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Quality Improvement Tips

Extended office hours save money

by Jordan Larusso on 11/2/2012 9:25:49 AM MST

Primary care practices functioning as patient-centered medical homes (PCMHs) offer patients greater access to healthcare, usually through extended hours on weekdays and weekends. A national study now finds that extended hours may also hold down healthcare costs.

The research, published in the Sept./Oct. 2012 Annals of Family Medicine, found that practices offering weekend and evening hours had lower total healthcare expenditures than those that didn’t. The correlation between extended hours and reduced costs was related to lower prescription drug and office visit-related expenses, such as testing. The study found that lower spending had no adverse effects on mortality.

Analyzing longitudinal data from the Medical Expenditure Panel Survey for the years 2000-2008 and for respondents enrolled in 2000-2005, the authors included 54,624 adults aged 18 to 90 years in the study. They examined associations between reported consistent access — or lack of access — to extended office hours from a usual source of care in two successive years, and total healthcare expenditures and subsequent death rates in the second year.

One goal of the PCMH is reducing unnecessary healthcare spending. Ideally, by extending access to patients, PCMH practices may diagnose and treat serious health conditions earlier than offices with traditional hours. PCMHs aim to prevent catastrophic events that lead to extensive treatment, emergency room visits and even hospitalizations.
The paper’s authors offer two interpretations of their findings:

  • “Clinicians in practices offering extended access may tend to provide more cost-conscious care in general, including a proclivity for prescribing less-expensive (e.g., generic) medications and less discretionary test ordering during office visits.”

  • “Additionally, or alternatively, practices offering extended access may attract patients less likely … to request brand-name medications and discretionary testing.”

Interestingly, they did not find an association between extended hours and clinicians’ familiarity with their patients — a key attribute of the PCMH. Rather, “clinician practice style (e.g., proclivity for discretionary testing) may influence total expenditures more than patient continuity,” they said. But they recommend further studies in this area.

If your practice offers extended office hours to patients, you may be offering more than convenience. You may be saving them time and money, and keeping them healthier.




Quality Improvement Tips

Embedding evidence-based guidelines into care

by Lisa Schneck on 9/14/2012 9:30:49 AM MST

Why would a primary care practice want to embed evidence-based guidelines into daily care?

Consistent adherence to evidence-based guidelines helps ensure that your practice gives patients the best care possible. By standardizing processes to deliver guideline-concordant care, you:

  • Reduce variation in delivering care;

  • Improve efficiency;

  • Improve process measures and clinical outcomes; and

  • Reduce costs due to variations in care.

“Embedding an evidence-based guideline drives the entire care process,” says BJ Dempsey, a quality improvement coach with HealthTeamWorks. “It provides clear direction for the care team, enabling physicians to practice the art of medicine.”

Guidelines help standardize care

When evidence-based guidelines drive the work at your practice, you can standardize many tasks. For example, standing orders could direct medical assistants (MAs) to ask diabetic patients key questions at the start of a visit. They could document answers about tobacco use, glycemic control, exercise, diet and the dates of patients’ most recent foot and eye exams. Physicians can distribute patient care duties among clinical employees, allowing them to work at the top of their licenses: MAs can give foot exams to diabetic patients; nurses can provide patient education, care coordination and care management, leaving more time for physicians to do physicians’ work.

By analyzing clinic processes and the current duties of each staff member, practice leaders can determine whose skills and time are best spent on particular tasks. Team-based care — a key component of the patient-centered medical home — allows you to reorganize staff roles around patients’ needs and the delivery of evidence-based care.

Apply guideline at every step of the visit

Let’s complete the example of embedding the HealthTeamWorks Diabetes guideline into a primary care practice, with all staff roles and tasks delineated:

Scheduler: Because evidence-based guidelines are part of previsit planning, she flags the patient’s diagnosis when the patient calls for an appointment. This triggers standing orders for the care team to follow.

Front-desk: When the patient arrives, she greets her and asks her to complete a self-management goal sheet.

MA: He checks the practice’s patient registry of diabetes patients and reviews the woman’s chart for previsit lab test results. He flags two that are outstanding. He escorts the patient to the exam room and inquires about tobacco use, blood sugar control, exercise and diet, and when she last got foot and eye exams. He conducts a thorough foot exam, in addition to taking her vital signs.

