Primary Care Practice Redesign Newsletter
Cohort 1 | Issue 2
November 28, 2018
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This newsletter is a biweekly forum to keep practices
connected and informed on the Cohort 1 Redesign efforts.
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A primary focus of practice redesign is team-based care, and huddles are a foundational part of delivering that care. A practice team caring for complex patients can benefit from communicating and coordinating efforts among its members on a regular basis, ranging from a few minutes to fifteen minutes daily. The implementation of daily huddles gives teams a way to actively manage quality and safety, avoid surprises, and ensure effective and efficient communication around patient care. Huddles impact the
practice
(ensuring smoother practice operations), the
health system
(in meeting population health needs), and, most importantly, your
patients
, who receive more streamlined care.
Some huddles focus on patient care and pre-visit planning while others address administrative issues and quality improvement. Our primary care redesign effort is focused on patient/panel management huddles, with the central goal of addressing the needs of patients on each provider’s panel – including both patients being seen that day and other patients who might need special attention.
What makes a good huddle?
Effective huddles consider the following:
Timing
:
Is it short and routine?
People:
Are the right people present?
Location:
Is the location convenient and central?
Data:
Is the data useful, accurate, and actionable?
Panel management huddles
Effective panel management huddles address three key areas:
Analytic Sources
Are you using both reactive and proactive data? Examples of reactive analytics include data from Epic or Patient 360 on care gaps, clinical documentation quality improvement (CDQI), and transitions of care data. Proactive data could include reports from Lumeris on complex care patients who need outreach.
Meeting Structure
Are you meeting daily for patient management and weekly for process improvement? What information is reviewed? Is someone documenting the huddle for follow-ups?
Team Roles and Responsibilities
Defining peoples’ roles in the huddles helps ensure that they will run smoothly. Who should be involved in huddling and what are their tasks? How are you closing the loop on huddle workflows (create accountability structure)? Are you engaging with remote social work and care management nursing team members?
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In Summary
Robust, routine huddles contribute to an interdependent team culture, improved relationships, and the delivery of safe and reliable patient care. All team members can serve as role models for the team by being focused, timely, and present.
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In Your Words: A Huddle by Any Other Name
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Mount Sinai’s
Williamsburg practice has five family medicine physicians (two full-time, three part-time), eight Medical Assistant/Relations Associates, and one LPN. We spoke with
Amber Grossman, Practice Manager, and
Dr. Danya Ellen Reich, Co-Medical Director, about their practice operations and efforts to move from a FFS billing/RVU model to a practice that embraces population health management.
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While Williamsburg may not do formal huddles just yet, they do something that many practices do not do – they have weekly staff meetings (with physicians joining every other week) to talk about issues that arise and to plan how the office can make improvements. Ms. Grossman commented, “Even before the concept of the huddles came about, we’d been doing ‘
reverse huddles’ where our MA and physician would get together at the end of each day to provide feedback on what went wrong and what went right that day. It’s challenging for us to do a beginning-of-the-shift huddle because MA and physician shift times don’t always line up.”
In implementing informal meetings with MAs and physicians, weekly staff meetings, and ‘reverse huddles’ at the end of the day, the Williamsburg practice is on their way to improving the management of their patients.
True population health management is challenging, as it involves caring for patients who are not on the schedule, in addition to patients who have appointments. While Dr. Reich commented that it would be lovely to huddle on patients who are
not on the schedule, she added that this type of panel management usually happens after hours when physicians respond to patients by phone or in myChart. “At the beginning of a transition nobody knows what it’s going to look like in the end, but panel management is the ultimate goal. At this time, we are really just doing day-to-day management,” she said.
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Population Health Podcasts
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MSHP’s Senior Director of Care Management,
Maria Basso Lipani
, LCSW, discusses the Mount Sinai approach to care management, different from case management, in its broad approach to understanding readmission risks and helping patients solve problems by understanding their deeper causes. This approach is based on the principles that the highest-risk patients can be reached, patient engagement is critical, and community collaboration is fundamental.
