Tackleemergency Departmentvisits

MethodstoHelp

TackleEmergency DepartmentVisits

Practice Toolkit

TableofContents:

Importanceof AddressingEDVisitswithPatients………………..…………………………………………………3StrategiesforPrimary CareProviderstoAddressED Visits……………………………………………………..4-5Primary CarePracticeAssessmenton ED Utilization……………………………………………………………….6-7SAMPLE:AccesstoCare,TelephoneandAppointmentSchedulingPolicy……………………………...8-9SAMPLE:ConversationStartersforEncouragingVisitstoMedical Homeratherthanthe EmergencyDepartment……………………….……………….……………………………………………………………….10-12 SAMPLE:Provider ChecklistforPost-HospitalFollow-UpVisits…………………………………….………..13-14SAMPLE:CarePlanTemplate…………………………………………………………………………………………………15-16 SAMPLE:DailyHuddle Worksheet…………………………………………………………………………………….…..17-18SAMPLE:After-HoursVoicemailScript………………………………………………………………………………………….19-20SAMPLE:NewPatientWelcomeLetter…………………….……………………………………………….……….….21-22SAMPLE:Primary CareReminder Letter…………………………………………………………………………… 23-24

EDVersusMedical HomePoster……………………...………………………………………………………………..25-26

The Right Care: At the Right Place, At theRight Time……...………………..………………………………….27-28Howto usethe CCNC InformaticsCentertoAccessyourpatients’ED Use..………………………. 29-30

ImportanceofAddressingEDVisitswithPatients

“Avoidable”ED visitsare commonandresultfrommanyfactors

KeydriversofEDusemayinclude:

Difficultorlackofaccessto alternativestotheEDforimmediatehealthcare(duringandafterbusinesshours)

Lackofadviceor information ofunderstandingaboutmanagingimmediatehealth careneeds

Lackof understandingthe benefitsofusingtheMedicalHomeratherthantheED

MentalIllness/BehavioralHealthneeds/Past Trauma

Socialfactors–e.g.lackof transportationduringregularhours, unsafe homeenvironments

Purpose:

Thistoolkitisdesignedforprimarycarepracticestointegratethetools and strategieswithintheirpractice workflowtohelpdecreaseavoidable EDvisits bypatients.

Weencourageyoutoutilizethesetemplatestobestfittheneedsofyourpractice.Assuch,thesetemplatescanbeeditedandadjustedasneeded.

We recognizethatdecreasingavoidableEDvisitscan beachallengingfeatandwill probablyneverbereducedcompletely.However, byusingthesetoolsand strategies incombinationwitheachother,wecanworktogetherandstart chippingawayattheproblemonepieceatatime, onepatientatatime.

OverviewofStrategiesforPrimaryCareProviders(PCP’s)toAddressEDVisits

Thefollowingstrategieshavebeendeveloped byresearchinghowotherPCPshavesuccessfullyimplementedchangeswithintheirpracticetoaddressEDvisitswiththeirpatients.Anoverviewofthesestrategiesislistedbelow.Onthefollowingtwo pages,thereisadetailedlistingofthestrategieswith specifictechniquesyourpracticemaybeable touse, alongwithhowthese can align withthe2014NCQAPCMHstandards. Samplesareavailablefor someofthe strategies, whichincludeinstructionsonhowyou couldusethem within yourpractice.

EnhancePracticeCultureand SystemsUsePatient-FacingTechnologies

Create AlternativeMethodsof PatientContact& SchedulingUtilizeDataforPatientIdentificationFollow-Up

Address EDUseHospitalizationRiskduringPCP AppointmentsStrengthenFrontDesk Capacity toDirectPatientsAppropriately

Create or Adopt EducationalMaterials forPracticeDisplayDistributionto Patients

Strategiesfor PrimaryCareProviders(PCP’s)toAddressED Visits

2014NCQA PCMH Standards are notedbyeachstrategy

*Denotesa sampleofthisstrategy foundwithinthis toolkitthatcanbeeditedto best fittheneedsof yourpractice

Enhance Practice CultureandSystems

CompleteaPrimaryCarePracticeAssessment onEDUtilization*SampleonPages6-7

Standardizeapracticedefinitionfornon-emergentED visits(NCQAPCMH1B:1-4)

Establishapracticewritten access-to-carepolicywhicheverystaff memberagreestosigns.Thispolicywillincludestandardsofresponsetime (NCQAPCMH1B:1-4)divisionofstaffresponsibility(NCQAPCMH2D:1-2)*Sample onPages8-9

ProvideStafftrainingincultural competencyto improveaddressing low levelsofhealthliteracy,cultural languagebarriers,socialdeterminantsofhealth(e.g.housing,transportation)

Providestafftrainingin Trauma InformedCare and Mental HealthFirstAidtoaddressbehavioralandMentalHealthneeds

ApplyMotivationalInterviewingtechniquesasapracticeteamtobetterfacilitatepatientunderstanding,awareness,andpatientcenteredness *SampleonPages10-12

Practiceteach-backmethodstobetterfacilitatepatienteducation(NCQAPCMH2D:7)

UtilizepracticeteamtocompleteProviderChecklistforPost-HospitalFollow-UpVisitsrangingfrompriorto visit,duringvisit,andat theconclusionofthevisit*Sampleon Pages13-14