Physician: She reviews the patient’s lab results, vital signs and other data in the chart, interpreting the findings in language the patient can understand. The physician, with the patient, discusses a course of ongoing care for diabetes and answers all her questions.

Nurse: After reviewing the patient’s self-management goals for her diabetes, the nurse uses motivational interviewing techniques to help the patient set a goal of walking at least five miles each week. The nurse also arranges for the patient to see an ophthalmologist for a complete eye exam.

In this way, with both clinical and nonclinical employees, the practice applies the Diabetes guideline along every step of a patient’s visit. This ensures that each diabetic patient receives standardized care according to the best medical evidence … and thus helps ensure the best clinical outcomes.

 

HealthTeamWorks has developed 19 clinical guidelines for primary care, available for free download from our website.

 

 

 




Quality Improvement Tips

A heaping dose of prevention

by Lisa Schneck on 9/7/2012 3:23:55 PM MST

Keeping people well is part of the PCMH

Although your training as a primary care clinician prepared you to diagnose and treat disease, you also strive to prevent illness and injury. And every patient visit offers a prevention opportunity.

The Partnership for Prevention, a coalition of businesses, trade associations, patient groups, health professional associations, healthcare delivery organizations and government agencies, ranks preventive services for the U.S. population. It lists the top five as:


1. Discussing daily aspirin use for men older than 40 and women older than 50
2. Childhood immunizations
3. Smoking cessation advice and help to quit
4. Alcohol screening and brief counseling
5. Colorectal cancer screening for adults older than 50

Of course, there are more than a dozen others, including cholesterol screening, breast cancer screening, immunizations and hearing tests, their appropriateness dictated by a patient’s age, medical history and physical condition. Other factors to consider are cost-effectiveness and clinical efficacy — for example, recent evidence suggests that testing for prostate-specific antigen (PSA) does not lower men’s risk for death from prostate cancer.

How do you ensure that patients get appropriate preventive services?

First, consider using the Prevention guideline developed by HealthTeamWorks, which addresses both children and adults. The guideline is based on U.S. Preventive Services Task Force recommendations intended for primary care settings.

If your practice is a patient-centered medical home (PCMH), it’s already adept at sharing care among all clinicians, having them work to the fullest extent of their licenses. Nurse practitioners, physician assistants and even medical assistants can help determine the preventive services appropriate for each patient. You can establish standing orders that call for the clinician who brings patients to the exam room to ask them about immunization status, the dates of pertinent screenings and tests and other preventive care they’ve had or wish to have.

Assessment tools can also support preventive care. Consider using:

  • An intake form that collects patients’ information about preventive services they’ve had recently and those they desire;

  • A prevention flow sheet to document tests and screenings; and

  • Your practice’s registry or electronic health record to track preventive services for your entire patient population.

Preventive care often calls for coordination between your practice and another facility, such as imaging centers for mammograms and colonoscopies, laboratories for blood work and audiologists for hearing tests. Does your clinic have a protocol to ensure that results come back and get recorded in patients’ charts?

HealthTeamWorks offers a rapid-improvement activity (RIA) on prevention: a one-hour, on-site training for the entire practice team — clinical and nonclinical staff — with lunch or breakfast provided. The RIA serves as the first step toward implementing a guideline into routine care and introduces the basics of quality improvement.

Contact us if you’re interested in a prevention RIA for your clinic or want more information on the Prevention guideline.

 

 




Quality Improvement Tips

New guidelines for pediatric, adult asthma update assessment and treatment

by Andi Hagerup on 9/4/2012 4:06:39 PM MST

HealthTeamWorks has updated the clinical guidelines for asthma, now presented separately for children 5 years and older and adults, and for children 0-4 years old. These recommendations replace the single guideline developed in April 2008. The new guidelines are available for free download.

Key changes to the asthma guidelines include:

  • New layout and management flow that emphasize the assessment of symptom control over symptom severity;

  • Defining persistent asthma as uncontrolled disease in someone not taking controller medication;

  • Further defining the use of spirometry;

  • Defining exercise-induced bronchospasm;

  • Defining a schedule of follow-up care; and

  • New tools and supplements. 

