East Cluster Meeting Notes, 2/25/2009

East cluster met today and spent some time reviewing what we've done in this first six months of dedicated cluster work.

To focus our attention on some goals (and hopes), we talked about what makes for a good day at work. Here are some of those ideas:

• Manageable schedules (enough time to do our work)
• Doing something specific, tangible, for a patient that helps them to feel better
• Having a well-stocked cluster
• Having time for providers and nursing staff to plan and reflect
• Attention to detail
• Appropriate appointing
• Running on time
• Helping colleagues to keep things running smoothly
• Great teamwork
• Providing good emotional support for our patients as well as good technical care
• Hearing back from our patients that they're happy with their care
• Seeing our colleagues smile
• Creating a safe, trusting environment for patients
• Giving our patients the care we would like for our families
• Feeling relaxed, ready, and confident
• We wouldn't need to see the quality numbers, because we would know our work exceeds expectations

We also discussed some barriers to having a good day, every day.

• Appointing challenges: some preventive exams should really be problem-oriented, for example, as there is a lot to do in a preventive exam
• There are very different practice styles among our providers. The providers agreed six months ago to standardize some of our practices, but our actions haven't matched our words.
• Some processes are difficult to standardize and create consistent flow breakdowns in our busy days. Immunization reconciliation, ordering, and delivery is one of these areas. A protocol would help everyone feel more confident that we'll get the right immunizations to our patients.
• Medication reconciliation is a huge job for our nursing staff, and a great benefit to our patients and the providers who advise them. Again, there is not an accepted standard for reconciling medications, and we sometimes create work for our pharmacy in the way we do it. A protocol would simplify things.

The solutions we think of have to work for all of us. Some of the things we've tried have worked well (the new blood pressure protocol), and other's haven't (flowstaff workflow charts, Epic tools and dot phrases, and to an extent, this blog).

We deliberately deferred solving specific problems today. I thank everyone for their patience with "the process" today. Ultimately, as the cluster facilitator, I am responsible for delivering results. The best I could hope to do is deliver your wish list for a good day, every day.

I have my marching orders: a good day, every day, and solutions that work for all of us.

State Pain Management Guidelines

A reminder to all that the Washington State’s Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain is available online and serves as the source of our own pain management/opioid guideline, designed around protecting patient safety.

This Guideline is in response to an emerging epidemic of deaths related to accidental overdose of prescription opioids in Washington State and nationally.

Residential Care

DESCRIPTION

The Residential Care Program (RCP), as part of Nursing Home Services (NHS), provides home visits by nurse practitioners to patients who meet the criteria below.

• The patient remains on the Primary Care Physician (PCP) panel and the nurse practitioner partners with the PCP to provide optimal care.
• The nurse practitioner manages episodic and chronic health problems and has a tool kit of standardized tests and measures such as the Geriatric Depression Scale, Mini Mental, and a falls assessment for use as needed to complete a comprehensive assessment. The nurse practitioner orders diagnostic tests and medications, makes referrals to Home Health and Hospice or other services, and recommends/makes referrals to specialists.
• All clinical documentation is recorded in Epic.
• The nurse practitioner communicates with the PCP via Epic staff messaging and collaborates with the PCP to assure seamless delivery of care and services.

CRITERIA FOR RCP
• Generally, but not exclusively, the RCP patient is a frail adult, over age 65, on Medicare, medically complex, and has been identified by Outreach staff, Care Tracker’s Adult Family Home census, the PCP, or other GH provider as a frequent utilizer of urgent care/ED/acute care.
• Patient is unable to follow up with PCP, i.e., is somewhat homebound, although does not necessarily meet the Medicare Home Health definition of homebound.
• Patient may not have been seen in PC for more than one calendar year.
• Patient may have more than one chronic diagnosis such as CHF, COPD, or Diabetes.
• Patient may have advanced dementia, and be unable to be managed in the clinic setting.
• Patient may live in an Adult Family Home, in a private home, or in some cases in Assisted Living.

CRITERIA FOR RETURNING TO PCP FOR ONGOING CARE (RCP DISCHARGE CRITERIA)
Patient is able to follow up with PCP.

CRITERIA FOR ONGOING SERVICE WITH RCP
Patient has ongoing medical needs, but is unable to follow up with PCP.

