The Pennsylvania Academy of Family Physicians |
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June 2012
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Managing Change while Improving Quality of Care |
Pennsylvania family medicine knows that health care has to change, and we are not waiting for a government directive to get started. Our grassroots transformation initiative just started its third year!
The PAFP Foundation’s Residency Program and Community Health Center collaboratives met June 8 in Scranton. The 45 participating practices are performing monthly PDSA cycles to implement advanced care delivery concepts such as care management and transitional care. The context for this education is diabetes and ischemic vascular disease, but the skills learned are applicable to any focus area and the change made should stimulate improvement in other areas, including other chronic diseases and preventive medicine.
The Residency Program Collaborative continues to be the largest single-state residency program collaborative in the country. And we’re not just the biggest; this is a successful community of family medicine practices serving some of our state’s most at-risk patients. Quality is improving because the teams participating are committed to making meaningful change at their practices – to better serve patients and train residents in true Patient-Centered Medical Homes.
The Community Health Center Collaborative, in its second year, is also critical: Community medicine is primary care and a career choice for many family physicians. The PAFP Foundation is working closely with the Pennsylvania Association of Community Health Centers to achieve the exact same goals as the residency program group.
What can you learn from their experiences? Change is hard, but it can happen. Look at your performance data and start making little changes. Check out our online CME to learn more! On Twitter, follow the PAFP at @PAFPandF; follow the collaborative with the hashtag #RPC.
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Tweets from the Collaboratives
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General Information and Insights:
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Chronic care focus + advanced care delivery transformation is what generates quality improvement.
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Statewide QI in residency programs is workforce development! Lots of residents will head into the field trained in QI and #PCMH.
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“Process” is critical. Practices must learn to continuously manage all process measures – tobacco, eye exams, foot exams, etc…
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Data fatigue is real. If working on lots of data is too much for your practice, pick the top 5 measures that need the most work.
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Wow: one residency program is using unblinded report cards. Everybody sees everybody’s performance. It works for them!
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UPMC tip: If outreach fails with your patients, get everything when they’re in the office. i.e. do nonfasting glucose tests, check all screenings, etc.
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Altoona tip: put check lists in the same place every time – you know where to look and it makes it easier to not miss stuff.
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Cultural transformation to the PCMH: staff are sometimes more engaged and enthusiastic than physicians who have trouble letting go of tasks*
<o:p></o:p>* A key learning point in the Collaborative is “decisions for physicians; tasks for staff.”
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Self-Management:
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Altoona tip: self-management is tough but most times you can find at least one thing you can work on together (and document it!).
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Penn State Good Sam tip: Are you following up on self-management goals? Doing so could be the way to keep improving clinical outcomes! Document it then follow up.
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St. Margaret’s UPMC tip: Self management has made a big impact and it continues to evolve. EHR system has been a challenge but they’ve been training staff and docs to look for that particular screen to document “health maintenance.”
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Supporting pt self mgmt: give info, tools, support patients to take care of their #health in their daily lives.
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Diabetes, Hypertension and BMI:
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Collaborative BP challenge: get 20 patients <130/80 by Oct. 31. Featuring intense BP control education. Watch for practice pearls from the PAFP.
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Williamsport tip: Re-check borderline high BP. Sometimes a patient has just walked to the office and BP will lower itself in a few minutes.
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Easy ways to improve BP: move the cuff to the chair, take BP after intake/vital signs.
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Double check the JNC 7 BP measurement rules – do it right!
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Lots of notes and no BP control = clinical inertia. Take a look at the chart. How long has that patient’s BP been out of control?
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McKeesport tip: Diabetes report card captures data on patients you don’t see often. Helps you stay on top of process measures.
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One team hounded a patient with out of control DM until he came in even though he didn’t really want help. The physician was thrilled because at least that patient is in the door – baby steps!
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BMI screening should pick up and document higher and lower averages. Good way to pick up eating disorders.
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Depression:
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Residency Program Collaborative will now report depression screening data to support their work to improve diabetes outcomes.
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You can’t make an asymptomatic person feel better. Except if you screen so screen for depression!
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If you are skipping depression screening because you don’t know what to do if the screen is positive, figure it out!
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PHQ 2 and 9 are screening tools, not diagnostic. But it’ll pick up subtle symptoms you’d otherwise miss.
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Depression is a chronic illness, and it often progresses so you need to screen and treat to assist with improved outcomes in other diseases.
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Screen at preventive visits and/or chronic disease visits. Screen high utilizers. Every patient with diabetes should be screened.
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You have met your responsibility to screen if you screen an asymptomatic patient using the PHQ 2 or 9. If there's a positive score or symptoms, triage.
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Don’t panic with a positive result, triage. Patient education, RN support, medication, collaboration with counselors are all reasonable things to do to help patients with depression.
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Staff who are uncomfortable treating patients with depression need more training because depression is “bread & butter” work in family medicine.
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If you have an EHR, see if the PHQ 2 or 9 is already integrated into the system. There are frequently tools like this already built in.
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Monday AM action plan: have a depression screening policy, use PHQ2, use PHQ9 for a positive PHQ2, have a plan, document the screen in discreet fields.
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Keynote Speaker Perry Dickinson, MD (Colorado): PCMH Transformation
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Dickinson on #PCMH transformation: patients involved in process ensures care is more patient-centered i.e. patient advisory group.
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Data is the lifeblood of advanced primary care; current systems are usually inadequate – perhaps our biggest barrier.
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Dr. Dickinson on change management: be persistent, evaluate & continually assess your outcomes.
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Dr. Dickinson on change management: Keep in simple, complex solutions often break down.
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Team meetings help clarify roles throughout the team, great teams develop and blur those lines for seamless care.
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Studies: Using staff at a higher level & working in teams has more impact on patients, staff satisfaction, quality and efficiency of care.
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Dr. Dickinson: Leaders need not be afraid of failure; you learn more from failures than successes.
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Perry Dickinson, MD: First three ingredients for practice transformation to #PCMH: Leadership, staff engagement, teamwork…
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Dr. Dickinson's #PCMH transformation ingredients, continued: ongoing change & improvement process, importance of data...
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Dr. Dickinson's #PCMH, part 3: patient self-management support, patient-centeredness & engagement... We need to do more of this.
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Tweet from Lancaster Downtown team: Dr. Perry Dickinson "PCMH is an initial tactic in the transformation in primary care"
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Tweet from Lancaster Downtown team: Innovation is a team effort, having a great support and help is paramount. Luckily, PCMH is growing!
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Another great example of #PCMH communication: Bryn Mawr's gingerbread PCMH http://twitpic.com/7ntggk
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Another great communications piece to explain #PCMH: @PAFPandF white paper http://pafp.com/pafpcom.aspx?id=5
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The RPC helps residents and you can too – donate here and select “PAFP Foundation” to support family medicine resident training in Pennsylvania.
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