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Conference on Practice Improvement 2018

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PR1 Extreme Makeover: Ambulatory Practice Edition Achieving the Quadruple Aim Through Transformational Practice Redesign (PPM)

Kathy Cebuhar, MA, LPC; Colleen Conry, MD; Aimee English, MD; Bethany Kwan, MSPH, PhD; Corey Lyon, DO; Peter Smith, MD

12/6/18 1:00 PM - 5:00 PM Florida Salon I

In 2014, the University of Colorado (CU) developed APEX—an advanced team-based care model based on the University of Utah’s Care By Design. Our goal was to simultaneously improve clinical quality, access to care, patient, staff, and provider experience including caregiver burnout through enhanced clinical teams. Our mixed-methods evaluation has demonstrated improvements in all these domains without negative financial implications. Since winning the 2016 STFM Practice Improvement Award for APEX, CU has hosted several academic delegations to learn from our success as they begin their own transformations. Five high priority themes have emerged from these visits: (1) What is your model and how did you choose it? (2) How did you get permission from your sponsoring institution to proceed? (3) How did you pay for it? (4) What were the operational challenges to implementation and how did you overcome them? (5) How did you sustain change and spread the innovation? In this interactive preconference, participants will work in small groups to address these essential questions in their own institutional context, guided by the CU experience. Participants can expect to end the day energized to build their own transformed medical home with a strategic blueprint in hand.

Upon completion of this session, participants should be able to:

  1. describe the three major change management tactics used in the CU's successful APEX team-based care transformation;
  2. translate CU’s transformation experience to their own institutional context through small group discussions and interactive exercises;
  3. develop a strategic plan for transformational practice redesign using the key strategies, tactics, tools, and experiences that we explore during the session.

PR2 Cooking Up the Alphabet Soup: TCM, CCCM, ADP, PsyCCM, E&M, MACRA, APM, MIPS, and HCCs

Thomas Weida, MD

12/6/18 1:00 PM - 5:00 PM Meeting Room 4

The payment environment is transitioning from payment-for-visit to payment-for-value. Understanding how to use codes for transitional care management, complex chronic care management, advanced directive planning, psychiatric collaborative care management, and evaluation and management coding is critical for a practice’s financial viability as well as for improved patient care. Medicare has added additional complex chronic care management codes and created a new psychiatric collaborative care management code. Practices will also need to prepare for the operational challenges and financial opportunities of the Medicare Reform and CHIP Reauthorization Act of 2015 (MACRA) legislation as well as use hierarchal condition categories to maximize value payment. The workshop will be interactive and utilize an interactive audience response system to engage learners. Participants will be required to bring a laptop computer to the workshop for hands-on training.

Upon completion of this session, participants should be able to:

  1. implement proper use and documentation of transitional care management codes, complex care coordination codes, advance directive planning codes, and evaluation and management codes;
  2. establish working criteria for the new psychiatric collaborative care management services code;
  3. prepare the practice for the challenges and financial opportunities of the MACRA legislation.

P03 PACER Progress Report: Quality Improvement Module (PPM)

Elisabeth Righter, MD; Fran Angerer-Fuenzalida, MPH, PhD, PA-C; Tim Crawford; Michelle Spurlock; Harriet Knowles; Todd Pavlack, MEd; Deanne Otto, PhD

12/7/18 9:30 AM - 10:00 AM Grand Ballroom A-D

A 90-minute quality improvement (QI) role-play exercise was developed as a Professionals Accelerating Clinical and Educational Redesign (PACER) module. The game was designed to encourage interprofessional health professions residents and students to work together to improve QI processes of a shared mock practice utilizing all professions at maximum capacity.

Upon completion of this session, participants should be able to:

  1. define quality improvement as it relates to the interprofessional team;
  2. explore roles of the inter-professional team within a clinical practice;
  3. identify barriers to implementing interprofessional quality improvement.