UtilizecorrectCPTandICD-10codesandproactivelyuseguidancefromtheMedicaidVisitLimitsexemptionprocesstorequest additionalvisits

Use Patient-Facing Technologies*HIPAA and HITECHlawsapply

Textmessagestoremindpatientsofappointmenttime/date

Online communitiesforpatients with common diseasestates(e.g. telephone, group visits,videochat)tosupportmedicationadherencediseasemanagement(NCQAPCMH1A:3)

Appsand/orPatientPortalswhich:

Allowhighriskpatientsto inputtheirhealth andmedical readingsthroughoutthedayallowingthepatientandproviderto easilytrackprogress
Providedisease-specificeducationalcontentforrecentlydischargedpatients withaimofreducingEDvisitsandhospitalreadmissions

CreateAlternativeMethods of PatientContactScheduling

AllowcaregiversaccesstoPatientPortalwhereappropriateandwithconsentofpatient

Offergroupappointmentsand/orperiodicclassesondiseasepreventionmanagementtopics

Createschedulingtemplatesthatleaveroomforwalk-inandsamedayappointments(NCQAPCMH1A:1)

Conductfollow-up callstopatientswith chronicdiseasewhohavefrequentED usetodeterminewhy theED visitswereneededand ifanychangetocareplanisnecessary

Ifusingtelemedicineorvideodemonstration,providespecialeducationand demonstrationsforpatientsaboutoptionsformedical devicesandhowtousethem(NCQAPCMH1A:3)

UtilizeData forPatientIdentificationFollow-Up

Reactive:

Standardize/automateaprocessfor schedulingPCP appointmentforanypatient whowasrecentlydischargedfromthehospital(e.g.pulling CCNCInformaticsCenterCurrentHospitalVisits report-

*InstructionsonPages29-31,generatingreportfromEHR,havingrelationship/accesstohospitalEHR)(NCQA PCMH5C:1-7)*Couldnarrowtodisease type if volumehigh

For EDvisitsthatcouldhave been handledbyPCP,make follow-up callsand/or sendpatient letteraftertheirEDvisittoreviewguidelinesforcareincludingregularofficehoursand contact numbers

Proactive:

Generateaweeklylistof10-20patientsnotmeetingcaregoalsanddevelop aprocessthatinvolvesweeklyteam huddlestobegindevelopinga careplananddiscusshowto impactthesepatients(NCQAPCMH4B:1-5,4A:2)*Couldnarrowtodiseasetypeifvolumehigh*SampleonPages15-16
Generatealistof patients withhighEDutilization(e.g.pullingCCNCInformaticsCenterEDVisit report-

*InstructionsonPages29-31,conductweeklyteamhuddlestobegin developingacareplananddiscusshowtoimpactthesepatients(NCQAPCMH4B:1-5,2D:3)*SampleonPages15-16

Flagthe chartofa patient withhigh EDutilizationtoprompt conversationduringPCPvisit

Address ED Use HospitalizationRiskduringPCPAppointments

Conduct dailyhuddlestoidentify anypatientswith high EDutilizationthatare scheduledforthatdayanddevelop aplantoaddressthat utilization*SampleonPages17-18

PCPsaskpatientsaboutED usagediscussappropriatenessduringregularprimarycareappointments

Flagthe chart ifpatient has ahistoryofhighEDutilizationandisnotalready flagged

Developorcompleteapatientcareplanandincludecaregiversinpatienteducationsessions (NCQAPCMH4B:1-5)*Sampleon Pages15-16

PCPswritepatient “prescriptions” orreferralsfornon-medicalneedswhich mayimprovetheir socialdeterminantsofhealth,suchaswellnessclasses,communityresources,etc.(NCQAPCMH4E:5-6)

Referpatientswithhighutilizationtocaremanagementtoserveasanintegratedcareteammemberandencouragepatientstoengagewithcaremanagers

StrengthenFrontDesk Capacityto DirectPatientsAppropriately

Newafter-hoursmessagewhichhighlightsafter-hoursnumberforadviceratherthandirectingpatientstoED*SampleonPages19-20

Emphasize reminderstoMedicaidpatientsaboutno costto callafter-hoursadvice line

Surveypatientsaboutafter-hourstoseeifmoreawareness/educationneeded

Providepatient withpractice after-hoursphonenumbersatcheck-inaskthemtoenterintheir cellphonewhilewaitingforappointment

Providedecisiontriageguidesforfrontdeskstafftohelp determine ifapatientneedsasame-dayappointment

CreateorAdoptEducationalMaterials forPracticeDisplayDistribution toPatients

Newpatientwelcomepackethighlightingpractice’s after-hourspolicies otherurgentcareoptions incommunity(NCQAPCMH2A:32B:2)*SampleonPages21-22

PrimaryCareReminderLettersenttopatient/family/caregiverwhohaverecentlyvisitedtheED(e.g.couldbesenttopatientswhoareidentifiedthroughInformaticsCenter,PracticeEHR,and/orhospitalreports)*SampleonPages23-24

Postcardormagnetforpatientswith informationonpractice’safter-hoursoptionstelephoneaccess

Posters,bookmarks,brochuresthateducatepatientsonchoosingthebestsiteofcare*SampleonPages25-28

Instructionson“Howto Use”–PrimaryCarePractice AssessmentonEDUtilization

ThePrimaryCarePracticeAssessmentonEDUtilization wasadaptedfromvariousassessmenttools.Thisassessmentcanbedoneatanytimeto giveinsightintohowyourpractice isworkingtowardsaddressingEDvisitswiththe goaloffinding areas ofpotentialgrowthfor yourpractice. Thisassessmentcouldbedoneatcertainpointsintimetoshowtheimprovementsmadeandrecordwhatisworkingwellandwhatareasneedmoresupport.

