Integrating Chronic Care and Business Strategies in the Safety Net (Coaching Manual)
Appendix of Meeting Agendas and Tools
Example: Practice Team Orientation Call Agenda
Integrating Chronic Care & Business Strategies in the Safety Net
Practice Name:
Date:
Time:
Dial-in Number:
Conference Code:
Participants: Coaches, medical director of ambulatory care, medical director of the site, administrative director of the site, physician, nurse, medical assistant, front desk staff, local trusted stakeholder.
Agenda
| Event | Participants | Time |
|---|---|---|
| Opening Remarks | Key Medical and Administrative Leadership e.g., Medical Director of Site, Medical Director of Ambulatory Care Administrative Director of the Site |
10 minutes |
| Introductions | All | 10 minutes |
| Overview | Coaches | 15 minutes |
| Questions & Answers | All | 20 minutes |
| Next Steps | Coaches | 5 minutes |
Example: Practice Team Site Visit Preparation Call
Integrating Chronic Care & Business Strategies In The Safety Net
Clinic Name:
Date:
Time:
Dial-in Number:
Conference Code:
Participants: Coaches, medical director of the site, administrative director of the site, physician, nurse, medical assistant, front desk staff.
Agenda
| Event | Participants | Time |
|---|---|---|
| Introductions | All | 10 minutes |
| Overview | Coaches | 5 minutes |
| Remaining Questions About Project Aims | All | 10 minutes |
| Prework Overview Clinical data Financial data Assessment of Chronic Illness Care Administrative Process |
Coaches | 20 minutes |
| What to expect during the observational assessment | Coaches | 5 minutes |
| What to expect during the learning session | Coaches | 5 minutes |
| Continued communication | All | 5 minutes |
Example: Assessment Day Agenda
Integrating Chronic Care & Business Strategies In The Safety Net
Clinic Name:
Date:
Time:
Dial-in Number:
Conference Code:
Participants: physicians, nurses, medical assistants, administrators, coaches, anyone else the team deemed to be part of their work (e.g., Certified Diabetes Educators, nutritionist, front desk clerk)
| Event | Participants | Time |
|---|---|---|
| Team Meeting | 1:00—2:00 | |
| Introductions | All | 1:00—1:10 |
| Overview & What To Expect | Coaches | 1:10—1:40 |
| Remaining Questions | All | 1:40—1:55 |
| Collect prework, complete "Know Your Process" | Coaches | 1:55—2:00 |
| Practice Observation | 2:00—4:30 | |
|
Patient perspective
Practice perspective
|
||
Tool: Clinic Observation Assessment
| Self-Management Support | Delivery System Design |
|---|---|
|
ASK! "How do you support patients to manage their __________ on their own?" What you're looking for: |__| Emphasize the patient's central role. |__| Use effective self-management support strategies that include assessment, goal-setting, action planning, problem solving,and followup. |__| Organize resources to support SMS. |
ASK! "Who is in charge of _________?" "Do you bring your patients regularly for planned visits?" Observe! Is a case manager part of the team? Is care provided in a culturally competent way? What you're looking for: |__| Define roles and distribute tasks among team members. |__| Use planned interactions to support evidence-based care. |__| Provide clinical case management services. |__| Ensure regular followup. |__| Give care that patients understand and that fits their culture. |
| Decision Support | Clinical Information System |
|---|---|
|
ASK! "How do you get your information about clinical guidelines?" Observe! Are guideline-based patient materials available? What you're looking for: |__| Embed evidence-based guidelines into daily clinical practice. |__| Integrate specialist expertise and primary care. |__| Use proven provider education methods. |__| Share guidelines and information with patients. |
ASK! "Do you have a patient registry that is useful in providing clinical information at the point of care?" "How do you monitor your performance?" What you're looking for: |__| Provide reminders for providers and patients. |__| Identify relevant patient subpopulations for proactive care. |__| Facilitate individual patient care planning. |__| Share information with providers and patients. |__| Monitor performance of team and system. |
| Community Resources and Policies | Health Care Organization |
|---|---|
|
ASK! "What community agencies do you all find particularly useful for your patients?" Observe! Is there a sense that the team members are aware of other resources in the community? Is information about referrals to other organizations readily available? |__| Encourage patients to participate in effective programs. |__| Form partnerships with community organizations to support or develop programs. |__| Advocate for policies to improve care. |
Observe! Are senior managers engaged with this project? Are they supportive of the teams? How does the organization handle problems? |__| Visibly support improvement at all levels, starting with senior leaders. |__| Promote effective improvement strategies aimed at comprehensive system change. |__| Encourage open and systematic handling of problems. |__| Provide incentives based on quality of care. |__| Develop agreements for care coordination. |
Example: Learning Session Agenda
Integrating Chronic Care & Business Strategies in the Safety Net
Clinic Name:
Date:
Time:
Dial-in Number :
Conference Code:
Participants: Coaches, medical director of the site, administrative director of the site, physicians, nurses, medical assistants, front desk staff.
Goals:
- Review data.
- Learn about the Chronic Care Model, PDSAs, Business Redesign tools.
- Identify what changes you want to make.
- Plan how to start.
