and Jeffrey T. Reiter2
(1)
Mountainview Consulting Group, Inc., Zillah, WA, USA
(2)
HealthPoint, Seattle, WA, USA
Electronic supplementary material:
The online version of this chapter (doi:10.1007/978-3-319-13954-8_12) contains supplementary material, which is available to authorized users.
Keywords
Target populationHigh-impact patientsPain and Quality of Life PathwayThe Living Life Well ClassGroup medical visitsPathway teamCooperative Health Care ClinicGroup Care ClinicPathway statementDrop-in Group Medical Appointment (DIGMA)Cluster visitDisseminationImproving Chronic Illness Care (ICIC)Living toolLogisticsTarget populationGroup formatWorkshopsDrop-in classesClass seriesGeneric skills“Coming together is a beginning. Keeping together is progress. Working together is success.”
Henry Ford
Pathways are care delivery plans that assure close working relationships between the BHC and other members of the team in providing care for a target population. They define the services that the BHC and team will deliver to that population, to bring evidence-based treatment to more members of the target group. Pathways also address workflow and often define responsibilities of other members of the team. Groups, whether freestanding or linked to a pathway, allow the BHC to deliver more intensive education, support, and skill training services to patients. Co-led groups (using a BHC and other members of the team) create fertile ground for co-learning between the group leaders, thus expanding the skill repertoires of all involved. Some group formats encourage patients to create supportive communities and thereby increase patient engagement in achieving better health. In discussing all of these services, this chapter aims to equip the reader with more ways to get more evidence-based interventions to more patients.
Pathways
Principles guiding the development of PCBH pathways derive from ideas about quality management generated in the 1980s. Key goals were to make the most of limited healthcare resources and improve the efficiency of care. Today, clinical pathways emphasize the use of evidence-based interventions and a focus on the patient’s experience interfacing with health care. Cross-functional teams design pathways, evaluate them over time, and change them as indicated. The following definition includes the key components of PCBH pathways in today’s PCMH healthcare context:
A PCBH pathway is a multidisciplinary management tool developed to improve outcomes for a target group of patients, using evidence-based practice and resources available.
With this definition in mind, let’s take a look at the steps BHCs can take to build successful pathways.
1. Identify a Target Population
The first step in building a pathway is to decide the population to focus on. Typically, a clinic selects a target population because current problems providing care for this patient group exist. Common examples of such problems include poor clinical outcomes, low patient satisfaction with care, and substantial unnecessary costs associated with care. A population may also be targeted when provider and nursing staff experience low satisfaction and high stress when caring for members of that group.
Survey PCPs and RNs
A BHC can help the clinic develop a list of potential pathway population targets by surveying PCPs and RNs. Figure 10.6 provides an example of a single-page survey, which can be changed as needed to better represent patient groups at the BHC’s clinic. Basically, the survey needs to ask the respondents to identify and prioritize high-impact patient groups.
High-Impact Patients
Patients may exert a high impact in a variety of ways. First, the very size of the group may drive impact. For example, patients with hypertension or prehypertension may include roughly half of the clinic’s patient population between the ages of 30 and 80. Another way of looking at impact is to look at the cost of healthcare services a patient group uses. For example, a healthcare system might develop a list of patients with the highest healthcare costs over the past year whose health care includes three or more ER visits. A third way to assess impact is to look at the level of stress associated with the interface of the patient with the healthcare system. Among patients with chronic pain, for example, a subset may have histories of disappointing experiences with health care, have deficits in interpersonal problem-solving skills, and be using opioid medications long term. These patients often conflict with staff and consume a great deal of time and energy, making them a potentially high-impact population to target for a pathway.
Patients Needing Better Access to Services
Some patient groups may experience difficulties accessing the services they need, making them good targets for pathway development. Patients with diabetes and other chronic diseases are examples. Pathways that move these patients toward enrollment in group medical visits can improve this group’s access to education, support, and skill development. Overweight and obese patients are another example. Effective treatments exist for these conditions but are not always available or easily accessible.
2. Develop a Pathway Team
Once a target population has been identified, the next step is to form a pathway team. This team needs to be cross-functional, with representatives from various departments, including administration and reception. Membership for different pathway teams may vary, depending on which departments are most involved in the population being targeted. In addition, certain staff members may have more or less of an interest in the pathway, depending on the population involved. Cross-functional teams are self-directed and focused on the single task of creating the pathway. The members need to be excellent at multitasking, as they will more than likely be simultaneously responsible for both their pathway duties and their normal day-to-day work tasks. While there is usually a team leader, decision-making will depend on team member consensus. Often, clinical members of pathway teams are self-selected and see participation as an opportunity to make an important difference.
