Primary Care Practice Redesign Newsletter
Cohort 1 | Issue 6
February 25, 2019
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This newsletter is a biweekly forum to keep practices
connected and informed on the Cohort 1 Redesign efforts.
Be sure to right-click to download pictures.
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Preparing for Transitions of Care
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Here’s what we learned from each other about implementing Transitions of Care processes
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At the recent Learning Collaborative Meeting, we had an engaging panel and practice activity on Transitions of Care (TOC). Practices co-designed a process to stay connected to their Care Management team or expand upon their current transitions workflow. As Cohort 1 practices are now embarking on TOC projects, here’s a summary of what we learned from each other:
Benefits of TOC Processes
- Improve patient care; utilization of care management resources aids doctors and staff in caring for patients
- Builds strong ties with patients to promote continuity of care
- Improves comfort and safety of patients, providing guidance and avoiding errors
- Makes patients feel important and well cared for
Current Challenges
- Practices aren't all aware of how to route patients to Care Management
- Practices do not always have access to discharge summaries
- Practices are not always notified about patients admitted or discharged from the hospital
- Need to improve relationships with inpatient physicians and ensure all information is in Epic for seamless TOC hand off from specialists and hospitals
Proposed Solutions
- Build relationships with the Care Management Team (e.g., invite Care Managers to team meetings; have a telephone encounter with Care Management to discuss patients requiring their services)
- Train staff on how to complete forms and work with Care Management
- Obtain daily listings of hospital discharges
- Engage pharmacists if available to do medication reconciliations
- Leverage data from Lumeris' ADSP system to identify patients in need of extra care
- Incorporate TOC into daily huddles to implement a plan of care
Thank you
to everyone for sharing your insights at the Learning Collaborative and we hope it was a useful kick-start for the TOC project! We look forward to reporting our progress in a future issue of this newsletter.
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In Your Words: Huddle Tips
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Interview with
Deborah Sammut, BSN, RN
and
Dr. David Coun
of
Mount Sinai Doctors Brooklyn Heights
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When’s a good time to huddle? For
Deborah Sammut, BSN, RN
, Clinical Manager of Mount Sinai Doctors Brooklyn Heights, it’s after rooming the first patient. While physicians are treating their first patient, the Medical Assistant prints and reviews the day’s schedule, along with the Patient 360 reports that have been placed in the clinician’s huddle folder, all in preparation for the day’s huddle.
The practice
developed a checklist
for use in daily huddles that embraces simple objectives, including a quick scan of the daily schedule, opportunities for sick patients, review of the InBasket, reviewing staffing issues of the day, and proactively addressing any issues for the day’s scheduled patients. This checklist provides an agenda for the huddle, and helps tease out any special patient needs and follow up required, as well as identifying patients who need care outside of a scheduled visit or who have been recently discharged from the hospital and require follow-up.
After huddling regularly for more than a month, Ms. Sammut commented, “Huddles have really improved our teamwork. They inspire staff members to communicate with each other and these more active communications between physicians and staff help improve patient flow.” Ms. Sammut also commented that the practice’s system of documenting the huddles means that staff members have the information and instructions they need available to them when filling in for each other.
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According to
Dr. David Coun, Chief of Medicine, the impact of huddles has been threefold:
- From a practical point of view, efficiency is a key benefit – such as proactively addressing tasks that can be done during rooming, like Strep tests and EKGs.
- Formally reviewing the day’s schedules allows opportunities to improve the flow of the day and could mean squeezing in additional patients.
- In our model, the nurses are the facilitators and initiators of the daily huddles, and they in turn empower the MAs to lead the huddles, thus elevating the MAs’ job descriptions and job satisfaction.
Friendly reminders from Dr. Coun and Ms. Sammut remind staff to “get on the huddle train.” The practice is currently being trained on Lumeris’ ADSP platform, which will provide further actionable data to inform the daily huddles.
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Mike Berger, Vice President of Population Health Informatics and Data Science for the Mount Sinai Health System, joins Dr. Fields in this episode to discuss data and population health. Mike Berger explains what it means to treat data as an asset – not just valuing data and hoping we have enough to make decisions, but investing time and technology in it to create feedback loops which can then be built into future models.
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Tip of the Day
Check out this huddle checklist
, prepared by Dr. David Coun of Mount Sinai Doctors Brooklyn Heights. What information from this checklist can you incorporate into your daily huddle?
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Clarifying Health Care Vocabulary
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Health care vocabulary abounds with jargon and acronyms. Advisory Board has prepared this health care dictionary to help “demystify wonky acronyms, provide context to everyday conversations and help you speak fluently about health care trends and concepts with your provider customers.” Download the
dictionary here
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