Guideline developed by expert panel

HealthTeamWorks, the authoritative creator of clinical guidelines for Colorado since 1996, developed the older child/adult asthma management revision with a committee led by Peter Cvietusa, MD, Department of Allergy, Asthma and Immunology, Kaiser Permanente, Highlands Ranch Clinic; and Joe Craig, MD, FAAP, pediatrician with Kaiser Permanente. Development of the young child guideline was led by Monica Federico, MD, associate professor of pediatrics, University of Colorado School of Medicine and director of the Asthma Program at Children’s Hospital Colorado; and special adviser Stanley Szefler, MD, head, Pediatric Clinical Pharmacology, National Jewish Health. The committee comprised six physicians, five midlevel providers, three nurses and one pharmacist representing local healthcare organizations.

“The new ‘early wheeze for children ages 0-4 years old’ is the first guideline directed specifically at children under 5 who wheeze,” said Federico. “It is based on data published after the most recent revision of the national asthma guidelines in 2007. We hope it will help providers navigate the confusing process of taking care of young children who wheeze with illness.”

Cvietusa said, “The revised asthma guideline for ages 5 and up has a new layout that emphasizes the assessment of control (over severity), the need to assess control at every visit and the use of spirometry. The guideline defines persistent asthma as uncontrolled asthma in a patient not taking daily medication. We also added a box on the diagnosis of exercise-induced asthma."

Stepwise approach to asthma meds, five steps of care

Each new guideline takes the clinician from diagnosis through assessment and monitoring. The young-child version covers categories of wheeze — episodic, transient, emerging asthma and multiple-trigger/persistent asthma — and the treatments for each. The older child/adult guideline delineates therapeutic approaches for levels of asthma control involving a number of variables, such as daytime symptoms, activity limitation and courses of prednisone. Both guidelines present a stepwise approach to asthma medications, starting with short-acting beta-agonists, such as albuterol, and progressing through inhaled corticosteroids and long-acting beta-agonists (LABA) to oral corticosteroids and LABA.

The guidelines committee drew on top sources of evidence, including the National Heart, Lung, and Blood Institute’s Asthma Education and Prevention Program Expert Panel Report 3; the Global Initiative for Asthma; and highly regarded papers in the recent medical literature.

Each guideline takes the clinician through five essential steps in asthma care:

1. Making the diagnosis
2. Assessing the patient’s asthma control
3. Considering other things at every visit
4. Taking the stepwise approach to medication
5. Scheduling follow-up care

Both asthma guidelines have supplemental material for clinicians and patients. Clinicians will appreciate the medication chart and spirometry interpretation; patients or parents will benefit from the asthma action plan and the information sheet that explains the disease.

For questions about the asthma guidelines, e-mail Emily Gingerich 
or call 303-446-7200.

 




Quality Improvement Tips

Check patients' health literacy IQ

by Lisa Schneck on 8/10/2012 3:15:33 PM MST

Comprehension of medical information can affect outcomes

You have a problem when your patients can’t understand information about their conditions or their care. Low health literacy — failure to grasp the significance of their illness, treatment protocols or self-care procedures — may lead to poorer outcomes. All too often, patients with low health literacy won’t admit that they don’t comprehend explanations or directions. Embarrassment or fear of appearing rude may cause them to act as though they follow your explanations and directions.

In the report Healthy People 2010, the U.S. Department of Health and Human Services identified health literacy as an important component of health communication and medical product safety. The report defines health literacy as “The degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions.”

The Office of Disease Prevention and Health Promotion, part of the U.S. Department of Health and Human Services, summarizes the sobering results of the first-ever National Assessment of Adult Literacy done in 2003:

  • Only 12 percent of U.S. adults had proficient health literacy. Over a third of U.S. adults—77 million people—would have difficulty with common health tasks, such as following directions on a prescription drug label or adhering to a childhood immunization schedule using a standard chart.

  • Limited health literacy affects all racial and ethnic groups. The proportion of adults with basic or below-basic health literacy ranges from 28 percent of white adults to 65 percent of Hispanic adults.

  • Although half of adults without a high school education had below-basic health literacy skills, even high school and college graduates can have limited health literacy.

  • Compared with privately insured adults, publicly insured and uninsured adults had lower health literacy skills.

  • All adults, regardless of their health literacy skills, were more likely to get health information from nonprint sources, e.g., radio, television, friends, family and health professionals. 

Low health literacy negatively affects patient safety, medication adherence, use of emergency rooms and hospitals, prevention, disease management and life expectancy. Research shows that people with low health literacy:

  • Are more likely to skip preventive services such as mammograms, Pap smears and flu shots;

  • Enter the healthcare system when they are sicker;

  • Are more likely to have chronic conditions and be less able to manage them effectively;

  • Have more preventable hospital visits and admissions; and

  • Use more services intended to treat complications of disease and less use of services designed to prevent complications.1,2 

Such behaviors have significant economic consequences for individuals and the healthcare system.