P04 Development and Implementation of a Social Needs Screener in Primary Care Practice

Beth Careyva, MD; Cathy Coyne; Roya Hamadani; Deborah Bren, DO

12/7/18 9:30 AM - 10:00 AM Grand Ballroom A-D

Unmet social needs result in worse health outcomes and increased cost of care, yet they are not routinely assessed in primary care practice. Developing a process to identify social needs, such as transportation to medical appointments and providing resources to meet those needs, may improve health-related outcomes, increase satisfaction for patients and clinicians, and decrease costs in alignment with the quadruple aim. We aim to describe our iterative process of identifying local priority social needs, creating a tailored social needs screener within a multidisciplinary stakeholder committee, and performing pilot testing of workflows to implement the computerized social need screener within clinical practice.

Upon completion of this session, participants should be able to:

  1. describe a process for development of a locally tailored screening tool for unmet social needs;
  2. discuss workflow development for completion of a social needs screener tool in primary care practice using tablet computers;
  3. identify opportunities to create linkages between social needs and local community resources.

P05 Implementation for Best Practice Tools to Improve HEDIS Scores Across a Large Diverse Outpatient Network

Judella Haddad-Lacle; Lori Bilello; Charles Haddad; Christopher Scuderi, DO

12/7/18 9:30 AM - 10:00 AM Grand Ballroom A-D

The project is a retrospective study analyzing Healthcare Effectiveness Data and Information Set (HEDIS) quality measure scores documentation before and after group educational interventions over a period of 1 year. The study was conducted in a large network of outpatient family medicine clinics. Each clinic worked to develop a team-based approach to address the selected measures as a partnership between providers, medical assistants and supporting staff. The department of billing collections collected the data for the study. The project leader analyzed the reports and communicated the results to the providers. Focused education on how to improve HEDIS scores was performed. Peer comparisons lead to competitive pressure among providers and resulted in significant improvement in scores for many of the HEDIS measures. At the end of the project the change in score was calculated for each physician. Wilcoxon Signed rank test was used for analysis. There was a significant increase in HEDIS score for seven of the nine measures from January to December.

Upon completion of this session, participants should be able to:

  1. understand the importance of HEDIS and the star rating associated with the quality measures;
  2. apply educational interventions with team based approach and peer score comparison to improve HEDIS scores;
  3. recognize the transition in the healthcare delivery system and payments shift from volume to value-based model for quality improvement.

P06 Positive Screenings for Substance Misuse, Depression, and Anxiety in a Family Medicine Residency Clinic: Factors Impacting Brief Behavioral Health Interventions

Christian Shue, DO; Jake Benn, BSC; Sean Jones, PhD; Carolyn Shue, PhD

12/7/18 9:30 AM - 10:00 AM Grand Ballroom A-D

Screening for substance misuse is consistent with our professional goal of meeting the behavioral health needs of our patients. SBIRT (Screening, brief interventions, referral to treatment) is a well-established means of determining the extent of comorbid substance use in the adult clinic population and the need for behavioral health services. We have extended the SBIRT program to include screening for comorbid depression and anxiety. Our extension, SBIRT+, recognizes the complexities of substance misuse and targets factors that may be driving the behavior. In doing so, we are better able to identify risky substance use to prevent future abuse, dependency, and health complications. This analysis presents 4 years of screening trends along with the number of corresponding brief behavioral health interventions. Several factors contribute to whether a positive SBIRT+ screening results in an actual brief behavioral health intervention. We identify the factors and discuss opportunities for improving brief intervention follow through to better meet the behavioral health needs of patients.

Upon completion of this session, participants should be able to:

  1. describe screening and intervention trends;
  2. list the factors contributing to the gap between positive screenings and brief behavioral health intervention follow-up;
  3. state strategies for increasing brief behavioral health intervention follow-up.

