Call Girls Bangalore Just Call 8250077686 Top Class Call Girl Service Available
February 15 2018 NCA Team Based Care Webiner
1. Welcome
The National Cooperative Agreement on
Advancing Team-Based Care
WEBINAR 1: Taking Team-Based Care to the Next Level
February 15, 2018
Presented by the
the Community Health Center, Inc.
2. Get the Most Out of Your Zoom Experience
• Use the Q&A Button to submit questions!
• Live tweet us at @CHCworkforceNCA and #primarycareteams
• Recording and slides are available after the presentation on our website within
one week
• CME approved activity; requires survey completion
• Upcoming webinars: Register at www.chc1.com/nca
Q&A
3. Learning Objectives
1. Participants will be able to describe the core concepts of team-
based care
2. Participants will be able to describe the roles and functions of the
primary care teamlet.
3. Participants will identify 3 additional roles beyond the core team.
Complete the survey at the end of the webinar to receive CME
credits!
4. Advancing Team-Based Care:
1. Advancing Team-Based Care: Building Your Primary Care Team
to Transform Your Practice
2. Enhancing the Role of the Medical Assistant
3. The Emerging Role of Nurses in Primary Care
4. Data Driven Dashboards to Support Team-Based Care
5. A Team Approach to Prevention and Chronic Illness
Management
6. Complex Care Management in Primary Care
7. Achieving Full Integration of Behavioral Health and Primary
Care
8. Dissolving the Walls: Clinic Community ConnectionsTransforming
TeamsPlease visit www.CHC1.com/NCA to access
NCA webinar recordings, presentations and resources
5. Upcoming Webinars
• Taking Team-Based Care to the Next Level
February 15, 2018 | 3 p.m. EST
• Advancing the Practice of RNs and Behavioral Health Providers
February 22, 2018 | 3 p.m. EST
• Beyond the Walls: Effectively Utilizing Community Health
Workers and Clinical Home Visitors as Part of the Team
March 1, 2018 | 3 p.m. EST
• Caring for Patients with Pain is a Team Sport
March 8, 2018 | 3 p.m. EST
6. CHC Profile
Founding year: 1972
Primary care hubs: 14; 204 sites
Staff: 1,000
Patients/year: 100,000
Specialties: onsite psychiatry, podiatry,
chiropractic
Specialty access by e-Consult
Elements of Model
Fully Integrated teams and data
Integration of key populations into primary care
Data driven performance
“Wherever You Are” approach
Weitzman Institute
QI experts; national coaches
Project ECHO®— special populations
Formal research and R&D
Clinical workforce development
CHC Locations in Connecticut
10. At the center is the Teamlet
February 21, 2018
J Am Board Fam Med January-February 2016 29:135-138.
11. “Core” and “Extended” team members
•Core = full-time (or close to full-time) individuals
on a team that works with specific PCPs caring for a
defined population of patients (a panel).
•Extended = practice staff who have an ongoing
professional relationship with the core team and
who provide services to any patient of the practice
or specific sub-populations.
12. Primary Care Team
February 21, 2018
CentCore
Team
Provider
-MA
Teamlet
Provider
-MA
Teamlet
Provider
-MA
Teamlet
Extended Care
Team
• Receptionist
• Team RN
• Health Coach
• Panel Manager
• RN Care Managers
• Lay Caregivers
• Pharmacists
• Behavioral Health
Specialists
• Administrative Staff
13. Team Structure:
Major Findings From Site Visits
February 21, 2018
Medical assistants, receptionists, and
lay-persons play key patient care roles .
Roles are expanded. All staff work at the
top of their license and skillsets.
All core teams supported by RN care
managers, behavioral health specialists,
pharmacists, etc.
Providers and their panels supported by
Core teams consisting of MAs, front desk,
and others.
14. Care that is Comprehensive: IPCP Team
Additional on-site specialties
Nutrition
Diabetes education
Chiropractic
Podiatry
Retinal screening
PATIENT
Medical
BH
Nursing
Pharmac
y
Prenata
l
Dental
15. • POD design
2 Medical Providers
1 Registered Nurse
2 Medical Assistants
1 Behavioral Health Clinician
Additional members: podiatrist,
dietician, Pharm-D, chiropractor, CDE
Student/Trainees
The Interdisciplinary Team
17. Planned Care
Delegated Ordering
Scanning/Faxing/handling of incoming faxes
Panel Management
QI/Microsystem Participants
The Role of the Medical Assistant
18. Split Screen: PCD and EHR
ID
ID
Provider Name
Provider Name
Patient Name
19.
20.
21.
22. • Recurring biweekly (40 min) dedicated time will be scheduled
for Panel Management activities
• Medical Assistant Reviews:
• Diabetes Dashboard
• HTN Dashboard
• Opioid Dashboard
• Missed Opportunities Dashboard
00/00/00 22
What is MA Panel Management?
23. • The goal of MA Panel Management is to:
• Re-connect patients who are overdue
• Ensure that uncontrolled patients are adhering to
defined treatment plans
• Ensure all planned care associated with HTN, DM and
chronic Opioid treatment have been completed
• The expected outcome of MA Panel Management is to:
• Improved rates of HTN & DM control
• Improved rates of Planned Care completion
• Improved adherence to defined treatment plans
00/00/00 23
Goals & Outcomes of MA Panel Management
24. The Role of the Provider
• Clinical Leader/Responsible
• Clinical Management
• Support planned care
• Evidence based care delivery
• Care coordinate with team
• Empower the Team
• Leverage the Team
• Engage in the Team
32. • Used the following week to identify opportunities to reach
back out to patients
00/00/00 32
Missed Opportunities
33. Medical Assistant Performance Appraisal
• Annual process led by CNO and
site Nurse Managers
• In FY 2017, it included 18
measures for which the MA has
direct responsibility.
36. • Defined and standardized documentation in the EHR
• Training existing and new staff to the standard
• EHR Registries, Clinical Alert, and/or BI
• Time given to teams
• Reasonable expectations
• Monitor and Support
00/00/00 36
Key Elements of Success
38. Speakers
From MacColl Center for Health Care Innovation, Group Health
Research Institute:
Brian Austin, Deputy Director
From Community Health Center, Inc.:
Margaret Flinter, APRN, PhD, Senior Vice President & Clinical
Director
Veena Channamsetty, MD. Chief Medical Director
Aislinn Edwards, Senior Medical Assistant
Tierney Giannotti, MPA- Senior Quality Improvement Manager for
Population Health
Anna Rogers- Project Director