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PPC-3 Care Management
Element C
The care team manages patient care in the following ways
- Data Point 1 Non-physician staff reminds patients of appointments and collect information prior to appointments.
- Data Point 2 Non-physician staff execute standing orders for medication refills, order tests and delivery routine preventive services
- Data Point 3 Non-physician staff educate patients/families about managing conditions.
- Data Point 4 Non-physician staff ordinate care with external disease management or case management organization.
All of the preventive health screening and preventive health measures are completed by the care team prior to the healthcare provider seeing the patient. In addition, non-physician staff completes the cardiovascular risk assessment and the LESS Initiative.
Currently SETMA utilizes both staff members and an automated system for calling and reminding patients of upcoming appointments. Patients scheduled to see a specialist are called by staff to remind them of the date/time for their appointment. Those patients scheduled to see internal medicine, family practice, pediatrics, or a nurse practitioner receive an automated reminder call.
The automated system is reviewed daily in late afternoon to identify any patients whose names are not recognized by the system. A staff member works with the HouseCall system by speaking the name of the unrecognized patients. Once this is done, the system is ready for making the automated calls. Calls from this system are done 48 hours in advance of an appointment which gives patients time to reschedule if necessary. The automated system is set to begin these calls after 5:30 pm. These calls also include the name of the patient, date/time of the appointment, as well as the provider they are scheduled to see.
Standing Orders
SETMA staff participates in training sessions designed to review documentation and requirements in association with standing orders. Many standing orders are built into the EMR such as the Consortium for Physician Performance Data Set for patients with diabetes and other chronic conditions. When completing the diabetes disease management templates, by choosing the Consortium Data Set, non-physician staff can see where patients are out of compliance with the standing orders based on the Consortium Data Set. At the time of review, non-physician staff have been trained to order lab, place referrals, administer flu vaccine, or complete a foot exam for any patient who is out of compliance with the set standards. Physicians review the data to verify accuracy.
HEDIS, AQA, PCPI, PQRI and NQF measures are used and reviewed/updated annually in order to maintain the highest level of care for patients. Monthly audits are performed by IT to determine utilization of these measures.
Tutorials for all functions of SETMA’s customized version of NextGen have been developed for both physician and non-physician staff to ensure compliance. As new functions are added, new tutorials area built. These tutorials are accessible from:
- The EMR,
- from SETMA’s Intranet, and
- from manuals which are available with color printed versions of the tutorials.
- SETMA’s website www.setma.com
Non-physician staff utilize standing orders for processing prescription refill authorizations via e-prescribing, or by calling the prescription refill authorization to pharmacies who are not yet quipped to receive e-prescriptions. SETMA works with all pharmacies who are not yet so equipped to help them develop the capability to receive e-prescriptions. Any medication refill falling outside of SETMA’s standing orders requires physician/NP approval.
Educating Patient and Families
SETMA EMR also facilitates ease of patient education. Patients received follow up documents which are built into the disease management templates. These documents are personalized for each patient. In addition to their on personal compliance and laboratory results, these follow-up notes list changes to plan of care, when the patient is to be seen and other special information related to a specific disease process. For example, the diabetes follow up note also informs the patient of the status of their compliance with the standards of care from the Consortium for Physician Performance Data Set as well as current vital signs, BMI, latest lab results, instructions about diabetic foot care and a current medication list.
The weight management follow up document acts as a form of encouragement for patients making progress with their weight loss. This document provides patients with their starting weight, weight lost to date and their weight goal. It also lets them know that reaching their idea body weight is NOT necessary in order to gain health benefits from weight reduction. The note lets them know that a 10-20 pound weight loss and particularly a 10-20% weight loss can have profound health benefits for ANY and ALL chronic conditions.