HOW TO REFER TO RCP or CONTACT RCP

Send an Epic staff message to "p Nursing Home Services" providing:

(this is a dot phrase waiting to happen)

Patient name and consumer number
Reason for referral
Urgency of referral: within 72 hours within 2 months routine
Current address and phone number for the patient or DPOA

RCP GOALS:
• In partnership with primary care clinics, nurse practitioners make home visits to GH members residing in Adult Family Homes and other residences including the patient’s own home; this service enhances care and decreases visits to the ED, hospitalizations, and SNF stays.
• Improved quality measures, including HEDIS scores.
• Increased end of life planning.
• Patient and family satisfaction with the program.
• NHS and PCP satisfaction with the program.
• NHS nurse practitioner FTE adequate to serve this patient population.
• Increased revenue secondary to improved diagnostic coding.

CORE MEETING Minutes Thursday, January 22, 2009

CORE MEETING Minutes Thursday, January 22, 2009

Topics that were discussed:

8:00- Changes in Staff Core Hours:
1. Core hours will be 8-5:00.
Injection Room will be closed 12:30-1:30
Last schedule Core/Injection Room appointment will be 4:30
Last scheduled wound care will be 4:00
Last Injection Room walk-in will be 5:00
Lunch will be staggered.
Pat will start at 8:00-5:00
Sheila and Bobbie will start at 8:30-5:30
Cindy Sewell will start at 7:45-4:30.

8:15 Injection room:
1. Containers that fit into the refrigerator: we have new containers for the Allergy
Serum, that we will trial.
2. Power failure/procedure to save and transfer medications: (Just a review)
We discussed new containers, labeling and hours that medications can be at room temperature.

8:30 Warm Transfers
1. Follow up from December 6ths meeting- Core staff have not noticed any
Change in the warm transfer of patients. Without the report staff often get
Confused as to why the patient is back in the core. (ABI vs. ted hose, IV
Fluids. Etc) because sometimes 2 core staff will assist with the same pt.
2. We are still in the process of putting together a team who will work on the transfer form

8:40 Wound Care: unable to discuss as we ran out of time
1. Changes in the wound product Formulary- unable to discuss as we ran out of time
2. Cost of Dressings.

TID BIT: Pat and Sheila are experimenting with sugar and wounds. The results so far are
outstanding.

Flow Nurse Chronic Condition Testing Outreach Responsibilities

Flow Nurse Chronic Condition Testing Outreach Responsibilities
East Cluster, Burien Medical Center

For a given patient overdue for hemoglobin A1C, LDL, or microalbuminuria testing, the flow nurse will do the following:

• Open an orders encounter and pend standing orders for all three tests if the patient is diabetic or LDL alone if the patient has heart disease but not diabetes. Choose different intervals depending on the test: Hemoglobin A1C = 12 weeks; LDL & microalbuminuria testing = 26 weeks.

• Create a smart phrase in your personal smart phrase folder that says the following: “.m .lname is due for the following tests: ***. Standing orders already exist for these tests at the lab. Tell patient that .he must go to the lab in order to refill .his medications. .He does need to be fasting.”

Note: there was some discussion about the ability to create standing orders for longer than a year, but according to CIS: "the Office of Inspector General (OIG), Model Compliance Plan requires that the plan of care be reviewed every year," and thus prohibits standing orders beyond one year.

• Locate a chronic condition drug for the patient that corresponds to the kind of test that is overdue. Identify a drug that is most likely to be filled next by looking at the date of the last fill. For example, if a patient is overdue for hemoglobin A1C or microalbumin (tests related to diabetes), you would ideally pick a diabetes drug like metformin or glyburide that will be filled soon. If a patient is overdue for LDL testing, you would ideally pick the statin drug. If there is not an appropriate drug, simply pick a drug that is going to be filled soon.

• Within the orders encounter, re-order the drug (or drugs) that you have identified and label them as “update and file.” When you clicked on the drug itself in order to label it “update and file,” you opened a comments field in the middle of your screen.

• In the comments section, insert the smart phrase listed above, listing the drugs that will need to be completed in the ***. This comments section is always seen first by pharmacy staff when filling a prescription and it will prompt them to notify the patient of the need to get testing done.