How can you and your patient-centered practice combat low health literacy? First, listen to the patient. Try to gauge her/his level of understanding. Use plain language, not medical jargon. When you think it’s necessary, give information in pictures or video. Use anatomical models. Ask patients to tell you what they understand about their condition, their care and the decisions they must make.

In your practice:

  • Emphasize prevention, self-management and shared decision-making;

  • Convey an expectation of patient engagement and activation;

  • Help people do as much for themselves as they can;

  • Help people ask for the healthcare they need; and

  • Help them say “no” to care they don’t need. 

By helping patients overcome low health literacy, you enable them to become partners in their care.

Sources
1. Health literacy. National Network of Libraries of Medicine. http://nnlm.gov/outreach/consumer/hlthlit.html/, accessed Aug. 10, 2012.
2. U.S. Department of Health and Human Services. Quick guide to health literacy fact sheet. Office of Disease Prevention and Health Promosion. Heath Communication Activities. 
http://www.health.gov/communication/literacy/quickguide/factsliteracy.htm




Quality Improvement Tips

Creating a patient-centered care process

by Lisa Schneck on 7/30/2012 9:14:22 AM MST

Patients first. That’s the fundamental principle of the patient-centered medical home (PCMH). The partnership that patients form with their healthcare team promotes trust and confidence. Improved health outcomes can result when patients feel connected to their caregivers and involved in decision making.

Amber Carlson, MS, a HealthTeamWorks quality improvement coach, says, “A comprehensive patient assessment lays the groundwork for all care and interactions in the PCMH. Your initial conversation has three aims: to establish a trusting and supportive connection, to gather information and to offer information.” More than a series of questions, a comprehensive assessment demands effective communication and relational skills. Your approach will depend on the patient’s needs and concerns and the goals for the encounter — the patient’s and yours.

Convey understanding, communicate at patient’s level

Greet the patient and attempt to establish rapport. Keep in mind the individual’s ethnic preferences. For example, in many cultures, including Hispanic, Asian, Middle Eastern and Native American, eye contact is considered rude. Regardless of whether you meet the patient’s gaze, give her or him your undivided attention. “Express interest in the person, not just the problem. Convey acceptance and understanding. Ensure that the patient’s situation in the room is comfortable and conducive to dialogue,” Carlson says.

Tailor the level of your conversation to the patient’s understanding. Avoid using medical jargon, keeping explanations simple. Listen carefully, letting the patient tell her/his story. Clarify your comments if the patient indicates confusion and ask her/him to state an understanding of the situation. Attend to the emotional content in the patient’s words and be empathetic to the individual’s feelings.

A key PCMH tenet is patient empowerment: Bring the person into decision making. Let the patient know she or he is a partner in the healthcare process.

Challenging patients require different approaches

Patients will present challenges, however. Carlson describes various ways that clinicians can handle the:

  • Silent patient – Continue asking questions, encouraging responses, even if they’re monosyllabic

  • Rambling patient – Clarify her/his statements and try to redirect the conversation to pertinent issues

  • Confused patient – Consider visual aids to help the individual understand the message; repeat it in the simplest language possible – multiple times, if necessary

  • Angry or disruptive patient – Try to diffuse the ire by asking about the patient’s goals for the appointment and how you can best achieve them together

  • Non-English-speaking, hard-of-hearing or literacy-challenged patient – Arrange for a translator if a foreign language is the issue – this could be one of the patient’s relatives. Deaf or hard-of-hearing patients appreciate information in writing. Patients with low literacy often benefit from pictorial aids and requests to repeat back spoken information to ensure their understanding.

Ask permission of the patient before addressing sensitive topics such as sexual history, mental health, alcohol and drug use, family violence, and death and dying. Most individuals are not comfortable discussing these topics; some will refuse.

Carlson says, “Ultimately, let the patient’s best interests guide your comprehensive assessment. Patients have the right to determine how, when and whether they receive healthcare. Honor patient-clinician confidentiality, and above all, do no harm.”

