Advancing Team-Based Care Webinar:
Enhancing the Role of the Medical Assistant and Nurse through
Implementation of Care Management to Improve Chronic Conditions
Wednesday, December 7th 2022
2:00-3:00pm EST, 11:00am-12:00pm PST

Continuing Education Credits
In support of improving patient care,
Community Health Center, Inc. / Weitzman
Institute is jointly accredited by the
Accreditation Council for Continuing Medical
Education (ACCME), the Accreditation Council
for Pharmacy Education (ACPE), and the
American Nurses Credentialing Center
(ANCC), to provide continuing education for
the healthcare team.
A comprehensive certificate will be sent after
the end of the series, Summer 2022.
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Disclosure
• With respect to the following presentation, there has been no relevant (direct or indirect) financial relationship
between the party listed above (or spouse/partner) and any for-profit company in the past 12 months which
would be considered a conflict of interest.
• The views expressed in this presentation are those of the presenters and may not reflect official policy of
Community Health Center, Inc. and its Weitzman Institute.
• We are obligated to disclose any products which are off-label, unlabeled, experimental, and/or under
investigation (not FDA approved) and any limitations on the information hat we present, such as data that are
preliminary or that represent ongoing research, interim analyses, and/or unsupported opinion.
• This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of
Health and Human Services (HHS) as part of an award totaling $2,082,933 with 0% financed with non-
governmental sources. The contents are those of the author(s) and do not necessarily represent the official
views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit
HRSA.gov.
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At the Weitzman Institute, we value a
culture of equity, inclusiveness,
diversity, and mutually respectful
dialogue. We want to ensure that all
feel welcome. If there is anything said
in our program that makes you feel
uncomfortable, please let us know via
email at nca@chc1.com
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National Training and Technical Assistance Partnership
Clinical Workforce Development
Provides free training and technical assistance to health centers across the
nation through national webinars, learning collaboratives, activity
sessions, trainings, research, publications, etc.
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Speakers
• Mary Blankson, DNP, APRN, FNP-C
– Chief Nursing Officer, Community Health Center
• Tierney Giannotti, MPA
– Senior Program Manager, Population Health, Community Health
Center
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Objectives
• Review models of complex care management, leveraging both in
person and remote teams
• Describe telehealth as an enhancement to complex care
management delivery
• Outline case examples of complex care management in action
• Discuss leveraging all team members to the fullest success of their
training
• Recognize practical examples of care management tools to ensure
success
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Resource Allocation
• Role of RN
• Role of other team members
• Care Coordination vs. Case Management vs. Care Management
• Role of Risk Stratification
• Role of Payers
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What is Care Coordination?
• “Deliberate organization of patient care activities between two or
more participants (including the patient) involved in a patient’s care
to facilitate the appropriate delivery of health care services” (AHRQ)
• An integral component of the National Committee for Quality
Assurance’s (NCQA) Patient-Centered Medical Home (PCMH) model
• Patient-centered care coordination is a core professional standard
and competency for all nursing practice (ANA)
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Case Management vs.
Care Coordination vs. Complex Care Word Soup
10 Source: Implementation-Guide-Care-Coordination.pdf (safetynetmedicalhome.org)

Complex Care
Management
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TEAM-BASED CARE
“Every Patient Has a TEAM”
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Core Team Roles
Things to consider:
 Centralization vs. site-level care
 Generalization vs. Specialization
 Hybrid models
 Processes vs. People
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Extended
Care Team
Core Team
Provider
MA
Teamlet
Provider
MA & RN
Teamlet
• Receptionist
• Health Coach
• Panel Manager
• Referral Coordinator
• RN Care Managers
• Behavioral Health
Specialists
• Administrative Staff
• Team RN
Virtual
Team
• Centralized Care
Manager
• Telehealth Triage
• Pharmacy
• Patient
Experience
Coordinators
• Digital Tech
Liaisons
• Scheduler
• Lay Caregivers/
CHWs
Primary Care Team
Care Teams
Virtual Care Team