Sample Cancer Screening Outreach Letter (Paste in Your Epic Smart Phrases)

Dear .m .lname,

As your personal doctor, I want you to undergo periodic testing to be sure you do not develop cancer. Many cancers are curable if detected and treated early. My records show that you are due for the following cancer screening tests:

MAMMOGRAM: a kind of xray used to identify breast cancer. You may schedule a mammogram on Capitol Hill by calling 206.326.3600. Alternatively, once a month, mammograms are also available at Burien Medical Center and can be arranged by calling 206.901.2400.

PAP SMEAR: an office procedure used to identify cervical cancer. You may schedule a pap smear at Burien Medical Center either with me or one of my colleagues by calling 206.901.2400.

FECAL OCCULT BLOOD TESTING OR COLONOSCOPY: tests used to identify colon cancer. They are equally effective screening tests. Fecal occult blood testing is the least invasive method and should be done yearly. I've enclosed a set of these cards for you with this letter including instructions on how to complete them (on the inside of the envelope). Alternatively, you may do a colonoscopy once every ten years. Colonoscopies are done in the gastroenterology department on Capitol Hill and require anesthesia and a colonic preparation the night before. It is a more involved procedure. A colonoscopy involves a camera being passed through your rectum and into your colon to visualize it in its entirety. If you would prefer to get a colonoscopy, you may schedule it by calling 206.326.3050.

Thank you very much for staying up-to-date with your preventative care.

If you have any questions, please let me know.

Sincerely,

.pcp

.brn

Decisions From East Cluster 1/28/2009

Regarding flow nursing outreach responsibilities in the East Cluster, at today's meeting we decided on the following points:

The one page sheet that summarizes the flow nurses' outreach responsibilities lists a variety of quality indicators that can be organized as to how the nurses will approach outreach.

Immunizations for Children. There is a statewide electronic database (Child Profile) that tracks completion of immunization rates for Washington's children. Becky is presently arranging for several nurses to get access to this database. If this is successful, our first effort at updating immunization rates will involve flow nurses looking up patients listed as behind on immunizations and making sure in the database that they have not already received the immunizations outside of Group Health. For now, this will be the main outreach effort in this category.

Tests (includes A1C, LDL measurement, microalbuminuria testing). Flow nurses will put in standing orders for these tests to be done on all patients who are due for testing. The flow nurses will do two things: 1) pending standing orders; 2) using the update and file feature on a chronic care medication that will likely be filled soon, they will use a dot phrase in the notes section of the pharmacy ordering field to ask the pharmacist at the time of medication pick up to ask patient to get appropriate tests.

Cancer Screening. We will draft a dot phrase letter that alerts patients of the need for mammography, cervical cancer screening, and colorectal cancer screening. Flow nurses will send these letters out to patients in need, deleting the sections that do not apply to them. Our outreach efforts for cancer screening will be limited to these letters.

Of note, in none of the above outreach efforts, are our flow nurses doing cold calls on patients.

North Cluster meeting minutes 1/26/09

New to do:
Liz: print and stock rooms with home BP monitor DME forms
Liz: print out March templates to look at timing of visits and phone visits
Nurses: lay out BP cards if BP's higher than target, work on pap exception reports
Providers: special attention to BP's, encourage home BP self monitoring and provide DME benefits form

Present: Anna, Christine, Jason, Lakisha, Liz, Mark, Ted
Absent: Becky, Diane, Lynn, Shiji

1. PCAC (centralized appointing) going live TODAY. Pt's will still call same number (901-2400), but phones will be answered centrally (they will still answer and say "BRN medical center." If we want to call, the back line number is 600-8724 (FP) and 600-8728 (Peds), and you will jump to the top of the queue immediately. The PCAC will schedule all appts up to the day of, as long as there are appts available.

If there is any feedback that you need to provide to the PCAC pool, please staff message the pools: "p pcac." Please choose either "PCAC SOUTH FP APPT FEEDBACK" or "PCAC SOUTH PEDS APPT FEEDBACK". In the body of the message, use the .apptfeedback smartphrase:
CSR: .mrn
Name: .name
Date of concern: ***
Description of concern: ***
Request for resolution/opportunity for improvement: ***

2. DME - BP monitor benefits. I passed out a double sided form today that we will start stocking in all rooms. It has a form to be completed to allow for partial coverage of a BP monitor (50-80%) for most patients. The other side has a BP monitor from the Take Care Store recommended by Shannon. Links are below, if you want to see them. Liz is going to make lots of copies and stock them in all the rooms. Patients can fill most out on their own. Docs can fill them out if they want. Nurses may be asked to do some too. Just be aware of it. It will help us provide better care for our patients (by having a home monitor) and save the pt quite a bit of money.