 

 




Quality Improvement Tips

The elephant in the practice - Part 2

by Lisa Schneck on 5/29/2012 10:46:01 AM MST

EHRs contribute to fragmented healthcare

 


By Kate Coburn, MS, MPH, HealthTeamWorks Quality Improvement Coach


Electronic health records (EHRs) in medical practices boost efficiency, accuracy and effectiveness. They promote data capture, storage and analysis and save untold hours of labor. But by presenting various staff members with just the information they need to do their jobs, EHRs can contribute to fragmented healthcare. Employees see only the screens pertinent to their jobs — demographic information, clinical information, insurance information. Thus, EHRs can create many impressions of a patient. Like the allegory of five blind men describing an elephant by feeling different parts of its body, medical practice staff and clinicians often miss the full picture of a patient.

The consequence can be care that fails to address the whole person. A diabetic patient with a literacy problem likely won’t benefit from educational material presented at the end of a visit. A patient without reliable transportation may have difficulty returning for follow-up care. A severely depressed patient may not take antidepressants, fearing they will they will not work.

The patient-centered medical home (PCMH) model of care solves the fragmentation problem with team huddles — brief strategy sessions — at least twice a day. The care team, usually a physician, a nurse and/or medical assistant(s) and a front-desk employee, use huddles to plan their approach for the next segment of the day and prepare for challenges, such as complex patients who require additional time, understaffing or room shortages.

Huddles serve as “check-ins” related to specific actions and goals. The physician and his/her staff review the schedule and patient charts before each morning and afternoon session in the clinic. They share what they know about each patient and plan the agenda for their visits.

Huddles:

  • Promote communication among team members;

  • Avoid duplicated work;

  • Ensure that members plan tasks with necessary input from others; and

  • Promote teamwork. 

In general, care team huddles should:

  • Occur twice a day — before morning and afternoon appointments;

  • Be kept to less than 10 minutes;

  • Become established in the practice’s routine;

  • Stay focused and pertinent; and

  • Allow no interruptions. 

During the morning huddle, the team reviews the previous day and the status of unfinished medical work, such as calls to consultants, review of lab and X-ray results and patient follow-up. It should also cover the status of clinic operations, including staffing, equipment and computer operability, patients with unexpected hospital visits, meeting and special events or external issues.

Team members then should identify: 

  • Patients with chronic disease;

  • Patients who have been in the emergency room or hospitalized;

  • Patients who are often late, problematic or have high service needs;

  • Canceled appointments; and

  • Patients for whom the provider will need assistance.

At the afternoon huddle, the team evaluates the appointments scheduled for the second half of the day. Members may also exchange information about the patients seen that morning.

Huddles also serve a team-building function. Members should be encouraged to maintain a positive, collegial attitude. Everyone should seek to learn from mistakes and review what went right, as well as what went wrong, so the practice can adopt more efficient processes.

Huddles ensure that all team members share information and create a plan for the patient together, eliminating fragmentation. This promotes whole-person care and smoother clinic functions for providers, staff and patients alike.
 




Quality Improvement Tips

The elephant in the practice

by Lisa Schneck on 5/21/2012 8:29:25 AM MST

EHRs contribute to fragmented healthcare


Part 1 of 2

By Kate Coburn, MS, MPH, HealthTeamWorks, Patient-Centered Medical Home Manager II

Healthcare in a medical practice today can resemble the allegory of the blind men describing an elephant. Each blind man, touching a different part of the animal’s body, arrives at a different conclusion about its appearance. The first, feeling the trunk, believes an elephant is like a great snake. The second, grasping the leg, says the animal is like pillar. The third, at the flank, compares the elephant to a wall. The fourth, holding an ear, conceives the animal to be like a great fan. And the fifth blind man, grasping the tail, thinks it resembles a snake.

Likewise, employees in a traditional medical practice develop impressions of patients based on their specific roles in the healthcare visit and the chart information they’re allowed to see. Electronic health records (EHRs) have advanced healthcare immensely, but they have also fragmented it. Staff members focus on the parts of the chart that pertain to their jobs. (Chart access is also restricted by the privacy rules of HIPAA*, which generally prohibits lay personnel from viewing clinical information.) Thus, each may learn aspects of patients’ lives and health not known to their colleagues.

For example:

  • Front-desk staff gets acquainted with patients through their demographic and scheduling information — where they live, what insurance they have, whether they show up for appointments on time or at all. Patients may tell front-desk employees about difficulties with transportation, child care issues and other facts that affect the medical visit.