P07 Patients' Insights on Missed Appointments in a Family Medicine Residency Clinic: A Qualitative Evaluation (PPM)

Samuel Ofei-Dodoo, PhD; Emily Manlove, MD

12/7/18 9:30 AM - 10:00 AM Grand Ballroom A-D

This study sought to find reasons associated with patients' no-shows, and to help health care professionals in their efforts in reducing the high rates of patients not showing up to their appointments in primary care residency clinics. A qualitative research design study was employed involving patients attending two residency clinics for their health care needs, but often do not show up to their appointments. Twenty-five randomly selected patients who had three or more no shows were interviewed over the phone. We used an immersion-crystallization approach to analyze the content of the interviews. Responses from 25 participants (21 females and four males) are presented in this poster. Three interconnected themes emerged from the data analysis as major reasons some patients do not show up for their scheduled appointments: forgetfulness, transportation, and health issues. The study results suggest that no-show rates among patients receiving care at family medicine residency clinics might be addressed by finding novel forms of reminders, such as utilizing text messaging among other things.

Upon completion of this session, participants should be able to:

  1. identify some of reasons patients do not keep their scheduled clinic appointments at family medicine residency clinics;
  2. learn the insight into what can be done to reduce their rates;
  3. understand that reducing no-show rates will positively impact patient care, productivity, and learning opportunities at academic family medicine family medicine clinics.

P08 Improving Hospice Consultations in the ICU Using a Modified Screening Tool (HFT)

Nicole Bentze, DO; Divya Aickara; Erica Heinrichs; Stuart Brown

12/7/18 9:30 AM - 10:00 AM Grand Ballroom A-D

End-of-life decision-making can be mentally and emotionally cumbersome for patients, their families, and the physicians providing their care. Hospice seeks to provide quality end-of-life care for individuals diagnosed with terminal conditions. However, the transition of care from curative to palliative care be impeded by delayed recognition of illness severity, communication barriers between care providers, and the patient’s difficulty coming to terms with their prognosis. Instituting a standardized screening tool could provide an objective evaluation of a patient’s likelihood of benefiting from a palliative care consultation. The Seven Point Palliative Care Criteria Screen was modified to expand and clarify criteria. This modified screening tool was then applied retrospectively and prospectively for all patients admitted or transferred to the intensive care unit. Use of the modified screening tool for patients within the ICU increases the number of consultations for hospice and the utilization of palliative care services. The modified hospice screening tool allows patients to receive hospice consultations earlier in the course of their terminal illnesses making transitions at the end of life less cumbersome for all involved.

Upon completion of this session, participants should be able to:

  1. recognize the importance of utilizing a protocol for early screening of patients in the ICU for hospice and palliative care consults;
  2. describe opportunities and challenges experienced during implementation of the new protocol;
  3. formulate a structured approach to implementing a similar screening tool and protocol in their home institutions.

P09 Family Medicine Prenatal and Obstetric Documentation Improvement Initiative

Laura Heinrich, MD

12/7/18 9:30 AM - 10:00 AM Grand Ballroom A-D

The University of Michigan Prenatal Care guideline identifies three components of prenatal care: early and continuing risk assessment, health promotion, and medical and psychosocial interventions and follow-up. This project is an initiative to improve documentation for obstetric notes, prompting the user for specific tests and counseling, with the goal of decreasing missed opportunities and identifying risk factors.

Upon completion of this session, participants should be able to:

  1. implement documentation standards for defined encounter types;
  2. explain physician perceptions on documentation templates;
  3. identify potential areas for risk in using either templated notes or free-text documentation;

P10 PACER Progress Report: Stewardship of Resources (PPM)

Deanne Otto, PhD; Christopher Bugnitz, MD; Tim Crawford; Todd Pavlack, MEd; Harriet Knowles; Michelle Spurlock

12/7/18 9:30 AM - 10:00 AM Grand Ballroom A-D

Stewardship of resources is the fourth of six interprofessional education modules developed for a Professionals Accelerating Clinical and Educational Redesign project. It was intended to catalyze meaningful change by building teams equipped with the skills to transform various clinical practice and educational programs.