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5
●Comprehensive, team-based
oral health care; preventive,
restorative, and transformative
●“Wherever You Are” (W.Y.A)
strategy to engage kids in school,
farmworkers, homeless in
community settings
●Integration with medical:
Diabetes prevention, fluoride
varnish application, etc.
●Comprehensive primary
medical care for all but the
most complex conditions
●Preventive health promotion
and chronic illness
management at every visit
●Chiropractors, Podiatrists,
Dieticians, OB-GYN, HIV
specialists all contribute to
meeting patient needs
●Behavioral health is central to
CHC’s primary care model
●Care may be initiated by patient
or by warm hand off-in person or
by “eWHO”
●SBHCs provides access to BH for
children and adolescents
●Trauma focused care, group
support, and access to integrated
medical/BH OUD
● Care delivered under standing and
delegated orders
● Nursing leads the team including
Medical Assistants and other
support members
● Focus on key populations such as
elderly (MAWVs, CCM), Homeless,
Transitions in Care
● Nurses also hold roles in triage,
Center for Key Populations,
leadership
Integration

Role of the Medical Assistant in Care Management
• Care gap closure
• Identifying patients lost to
follow up
• ER transition follow up
• Obtain hospital discharge
summaries and other important
documents
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Role of Nurse
in Care Management
• Working with vulnerable patients
• Motivational interviewing and self
management goal setting
• Independent Nurse Visits under
standing and delegated orders
• Quality improvement leaders, coaches,
and team members
• Intensive coordination of community
resources, directly or through an
assigned case manager or community
worker
• Remote patient monitoring
• Telehealth nurse: transition of care
visit within seven days of discharge
• Population Health RN teams: support
care gap closure and other initiatives
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Behavioral Health Collaboration
with RNs for Care Management
• Increased collaboration Psychiatry & RNs
– Safety
• Controlled substance visits
• Medication adherence
• Antidepressant f/u visits
• Long acting injectibles (LAI) Psychotropics
• Others
– Overall wellness
• Insomnia
• Diabetes management
• Others
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Key Supports to Accomplish Care Management
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Electronic Tools
• Training and education
• Dashboards
• Scorecards
• E.H.R. Tools:
– Templates
– Order Sets
– Macros
– Remote Monitoring
– Others
• E-consults
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Weitzman ECHO:
RN Complex Care Management
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Systems and Technology
to Support Care Management
• Integrated Scheduling System
• Call any CHC number and connected to same scheduling group
• Medical, dental, therapy and psychiatry services all scheduled through one system
• All Recalls visible at all points of contact
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Performance
Appraisal Reviews:
Clinical Scorecards
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Content:
Job Tools
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New Areas of Focus in Care Management
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Remote Patient Monitoring
Initial Questions
• Which chronic illness are you planning to utilize RPM for?
• Which devices are you planning to use?
• Are you giving away the devices? Loaning? Prescribing?
–If yes, create a process/standing order
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Remote Patient Monitoring
Once Device Selected
• Who will train the patient to use the device?
• How and where in the E.H.R. is the data coming back to the organization?
• Who is responsible to act on the data?
– By whose authority?
– How often?
• Who is responsible to manage abnormal values?
• Develop scripting for staff to talk about RPM and why it is important
– Add a checklist to support eligibility screening
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Remote Patient Monitoring
Evaluation
• How each team member’s success be evaluated for their part of the work?
• How will the program processes be improved over time?
• How will the program be sustainable?
– In terms of staff time & satisfaction
– In terms of financial impact/ROI
• Ensure there is a little “gatekeeping” as possible
• Break down every measure into sub-parts to identify all process measures that
contribute to the final clinical outcome
• Create an iterative feedback loop to ensure best practice development
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Standing Orders
• Planned Care:
– Publish Clinical Expectations for teams (part of the plan of care policy)
– Create a grid of all measures
• Denominators
• Numerators
• Frequency
• Explanation of data entry options
• Follow-up or care coordination required
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Standing Orders
• Chronic Illnesses Care Management
– Select evidence/ensure it matches organizational clinical expectations
– Outline expected data collection
– Outline optional data collection/care delivery based on assessment
completed (think “menu”)
– Create a grid of all examples