  • The nurse or medical assistant (MA) who escorts patients to the exam room, takes vital signs and inquires about the reason for the visit learns whether the patient is taking his/her medications; the status of blood pressure, blood sugar levels, weight, etc., and whether patterns emerge from previous visits; immunization status; and status of regular clinical tests and procedures for a chronic illness. The nurse or MA will often recognize language and/or cultural issues that can affect the medical visit.

  • The treating physician, nurse practitioner or physician assistant forms impressions of patients based on review of the clinical portions of the chart, conversations in the exam room and physical examinations. They know patients’ medical issues in depth. But unless they’re told, clinicians may not know patients’ registration, insurance or socioeconomic circumstances.

  • After the visit, employees in the practice’s back office get to know patients from the financial angle. They know whose insurer granted prior authorization for treatments and whose denied payment. They know which patients pay their bills and the ones in arrears. They may identify individuals who would benefit from social services, such as credit counseling or Medicaid. OTHERS? Home Health nursing, WIC or food stamps, senior transportation, to name a few.

Thus, there can be as many impressions of a patient as there are employees in specific roles. Like the five blind men and the elephant, each staffer sees only a piece of the bigger picture. No one sees the entire person and her/his individual circumstances. This fragmentation can prevent a practice from giving whole-person care — addressing the medical, emotional, social and economic issues affecting health.

In our next blog, we’ll describe how the patient-centered medical home overcomes fragmentation in healthcare.

*Health Insurance Portability and Accountability Act

 




Quality Improvement Tips

Wasteful spending in primary care

by Lisa Schneck on 5/7/2012 9:11:48 AM MST

Commonly prescribed tests, treatments not always necessary

Do you practice care-appropriate, fiscally responsible medicine?

In mid-April, healthcare headlines buzzed about the “Choosing Wisely” initiative, established to spur discussion between patients and their healthcare providers by helping patients choose care that is:

  • Evidence-based;

  • Nonduplicative of care already received;

  • Free from harm; and

  • Necessary. 

Nine medical specialty organizations each offered a list of five tests or procedures used commonly in their fields that may not always be needed — and that contribute to our nation’s staggering healthcare bill. By bringing these services to the forefront, the organizations — American Academy of Allergy, Asthma & Immunology; American Academy of Family Physicians (AAFP); American College of Cardiology; American College of Physicians; American College of Radiology; American Gastroenterological Association; American Society of Clinical Oncology;
American Society of Nephrology; and American Society of Nuclear Cardiology — hope to promote more effective use of healthcare resources. “Choosing Wisely” sprang from an article published in an August 2011 issue of Archives of Internal Medicine.

The AAFP’s list of five things that primary care providers and patients should question encompasses:

  • Imaging for low back pain within the first six weeks when no red-flag conditions exist;

  • Antibiotics for acute mild-to-moderate sinusitis;

  • Dual-energy X-ray absorptiometry (DEXA) screening for osteoporosis in women younger than 65 or men younger than 70 with no risk factors;

  • Annual electrocardiograms (EKGs) or other cardiac screening for low-risk, asymptomatic patients; and

  • Pap smears on women younger than 21 or who have had a hysterectomy for noncancer disease. 

To that list we would add certain treatments for headache and enlarged prostate. The complaint of headache rarely warrants costly imaging studies such as sinus X-rays, CT scans and MRIs. The patient’s headache history is often the clinician’s best diagnostic tool — the headaches’ frequency, duration, associated symptoms, location of the pain, severity, family history, etc. Imaging tests are called for only after the patient’s headaches don’t respond to lifestyle changes and standard analgesic medications or physical and neurological examinations lead the clinician to suspect a serious underlying cause.

An enlarged prostate should not spur the clinician to order a prostate-specific antigen (PSA) test immediately. The most recent evidence suggests that PSA testing does not lower the risk for death from prostate cancer.1 A 13-year follow-up report published in the Journal of the National Cancer Institute concluded that there is no evidence of benefit from PSA screening. The test can, in fact, cause harm because of false-positive tests and overdiagnosis. This finding extends the trial's 10-year results, which also showed no mortality benefit.

Martha Johns, MD, MPH, FACPM, HealthTeamWorks medical director for Guidelines and Implementation, notes, “Many studies have now demonstrated that evidence-based healthcare recommendations such as the ones discussed above are not only better for patients but can help avoid needless expense. This is good news for our healthcare system.”

