I would like to know how is the project going. What are the outcomes if you have analyzed them already? Did you have difficulties with patients compliance? What is their reaction?

Thank you again and keep up with your wonderful work.

Andi Qipo, MD, MPH
Quality Improvement Specialist 
East Boston Neighborhood Health Center
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I have a story to share that is short, but I intend to get some details and post them later.  I didn't want to lose the thought.

At Family Health Associates there is a doctor that was under the impression, with the changes we have been making in our move toward open access that he was seeing fewer patients a day and he was unhappy about that.  When we went back and compared his current visits to those he had the same time last year in the "old system" we found that he is actually seeing 1-2 more now.

So, not only is he seeing more patients now - it feels like he is seeing less!

They also have some reporting that they do on the figures that are transferred between clinicians that are panelled with Group Health (the crossover report).  The amount of money changing hands because they are caring for each other's patients has gone down:

December - $xxx, January - reduced by 42%, February - reduced that by 30% (overall reduced by 60%).  That indicates that clinicians are seeing more of their own patients.

More details to follow....

Okay, today I felt success.  I mean I really felt success.

I was at a clinic and one of the staff members pulled me aside.  She showed some real excitement about what she was about to show me.  "You'll like this," she said.  "It was really fun and you'll like this."  She searched high and low for a sheet of paper.  When she finally found it, a post-it note with major scribbles all over it, she relayed what she had done.  She had been requested by one of the physicians in the office to make a call to a patient and to change the dose on a medication.  She had kept track of all of the steps that took place and all of the events that occured as a result of that one request.  Several hours later, 8 people involved, request complete.  She looked at that information with a co-worker and they determined how they might remove a few of the steps the next time.  They decided on an issue to bring to one of the teams to have them look at for possible improvement.  "I just knew that we were spending more time and energy on some of these requests than we thought, look at this, can you believe it?"  You bet I can.  But I couldn't hardly believe the excitement that came from that 3 inch yellow post-it note.  I had feelings not unlike the times my first grade daughter brings home some of those "first time accomplishments".

They have the bug!  They can't leave things the way they are!  They notice inefficiency and they want to track it and figure out what they can do to change it now.  This was an effort taken completely outside of one of the improvement teams in Ferndale, by one of the staff members that was seemlying the slowest on board with this "process flow improvement stuff".  We win - 'cause now, she's got the bug!

The hard thing to change is the culture and now the signs to show that the culture is changing are starting to surface.  And now I'm starting to feel successful.  Successful because they have the bug and now they won't be able to get rid of it, and that means sustainability.  And it goes to show - when the foundation is set, the building will follow :-)

I have a few ideas that I want to make sure I capture.  Mostly because if I don't - I'll forget.  I don't have any conclusions as of yet, but I am aware of the need to dig deeper.  My tendency is to crunch numbers.  I like to see things as black and white.  Do or don't.  You know, based on these guidelines that if a patient is in this range we need to make this intervention (medically).  Simple, right?

I've got a few stories about the changes we are making and how they are affecting outcomes and I think I may be noticing a trend.  I'm wondering what others may think.  Here it is....

1. Much of the work being done by the clinical care specialists seems to be of a social nature.  They are providing great care, but the needs are high on the social end.
2. When I "followed a physican for a day", I noticed that many of the issues people had hinged on social issues - depression, counselling was a big part of those visits
3. The group visits at Ferndale are seeing very good outcomes.  I don't think there is anyone that has attended that doesn't have improved outcomes - they are all encouraging others and giving each other tips on how to manage their disease - that's the benefit to the physician.  Patients can get them to do things that the physician would not have been able to otherwise.  They are also getting recognition for improvement from peers, a celebration of success.
4. When we first started looking for patients for our Chronic Care Team in Ferndale, patients were referred by a CCS if they were thought to be interested.  Of the three I took, one of the patients was thought not to be appropriate because of 'the way she was'.  Once contacted, she indicated she was interested and so, we got her on the team.  The physician couldn't believe the turn around in how she was.  Her numbers had improved as well.  Her social situation had completely changed and the outcomes were drastically improved seemlying as a result of that social intervention.
5. It has been noted many times in re-design conversations over the past few months that there are people that either do not take what is prescribed because they can't afford it, or they might for example decide to alternate the weeks they take their heart meds and their diabetic meds in order to stretch them out. A very large amount of time is spent on searching for programs to help patients with the cost of meds.  This is clinical staff time that is deemed ''necessary" to support the patient but is not reimbursed.
6. I have picked up that it appears many people with one of our two chronic diseases in this project scope also have 'depression' and that is consistent.
7. I've heard stories of clinics that have instituted regular phone calls out to patients that have been "frequent flyers" and that has proven quite often to be enough to keep the patient out of the office quite a bit of the time.  They just need to talk to someone.  Again, not reimbursed but done because it makes room for those patients that need "medical attention''.