Upon completion of this session, participants should be able to:

  1. define and list the principles of stewardship and its role in provide high value health care;
  2. describe how interprofessional teams collaborate to achieve the quadruple aim;
  3. demonstrate how the interprofessional team approach to patient care promotes just allocation of limited resources;

P11 A Pilot Study to Assess Impact of a Clinical Decision Support Tool on Treatment of Uncomplicated Urinary Tract Infections in a Family Medicine Resident Clinic

Sarah Eudaley; Shaunta Chamberlin, PharmD; Alexandra Foster; Rebecca Higdon; Julie Jeter, MD

12/7/18 9:30 AM - 10:00 AM Grand Ballroom A-D

Antimicrobial stewardship in the outpatient setting has become increasingly important in recent years in light of rising resistance rates and a decline in the development of antimicrobials. Overuse and misuse of antibiotics contributes to development and spread of resistance. According to the Centers for Disease Control and Prevention (CDC), approximately 50% of outpatient antibiotic prescribing is considered to be inappropriate, which includes unnecessary use of medication as well as antibiotic choice, dose, and frequency. The 2015 National Plan for Combatting Antimicrobial Resistance sets forth goals of establishing stewardship programs in all practice settings and reducing inappropriate prescribing of antibiotics in the outpatient setting by 50%. The CDC supports use of clinical decision support (CDS) tools as effective methods to impact antimicrobial prescribing. There is a paucity of data on effectiveness for treatment and diagnosis of urinary tract infections (UTI). Because of opportunities in our clinic to optimize utilization of both antimicrobials and urine cultures for diagnosis and treatment of UTI, a multidisciplinary team developed and implemented a CDS tool into the electronic medical record in a family medicine resident clinic.

Upon completion of this session, participants should be able to:

  1. describe current efforts focused on outpatient antimicrobial stewardship;
  2. identify effects of a clinical decision support tool on treatment and diagnosis of uncomplicated urinary tract infection in a family medicine resident clinic;
  3. determine utilization of similar strategies for practice improvement in other disease states and practices.

P12 Faculty Dashboard—Consolidating Key Metrics and Clarifying Expectations (PPM)

Margaret Day, MD

12/7/18 9:30 AM - 10:00 AM Grand Ballroom A-D

We present the development of a faculty dashboard including key metrics identified as FCM priorities: productivity, patient panel size and continuity, timely documentation, population health measures, and patient satisfaction. The report is emailed monthly and serves to consolidate important information for faculty members.

Upon completion of this session, participants should be able to:

  1. identify key metrics for providers to understand to provide excellent clinical care of patients;
  2. identify reasons providing clinicians with clear expectations can lead to improvements in patient care and reduce burnout;
  3. apply a similar dashboard in your own practice setting.

P13 Reducing No-show Rates and Increasing Patient Care Access in a Family Medicine Center (PPM)

John Malaty, MD

12/7/18 9:30 AM - 10:00 AM Grand Ballroom A-D

It can be challenging to increase patient care access when physicians’ schedules are full in a busy clinic practice. However, when patients need to be seen, we need to have availability while also minimizing open slots, in order to balance clinic finances and physician productivity. In our family medicine center, we have limited staff, but decided to have them call all our extended return visit types in an effort to decrease our no-show rate and open up these appointments for other patients ahead of time. This applied to new patient visits, hospital follow-ups, procedure visits in our procedure clinics (for more involved procedures), well-child checks, and other miscellaneous extended visits. This made a large impact in our family medicine center, where we had a reduction in no-show rates for new patients from 22.9% to 14.9% (P< 0.0001) and for return patients from 15.7% to 13% (P< 0.0001 but underestimate without procedure slots). There was also decreased missed opportunities for clinic encounters by 85.2% (combination of open slots, no-shows, late cancellations, bumps, and patients leaving without being seen), as well as increased patients actually seen by one to two patients per provider per clinic half-day session.

Upon completion of this session, participants should be able to:

  1. list 3 critical components of missed opportunities for clinic encounters;
  2. utilize a targeted approach to reduce no-show rates and improve scheduling efficiency/effectiveness;
  3. explain what needs to be done during staff phone calls to optimize scheduling efficiency.

