Posts Tagged ‘advanced medical home’

Bon Secours Blueprint for Advanced Medical Home: From Mortar to Measurement

October 7th, 2014 by Patricia Donovan

The building of Bon Secours Health System’s Advanced Medical Home1 began with a walk-through—an assessment of bricks and mortar, explains Robert Fortini, vice president and chief clinical officer at Bon Secours Health System.

In Phase 1 of our Advanced Medical Home project, my team goes into a practice and does a basic workflow discovery—an assessment of bricks and mortar. Oftentimes, the physical plant is not effectively used.

Our objective in a primary care practice is to give each physician at least three or four exam rooms whenever possible. We will do that in a number of different ways, even if it means putting up walls or moving charts out now that we are electronic, or eliminating sample medication closets. We will do whatever it takes to achieve those three rooms per physician.

Next, we review the staff that is providing clinical support. We have developed competency assessment tools for patient service representative (PSR) staff, medical assistant (MA) staff, several different levels of licensed practical nurse (LPN) and our registered nurse (RN) navigator, which is the embedded case manager.

Third, we do an analysis of the physician’s panel size and risk acuity levels and form teams. Team formation is a difficult thing to do because you not only have to assess skills, licensures, panel size and patient acuity, but you also have to take personalities into consideration as well. That is the single most difficult obstacle to being effective.

Fourth, we introduce equipment and training on that equipment so the staff has tools they can use. We do wave testing point of care again, the objective being to eliminate that patient behavioral component and capture an actionable result on the spot before they leave the office. Their hypoglycemic agent or their Coumadin® dose could be titrated accordingly.

Fifth, we do optimization training with the use of our electronic medical record (EMR). We make sure everyone knows how to navigate and is comfortable with the documentation we require. We also use a coding training for the physician’s staff.

Finally, we have a set of metrics to establish baseline so we measure performance.

1. The Advanced Medical home is a model developed by the American College of Physicians involving the use of evidence-based medicine, clinical decision support tools, the Chronic Care Model, and other strategies to manage a patient population.

embedded case management

Robert Fortini, PNP, is vice president and chief clinical officer for Bon Secours Medical Group in Richmond, Virginia. He is responsible for facilitating provider adoption of EMR, coordinating clinical transformation to a patient-centered medical home care delivery model, and facilitating participation in available pay for performance initiatives as well as physician advocacy and affairs.

Source: Case Managers in the Primary Care Practice: Tools, Assessments and Workflows for Embedded Care Coordination

Severity Index Drives Patients’ Touch Points with Nurse Navigators

August 12th, 2014 by Patricia Donovan

Beyond telephonic outreach, assessment and education, nurse navigators in Bon Secours Health System Advanced Medical Home also manage a case load for face-to-face patient work, explains Robert Fortini, vice president and chief clinical officer at Bon Secours Health System. Here, he describes the process of assigning patients to nurse navigators.

Based on our learning experiences with the Geisinger system, it becomes difficult for an RN to handle more than about 150 patients, depending upon the complexity of the patient.

We also give back-line access, and the RNs all have beepers as well. They have the license to give that beeper number to the more complex patients—the frequent flyers who are going to need more attention. Or they can give that access to our colleagues on the managed care side who might be engaged in managing patients with a severe illness. To our case management team in the hospital, it just allows for more bandwidth and clearer communication across the spectrum of care delivery.

How does a patient get into a case load? It is by the physician’s decision. For example, Mr. Smith has seven different major active problems. He is on 18 different medications, he is 87 years old and he has a touch of Alzheimers. That individual needs hand-holding, so that would be the first way to give the patient case management. We also take referrals from the hospital and from our managed care colleagues. We are also using some predictive modeling tools provided to us by insurers to identify patients who need closer following.

How frequently a patient is touched, brought in for face-to-face care or called on the phone depends on the severity index. We use a tool my colleague designed that will calculate a relative readmission risk index based on several sets of criteria: number of medications, length of stay in the hospital, the acuity level of the patient in the hospital and whether or not they are in intensive care unit (ICU) initially, etc. How frequently they are touched depends on how high up the severity index they are.

Excerpted from: Case Managers in the Primary Care Practice: Tools, Assessments and Workflows for Embedded Care Coordination