DME benefit for for home BP monitor:
http://incontext.ghc.org/rx/ops/documents/takecare_order.pdf

Popular home BP monitor at the Take Care Store
http://www.take-care.com/medi/712Com.html

3. Pap exception reports. Instructions for 2 step process to remove pts from pap lists (HEDIS and BPA's). This would be a nice thing to concentrate on since we would like to improve HEDIS measures without having to call pts in for right now (since access is poor). Nurses will work on this for now. I figured out a way to make a list, so will share that at next meeting depending on how Liz finds it.

http://incontext.ghc.org/quality_informatics/qie/strategies/cervical_ca_hm_bpa.pdf

January 21, 2009 West Cluster Meeting

January 21, 2009 West Cluster Meeting

Present: Kelly, Ashley, Sarah, Becky, Doug, Star, Esma, Timieko, Marilyn, Cindy Woody.

Discussion of Hedis measures

Discussion of blood pressure / Hedis measures- maybe having a once a week Group BP visit with an RN and an LPN/MA taking blood pressures in the North Annex?

Can the diabetic nurses target DM pts for Hedis measures during their visits also?

Pap / PE access is out about one month. There are three visits scheduled per session (1/2 day)

Discussion about scheduled PE’s; sometimes pts come in and they are not really here for a PE, they may have told the PCR an ‘annual’ which may mean something different to pt. This should clear up with the new model; they call center is going to ask probing questions.

Discussion about DTM time placement.

March 1 phones will not be turned on until we open at 8AM; so we will not be able to access cancellations until we open.

Discussion about if releasing secure messages earlier in the day to providers would give them more time to respond especially if they are in for ½ session.

40 minute appointments should be: 1st OB, ADHD children, confused elderly, OTJ 1st visit, Diabetes 1st visit, CDL / PRV.

Discussion about 1st OB being 40 minutes; there may not be enough openings and they need to be seen sooner for lab testing; Dr. Lindell will bring this up at the provider meeting.

There will be a new Occ Med physician starting next month. She will be doing most of the Occ Med appts and can do CDL’s also.

Meeting closed at 2:20pm

Star Morales, CMA

Burien Medical Center Nursing/Admin Retreat

Burien Medical Center Nursing/Admin Retreat
Friday, Jan 16th, 2009
Acme Bowling, Seattle, WA

Attendees: Sheila Collins, Esma Delalic, Becky Dolan, Sherrie Elmer, Pat Emswiler, Cindy Ferron, Anna Garcia, Lakisha Lollie, Nan Maharaj, Faith McGunagle, Barb Meier, Star Morales, Liz Roberts, Cheryl Rogers, Katie Teurn, Lynne Thompson, Christine Westby.

Agenda:
o Teambuilding using the Lencioni Model
o Define a Team Goal
o Participate in a Team Assessment Survey
o Participate in a Trust and Feedback Enhancement Exercise
o Meeting Summary with next steps
o Bowling/Scrapbooking and Lunch


Team Goal
Create an open and supportive environment for a team that works together with mutual respect, genuine support and shared responsibility that appreciates each other’s strengths and weakness in order to achieve a shared goal.

5 Dysfunctions of a Team Survey:
Absence of Trust: 7
Fear of Conflict: 8
Lack of Commitment: 8
Avoidance of Accountability: 7
Inattention to Results: 8

(Score of 8-9 is probable indication that the dysfunction is not a problem for your team.
Score of 6-7 indicates that the dysfunction could be a problem.
Score of 3-5 is probably an indication that the dysfunction needs to be addressed.)

Retreat Summary

Future Team-building plan/Strategies

Improve Communication
Cross Training for all Nursing Staff
Define our goals
Define a Collective Clinic Goal
Discuss our strength/weaknesses

What we liked about today:
Providers are engaged and very supportive of Burien Nursing!!!
Getting to know each other
Knowing other’s challenges
Mixing work with fun
Food/Drink
Relaxed environment
Feel safe
Afford retreat for Burien Nsg team
Thank Becky

What was Challenging about today:
Venue selection-room
Team pick exercise-Individual assessments
Share written feedback versus verbal

Stress-Free Primary Care?