P14 Provider-Driven Panel Management: Improving Quality in a Fee-for-Service Environment (PPM)

Michael Bryan, MD

12/7/18 9:30 AM - 10:00 AM Grand Ballroom A-D

Panel management, defined as the proactive process of notifying patients overdue for services, is an important service to identify potential gaps in care. A physician-led panel management process was initiated at a tertiary care center in Phoenix, AZ with two primary goals identified. The first goal was to evaluate if this process could improve quality while staying financially viable, thus preparing us for value-based reimbursement while living in a very much fee-for-service environment. The second goal was to compare this process to an existing panel management process managed by Allied Health staff.

Upon completion of this session, participants should be able to:

  1. define the quality conditions and metrics that were utilized in this project;
  2. explain the panel management process that was implemented;
  3. apply the findings from this project to his/her own practice for implementation.

P15 PACER Progress Report: Self-Management Module

Paul Hershberger, PhD; Thaddeus Franz, PharmD; Angela Castle, MA; Todd Pavlack, MEd; Tim Crawford; Deanne Otto, PhD; Harriet Knowles; Michelle Spurlock

12/7/18 9:30 AM - 10:00 AM Grand Ballroom A-D

An interprofessional education module on the topic of patient self-management was developed as part of Wright State University’s PACER (Professional Accelerating Clinical and Educational Redesign) initiative. PACER educational modules emphasize improvement in all four aspects of the quadruple aim, (health outcomes, health costs, patient satisfaction, and provider well-being). The patient self-management session centered on a case for which interprofessional student and resident teams initially developed collaborative care plans without buy-in from the patient. Subsequently, a simulated patient responded to the care plans with reasons why most of the components of the plans wouldn’t work. Following discussion of important features of how patients can be more fully engaged, the teams determined how they could better approach the patient. Representatives from each team then had the opportunity to interact with the simulated patient in a manner more conducive to fostering patient self-management. The primary objective of the self-management module was to emphasize how critical it is to develop treatment plans from the patient’s perspective and with patient initiative, if adherence and meaningful behavior change are to occur.

Upon completion of this session, participants should be able to:

  1. define patient self-management;
  2. identify the significance of patient self-management for health outcomes, health costs, patient satisfaction, and provider well-being;
  3. describe elements of an approach that a provider can implement to enhance patient self-management.

P16 A Collaborative Approach to Transitional Care in Family Medicine Residency Program (HFT)

Amber Porter, DNP, FNP; Jason Leubner, MD; Isaac Hensleigh, BSN, RN

12/7/18 9:30 AM - 10:00 AM Grand Ballroom A-D

This poster details a quality improvement project consisting of the implementation of a multidisciplinary approach to transitions of care within a primary care resident program. 

Upon completion of this session, participants should be able to:

  1. identify components for safe and effective discharge home from inpatient hospital experience of skilled nursing home;
  2. identify effectiveness of highly coordinated care at times of discharge from hospital and/or skilled nursing facility;
  3. identify key components to multidisciplinary team approach for transitions of care.

P17 Evaluation of Longitudinal, Integrated ACLS Training in Education Curriculum for Family Medicine Residents

Natalia Galarza Carrazco, MD

12/7/18 9:30 AM - 10:00 AM Grand Ballroom A-D

Traditional Advanced Cardiac Life Support (ACLS) simulation training has been found to be an effective training tool for improving resident physician performance, in both simulated and actual cardiopulmonary events according to different studies. Similar studies show improvement in residents' confidence in running ACLS codes and small to moderate improvement in patient outcomes, although not statistically significant; also none of the studies use similar methods or study design. Our goal in this study is to determine if ACLS simulation training, integrated at regular, repeated intervals into the curriculum of our family medicine residency program, improves knowledge, skills and confidence metrics with ACLS protocol assessment.