Primary CarePractice AssessmentonED Utilization

Thefollowing assessmentcan becompleted atanytime to assesshowyourpractice is workingtowardsaddressingEDvisits.

PracticeName:

Date Completed:

1.On average,howquicklycana patientbeseenfora sickorurgentvisit?

☐Sameday☐Nextday☐2-4days☐3-5days☐1weekormore

2.Howdoesyourpracticehandleexternalcallsduring officehours?

☐Callerutilizesphonetree,such as interactivevoiceresponsesystem or push-button system☐Calls areanswered directlybystaff

☐Messagesarecollected and giventoRN/MD☐Triageprocess–callsansweredby on-call staff

☐Decisiontree☐Practicehas no standardprocess in place

3.Howdoesyourpracticehandleafter-hoursemergency calls?

☐Patient callsarescreened byan answering servicepriortospeaking withprovider☐Patient contactsproviderdirectly

☐PracticedirectspatientstoED via recordedmessage☐Practicehasnostandardprocess in place

☐Nurseprovidesadviceto patienton provider’sbehalf

Noprocess / Beingplanned / Workspoorly / Workssomewhat / Workswell / Whatmakesitwork? / Whatcausesitnottowork?
Processes
4.KnowingwhenpatientshavevisitedtheED? / 1 / 2 / 3 / 4 / 5
5.RecognizinghighEDutilizers? / 1 / 2 / 3 / 4 / 5
6.Provideinformationand/oreducatepatientsonappropriateuseofED? / 1 / 2 / 3 / 4 / 5
7.Providefollow-up(visits,communication)withpatientswhohaverecentlyvisitedtheED? / 1 / 2 / 3 / 4 / 5

8.Do you have asenseofwhypatientsareusingthe ED insteadofPCP?If yes,whatarethey and howdoyouknow?

9.DoesyourpracticeshareEDvisit informationwith anyof the following othercareteammembers?

☐OtherSpecialists(BH,Endocrinologist,Cardiologist,PainSpecialist,etc.)

☐Care/CaseManager

☐Noprocess in place

10.On ascaleof1 to10(1 –noprocessand10 –worksefficiently)howwould yourate yourpracticeasawhole in addressingED visits?

If you need assistanceimplementing withinyourworkflow,pleaseutilizethetools andstrategiesfound within thistoolkit

Instructionson“Howto Use” –Accessto Care, Telephone, andAppointmentSchedulingPolicy

Thishelpstoestablishawrittenaccess-to-carepolicyin whicheverystaffmemberagreesto,signs,anddates alongwiththeirProvider/Manager.Thiscouldbesignedonatleast an annualbasisbyall currentstaffmembers,whennewstaff membersjointhepractice,and/orwhenthe policyisupdatedtoreflectnecessarychangesmadewithinthepractice.

This allows for eachstaff member to understandthepractice’sdefinition ofaccesstocareandoutlinesstaffmember’sresponsibilities inmeetingthe policy.

TheAccesstoCare,Telephoneand AppointmentSchedulingPolicywasadaptedfromTheAmericanJournalofManaged Care.Thispolicyincludesstandardsof responsetimewhichmeetstheNCQAPCMH1B:1-4standardsanddivisionofstaffresponsibilitywhichmeetstheNCQAPCMH2D:1-2standards.

SAMPLE:AccesstoCare, Telephone andAppointment SchedulingPolicy

OfficeTelephoneFaxNumberRegularOfficeHours

Phone#: (XXX)XXX-XXXX / Monday / X:XXAM –X:XXPM
AfterHours#:(XXX)XXX-XXXX / Tuesday / X:XXAM –X:XXPM
Fax #: (XXX)XXX-XXXX / Wednesday / X:XXAM –X:XXPM
Thursday / X:XXAM –X:XXPM
Friday / X:XXAM –X:XXPM

Responding toPatientInquiries:

Ensure patientshavetelephoneaccess24/7. Answerall phonecallsby the3rdring during officehours.Officehoursarelisted on answeringmachine. Allpatientshaveaccesstoa physician orclinical decisionmaker24hourseverydayforthemanagementof urgent and emergent conditions. Answering serviceisusedwhentheofficeis closed.

If a clinical phone callisanswered by a non-clinical staffmember,thestaffmemberwill:

1.Notanswerclinicalquestions

2.Fill out atriageform/book/note inEHRtohelp the clinical staffassess theneed and urgencyof thepatient’sconcerns

3.Informthepatientthat thenurse/healthcareprovider/doctor will return theircall as soonas possible(practicecould leavereturncall timeas generic orspecify a periodoftime)

4.Send/givetriagenotetothemedicalassistant/nurse/healthcareproviderwhowill thenutilizeofficeprotocolstoanswerinquiryASAP

AppointmentScheduling:

As muchaspossible,scheduleappointmenttomeetthepatient’srequests,withsame-dayaccess.Well-care appointmentsmaybemadeupto threemonthsinadvance.Sickappointmentswill beseen thesameday or nextday.