In addition patients are given SETMA’s LESS Initiative (Lose Weight, Exercise, Stop Smoking) educational document. The LESS Initiative is done with every visit and at set intervals, (At each visit which is separated by at least two months. In other words, if a patient comes in after two weeks, the LESS Initiative is not given to them again until two months after their last receiving it. Compliance with the LESS Initiative by providers is audited.) the document will be printed and given to patients. A detailed explanation is given to the patient by nursing staff on the LESS Imitative and the physician or NP reinforces the elements of the LESS. Other educational material will automatically print to designated printers facilitating patient education automatically.
Patients will also receive a document summarizing the status of their Medical Home Coordination Review. This document includes pharmacy information, emergency contact information for patients, any ancillary services the patient is receiving (Hospice, Home Health, Physical Therapy, Nursing Home) and the current status of their care’s compliance with HEDIS and Preventative Care Requirements. The document will inform patients who the members of their Care Coordination team are and how to contact each one. Each patient has a team made up of physician, nurse practitioner, Care Coordinator, nurse and unit clerk. Also, in keeping with the emerging concept of a Medical Neighborhood, the document contains the name of all other physicians who regularly participate in their care. The document will also indicate compliance with the Medical Home’s patient communication plan through clinic visits, home visits, correspondence and phone calls.
The Care Coordination Review will also detail the patient’s barriers to care whether they are social, financial, or the necessary use of assistive devices. Staff will also note which patients may need assistance during evacuation periods for our area. Medical Power of Attorney and Living Wills and Code Status will be denoted on this document as well.
The Care Coordination Review collects, and displays all preventative health care measures which will allow at a glance, a review of items a patient may be lacking and allow for ease of maintaining/reviewing/updating these measures. HEDIS measures will also be utilized as an educational tool both for staff and patients to note areas in need of additional services or information.
The following are screen shots of the Coordination of Care templates along with pop-ups for preventive health care and HEDIS review.
As part of the development of Medical Home in SETMA, we have designed a Medical Home Coordination Review. It is composed of a main template as seen here and two “pop-ups” which are launched from the middle of the second column. See below for the screen shots and explanation of these two pop-ups. As part of the empowerment of the family and the patient in Medical Home, they will receive a document which is automatically built from these screens. With this document, they can know:
- What they can expect in the way of preventive and integrative care.
- Where they are in fulfillment of Preventive Care and HEDIS requirements. We will also be building a quality standard based of Lean Six Sigma standards.
- What tools are being used in the management of their chronic conditions and particularly those which are the key ones selected by SETMA to measure, i.e., Diabetes, Hypertension, Lipids, CHF.
Below is a thumbnail sketch of Preventive health Care – this is gender specific and will look different for male and female. As we review this other issues will be added. For instance, the Tetanus may be changed to Tdap.
Below is the HEDIS template. Contemporaneous with a patient encounter and care, automatically, in the back ground, data will be being collected on HEDIS measures. Some measures require brief input by the physician, for instance when a patient is treated for Acute Bronchitis, the provider will simply click on the HEDIS button and note that antibiotics were or were not used. When the patient is treated initially for back pain, the provider will note on the HEDIS template that this encounter involved new-onset back pain and that imagining studies were or were not ordered
The buttons at the top the HEDIS template (see below) are blue in the EMR and they are navigational buttons which will automatically take a provider that part of the HEDIS. If this patient were a female, there would be a blue button entitled Gender Specific Female which would take you to the section for Mammogram, Pap, Pelvic and Bone Density. At the end of the year, aggregation of the HEDIS measures on the physician’s part be just a matter of aggregating structured data which will take a few minutes.
While this may seem daunting, it is being used successfully in the normal workflow of our practice. The workflow issues have been worked out, particularly in that almost all of the data is automatically collected incident to patient care. We expect SETMA’s HEDIS scores for 2009 to be outstanding.
SETMA believes that this innovation will provide an excellent foundation fo :
- Fulfilling standards of care in patient care
- Employing evidenced-based medicine in that care
- Engaging patients in taking responsibility for their own care.
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