- Build team confidence.
| Event | Participants | Time |
|---|---|---|
| Reflections on where we are | 1:00—2:55 | |
| Coach | Present the Chronic Care Model (Tool: Key Change 1.2, Chronic Care Model Primer) |
1:00 -1:30 |
| Coaches | Review ACIC Scores & discussion (Tool: Key Change 2.1, Assessment of Chronic Illness Care) |
1:30—1:50 |
| Coach | Review "Know your Process" & group discussion (Tool: Key Change 2.1, Primary Care Practice Know Your Processes) |
1:50- 2:10 |
| Coach | Present Model for Improvement (Tool: Key Change 1.2, A Model for Accelerating Improvement) |
2:10—2:40 |
| All | Review themes from observational assessment & group discussion | 2:40—2:55 |
| Break | 2:55-3:10 | |
| Where To Start | 3:15—4:50 | |
| Coach | Present "menu" concept of where they might start What's missing? Anything from the data/presentations that wasn't covered? (Tool: see below, The "Change Your Practice" Menu) |
3:15—3:40 |
| Team Breakout | Decide where to start & what you will track monthly List as many PDSAs as you can (Tool: see below, Getting Started Logistics) |
3:40—4:30 |
| Coach |
Present business redesign elements from the toolkit & introduce the toolkit as a resource Introduce monthly report template |
3:40—4:30 4:30—4:50 |
| Wrap-Up & Next Steps | 4:50—5:00 | |
| Coaches | Thank you & last minute comments | |
| Teams | Complete Coach Evaluation (Tool: see below, Tell Us What You Think!) | |
Tool: The "Change Your Practice" Menu
Below are some ideas to begin testing in your practice. These are not meant to be an exhaustive list. You may have other ideas not on this menu. So please do not feel constrained by this menu. It is meant to stimulate thought.
Delivery System Design
- Conduct team meeting or huddle tomorrow.
- Assign roles and responsibilities for the care of chronically ill patients.
- Call patient and conduct a planned visit.
Self-Management Support for Patients
- Set goal and create action plan at next patient visit.
- Refer patient to self-management program in community.
Decision Support
- Use registry data as reminders.
- Use care coordination agreement with a specialist.
- Create patient care guidelines wallet card for patient use.
Clinical Information
- Design process for getting patient information into registry.
- Use registry population report at team meeting to plan care for patients in the following month.
- Use a patient summary of information from last visit to drive care at current visit.
Community Resources
- Contact DOH, ADA, or other patient organizations for patient resources.
- Connect patients with resources.
- Discuss potential partnering with outside organizations to create needed services.
Process Efficiencies
- Develop checklist of all the patient information needed at the time of the visit and brainstorm ways to ensure you get all the info you need before the visit.
- Create a process map of a visit from the perspective of a patient.
Revenue Optimization
- Review your coding practices by provider. Are you fully capturing the work you're doing?
- Review your copay and self-pay policies to ensure that you collect your portion of the cash up front.
Tool: Getting Started Logistics
1. Who Will be on our Team?
Physician ________________________________________________________
Nurse / MA ________________________________________________________
Nurse/ MA ________________________________________________________
CDE? ________________________________________________________
Data guru? ________________________________________________________
Office manager? ________________________________________________________
Others? ________________________________________________________
________________________________________________________
________________________________________________________
2. What is our Aim?
To improve chronic illness care for patients in the most effective, safe, and efficient way using the Chronic Care Model and business strategies and facilitated by the toolkit and practice coaches.
3. What measures will we look at to know if we're improving? (select no more than 6-8 of the options below, a mix of process and outcome measures)
Process Measures
|__| % of patients with documented self-management support goal
|__| % of patients with 2 HbA1cs in the last year
|__| % of patients with retinal exam
|__| % of patients with foot exam
|__| % of patients who are current smokers
|__| % of patients with influenza vaccination
|__| % of patients with pneumococcal vaccination
|__| % of patients with depression screen in the last 12 months
|__| % of patients with annual dental exam
|__| % of patients 18 to <70 not on ACE/ARB with Microalb Screen in last 12 months*
|__| % of patients 55 & older on ACE/ARB*
|__| % of patients 40 & older on statins*
|__| % of patients 30 & older taking aspirin*
Outcome Measures
|__| % of patients with HbA1c < 7
|__| % of patients with BP < 130/80
|__| % of patients with LDL < 100
* indicates measures requiring a customized denominator. All other measures will use your panel of diabetic patients as the denominator.
4. What data will we need for those measures? How will we collect these?
Most of the measures can be captured from electronic sources, though they may not be completely accurate. The following measures often are not captured electronically so may require designated data entry.
- Blood pressure.
- Monofilament foot testing.
- Self-management support.
- Smoking status.
- Depression screening.
- Patients on aspirin.
- Annual dental exam.
5. How often/when will we meet?
- Individually or as a group.
- Daily huddles or weekly meetings.
6. Plan-do-study-act cycles to get started with:
| Description of change | Responsibility | OCT | NOV | DEC |
|---|---|---|---|---|
Tool: Tell Us What You Think!
Date
PART 1: Circle the number of the statement you most agree with.
The Trainers .
Were helpful:
1 2 3 4 5
not at all a little sort of mostly totally
Knew the topic:
1 2 3 4 5
not at all a little sort of mostly totally
Gave us what we needed to get started:
1 2 3 4 5
not at all a little sort of mostly totally
Communicated clearly:
1 2 3 4 5
not at all a little sort of mostly totally
PART 2: Write any additional comments that may help the trainers improve.
Things I liked:
Things I didn't like:
Other recommendations/comments:
Page originally created April 2009
The information on this page is archived and provided for reference purposes only.
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