visit :

1. Attendees: PCP, Cardiologist, CSH Staff RN , Process Facilitator.

2. 7 patients were pre-selected that had CHF as a diagnosis - 6 patients showed up and participated in our group visit.

3. Pre-Visit: 1-1:15 pm Patients were greeted and given Patient Information Packets.

4. The actual visit lasted 1:15-2:45 pm ( 1 1/2 hours) .

5. The HF Group Visit Agenda as it evolved:

1:15 -1:30 pm Explanation of Group Visits and Introductions

1:30-1:40 pm P2 HIPAA Form and Group Visit Confidentiality Forms.

1:35-1:55 pm Explanation of CHF by Dr. Trenouth followed by Question/ Answer period.

1:55-2:00 pm Explanation of what a patient can do to help themselves on a daily basis.

2:00-2:10 pm Vital Signs taken and Recorded (Pulse and Blood Pressure).

2:10-2:20 pm HF Medications Discussed.

2:20-2:35 pm Evaluation of Group Visit.

2:35-2:45 pm Individual Concerns Addressed.

6. Suggestions / Feedback from patients:

Do Not Tell Patients over the phone that they have CHF - need to have a face to face encounter with a patient in person.

CHF is a shocking diagnosis for a patient - they need to be able to ask questions and receive patient education handouts with information.

Patients felt strongly that it was the Clinicians responsibility to educate and inform the patient regarding their condition.

Input regarding this group visit today patients stated :

" I am impressed with all of the effort and degree of care that was put into this."

" I thought this was wonderful, over time we would know so much more. It gives us an opportunity for thoughts and questions".

" I thought it was good, would like to see it continue. There were a lot of helpful things shared".

" I got a real good explanation of what Heart Failure is".

" I thought it was interesting but not too much new information that I didn't already know".

7. Future Group Visits could expand upon Diet, Medications, Drug Interactions, latest research and treatment options.

It was a wonderful alternative to providing care in a new way . Your questions and comments are welcome.

Terry Wagner RN BSN

Process Facilitator

Pursuing Perfection Project

800 E. Chestnut Street

Bellingham, WA 98225

Cell # (360) 815-4158

SeaMar's Success

Tue, 25 Feb 2003 22:04:32 GMT

SeaMar Community Health Center

SeaMar's most recent success of implementing a Diabetes Registry in real time each day, has been a work in progress. I believe it has been so successful because of their fantastic attitude and readiness for change.

SeaMar Community Health Center is one of the pilot sites for Pursuing Perfection Project in Whatcom County. They have done an amazing job over the past few months, and here are some of the reasons why. The Clinical and Reception Staff and Physicians are upbeat, open and receptive to change, deliver respectful caring and compassionate care to a diverse patient population , staff are bilingual and speak Spanish and are very supportive of one another as individuals. It has been my pleasure to work with this dynamic group of people as their Process Facilitator.

Let me share with you some of their accomplishments in Celebration of their success:

July 2002 - Start referring Diabetic and /or Congestive Heart Failure patients to a CCS (Clinical Care Specialist).

August 2002- Clinical Staff Trained on LastWord Registry Data Entry.

September 2002 - Joslin Diabetes Center Presentation to include Patient Education Groups in English and Spanish; Patient Focus Groups in Spanish led by Health Educator regarding email access, group visits, and telephone consultations.

October 2002 - Computer Touchscreen Patient Satisfaction Survey implemented; Diabetes Group Visits in Spanish piloted.

November 2002 - Retrospective Diabetic Chart Reviews with data entry in progress.

December 2002- SeaMar's Annual Children's Christmas Party. It was my pleasure to volunteer on a Saturday with their staff and physicians in serving a delicious hot luncheon followed by the appearance of Santa Claus and Mrs. Claus in a gift giving celebration for those in need. This is just one example of SeaMar's caring and compassionate care demonstrated toward their patients on their day off from work.

January 2003 - In preparation for implementing the Diabetes Registry in February, a decision was made to transition to a different lab vendor. The lab transition to NWRL was very smooth and implemented in January; Berdie Safford MD did a presentation on the Diabetes Registry to all staff and physicians; Erin Baumgart and Jeanmarie Mueller did a presentation to the physicians on the Diabetes Reports available on Crossroads; Joslin Diabetes Center Presentation to include Patient Education Groups in English and Spanish;

February 2003 - Diabetes Registry Implementation" Live" - WOW!

