Step 5 User Guide. Develop Care Guide-Providers & Clinic Staff Work Processes 2B062013

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Step 5

User Guide

Develop Care Guide-Providers & Clinic

Staff Work Processes

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STEP 5

Develop Care Guide-Provider/Clinic Staff Work Processes

Early in the program planning process, we recommend that your care guide program leadership team engages providers and leaders at each clinic in which care guides will be placed. The program’s implementation team will start developing care guide workflow processes with providers and clinic staff by first understanding job duties and workflows of the clinic’s existing roles (i.e., registered nurse, licensed practical nurse, triage nurse, medical assistant, etc.). The primary goal of engaging clinic role leaders is to ensure equal input in developing specific workflows for care guides to integrate their work. This collaboration will help to ensure that care guide interactions with providers and clinic staff closely align with the clinic’s existing workflows and efficiently streamline work processes. Some key elements your leadership team may wish to consider include:

• How care guides will inform providers and clinic staff of eligible patients

• How care guides will work with providers and clinic staff to initially meet patients

• How care guides will communicate patient issues to clinic members

• How care guides will provide patient care notifications

Documents provided here are intended to help inform conversations between your program leadership team and clinic role leads.

Snapshot of Documents Included in this Section:

• Daily Patient List. An example template listing eligible patients that providers may receive from care guides

• Patient Routing Sheets. A suggested method for clinic staff to help connect patients with care guides

• General Care Guide Communication Guidelines. Considerations to help care guides, providers, and clinic staff understand the care guide’s role in patient care

• Examples of Care Guide Communication. Examples of typical types of care guide communication with providers and clinic staff

• Using the EHR Messaging System. An example tutorial for care guides in training to aid understanding of the EHR messaging process

• Routing a Phone Encounter. An example tutorial provided to care guides in training to become familiar with the routing process

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How to Use these Documents

Daily Patient Lists

Providers and medical assistants (MA) are given a list of patients eligible to work with a care guide. Care guides will generate an EHR report (a tool specifically built for care guide utilization) in order to compile each provider’s list. These patient lists are customized to providers’ appointments scheduled for that day. We suggest using a simple and concise template, similar to the example included in this document, in order to encourage its review.

Patient Routing Sheets

You will need to determine a method for reminding patients to visit their care guides while in the clinic for an appointment. This method may differ between clinics and will largely be determined by clinic role leaders in order for workflows to be integrated. One suggested method, using patient routing sheets, is included in this document. When patients check in for their scheduled appointment, the front desk staff will check off all resources the patient should visit before leaving the clinic. The front desk staff will check off “Visit care guide” on this patient routing sheet if the patient’s EHR is marked as a care guide program participant.

General Care Guide Communication Guidelines

We recommend using this document as a general guideline to help your care guides better understand how to interact with providers on patient care issues. As care guides gain more experience working in the clinic interacting with providers, he/she will be able to better gauge how to most effectively approach each provider on patient care issues.

We suggest your program leadership team provide a handout similar to this document for care guides in training to reference as they learn more about the role and responsibilities.

Examples of Care Guide Communication

Included in this document are examples of care guides’ communication with providers. These examples may be adapted by your leadership team to create a starter communication template for care guides at your organization. During the research phase of our care guide program, general templates of these communication examples were stored as smart text phrases in our EHR system for easy recall by care guides.

Using the EHR Messaging System

During the research phase of our care guide program, care guides utilized the EHR’s messaging system to communicate patient issues with providers and clinic staff. If such a feature exists within your organization’s EHR system, we recommend composing a short tutorial to help train your care guides on this feature. As included in this example document, we suggest a tutorial that is easy to follow and able to act as a quick reference for care guides.

Routing a Phone Encounter

Among the various skills care guides will learn in their training, one of the most critical is learning how to effectively utilize the EHR system to communicate patient care issues. Care guides document patient information gleaned from in-person encounters and routine telephone calls in the form of a “phone encounter” in the patient’s EHR. Through training and careful supervision, care guides come to understand the appropriate person (e.g., provider, nursing staff, diabetes educator, etc.) to route information in order to address the patient’s issue. We suggest composing a similar tutorial document to help familiarize care guides with this process.