3. Describe Current Practices
After identifying a target population and forming a team, the next step is to look closely at how patients in the group currently interface with the clinic. What services do they receive, and from whom and when? What are the outcomes of these services? What do these services cost? Are there clear outcome reports on these services generated on a regular basis? Often, there will be a great deal of variation among patients in what services they receive. If this is the case, it may be helpful to survey a subset of patients in the target group who have better outcomes, as well as a subset with worse outcomes. Feedback like this can help inform the development of pathway processes that mimic those that were helpful to the patients who had better outcomes.
4. Review Evidence for Improving Care
The next step involves reviewing the evidence for ideas about how to improve outcomes for the target group. Outcomes of interest may include clinical, cost, and/or patient and provider satisfaction. In some cases there may be a robust literature suggesting different strategies for improving outcomes, while in other cases the literature may provide little or no help. Sometimes this review is also done informally, by contacting other clinics and organizations that anecdotally have developed improved care processes for the same population. Creating a table that summarizes strategies for improving each of the desired outcomes provides the pathway team with a visual frame of reference.
5. Cost-Out Options
The team will also need to cost-model the possible interventions that may be implemented. Once an estimate of the cost per patient is available for each of the interventions and the number of patients in the group is known, then the team is able to make an estimate of the cost of implementation for each of the possible interventions and add that information into the evidence table mentioned above. Quite often, teams will quickly see that what may seem ideal is not feasible because it is not affordable. However, even a less-intensive intervention that is delivered consistently to members of the target group will often improve outcomes. In addition, less-intensive interventions are often easier to implement and, if successful, may lay the foundation for more intensive approaches later.
6. Design a Pathway Statement
A pathway statement describes who will provide what service when. Table 11.2 provides an example of a pathway statement. It concerns screening and intervening with young children in regards to neurodevelopment. A typical pathway statement is simple and straightforward. It may reference specific materials, such as screeners or patient education handouts. The team will provide the pathway statement to a PCMH team that has volunteered to pilot the pathway and then collect feedback as to its clarity and feasibility before the pilot begins. Adjustments may be made to the statement according to feedback. Of particular importance is the assurance of optimal workflow processes.
7. Define Pathway Goals and Measurement Strategies
The goal statement specifies the processes and outcomes that the pathway targets. Processes might include referring patients in the group to the BHC or the BHC making a call to patients in the target group. Outcomes may be quite specific, such as improving patient physical and mental health scores on the Duke Health Profile or improving blood pressure readings or specific diabetes outcomes measurements. One of the goals of the neurodevelopmental pathway in Chapter 11 was to increase the completion of warm-handoff BHC visits with children who screen positive for neurodevelopmental delays. Having a goal like this that the EHR can track is ideal. Other goals included improved relationships between PC and specialty care providers concerning children with neurodevelopmental differences. The team developed a brief survey to assess the level of communication and collaboration before the pathway and again at 6 and 12 months after implementation.
8. Pilot and Revise the Pathway
The next step includes finding a team in the clinic willing to pilot the pathway and conducting a pilot study. Often, the PCP on the pathway team will be able to recruit her team to volunteer for the pilot. This is a great opportunity to study workflow and overall feasibility of the pathway. Additionally, piloting often better informs the development of posters, practice support tools, checklists, and patient education handouts. In a pilot, it is easy to make changes quickly; a pilot is highly recommended prior to implementation of a pathway on a larger scale.
9. Disseminate
After piloting to work out kinks, the team should feel more confident about disseminating the pathway on a larger scale, which is the next step. Results from the pilot are also a great way to introduce the pathway to others. They can be highlighted during a formal presentation at provider and staff meetings, and posters displaying results can be placed in common areas such as the break room or even the staff restroom. Even when PCPs are sold on the pathway, making consistent changes in practice habits can be a challenge. Highlighting and reinforcing even small successes with implementation can help with this.
System size is a factor to consider when planning dissemination. In small systems, the teams may be ready to implement a pathway after a brief presentation or training and may stay on track with intermittent positive feedback. Larger systems are more complex which sometimes results in more confusion (e.g., “Who is going to do this?”) and difficulties with buy-in (e.g., “Why are we doing this?”). To enhance the likelihood of a quick uptake in this situation, the pathway team may want to select certain clinics in the system for implementation and develop an implementation team within each clinic. The implementation team may decide to pilot the pathway before moving forward with it. It is always preferable to have pathway team members self-select for participation. With pathways, starting with small steps is better than failing because the pace of dissemination is too brisk.
10. Pathways Are Living Tools
Remember that pathways need to be evaluated and revised on an ongoing basis. Once the pathway is up and running, the pathway team need not meet often, but it needs to continue as a group. Pathway team members can take the lead in training new staff on pathway processes and outcome evaluation. Providers may be surveyed after implementation several times a year; the pathway team can assist with making indicated changes.