Accommodatethepatientwheneverpossible.Encourageearlymorning appointments, if scheduling foranother day.Ifthe patientinsists ona latertime,scheduletheappointment asrequestedbypatient,ifpossible. Trynottoscheduleanyfurtherthantwo weeksout,sincetheno-showraterisesafterthatlength oftime.

Follow-up witharemindernotice(letterorcall) ifthescheduled appointment isnot during thecurrentweek. Besurethe patientknowswhatheor sheis required todoand/orbring fortheappointment:

1.Medication list ormedications/devices

2.Self-monitoringtools/resultsform

3.Goal sheet

4.Completion ofmedicaltests

Coordinateotherspecialist appointmentsand/ordiagnostictestswheneverpossible–usuallythepatientwillscheduletheirown appointments.An authorization/referral willbefaxed/sentto thespecialistwithina24hourperiod.

Follow-UpPostED Visit:

Upon receiptof patient ED visitnotice(eitherbyfaxorsecurehospitalconnection);physician reviewsdocumentation andinstructsstafftoeitherplacea follow-up callto thepatient,schedulepatientforappointment,or filenoticein EHR.ForED visitsthatcould havebeentreatablewith a primarycarevisit;send “PrimaryCareReminder”.

EmployeeSignatureDateProvider/ManagerSignatureDate

Instructionson“Howto Use” –SampleConversationStartersforEncouragingVisitsto MedicalHome rather than the Emergency Department

TheSampleConversationStartersforEncouragingVisitstoMedicalHomeratherthantheEmergencyDepartmentwas createdbyCCWJC’sMotivationalInterviewingChampions.

These canbeutilized byanymemberof yourpracticeteam toprovideuniformityintheseconversationsandencourageacultureofopencommunicationwithyourpatient/family/caregivers.

Sample ConversationStarters forEncouragingVisitstoMedical Home ratherthan theEmergencyDepartment(ED)

GeneralPracticePopulationEducation

Providerand/orNurseatend of visitand/orFrontdeskatcheck-outcould usethese toencourageallpatientsorparentstocall theoffice, if needscomeupin betweenplanned visits.

“Your next regularcheckup/plannedappointmentis. Ifyou needusbefore then,please call.Wehave ourregularand ourafter-hours line,soyoucan get helpwhenever you needit.”

“Sometimes medication questions can comeupafter-hours,especially if youare feelingsick.Ifthishappens,whatwouldyoudo?Whowouldyoucall?”

Let themanswer.Providethe brochure/information aboutcallingthe officefirst.

“CouldIsharesomeinformationabouthowourpracticehandlesafter-hours calls?”If theysayyes,you can hand themthe brochure and/orprovidetheafter-hoursinformation.

ForPatientswith RecentEDUse

Could beusedforfollow-upcalls/visitsforpatientswith recentED use

“Isee thatyouhavebeenintheEmergency Departmentrecently.Woulditbeokayif wetalked aboutthis for a fewminutes?”

If they say yes,continue…

“Canyoutellme alittlemore about this visit?”

Letthemexplainwhy they wenttotheED.Thiswillgiveyoumoreinformation aboutwhathappened, etc. Thiswill giveyou an “in” tofind outwhy they wenttotheEDinstead of yourpractice.

“Whatdoyousee asthebenefits(goodthings)ofyoucominghereinsteadofgoingtothe emergencydepartment?”

Thisgivesthepatienta chanceto voicewhat theyseeas positive.Italso maygiveyoumoreinformationaboutwhattheymightNOTknowsoyoucan fill in theblanks.Explainto thepatient thebenefits ofbeing seenbytheirownprovider.

“CouldIshare someinformationabouthow wehandle after-hours calls?”

If theysayyescontinuewith:As yourmedical home,we haveanafter-hoursplan–youcanstartbycalling themainnumber,itis XXX-XXX-XXXX.

“Whatdoyou thinkabout what we’ve talked about?”

“Whatareyour thoughtsaboutcallingusthenexttimeyougetsickbeforegoingdirectlyto theEmergency Department?”

ForPatientswithHighEDUse

Could beusedby Provider,Nurseotherofficestaff

“Isee thatyouhavebeenintheEmergency Departmentseveraltimesthispastyear. Woulditbeokayif we talked aboutthisforafewminutes?”

If theysayyes,continue…

“Canyoutellme alittlemore about these visitsor oneof these visits?”

“Whatdoyousee asthebenefits(goodthings)ofyoucomingtosee me/usvs.goingtothe EmergencyDepartment?”

Thisgivesthepatienta chanceto voicewhat theyseeas positive.It also maygiveyoumoreinformationaboutwhattheymightNOTknowsoyoucan fill in theblanks.Explainto thepatient thebenefits ofbeing seenbytheirownprovider.

“Onascaleof1to10 (1beingnotlikelyand10being very likely)howlikelyareyoutocome tosee me thenexttimeyouget sick vs. goingtotheEmergencyDepartment?”

Youcanusetherulerto elicit orhelp them verbalizeand build intrinsicreasonsforcoming toseeyouvs.going to theED.