This episode and all other episodes are also available
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Your feedback matters!
Thank you for participating in the Primary Care Wellness Survey. If you have not done so already, you have until
December 3
. The practice with the highest survey response rate will win a pizza lunch. Stay tuned for results!
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Epic Optimization Progress
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As Mount Sinai continues to deploy the Epic electronic health record system throughout its ambulatory practices, we have also revisited practices, specifically focusing on Cohort 1 of the Primary Care Practice Redesign initiative. Once a practice is beyond the initial learning curve of using Epic, it’s essential to revisit and optimize system functionality. The focus of Epic optimization is improving patient care through increased productivity and efficiency.
According to Brad Rowlands, Project Manager, Epic Optimization, “
Our goal is to try to save providers clicks, focusing on efficient use of the system
. Our training team includes a physician lead, a clinical nurse informaticist, and a systems analyst. Through the discovery process and throughout the training sessions we collect and evaluate enhancement requests.” The Epic Optimization Team just completed its sessions with Cohort 1 in October and will follow up in December.
For sustainability, the Optimization Champions Program trains “champions” in each practice to act as the point person for the practice and liaison with IT. IT continues to work with the practices through the champions, who collect “wish lists” of ongoing improvements the practice would like to see and communicates these requests back to IT.
Quick Wins – Recently Implemented Updates to Epic
- Sticky notes are a way to document something personal and non-clinical about a patient that is not clinically relevant or part of the chart. Use sticky notes to record important events coming up in your patient’s life or write yourself a sticky note to remember your patient’s favorite pet’s name.
- Tired of getting notifications for every single addendum to your charts? Mount Sinai was previously sending 300% more addendum notifications than the average Epic Optimization. Now, you’ll only get meaningful addendums that require notification.
- Need a faster way to chart conditions? Now the number of clicks for certain diagnoses have been reduced into an “Express Lane” that automatically pulls in a note, orders medications, and pre-populates necessary order questions.
- The warning range for high blood pressure for adults has now been reconfigured to 140/90 mm Hg, as defined by the American Heart Association.
Thank you for your help in the Epic Optimization process! Brad Rowlands noted: “We know that these sessions require time away from patients and we appreciate Cohort 1 being so responsible and engaged during the sessions.”
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National Transformation News
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Modern Healthcare recently featured
Bellin Health in Green Bay, Wisconsin in an article that details the program they launched to revamp their primary care delivery program. The goal was to give physicians at its 29 clinics greater team support to reduce administrative burdens and certain patient care duties so that they could see more patients more efficiently. Family physician James Jerzak, MD said that the new structure in place — that includes care team support in documenting information in the electronic health record — permits him to better engage with his patients.
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Introducing Your Practice Redesign Team
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Here's a directory of your Redesign Team and their individual roles in this initiative.
Have a question? Reach out!
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Lisa Bloch
Title:
Senior Director, Provider Communications
Role:
Communications Lead
Roy Cohen, MD
Title:
Director, Primary Care Institute
Role:
Redesign strategic planning; integration with value-based care initiatives.
Jennifer Leone
Title:
Director of Quality and Performance Improvement
Role:
Designer of Learning Collaboratives
George Lourentzatos
Title:
Senior Manager, Practice Facilitation
Role:
Practice Facilitator
Matt Miesle
Title/Role:
Practice Facilitator
Sabine Nicoleau
Title:
Consultant
Role:
Practice engagement and practice assessments, advisory services on Practice Redesign rollout
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Bernard Ortega
Title:
Program Administrator, Peak Health
Role:
Compensation Lead
Jorge Rodriguez
Title:
Senior Vice President, Primary Care
Role:
Executive Sponsor
Stella Safo, MD, MPH
Title:
Senior Medical Director Clinical Transformation, Population Health
Role:
Redesign content generation; practice engagement; and practice facilitation
Chris Scalamandre
Title/Role:
Practice Facilitator
Jana Wong
Title/Role: Project Manager, Primary Care
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