Upon completion of this session, participants should be able to:

  1. determine if ACLS simulations are a good method teach ACLS protocol at family medicine residency programs;
  2. determine if ACLS simulations are a good method to maintain ACLS skills and medical residents confidence to participate in "code blue" events;
  3. determine if they need to implement ACLS simulation at regular intervals on their educational curriculum.

P18 Developing an Ambulatory Patient Safety Reporting Structure: Pilot Program Results (HFT)

Brian Stello, MD; Nicole Burgess; Lori Izzo; Melanie Johnson, MPA; Kyle Shaak, MPH; Megan Snyder

12/7/18 9:30 AM - 10:00 AM Grand Ballroom A-D

Patient safety events occur up to 300 times more frequently in the ambulatory setting than in hospitals. In response to federal and state regulations, and with support from initiatives by certification bodies such as the Joint Commission, much has been accomplished in the recognition, reporting, and prevention of events in the hospital setting. However, little formal structure exists for patient safety management in the ambulatory setting. In fiscal year 2018, Lehigh Valley Physicians Group, a multispecialty provider group supporting Lehigh Valley Health Network in eastern Pennsylvania, initiated a pilot program in three family medicine practices to develop a formalized patient safety event reporting structure. Using the health network’s existing reporting system, each practice was educated on reporting process and reporting content by an associate medical director and patient safety officers, and asked to meet monthly to review and act on practice reports.

Upon completion of this session, participants should be able to:

  1. define and identify patient safety occurrences in family medicine practices;
  2. identify the elements of a patient safety reporting and management process;
  3. identify barriers to patient safety reporting.

P19 A New Structure for Precepting Patients in Clinic (RI)

Alethea Turner, DO; Andrea Darby-Stewart, MD

12/7/18 9:30 AM - 10:00 AM Grand Ballroom A-D

Residents in a busy family medicine clinic often struggle to stay on time. One factor contributing to this is the volume of patients that they must precept with an attending, and the length of time it takes to do so. Attendings and residents vary in their ability to keep their communicative exchange focused while still addressing key clinical questions and adhering to the basic concepts of the 5-Step Microskills model of teaching. At the HonorHealth Family Medicine Residency program we created a guideline for residents and faculty to use while precepting that incorporates the residents' year of training, relevant milestones and elements of the Microskills. We measured resident and faculty satisfaction with regards to time spent precepting and its overall impact on clinical efficiency before and after implementation of this precepting guideline.

Upon completion of this session, participants should be able to:

  1. adjust precepting styles based on residents’ year of training;
  2. map applicable milestones to the residents’ experience in the continuity clinic;
  3. develop a similar infrastructure for their family medicine residency clinic.

P20 Bridging the Gap: Improving Transitions of Care

Victor Catania, MBA, MD; Grant Greenberg, MD, MA, MHSA; Deborah Bren, DO

12/7/18 9:30 AM - 10:00 AM Grand Ballroom A-D

Transition of care (TOC) management in family medicine outpatient settings represents an opportunity to improve outcomes and reduce hospital costs. The time between a patient discharge from an inpatient facility until they are seen by their primary care provider represents a delicate shift in their health and status. Within our region comprising of 12 clinicians and 9 offices, at baseline fewer than 10% (N=500) of hospital discharges annually received a transition of care appointment within 14 days. To improve these rates, we introduced a dedicated licensed practical nurse (LPN) to provide care coordination across all nine satellite offices. This LPN has access to a daily discharge census report and follows a preapproved transition of care script to ensure that the patient is contacted within 48 hours of discharge and all necessary CMS documentation components are completed before scheduling the patient directly with their primary care provider. This intervention should yield both improved health care value by increasing TOC visit rates, yielding lower readmission rates, and netting incremental outpatient revenue

Upon completion of this session, participants should be able to:

  1. Generate a system to track their hospital discharges for identified practitioners.
  2. Implement a workflow for a clinical support staff member that interfaces with the EHR to facilitate transition of care appointments.
  3. Provide efficient, effective transition of care visits without onerous additional work.


Copyright 2018 by Society of Teachers of Family Medicine