Source
1. Andriole GL, et al. Prostate cancer screening in the randomized prostate, lung, colorectal, and ovarian cancer screening trial: Mortality results after 13 years of follow-up. http://jnci.oxfordjournals.org/content/early/2012/01/06/jnci.djr500.abstract JNCI J Natl Cancer Inst (2012)doi: 10.1093/jnci/djr500First published online: Jan. 6, 2012


 




Quality Improvement Tips

Fashioning the facilitator

by Lisa Schneck on 4/30/2012 9:25:49 AM MST

HealthTeamWorks Coach University grad discusses her take-aways

“At [HealthTeamWorks] Coach University, you begin with data, with assessments of the practice. I’ve never seen anything like that. It’s is empowering to the clinic. You give them a snapshot of where they are and show them how to make measurable, meaningful changes [in processes and systems] to push their performance forward. The training is based on clinical guidelines and best practices. You build from these using the science of change,” says Kate Coburn, MS, MPH.

Coburn is HealthTeamWorks’ new Patient-Centered Medical Home (PCMH) manager, responsible for overseeing practice transformation work, coaching coaches, assessing medical practice systems and “making change happen.” She attended HealthTeamWorks’ Coach University in December 2011. She and nine other students spent a week in Lakewood, Colo., learning from HealthTeamWorks’ experienced quality improvement coaches in the classroom and on site in medical practices.

Most practices that make the transformation from traditional medical care to the patient-centered medical home (PCMH) model of care do it with the help of a trained facilitator or coach.1,2,3 HealthTeamWorks Coach University is one of only a few places in the United States that trains quality-improvement coaches to develop PCMHs.

Curriculum covers all aspects of PCMH transformation

“You can’t ever get enough information in what it takes to facilitate a practice — in systems redesign, systems improvement, IT, data collection and application, population management, patient self-care facilitation, NCQA* certification requirements — every aspect of this complex process,” Coburn says. “HealthTeamWorks manages PCMH transformation by coaching coaches, assessing systems, leading initiatives that make change happen. HealthTeamWorks has an unbelievable ability to assess a practice’s current state, address gaps in performance, and enable the practice to set and reach ambitious goals.”
The Coach University curriculum includes: 

  • The model for improvement;

  • The chronic-care model;

  • Evidence-based guidelines;

  • Leadership development and the dynamics of the team approach to care;

  • Quality measures and population management;

  • Patient engagement and self-management support; and

  • Technology to support the delivery of patient care.

Unlike many Coach University trainees, Coburn arrived with an extensive background in health system transformation. Since 2008 she had coached practices of Fletcher Allen Health Care, Vermont’s academic medical center, in achieving NCQA PCMH recognition.

Use of data, culture change enable practice transformation

Coburn notes that the HealthTeamWorks’ coaching approach is steadfastly patient-focused and connects with the three credos she stands by:

  • Words create worlds;

  • You can’t manage what you don’t measure; and

  • Every system is perfectly designed to get the results it does.

Guided by these beliefs, “I focus on growing from a positive core,” Coburn says. “In every practice we will assess what they have, determine opportunities for change and learn what data are measurable and available. Then we identify the practice superstars. Who embraces patient advocacy? Who understands the data? Who are the leaders and who are the doer-bees?”

The leaders — who can exist at all levels of a practice — will help establish the new practice culture. “You might find a practice leader at the front desk,” Coburn says. “A leader might be a medical assistant. Part of our work in transforming healthcare is to get a feeling for people’s strengths.” Ultimately, she believes, everyone must share data and move in the same direction to transform care delivery to be patient-centered and driven by best practices.

*National Committee for Quality Assurance

Sources
1. Baskerville NB, Liddy C, Hogg W. Systematic review and meta-analysis of practice facilitation within primary care settings. doi: 10.1370/afm.131 2 Ann Fam Med January/February 2012 vol. 10 no. 1 63-74.
2. Nutting PA, Crabtree BF, Miller WL, Stange KC, Stewart E, Jaén C. Transforming physician practices to patient-centered medical homes: lessons from the national demonstration project. Health Aff (Millwood). 2011 Mar;30(3):439-45.
3. Crabtree BF, Chase SM, Wise CG, et al. Evaluation of patient centered medical home practice transformation initiatives. Med Care. 2011 Jan;49(1):10-6.


 




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