• Who it applies to (i.e. age and symptom(s))
• Any exclusions?
• Don’t forget data entry issues
– i.e. order sets, templates, order link with diagnosis/ symptom, CPT codes
– What to do if something else comes up?
– References
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Medical Assistants:
Planned Care Dashboard
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E.H.R. Templates & Order Sets
Designed to ensure:
→ Minimum data set
→ Consistency in documentation of encounters
→ Emphasis on MI and SMG setting
→ Appropriate education
→ Ensures safety
→ Creates efficiency
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Complex Care Management Dashboard:
Diabetes
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Example: Patients with Diabetes
• Population: 7,440 patients with diabetes
• Subgroup: 866 patients whose last A1c > 9.0 who did not have an
upcoming visit scheduled and no visit in the prior 3 months
• Assign and Train: 5 Patient Service Associates to schedule telehealth
encounters
• Results: 32% of patients were scheduled for a visit with PCP.
• Any patient who had been seen by a PCP within the past 3 months
with last A1c > 9.0 were scheduled with an RN for care management
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Telehealth Population Health Approach:
Patients with Chronic Conditions
• Define the population
• Scale the subgroup of patients to meet the operational capacity ->
highest of the high risk
• Develop and test scripts
• Identify who should see the patient (PCP, RN, CDCES, etc.)
• Obtain feedback iteratively from those reaching out to patients
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Monthly IMZ File
• On a monthly basis the Population Health Team, with data from dashboards created
by Business Intelligence, sends two targeted lists of patients due for childhood
immunizations.
• The information is sent to Nurse Managers and include:
– The first list separated by site, identifies infants 12 to < 15 weeks who are due for
their first Rotavirus vaccine.
– The second list, also separated by site, identifies children 18-23 months old who
are not up to date on their 24 month old immunizations. The specific
immunizations that are due for the child are highlighted.
• Nurse managers are expected to review the information and outreach to patients as
needed. They report their follow up in the Excel file and return it to population
health.
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Potential Points of Friction
• Physical plant space for longer teaching sessions vs. use of the
virtual environment
• Gatekeeping vs Top of license/training practice
• The art of medicine vs. evidence basis
• Duplicative work/duplication of efforts
• Feedback seen as punitive instead of routine
• Others?
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Managing Culture
• Create an environment of team-based care that is based on the
value of every role (not just as a downstream catchall to support
providers)
• Focus on measurement in everything that you do
– Normalize feedback and data as an invitation to partner and troubleshoot
• Invite patients to help you test new technology
• Embrace failure as just another data point on the way to a best
practice
• Celebrate success (often!)
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References
• Bauer, L., & Bodenheimer, T. (2017). Expanded roles of registered nurses in primary care delivery of the future. Nursing
Outlook, 65(5), 624-632.
• Bodenheimer, T., & Laing, B. (2007). The Teamlet Model of Primary Care. Annals of Family Medicine, 5, 457-461.
• Community Health Center, Inc. & The MacColl Center for Health Care Innovation. (2016). HRSA National Cooperative
Agreement: Workforce Development: Complex Care Management in Primary Care. Retrieved from
https://www.slideshare.net/CHCConnecticut/advancingteambased-care-complex-care-management-in-primary-care
• Flinter, M., Blankson, M., & Ladden, M.J. (2016). Registered Nurses in Primary Care: Strategies that Support Practice at the Full
Scope of the Registered Nurse License. Registered Nurses: Partners in Transforming Primary Care. Recommendations from the
Macy Foundation
• Flinter, M., Hsu, C., Cromp, D., Ladden, M., & Wagner, E. (2017). Registered Nurses in Primary Care: Emerging New Roles and
Contributions to Team-Based Care in High-Performing Practices. Journal of Ambulatory Care Management, 40(4), 287-296.
• Implementation-Guide-Care-Coordination.pdf (safetynetmedicalhome.org)
• Norful, A., Martsolf, G., de Jacq, k., & Poghosyan, L. (2017). Utilization of registered nurses in primary care teams: A systematic
review. International Journal of Nursing Studies, 74, 15-23.
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Questions?

Interested in receiving coaching support to
move your health center from planning to
implementation of replicable models?
Our NTTAP offers learning collaborative
opportunities in Training the Next Generation,
Team-Based Care, and HIV Prevention!
For more information, please reach out to
Meaghan Angers (angersm@chc1.com)
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Contact Information
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For information on future webinars, activity
sessions, and learning collaboratives:
please reach out to nca@chc1.com or visit
https://www.chc1.com/nca