CTC-RI is an active learning collaborative that brings practices together to share best practices to achieve the triple AIM-- improved quality and patient experience of care and reduced health care costs. CTC-RI practice teams have multiple forums for sharing best practices, strategies, and results that improve patient and health care system outcomes including attending and participating in: CTC-RI’s annual conference; quarterly learning sessions; multiple committees and workgroups; and an online collaborative data portal.
Primary care practices are often challenged by creating consistent processes for stratifying patients based on risk status and using the electronic health record to develop and implement standardized nurse care manager assessment and care plan templates.
Marna Heck-Jones (information manager) and Kenny Correlia (pharmacist) shared the work that Anchor Medical has done to assist nurse care managers document the work they do with high risk patients. Anchor used AAFP guidelines to define patient risk status and developed care assessment templates within Athena, the electronic health record. The care manager assessment template triggers the pre-configured follow up reminder between visits and the care plan template prompts the NCM to identify barriers, patient functional abilities and self-management goals.
Anchor additionally developed a Training Guide to assist staff with implementing these care manager tools. Many thanks are extended to Marna and Kenny for sharing their great work at the June Practice Reporting Committee meeting.
With March being Colorectal Cancer Awareness month, the Practice Transformation Committee wanted to high light some of the important work that WellOne has done to improve their colorectal cancer screening rates at their three practice site. Patty Kelly-Flis, Director of Quality at Wellone discussed how the practice sites were able to utilize resources from the Rhode Island Department of Health and the American Cancer Society to implement a patient navigator program to increase outreach, patient engagement and follow-up. Her presentation discussed challenges and successes and offered helpful considerations including garnering leadership support for this public health effort, workflow recommendations, patient communication tools and techniques to improve practice reporting of screening rates within the electronic health record.
Organizations looking to improve their colorectal cancer screening results may want to consider an approach recommended by the American Cancer Society (ACS) “Take the Pledge” and set the goal of reaching 80% screened for Colorectal Cancer Screening by 2018 (insert link to “Take the Pledge”. Your organization could join the growing number of groups that have signed up to take the pledge, including: WellOne, BCBS RI, Providence Health Center, Amicia, Gilbane, Latino Cancer Control Task Force, Health Literacy Consultants, Gastroenterology Specialist Inc., The Rhode Island Department of Health, The Partnership to Reduce Cancer in RI, RI Medical Society and University Medical Group, Inc. at RWMC and Lifespan who be announcing their pledge this month.
The ACS has a number of helpful resources to assist primary care practices with implementing a colorectal cancer screening initiative (insert link). Additionally, Jennifer Cormier from Rhode Island Quality Institute demonstrated how Current Care can be used to obtain colorectal cancer screening results and provided practices with a “Quick Tips” guide.
Colleen Polselli and Deborah Golding from the Office of Special Needs/ Health Equity Institute at the RI Department of Health presented at the November Nurse Care Manager/Care Coordinator Best Practice Sharing Committee meeting. Their presentation* provided valuable information and resources for pediatric practices that are looking to provide support for adolescents and family members that are transitioning to adulthood. Information sharing during their presentation included recognizing the issues of transition, sample practice transition policies and resources that practices can use to help prepare families and adolescents for successful transitions. The Department of Health has created and is maintaining a Medial Home Portal that practices can use to access information, resources and best practice recommendations to assist them with establishing a purposeful, planned transition processes ("Got Transitions" ri.medicalhomeportal.org). Some of the resources discussed during the presentation that practices can use in their office settings include: Parent Brochure: "What Parents and Caregivers Need to Know", a Guide for Young Adults: "Graduate to Adulthood" and an Adolescent Checklist: "Ready? Set. Go!". There are also programs available for youth and families including "Youth Advisory Council" and Community Information Sessions. Pediatric practices are using their practice staff, including Care Coordinators, to assist adolescents and families to better ensure smooth care transitions.
*For a copy of the presentation at the November Nurse Care Manager/Care Coordinator Best Practice Sharing Committee meeting, please email Michele.Brown@umassmed.edu.
At the August Nurse Care Manager/Care Coordinator Best Practice Sharing Committee, Sheri Sharp Assistant Clinical Manager and Nicolette Reyes, Clerical Lead at Hasbro’s Medicine Pediatric Primary Care Center presented on their use of team huddles to improve communication and care coordination. Over the years, the practice team has developed and refined tools and work flows to help support consistent use of team huddles in the practice setting. The practice sees huddle time as the gold standard for pre-visit planning and assuring that children and families have an effective and efficient patient visit. Special thanks are extended to Hasbro’s Medicine Pediatric Primary Care Center for sharing their resources and “lessons learned” with the PCMH Kids and other CTC practices.
At the August Practice Transformation Committee meeting, Jayne Daylor RN MS, Quality Manager from South County Medical Group, presented the Lean Training Project that the SCH East Greenwich office selected to improve the efficiency of the referral management process. The practice team (including IT department, documentation specialist, physician, medical assistant, and quality manager) wanted to better understand which specialists patients were seeing, which specialists’ patients needed and how the electronic health record could be better utilized to assist the practice t with managing the referral tracking process. Using the team based approach to improve performance, the team worked to improve the staff knowledge base of specialists working within the SCH system, what other referral sources were needed and were able to better utilize the EHR for referral management (Click here to view the power point on Referral Management Lean Project). Referral management is an important aspect of providing comprehensive, coordinated care as highlighted in the OHIC Cost Management Strategies and the NCQA Patient Centered Medical Home standards. Congratulations to SCH for working to improve this important process.