A Pathway Example
The Pain and Quality of Life Pathway developed over the course of years in the Gather Clinic. It began with a survey of PCPs conducted by the BHC in the first month of starting the PCBH practice. The PCPs identified four patient groups of particular concern: chronic pain, depression, alcohol misuse, and domestic violence. However, a survey of patients visiting the clinic for a routine family practice visit over the course of three days found that over 50% screened positive for one or more of these conditions, which led to the conclusion that the pathway should target just one of the conditions. After conferring about these results, the providers decided that of the four, the most important was chronic pain—patients with chronic pain taking opioids, more specifically. Current approaches were costly and ineffective. Patients were often dissatisfied and providers wanted to be more effective and efficient.
A review of the literature suggested that a multidisciplinary approach and the use of cognitive behavioral interventions were likely to improve outcomes. Considering the prevalence of this condition, there were far too many patients for the BHC to reach in an individual format, so a group approach was necessary. Already, the providers had medication agreements (see Chapter 14), so it was decided to build on this by amending the agreement to stipulate required attendance at a monthly Quality of Life Class led by the BHC. The BHC would collect a measure of health-related quality of life at the monthly classes and chart this so that PCPs had a better idea of how the treatment plan was affecting patient functioning. Additionally, the BHC planned to teach a wide range of skills for pursuing a meaningful life, despite pain, given that patient reliance on pain suppression and avoidance strategies was associated with poor outcomes. Because prior experience with the medication agreements had suggested that many patients failed to keep to one or more terms, it was decided that the BHC would go over the agreements with patients in a brief visit that would also orient them to the monthly class. Another feature of the pathway was for patients to see the BHC for additional visits if they had any problem keeping to the terms of the pain agreement.
The Pain and Quality of Life Pathway started with two groups of family medicine patients from three PCP panels. Between 10 and 15 people came to each class and the format allowed for new patients to join at any class. Prior to the start of the class, the PCPs, RNs, and a group of family medicine patients with chronic pain were surveyed as to their level of satisfaction with services/care. The survey was repeated in four months: PCP/RN satisfaction had doubled and patient satisfaction improved as well. Improving satisfaction and improving efficiencies in delivery of services were the two targets in the initial design and results suggested improvement in both areas. It was at the four-month mark that the internal medicine department initiated a request that the program be extended to serve internal medicine PCPs, RNs, and patients, and so it was.
This pathway started in 2004 and it continues today. After the first two years, the pathway team rolled out a prevention component of the pathway. This aspect involved PCPs using the Bull’s Eye Plan as an intervention for patients complaining of pain six weeks after injury or illness and receipt of recommended procedures, treatments, etc. The PCPs learned to engage patients in conversations about values and small daily changes that would make life more consistent with what mattered. Rather than drill down and try to eliminate the pain, PCPs leaned in and asked about the patient’s principles concerning life and how it should be lived. It’s been 10 years since, and at times, the Gather Clinic (a rural healthcare clinic) has been without a BHC and still they managed to keep four monthly Pain and Quality of Life Classes going, as well as other aspects of the pathway. One of the original pathway team members continues to be pivotal in evaluating and preparing new PCPs, RNs, and BHCs for their work in the Pain and Quality of Life Pathway—that’s a good PCBH pathway!
Groups
Group services in PC offer many opportunities for improving patient care. They may support the delivery of more services at a lower cost. They may also encourage patients to take a more active role in care and offer support to others. Group services are also consistent with the community aspect of PC. There are a variety of formats possible for PC groups, and the format one chooses is typically based on the target population for the group service and the goal of the service. Once the BHC is clear on the target and the service’s goals, she will need to turn her attention to selecting a format that supports them. However, tasks related to logistics, including marketing, should be addressed first.
Logistics
Logistics involves the detailed organization and implementation of a complex operation, and offering a group service in PC is a complex operation indeed. Preplanning and attention to detail is pivotal to the group’s success. Perhaps the first concern is the availability of a space. Space should be available at the time most of the participants will be able to come to the clinic and it should be large enough to accommodate the group. Some groups may be small (three to four people), while others may be larger, with 15–20 people. Once a space is determined, the BHC should reserve it for the time planned for group meeting(s). The BHC should also work with the front desk lead to anticipate the impact of many patients checking in at the same time for group visits. There are creative scheduling and check-in solutions, but they take time to work out and vary by clinic. The BHC should begin coordinating with clinic management early on and engage the front desk staff in creative problem-solving.
The BHC should also anticipate her own needs for support with the actual delivery of the class. For example, the BHC will likely need assistance moving participants in a larger group from the waiting area to the classroom. It is not uncommon to have several participants come late, so having an assistant to escort them from the waiting area to the classroom helps the BHC avoid interrupting group once it has begun to fetch late-coming patients. If the clinic provides the BHC with an NA to help with group visits, the BHC may request the NA help score outcome measures, make copies of handouts, distribute and collect materials, put the classroom back in order following a group visit, coordinate care with a patient’s PCP, and even assist a group participant with scheduling a same-day medical visit when appropriate. Otherwise, these tasks will need to be done by the BHC.
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