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Step 5

Reference Documents

Develop Care Guide-Providers/Clinic

Staff Work Processes

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Daily Patient List

Provider/Physician: ___________________________________________ Date: _______________

These patients have characteristics suggesting they might benefit from having a care guide:

Patient Name Patient’s Scheduled

Appointment Time Type of Visit (i.e., office visit, preoperative exam, etc.)

In addition, please refer ANY patient with HTN, DM, CHF who may benefit from increased help by working with a care guide.

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____ Lab First ____ Lab

____ Mammography

____ X-Ray ____ Spirometry ____ Ultrasound

____ Resource Nurse ____ Allergy/injection ____ Care Guide ____ Check-out Desk

SPECIAL PRECAUTIONS:

____ Mask ____ Gown ____ N95

RETURN TO ROOM#: _______

____ Lab First ____ Lab

____ Mammography

____ X-Ray ____ Spirometry ____ Ultrasound

____ Resource Nurse ____ Allergy/injection ____ Care Guide ____ Check-out Desk

SPECIAL PRECAUTIONS:

____ Mask ____ Gown ____ N95

RETURN TO ROOM#: _______

Patient Routing Sheets

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General Care Guide Communication Guidelines

Care guides should maintain regular contact with a patient’s provider, relaying any relevant patient information that may help the provider with patient care.

The primary categories of communication topics impacting patient care may include:

• Medication issues

• Patient care goals

• Patient communication

• Patient follow-up

The following information presented in this section serves as an example guideline to help care guides better understand the type of information providers should be made aware of within each of these categories.

Medication Issues

(Only relevant to ACE-I, ARB and/or beta-blocker medications as related to the patient’s DM, HTN and/or CHF diagnoses.)

Care guides should send reminders/updates to the primary care provider if:

• The medication list in the patient’s chart does not reflect a patient’s current list or what is stated in the most recent progress note

• A patient is confused about their medication regimen, or if you receive information that a patient is not following the medication regimen indicated in their chart

For example: if you suspect a patient does not understand or is incapable of self-medication

management, he or she may need a home health care aide to help set up medications. This is important information to pass on to the provider, so he/she can start the process.

• The patient can’t afford a medication. You may suggest to the provider a cheaper medication within the same medication class. Remember, many providers have no idea what medication costs are.

Note: check with your manager/supervisor before sending such a message

Patient Care Goals

• Notify the primary care provider if you think a patient may benefit from a support group, smoking cessation counseling, etc., and/or suggest referral to dietitian or diabetic education if not already done within the year

• If you notice a patient is struggling with blood glucose control, you may suggest to the provider that you could call the patient frequently to get blood glucose measurements and report updates back to the provider

• Quarterly reports/chart updates: route this electronic health record (EHR) tool to the primary care provider giving them feedback on how their patients are doing with their care contract goals; be sure to itemize the unmet goals in the progress note section before routing this to the provider

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Patient Communications

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Notify the provider if a patient calls you and has not yet received lab or imaging results

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Notify the provider if you receive important information from a patient that may affect their care

Patient Follow-Up

Consider notifying the primary care provider if:

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A patient is overdue for follow up and not making an appointment despite care guide reminders and encouragement

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No follow-up date is indicated in the progress note, and it has been awhile since the patient has been in clinic

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Examples of Care Guide Communication

Message 1:

Hello Dr. ***,

In an effort to help our patients meet their care goals, we have been asked to send updates on patient progress as they come in to the clinic. Below is your friendly reminder for today’s patient(s).

[Patient] is working on several care goals for DM. The following are goals that have not yet been met:

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Daily aspirin use

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LDL below 100 (I do not see record of this having been checked at [clinic name])

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Blood pressure below 130/80

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Tobacco cessation

Please remind her to stop by and see me after her visit. You will also be seeing [patient] today- he is enrolled in the Care Guide program as well, and is meeting both of his HTN goals.

Thank you, Care guide

PCP Response:

Thanks for the reminder! I’ll remind [patient] to stop by and discuss the issues you raised. PCP

Message 2:

Below is your friendly reminder for tomorrow’s patient: [Patient] is working on meeting 3 care goals:

1) Aspirin use (I realize this may be a deliberate medical decision; if so, please disregard) 2) Blood pressure below 130/80

3) Diabetic eye exam within the last year

Please let me know if there is anything I can do to assist this patient in reaching his health care goals. Also, please note that you will be seeing [patient] tomorrow as well--he is enrolled in the Care Guide program as a patient with HTN, and has met both of the HTN care goals.