“That’sgreat-you’rea “5”.Tellme whyyou’re a5 and not a1?”and/or“Whatwould ittaketo moveyou toa highernumberon the scale?”

Hint:we’retrying togetthepatientstotell uswhatwould increase thelikelihood of themmaking thisbehaviorchange.

“Whatdoyouthink aboutwhatwe’ve talkedabout?”

The routine to adoptwhen givinganypiece ofinformation isto:

1.Understand whatthe patientalreadyknows,andwhattheywouldlike to know,byasking.

2.Provideinformation inasneutral a way as possible.

3.Checktheirunderstandingofwhatyou have justsaid- “whatdoyou make ofthatinformation?”

Therearesome othergeneral rulesforgiving information.

Themostimportant istoalwaysask permission first.If youdonot,it could feellike a lectureandthepatientmaynotbereceptive,even ifyou arepresenting useful information.Thiscan bedonequickly,simplybysaying: “Is it OKifI tellyoua littlemoreaboutthat?”

Instructionson“Howto Use” –ProviderChecklistfor Post-HospitalFollow-UpVisits

Thiscouldbeused as aninternal checklist and/oradded asatemplatewithin yourpractice EHRforfollow-up on ED visitsand hospitalizations.There arethree stagesinwhichthe checklist iscompleted:Prior totheVisit,DuringtheVisit,andattheConclusionoftheVisit.Dependinguponyourpractice team andstructure,variousstaffmemberscouldassistwitheachstageoftheprocess.

Forexample:IdentifyingastaffmemberwhocouldassistwithaccessinghospitaldischargesummariescouldstarttheprocessofgainingappropriateinformationfromtheEDorhospitalvisit.Anextstep shouldinclude sometypeofcommunicationwithProviders/Nursesor otherstaffwhocanhelpindeterminingoutstandingquestionstoclarifybeforethefollow-upvisit.Ifthere areanypreliminarypreparationsthatcouldbeperformedtostartthemedicationreconciliationprocess,itisidealtostartthisprocessbeforethevisit sothatduringthe visitareconciliationprocess canbeperformedandthencompletedattheconclusion ofthevisit.

TheProviderChecklistforPost-HospitalFollow-UpVisitswasadaptedfromThePost-HospitalFollow-UpVisit:APhysicianChecklisttoReduceReadmissions.

SAMPLE:ProviderChecklistforPost-HospitalFollow-UpVisits

PriortotheVisit:

□Reviewdischargesummary

□Ifthereareanyoutstandingquestions,clarifywithsendingphysician

□Initiatemedicationreconciliationwithattentiontothepre-hospitalregimen

□Remindercalltopatientorfamily/caregiverto:

□Stressimportanceofthevisitand addressanybarriers

□Remindpatient/family/caregivertobringmedicationlistsandallprescribed andover-the-counterprescriptions

□Provideinstructionsforseekingemergencyandnon-emergencyafter-hourscare

□Coordinatecarewithhomehealthcarenursesand casemanagersifappropriate

DuringtheVisit:

□Askthepatient/family/caregivertoexplain:

□His/her goals for visit

□Whatfactorscontributed to ED visitorhospitalization

□Whatmedicationshe/she istakingandon what schedule

□Performmedicationreconciliationwithattentiontothepre-hospitalregimen

□Determinetheneedto:

□Adjustmedicationsordosages;

□Follow-upontestresults;

□Domonitoringortesting;

□Discussadvancedirectives;

□Discussspecificfuturetreatments

□Instructpatientinself-management;havepatientrepeatback

□Explainwarningsigns and howtorespond;havepatientrepeatback

□Provideinstructionsforseekingemergencyandnon-emergencyafter-hourscare;havepatientrepeatback

AttheConclusionoftheVisit:

□Printreconciled,dated,medicationlistandprovideacopytothepatient/family/caregiver,homehealthcarenurse,andcasemanager(ifappropriate)

□Communicaterevisionstothecareplantopatient/family/caregiver,healthcarenurses,and

casemanagers(ifappropriate).Considerskilledhomehealthcareorothersupportiveservices.

□Ensurethatthenextappointmentismade,asappropriate

Instructionson“Howto Use” –CarePlanTemplate

ThisCarePlancouldbeused asaninternaldocumentand/oraddedasatemplatewithinyourpractice EHR.It’simportantto includepatientself-managementgoals,addressingbarriersandthendevelopingstrategiestoovercomebarriers.Communicating outcomesofthecareplanishighlyrecommendedtoothercareteammembers,sothatallmembershaveashared awareness/understandingaboutthepatientneeds,goals,andprogressmadethusfar.

TheCarePlanTemplatewas adaptedfrom various tools. This meetstheNCQA PCMH 4B:1-5standards.

SAMPLE: CarePlanTemplate

Date:Patient:DateofBirth:

InsuranceType:

Address:Pharmacy: Prescriber:

SummaryofReferral/Utilization(includedatesif relevant):

# ofPCPVisitsin past12months:
# ofEDVisitsinpast12months:
# ofHospitalVisitsinpast12months:
ReferralSource:

Diagnoses:

MedicalDiagnosis:
Behavioral Health(BH)Diagnosis:
CurrentProblems(mayincludehistorical problems):
CurrentMedications:

Action Plan:

Reason forvisit:
TreatmentGoals: / PatientSelf-ManagementPlan:
Short-term / Short-term Goals
Long-term / Long-term Goals
Patientpreferences/LifestyleGoals:
PotentialBarriersin meeting goal:
StrategiesforaddressingPotentialBarriers:
Recommendedand/orPending Referrals:

Care TeamMembers:

ProviderType / ProviderName PracticeName / PhoneNumber
SpecialtyProvider:
BH Provider:
OtherCareTeam MembersRole:

PatientSignatureDateProviderSignatureDate

Considerationsforsharingplanof care:

☐OtherSpecialists(BH,Endocrinologist,Cardiologist,PainSpecialist,etc.)