I'm wondering whether evidenced based  is 'medical outcomes based on clinical intervention' only, or if there is some indicator of the effects of social interventions on these same outcomes and if that aspect of the changes we are bringing is having the largest affect.

If we are looking at changing what we pay physicians for and what services we supply when, we might want to think about having MSWs accessible at each clinic to take some of the load from physicians.

FHA had their first pursing perfection retreat on Saturday.  This is just the beginning of the action with this group.  I am excited about what is to come!  They are full of energy, some of it not extremely positive but if we can manage to channel it we will be very successful.

They are a group that do not appear to hold back opinion.  The way I look at things, as long as we all feel like we are able to contribute and do, and all the ideas get on the table, the sorting of them and organizing them into something that works well is really the easy work.  So, it's getting them to the point where they feel like their ideas have value: that is the real work!  And I believe we are headed in the right direction, many thanks to Cindy's leadership.

The three staff members that are a part of the guidance team in that clinic are already transforming before our very eyes.  It is absolutely amazing what people will do if they feel they have permission. 

That is one of the concepts that I have really been kicking around that I feel coming from Marc Pierson on this project.  If you don't feel you have permission, take it.  I am paraphrasing but that is how I have understood it.  That doesn't mean moving forward when it doesn't make sense, it means that if it does make complete sense and you feel you can't you need to explore why that is.  Is it because you have made up a barrier that doesn't exist?  Is it because there is a barrier that really does exist that needs to be removed?  Or is it because there is a barrier that is well placed, and we decide that it's appropriate after further reflection?

The group at FHA is finding out that there are some of all of those.  We never know which they are until we push on them a little. 

http://www.familyhealth.org/clinics/familyhealthassoc/pursuingperfection.html

Cindy manning's weblog titled "It's what you do next" gives a good summary as well...
http://www.wwpp.org/users/0000022/

 

ing able to 'think' about things.  Mull them over in my head.  That is what I have found seems to be missing quite often.  Think time.  I'm drawing a line and am going to make efforts to 'schedule' think time.  We'll see how it goes.  

The shared care plan met with a grand reception.  Berdi did an excellent job at the plenary session yesterday and the workshop went quite well as well.  Many seem to be excited about the possibilities.  Many wanted to know when they could use it. 

It is exciting to see more and more getting excited about the possibility of being able to provide same day appointments to patients as a normal part of life in the clinic. 

We went over the data collection for demand at the clinic and made sure everyone was on the same page about all of the different scenarios and how to 'tick' for them.  The team will present this at their staff meeting this Thursday and start a two week re-collection of the data Monday April 14th .  I will be in St.Louis at the IHI international summit on Redesigning the Clinical Office Practice.  I am looking very forward to the workshop on Sunday with Catherine Tantau and Gordon Moore on improving access and efficiency in Specialty Practices (with NCC in mind).

Jim Byrnes, the practice manager at FFMC and FHA will be supplying the information we are needing on utilization and continuity.  We already have some initial panel sizes but the doctors are going to meet and decide on how they want to "adjust" those numbers for gender, age etc.

There is no lack of energy in Ferndale around open access!

In the chronic care team at the Ferndale clinic we are currently ramping up the pilot of the shared care plan.  Slow but sure and always headed forward.  We think we can, we think we can, we think we can....

Berdi has made efforts with some diabetic patients and it appears that quite often either there is little interest or it really isn't as urgent a need for them as it could be for others. In thinking about what might be a good first target group, the idea was raised to work with the population with HF. There appears to be a few benefits to this approach.

• We are going to have to identify these patients later to enter into the HF registry anyway, so by identifying them now, we can obtain our target population and also lay some ground work for future HF registry implementation (list of patients).
• The specialist on the care team for HF patients very often (not always) is part of NCC which is a pilot site. This will allow us to see the flow of the shared care plan from both ends as we have access to NCC.
• And these patients appear to be a group that may be more receptive because they have a greater need for a tool like the Shared Care Plan (SCP).