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PCP Response:

You’re right about the aspirin. Could you let him know he should be on a baby aspirin daily?

For the eye exam I think he has an ophthalmologist at Hennepin. He was due to see them May 2009. I did not ask him if he had.

BP now at goal. Thanks, PCP

Message 3:

Hello PCP,

Just spoke with [patient], and wanted to pass on a few things.

1. He is interested in quitting smoking, and was asking about nicorette gum. Would you like me to get him set up with the QuitPlan Program, or would you rather address this at your next clinic appointment?

2. I transferred him to PEI (Phillips Eye Institute), and has an eye exam set up for June 1. 3. He wanted to ask you about when his next potassium lab is due. I have no idea if this is

something you do regularly, but I told him I would ask.

4. He would like a refill on his ibuprofen—it may be cheaper for him to get a prescription than OTC, given his medical assistance. Is this something that he needs to call for?

PCP Response:

Hi Care guide -

1. QuitPlan and the gum together would be fine. He can start QuitPlan anytime; we can talk about nicotine replacement at the next visit.

2. Thanks for the PEI referral!

3. We can check K on next visit (annual)

4. I think he should cut back on ibuprofen; we can talk about this at next visit. Thanks!

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Message 4:

Hello PCP,

I just spoke with [patient], and wanted to give you an update:

[Patient] says she went off of glyburide and switched to an increased dose of metformin, as suggested at her last visit. When she made that change, however, she had a noticeable change in vision--things became more blurred. She has since switched back to her old medication regimen, and says her vision has improved. I thought I would pass this along, since it struck me as troubling.

Relatedly, I was going to ask you when this patient should return for a follow-up appointment. She does not have anything scheduled at the moment, and wasn’t sure when she should come in next. Thanks very much,

Care guide

PCP Response:

Hello Care guide,

Blurring of vision does seem striking. It could have been poor control of glucose. I want to see her in 1-2 weeks.

Thanks PCP

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Using the Electronic Health Record Messaging System

There are several methods in which care guides can communicate with primary care providers. One common method is through the electronic health record (EHR) system’s messaging feature. This messaging feature may be called an “In-Basket” message in specifi c EHR systems, and is comparable in its function to email. Care guides will need to understand that using the EHR messaging system is integral to patient care activities. Communication via the EHR messaging system allows for members of the patient’s care team to communicate across multiple disciplines and attach patient EHR information for easy reference.

Below is an example tutorial to help familiarize care guides with the process of EHR communication on patient care issues.

To send an In-Basket:

1. Click on the “In-Basket” tab on top of the patient’s chart.

2. Click on “New Msg.”

3. Type the recipient’s name, or click on the box marked “To…” to search for the name. Include a subject line, and in the “Patient” fi eld, click Patient Lookup or type F3 to pull in the current patient’s chart. Write your mes-sage, and click “Accept” to send the message.

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Routing a Phone Encounter

If you need to notify the primary care provider (PCP) of patient information learned in a phone encounter, you can always send an electronic health record (EHR) message (i.e., an in-basket message). However, another convenient way to relay this information is to route the encounter to the PCP. The PCP may wish to enter his/her own notes to the encounter and route it back to you, or they may simply read the information.

How to route a phone encounter

There are two methods to route an encounter while you are in the patient’s EHR phone encounter:

1. Scroll down to “Routing” in the phone encounter and click on the header to open that fi eld, or 2. Click on the “Routing” category in the left-hand menu.

After you have selected “Routing”, a new window will appear for you to select the individual(s) in which the encounter will be routed.

Click the “Add PCP” button, and enter any necessary comments.

For example: “Dr. X, please see the latest progress note in this encounter regarding Mr. Z’s medication ad-herence. Please let me know if you would like me to call his pharmacy to investigate further.

Close the routing fi eld and exit the workspace to send this message. You should leave the phone encounter open when routing so the PCP can add his/her own comments if necessary.