☐Care/CaseManager

☐Hospital(s)

Instructionson“Howto Use” –DailyHuddleWorksheet

Huddlesaredesignedtolookahead onthe dailyscheduleand anticipate theneedsofpatientscominginfor theday.Idealtimeforhuddlesareatthebeginningofeachdayand/ormid-day.

Follow-uphuddlesthatoccur throughoutthedaycouldbereferredto astouch-pointswithyourstaffmembers,smallerteamsand/orpartners,toassesstheneedtoadjusttheplan.Thesetouch-pointsarenecessarytomaintaincommunicationandfollow-upthroughoutthe workdaytomaintainacultureofsafe,efficient,effective andhighqualitypatientcare.

Itisidealtoarchiveprevioushuddleworksheetseitherelectronically,handwritteninanotebook,orinapatient’scorrespondingrecord/chart.

Aspart ofthehuddle,note anypatientsonthe schedulewhoareknownto havehigh EDutilizationanddiscussthe planfor addressingthat utilization.Asyourteam gainsproficiencywithhuddles,teamscanalso discuss:whichpatientsonscheduleare unlikelytoshowupforappointments(becausetheyarecurrentlyhospitalized, cancelledappointmentorwerejustseenlastweek);whatequipmentisneededin room;and additionalservicescareteamcan provide for patientattoday’sappointmentto makeare-visitand/orEDvisit lesslikely.

TheDailyHuddleWorksheetwasadaptedfromvarioushuddletools.ThismeetstheNCQAPCMH2D:3 standard aroundconductingteam huddles.

SAMPLE:DailyHuddleWorksheet

DailyHuddleWorksheet
Practice/Team:Date:
Follow-up fromYesterday
“Headsup”forToday:(include visittimes,betweenvisitinformation,specialpatientneeds,contingencyplansforstaffingissues,other)
ReviewofTomorroworWeek–OpportunitiesforProactivePlanning

PotentialHuddleDiscussions:

Checkforpatients on theschedule whomayrequiremoretimeand assistancedueto age,disability,personalityorlanguagebarriers. Who canhelp?

Checkforback-to-backlengthyappointments,such as physicals.How cantheybeworkedaroundtopreventbacklog?

Checkforopenings that canbefilledorchronicno-shows that canbeanticipated. Anyspecial instructionsforthescheduler?

Checkproviderandstaffschedules. Doesanyoneneedto leaveearlyorbreakfor a phonecall ormeeting?

Askwhetherlabresults,testresults and notesfrom otherphysiciansareready in thepatient's chart.Whatwillbethemost efficientpathofpatient flow?

AskwhetherED and/orhospital dischargepaperworkareready in thepatient’s chart.Whatwillbethemost efficient pathofpatient flow?

Instructionson“Howto Use”–After-HoursVoicemailScript

TheAfter-HoursVoicemail ScriptwasadaptedfromTheAmericanJournalofManagedCare.Thisillustratestheadvice nurse/provideron-callratherthan directingpatientsdirectlytothe ED.

Itisimportanttomakepatient/family/caregiverfeelcomfortablewhencallingtheirProvideron-call iftheybelievethematterisurgent andcannotwaituntilnormalbusinesshours.Remembertouse acalm,relaxed andinvitingtonewhenrecordingthismessage.Inknowingyourpatientpopulation,thismessagemayneedtoalsoberecorded in Spanishoranotherlanguagethat maybemoreprominent inyour practice.

Thismessageshouldbeupdatedastheadvicenurse/provideron-callphonenumberchangesand/or ifthereis achange in regularoffice hours.

SAMPLE:After-HoursVoicemailScript

Thankyouforcalling[PracticeName].We arecurrentlyclosed,however,pleaselistencloselytothefollowing options.If youare apatientand yourproblem isurgentand cannot waituntilregularoffice hours,thereisan advicenurse/provider availabletohandleyoururgentproblem.PleasecallXXX-XXX-XXXXfortheadvicenurse/provideron-call.

Forallothernon-urgentrequestspleasecallduringnormalbusinesshours.OurregularofficehoursareXXXX.

Instructionson“Howto Use” –NewPatient Welcome Letter

ThisletterisjustonepieceyoumayselecttoincludeinyourPatientWelcome Packet.Thisspecific letterhighlightsthepractice’safter-hourspolicy andotherurgentcareoptions in thecommunity.

This lettercould beincluded inyourpractice’sNew Patient Welcome Packetwhich isgiven to allnewpatientsand giventoexistingpatientswhenthepacket isupdatedtoreflectnecessarychangesmadewithinthepractice.

TheNewPatientWelcomeLetterwasadaptedfromTheAmericanJournalofManagedCare.ThismeetstheNCQAPCMH2A: 3and2B:2standards.