Once our list is finalized we plan on pulling the charts and labelling them like charts are labelled for Diabetes in the FCN clinics (this was implemented when the DM registry was put in place before P2). We have two labels being generated - A hot pink label for HF and a neon green label for SCP.

Kaye Palmer is getting a list from Nancy Stothart and from Sally who is the FCN care manager for CHF with group health's program and people with either of those two will automatically be flagged without a confirmation required. She is also looking into reporting on IDC9 code within their data and trying to flush out the right patients. Once a list has been generated we were going to look to the PCP to confirm the diagnosis before labelling the charts etc.  Jeanmarie and Brian are confirming the ICD9 codes used by systems dynamics and in NCC's implementation of the HF registry to confirm we are all talking about the same patients.

Discussions with Lori Nichols and Dawn Gauthier triggered some question as to whether the registry input might be used to help with the initial volume of SCPs to be created.  The hope was that the demographic information already entered for the registry could be 'scooped' for the first pass 'mass SCP creation' for those patients.  They are looking into this and to date it appears this would be fairly simple once the patients have "c" accounts for the registries.  Jeanmarie estimated that perhaps even within 3 weeks we might have the registry patients entered and confirmed and at that time we could isolate those patients within NCC that have a PCP in Ferndale and start from there.

Heads were also put together to try and simplify the process in the clinic for outputting medication list information from the SCP.  Dawn is going to make some modifications to the printing to have it default to no sections checked but also add an option for the entire plan, currently each section has a checkbox and the default is that they are all checked.  Every little improvement for the clinic will help in the final implementation.  I believe there needs to be a way, as Lori had already commented previously, that we can somehow replace our medication list flowsheet in the charts at the clinics with the meds section of the SCP.  This would involve having it print differently.  I look forward with anticipation working with Dawn and crew on the single medication list implementation.  That is obviously extremely interwoven into the Shared Care Plan success in the clinics.

Still advocating computers in the rooms as soon as possible....

Looks like a little bump in the road of medication list accuracy.  We were starting to see patients arrive with thier bags of medications in hand for their appointments and then observed almost a complete stop.  The clinic had switched to an automated reminder system and had included some verbage in that message to indicate they should be bringing their medications in with them.... but obviously something has gone amiss.

We will be modifying the script for the reminder messages and see over the next week or so if that has any effect on the patients.  We are collecting in the rooms the numbers that indicate both whether they received a reminder and if they understood from the reminder that they were to bring in their meds.

The Guidance team at FHA was launched after the first of the year, after the second staff retreat at FFMC.  The team consists of those that are involved in FFMC.  The two clinics share a practice manager, Jim Byrnes and we also have someone cross clinics responsible for clinical processes, Kaye Palmer.  That is great for continuity, they have a direct connection to the learning in Ferndale.  We have a couple of doctors - Berdi Safford and Dave Lynch, and we also have a few of the clinic's staff.  One from the front office - Nicole Leveck, one from nursing - Rhonda Hogue,  and one from the business office - Jody Amos.  We also have on board a practice manager from another site to try and build in spread for the next FCN clinic.  A great mix!

Cindy has done an exceptional job of 'Manning' the ship (couldn't resist).  She took us through the process of forming team agreements and we've done some orientation to the P2 project to help newcomers feel more comfortable with what this is all about.  We have set the clinic goals and are now in process of setting up their first staff retreat for April 26th.  The staff members are energetic and engaged! 

The FHA team has decided to adopt the same goals as FFMC and in fact they beleive they will become FCN wide, with one exception.  They wanted a change to the first goal to reference that the methods to provide the care will reflect the patients wants.  FFMC have updated their goals to reflect the change as their guidance team is a subset of the FHA team.  So their goals are as follows:

1. FCN will provide patients the health care they need at the time that they want and need in the way they find most helpful.
2. FCN will provide pre-planned chronic illness care as a pro-active knowledgeable health care team interacting with our patients who are as active and informed managers of their chronic conditions as they desire to be.
3. FCN will be the workplace of choice for our physicians and staff because of our high satisfaction with work and our high patient satisfaction.
4. FCN will be a highly efficient office that does not waste the time and money of our staff and patients.

They are slowly going to be introducing these goals to staff.  They intend to take the first goal and post it in the lunch are where there is high staff traffic.  There will also be an effort made to start the 'right' conversations around change and what healthcare could look like.

Stay tuned....