When I graduated from medical school in 2005, my friend Liz gave me a label maker and a book called Getting Things Done (GTD). I assumed it was a gag gift, though I knew Liz to be a fan of GTD and its author, David Allen, a productivity swami. I thought it was interesting, so I read it.

And then I labeled everything.

Over the last few years, I have practiced a watered-down version of the GTD process, which advocates "stress free productivity" through effective management of the information that comes to us faster and faster. When the mind is unburdened of the task of remembering all the things there are to do, it is possible to be present for whatever task is at hand.Through residency, this was tough. The task at hand generally involved some high-stakes activity performed in the setting of sleep deprivation and incompetence-by-design. Delivering babies, for example: you become competent by doing it, they come in the middle of the night, and it's a big deal if you screw it up.

There was little about residency that allowed for stress free productivity. I did what I could, but there were limits. Mostly, I just crashed through.

I've been out of residency less than a year, and have been a full time family doctor for a little over six months. I work five full days in clinic, seeing about eighteen patients a day for multiple concerns, acute and chronic. I also manage dozens of lab and study results every day, and respond to patient phone calls and email.

My goal: go in every morning relaxed and prepared for whatever comes my way and leave at the end of the day having acted on every piece of information that came my way. That doesn't mean I've cured everybody, cure is pretty rare in medicine.But hope that by day's end I will have responded to every item that demanded my attention in a appropriate way:

• Every patient visit ends with a mutually agreed plan;
• Every patient call that came in got an answer, a plan;
• I reviewed every lab or study result and made a plan;
• I updated patient charts to clearly describe the plan to everyone who might need to know.
• I set up reminders to myself so I don't worry that I'll forget about important parts of the plan.

When I accomplish all those things, there is an empty in-box in front of me, ready to receive whatever might arrive next. More importantly, my head is not cluttered with all the things I "should" be doing or trying to remember all the things that might be coming in. Unburdened, I feel much more able to be fully present for patients during the twenty minutes I get with them. We have a lot to do in those brief visits and they expect my full attention. When I'm on my game, they get it.

Maybe I'll write more about this later. It seems like a good topic to explore further (running a visit, how the day flows, setting reminders, updating care plans, teamwork and communication, cross-covering for colleagues...)

Crossposted.

Take Care Store dot phrases

Chris Thayer is spending some locums time at BRN to help us out, and last week shared with us his very helpful dot phrases to help patients get some coverage for home blood pressure monitors. We asked him to send the phrases for inclusion in the blog. Chris writes: "Here are the smartphrases that I use for getting the blood pressure cuffs covered by the Take Care Store. Note there are two different ones. "

Many thanks to Chris!

The first is a letter to be faxed to the Take Care Store:

.date[t Take Care Storefax: (206) 901-6888

Hello: The patient mentioned below would like to purchase a piece of
durable medical equipment.I have told .him that you are an excellent place to purchase such equipment, and that you can automatically apply insurance benefits. Can you please contact the patient at the numbers listed below to help them order
this item?

PATIENT NAME: .name
PHONE: .phDOB: .dobPRODUCT: blood pressure cuff
DX: Hypertension (401.1)
PROVIDER: .me
PROVIDER CODE: xxx
If you have any questions regarding this request, please don't hesitate to
contact me.

Best Regards,.me

The second is put in the AVS of the patient:

DURABLE MEDICAL EQUIPMENT
The most convenient place to get most durable medical equipment (blood
pressure cuffs, braces, etc.) is at the Group Health's Take Care Store.
The advantage of buying the item there is that any insurance coverage you
have for the item is automatically deducted. You can go somewhere else if
you'd like, but you then have to pay full price and fill out a form to get the
insurance coverage re-imbursed.

To make this easier yet, we will contact the Take Care Store and ask them
to give you a call. You should expect to hear from them within 1-2
business days. If you don't hear anything, feel free to call them M-F
8am-4pm at 1-800-447-2839.

You can see their various product offering at www.take-care.com. If
you prefer, you can also go directly to their retail location in Capitol Hill.
It is located in the South Building on the ground floor. The address
is 125 16th Ave East Seattle, WA 98112. Their phone number is (206)
326-3496. They are open M-F 9:30am - 5:30pm.

Here is the information that we'll fax to the Take Care Store at (206)
901-6888:
Your name: .name
Your phone numbers: .ph
Your date of birth: .dob
Product: blood pressure cuff
Diagnosis Code: Hypertension (401.1)
Provider: .me
Provider Code: xxx