SAMPLE:NewPatientWelcomeLetter

[Practice Name][Address]

YourPartnerin ExcellentHealth Care

When you chooseour practice,yourhealthcarebecomesour responsibility andwework as hard foryour health asyou do.Weall sharethatcommitment,setting high standards forourselvesand thequalityofourcareandwedeliveronthat promisethrough caring,convenience and qualifications. Wewill attempttohaveyouseeyourpersonalprovider ateachofyour appointments.However, if he/she isnot available,our providerswork asa team anduseourelectronicmedicalrecordsystemto providecoordinated care.

Providing moreservices isa growingtrend forour practice to helpourpatientsfind accessto multipleservicesat a singlesite.[PracticeName]proudlyoffers XXaswellas[in-houselaboratory]forpatientconvenience.

SchedulingAppointments

When you calltheofficefor an appointment,besuretotellusthereason foryourappointmentso wecan plan onadate and time that is mostconvenientforyou.Appointmentsforphysical exams androutinevisitsare typicallyavailable andcan bescheduled as needed.Weknowthatillnesses areunexpectedandwewilltryto workaround yourschedule to bring youin forimmediatecareandattention.

Regular OfficeHoursUrgentCareCenter:

Telephone#:(XXX)XXX-XXXXTelephone#:(XXX)XXX-XXXX

After Hours#: (XXX)XXX-XXXXName

Fax #: (XXX)XXX-XXXXAddress

Monday / X:XXAM– X:XXPM / City,State,Zip
Tuesday / X:XXAM– X:XXPM / *(OpenDailyX:XXAM–X:XXPM)
Wednesday / X:XXAM– X:XXPM
Thursday
Friday / X:XXAM– X:XXPM
X:XXAM– X:XXPM

Extended Hoursand After-HoursEmergencies

Health careemergenciescan happenanytime. Ifyouhave anurgentproblem and theofficeisclosed, call usanyway(XXX)XXX-XXXX.Weareoncall24hours a day. Ifyou feelthat you havealife-threateningemergency, call911or gostraighttothenearesthospitalemergencyroom.It isyourresponsibilitytoinformthepracticeregarding care withanyotherhealthcare facilitiesandproviders.

FirstVisitand Follow-Up Visits

Onyourvisit,check inat theregistration deskso yourinformationcan bereviewed foraccuracy.Youcan help usserveyou betterbynotifying theregistration deskofanychanges in name,address,telephonenumberorinsurancecoveragesincethetimeofyour lastvisit.Verifying thisinformation ateach visitwill help ensuretheaccuracyof submittingyourservicesto yourinsurance(s)company inatimelymanner.

We trytofollowour scheduled appointmentsas closely as possible.However,due to unavoidablecircumstancesoremergencies, a providermayhavetospend additionaltimewith a patientwhomayhavehad an appointmentpriorto yours.Thismayresult ina delay in seeing yourprovider. Weappreciateyourpatienceand understanding in suchcircumstances.

Prescriptionsand Refills

We proudlyuseelectronicprescribing to improveprescription safety andefficiency.Prescriptions andrefills areissuedduring regular officehours.Call yourlocalpharmacyfor all refill requests.

Instructionson“Howto Use” –PrimaryCareReminderLetter

ThePrimaryCareReminderLetterwasadaptedfromTheAmericanJournalofManagedCare.

Thisletterissenttopatient/family/caregiveriftheyhaverecentlyvisitedtheEDforavisitthatcouldhave beenconductedbytheirPCP(e.g.noturgent).Thisletteroutlineshowtoseekemergencycare and other careandcontainsthepractice’sregular officehours,telephoneand after-hoursnumbersalongwith aremindertoschedule afollow-upvisit withtheirPCP.

Thislettercouldbemailedthroughregularorelectronicmail/PatientPortalaccounttopatientswho are identifiedthroughCCNC’sInformaticsCenter(IC)reports,yourPracticeEHR,and/orhavingrelationship/accessto hospitalEHR.Ifyouhavealargerpatientpopulation,you couldnarrowdownbydisease type;EDvisitreason;day(s)ofweekED visitoccurred;certainprovider(s);etc.

Itisrecommendedthat if thepracticehasnotreceived areturnphonecallfromthepatient/family/caregivertoscheduleafollow-upvisitwiththeirPCP,thepracticeproactivelycallsthepatient/family/caregivertoscheduleappointment.Thetimeframefromsendingoutthelettertoproactivelycalling thepatient/family/caregivershouldbedefinedbythepractice.

SAMPLE:PrimaryCareReminderLetter

Date:

Dear,

Accordingto our records,yourecentlywent totheemergencydepartmentfora problemthat we couldhave helped youwith. We wouldlike tobeableto help youwiththesekinds ofproblem and be abletoknowyou/yourchildaswellaswe can.

Pleasecontact ourofficeto schedule a follow-up appointmentso wecanbesureallyourneedsaremet.Regular appointmentshelpus to knoweachotherbetter andbesureyouare getting all the careyou/yourchild’sneeds.

Pleasetake afewminutestoreviewthefollowingguidelinesforcare:

EmergencyCare:Ifyouhave an immediateand seriousinjuryor illnessand thetimeneededto contactyourphysician/providermaymeanpermanentdamagetoyourhealth,youshouldseektreatmentfrom the nearestemergencydepartment or call 911 for assistance.

