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.
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.