Milestones Achieved as of February 2003 :

1. Scope of Implementation- Our initial scope for the Diabetes Registry Implementation was for 2 Clinical staff and 2 Physicians - by the end of the second week, we fulfilled a request to spread to 9 Clinical staff, 2 PST (Patient Support Techs), 5 MD's and 1 PA-C.

2. Mono-filament Foot Exam-some physicians are now having their clinical staff do the mono-filament foot exams .

3. Smoking Cessation -When the Clinical Staff assess the patient, they are addressing and initiating Patient Behavioral Change Goals - Diet, Exercise and Smoking are discussed. Several patients in the first week of the Diabetes Registry Implementation were referred to Smoking Cessation Programs, just because the Clinical staff asked the question, "Would you be interested in stopping smoking?". One patient stated while I was in the room, "I would love to, but I thought the patches would be too expensive, are there other things I can do? ". WOW, what an opportunity!

4. PSAT (Patient Satisfaction Survey) Score for SeaMar over the past 3 months demonstrated a statistically significant and substantial increase from 63.8 to 69 .3 over all score .

They are able to do today's work today -at times even in the room with the patient; doing data entry for every diabetic patient within 24 hours; running diabetes reports to capture all that is needed in a visit. The behind the scenes work began several months ago, I will try to chronicle where we began: Initially, we had to identify the Diabetic Patient Population followed by a chart review; Patients were then registered in LastWord with the Clinical Snapshot data; Processes were identified; Lab transition identified as a need; Reception, Clinical and Staff Training occurred. They are having receptionists note on the schedule that the patient is there for a diabetes visit; the PST print the Diabetes reports attach them to the charts; the clinical staff review the charts prior to the appointment for medications (ASA, ACE Inhibitors,ARB's) which is also confirmed with the patient when they come in and the last Opthalmology Consultation. If a patient did not have an eye appointment in the last year, a referral form is placed on the chart. A lab card is also placed on the chart so that patients are advised to come in 1 week prior to their appointment to have their labs drawn as needed for Hgb A1c , LDL, etc. All patients are having a visual foot exam done at every office visit. If a mono-filament foot exam is needed a mono-filament kit will be set out. Recalls, are also now in place with the Patient Exception Reports being run the first of every month for each MD. Patients are now being identified and scheduled for a follow-up appointment.

As a result of all of the above, this they have transformed how they deliver patient care to diabetics by becoming a proactive prepared care team!

Your thoughts and comments are welcome!

Terry Wagner RN BSN

Pursuing Perfection Project

800 E. Chestnut Street

Bellingham, WA 98225

Cell # (360) 319-9786

Email twagner@peacehealth.org

Mon, 18 Nov 2002 17:21:41 GMT

SeaMar - Pursuing Perfection Project

A Month At A Glance- November 2002

Accomplishments to date:

1. Wiring/hardware installation for computer touch screen patient satisfaction survey -done.

2. Basic Metric Data Collection - done.

3. Team Development Survey - done .

4. Training for Clinical staff for Diabetes Registry - done.

5. 273 diabetic patients have been identified and accounts set-up in Last Word for implementation of the Diabetes Registry. Thanks Tracey!

6. Spanish translation for patient satisfaction touch screen survey -done. Thanks Wendy and Norma!

7. Focus Group for Spanish Diabetic Patients in regards to group visits, email access, and phone consultation/follow-up-

Thanks Jennifer!

8. Clinical Snap-shot completed in preparation for Diabetic registry - done.

9. Patient Satisfaction Survey - computer touch screen "LIVE" as of 10/28/02. This will be an on-going process everyday..........

Upcoming Meetings/ Events:

1. Daily random patient selection for Patient Satisfaction Survey - computer touch screen.

2. Friday November 8, 2002 9-9:30 am (Jackie, Lyly, Terry) meeting to discuss process for patient satisfaction computer touch screen

survey; meeting 9:30-11:00 am ( Jackie, Terry, Jean Marie) to discuss implementation of Diabetic registry.

3.Next Guidance Team meeting on Wednesday 11/13/02 12 noon - 3 pm @ SeaMar

( Dr. Adams,Jackie Coggins, Lyly Cummins, Terry, Mary, Cindy, Mary Bartolo ( via phone) ).

4. Next Implementation Team Meeting Wednesday 11/13/02 7-10 am @ FHA ( Dr. Adams) .

Terry Wagner RN BSN

Process Facilitator

Whatcom County Pursuing Perfection Project

twagner@peacehealth.org

Cell # 360 319-9786

Month At A Glance - November 2002

Thu, 07 Nov 2002 22:03:57 GMT

Center For Senior Health - Pursuing Perfection

A Month at a Glance- November 2002

Accomplishments to date:

1. Wiring/hardware installation for touch screen patient satisfaction survey -done.

2. Training for clinical staff for CHF Registry-done . Thanks Jean Marie!

2. Clinical snap-shot for 94 patients complete for CHF Registry- Thanks Liz!

3. Basic Data Collection -done.

4. Team Development Survey -done.

5. CHF Registry is actively being piloted.

6. Patient Satisfaction Survey Computer Touch screen - is "Live" as of 10/28/02.

7. Matt Groening - oriented to Pursuing Perfection Project .

Upcoming Meetings/Events:

1. Monday 11/4/02 CSH Guidance Meeting 11:30 am - 1 pm ( Matt Groening, Erin Baumgart, Cindy Manning, Mary Minniti, Stacey Pruim, Terry Wagner).

2. Wednesday 11/6/02 9:30 -11:30 am meeting with Project Evaluators (Erin, Mary, Terry).

3. Tuesday 11/12/02 12 - 1 pm Nurses meeting ( Terry to attend) .

4. Wednesday 11/13/02 Next Implementation Team Meeting 7-10 am @ FHA ( Erin , Matt ).

5. Thursday 11/14/02 11:30 am - 1 pm Technical Support Round Table Luncheon (Erin, Matt).

* Location to be announced soon.

Future Meeting:

1.Monday December 2, 2002 Next CSH Guidance Team meeting 11:00 am -12:30 pm

( Mary, Terry, Cindy, Matt, Erin ).

Terry Wagner RN BSN

Process Facilitator

Whatcom County Pursuing Perfection Project

twagner@peacehealth.org

Cell # 360 319-9786

Month At A Glance - November 2002

Thu, 07 Nov 2002 20:44:20 GMT

North Cascade Cardiology - Pursuing Perfection Project

A Month At A Glance - November 2002

Accomplishments to date:

1. Wiring/hardware installation for computer touch screen patient satisfaction survey -done.

2. Basic Data Collection -done.

3. Team Development Survey -done.

Monthly Meetings/Events:

1. Wednesday 11/6/02 11:30-1:00 NCC Guidance Team Meeting ( Dr.Trenouth, Andrew McLaurin, Marilyn Owen, Kate Garrett, Mary Minniti, Cindy Manning, Terry Wagner).

2. Monday 11/11/02 11:30-1:30 All staff meeting with Terry and Cindy to go over vision of Project and process for implementation of Patient Satisfaction Survey on computer touch screen.

There will be 4 sessions ( 11:30-12 ; 12-12:30; 12:30-1; 1-1:30 ) on 3 rd floor . Staff need to sign up for 1/2 hour session. Please see Marilyn and Kate for sign-up sheets and times.

3. Tuesday 11/12/02 8 am - 5 pm Pilot for the Patient Satisfaction Survey on computer touch screen

( Terry and Stacey) .

4. Wednesday 11/13/02 Target date to go "Live" with patient satisfaction survey on an on-going daily basis.

Future Meeting:

1. Next NCC Guidance Team meeting Wednesday 12/4/02 11:30 am -1 pm ( Dr.Trenouth, Andrew McLaurin, Marilyn Owen, Kate Garrett, Mary Minniti, Cindy Manning, Stacey Pruim. Terry Wagner).

Terry Wagner RN BSN

Process Facilitator

Whatcom County Pursuing Perfection Project

twagner@peacehealth.org

Cell # 360 319-9786

Tue, 05 Nov 2002 16:32:47 GMT