OtherCare:Pleasecallouroffice if your problemsareurgentandcannotwait until regularofficehours. An advice nurse/provider on-callis availabletoansweryour questionsanda doctor isoncallifthe nurse cannot helpyou.

We hopethisinformation ishelpful.Sincerely,

[Insertphysicianor practicename][InsertAddress]

OfficeTelephoneFaxNumberRegularOfficeHours

Instructionson“Howto Use” –ED versusMedicalHomePoster

TheED versusMedicalHome Posterwascreatedasapatienteducationtooltoeducatepatients/families/caregiversonchoosingthebestsiteofcare.

These canbedisplayedwithin yourpracticeinvariousareas suchaswaitingroom,patientexamrooms,check-outareasandotherareasinwhichpatientsmayuse.

“Provider officename”is…
YourMedicalHome
APatient-DoctorPartnership
AMedicalHomeisthe oneplaceyoucangoforallofyour health careneeds.YourMedicalHome offersthe bestcarebecausethestaff knowsyouandyourhealth history.
UseyourMedicalHomefor:

Annualpreventivecheck-upsand fluvaccinations

Sickcarelikefever,flu,cough,andsorethroat
Urgentneedslike asthmaflairs,infections,sprains,andcuts

GototheEmergencyDepartment ifyouneedimmediatehelp!
Forexample…..

Whenbleedingwon’tstop
Whenbreathingis difficult
Aftera seriousaccident
Aftera seizureorconvulsion

YoucancallyourMedicalHome24hoursaday,
7DaysaWeekforUrgentMedicalAdvice

Instructions on “HowtoUse”–TheRight Care, AttheRight Place, AttheRightTime

The Right Care, AttheRightPlace,At theRightTime handoutwascreatedbyCommunity Care of North Carolina (CCNC) as apatient educationbrochureonchoosingthe bestsite of care.

Thesecanbedisplayedwithin yourpracticeinvariousareas suchaswaitingroom,patientexamrooms,check-outareasandotherareasinwhichpatientsmayuse.Thesecanalsobe sharedwithpatient/family/caregiveraspart ofyourpractice’sNewPatientWelcomePacket,giventopatientsupontheircheck-out,mailedtopatient/family/caregiverwhorecentlyvisitedtheED,etc.

Instructions on “HowtoUse”–How to Use the CCNC Informatics Center to Assess your patients' ED Use

Thisguide wascreatedtooutline reportsavailableintheCCNCInformaticsCenter(IC)around EDvisits.

Howtouse theCCNCInformaticsCenter

toAssess yourpatients’EDUse

Step1:Log intotheCCNCInformaticsCenter(IC)at reportsdirectlyat

Step2: Click on“GotoPracticeStandardReports”andselectyour practicename toaccessyourpractice’sfolder

Tosearchforreal-time patientdata:

1.Openthe“CurrentHospitalVisits–Real-TimeEDandInpatient”ICreport

2.Drop-downboxes inthetop section canbe selectedtoset parametersonyourreportifdesired.Underthe“VisitType” section,select“ED” fromthedropdownbox.Tonarrowyoursearch, thefollowingselectionscouldbemade:hospital, Dualvs.Non-Dual,admission anddischargedates,andages.

3.Click“ViewReport”intheupperrighthandcornerand caneitherviewinformation withinthereportorexporttoExcel.

*OnlyhospitalswhoareparticipatinginADT feedswillhave informationreflectedinthisreport

IdentifywhichofyourpatientsvisitedtheEDwithinthepastweekto addthevisitto patient’s recordand/orproactivelyreachoutandscheduleaprimarycarevisit

•Identifythemost common timesand daysofweekyourpatientsarevisitingtheEDtodeterminewhetheryourpracticemayneedadditionalafter-hoursavailabilityatcertaintimes

•Identifythemostcommonprimarydiagnosestodetermineifpossible patienteducation/outreachisneeded

•Determinewhetherrelationship(s)areneededwithanyhospitalwhichpatientsarevisitingfrequently

Toexamineyourpracticetrends:

Practice TrendsandVisitDetails:

1.Openthe“EDVisitreport”ICreport

2.Drop-downboxes inthetop sectioncanbeselectedtosetparameters onyourreportifdesired.Tonarrowyoursearch,thefollowingselections couldbemade:servicemonth,ages,paiddate,clinicalcategory,Dualvs.Non-Dual,emergentvs.non-emergent

3.Click“ViewReport”intheupperrighthandcornerand caneitherviewinformation withinthereportorexporttoExcel.

4.Thereare3levelstoviewthis data:Tallyby practice,Tallybypatient,VisitDetail

Usecaseexamples:

•Quicklyidentifypatients withhigherEDuse in“TallybyPatient”tab.You canuse this to seewhichpatientsmayneedmoreeducationorareferraltoCCWJCiftheyarenotalreadyin caremanagement.

•Onapatient level,viewvisitdetailstoidentifytrendswithprimarydiagnoses,dates ofserviceandhospital

•Determine howoften yourpatientsarevisitingtheEDforemergentvs.non-emergentvisitsandseediagnosisdetail

Benchmarking:

1.Openthe“PatientSummaryStatistics” ICreport

2.Drop-down boxes inthetop sectioncanbeselectedtosetparameters onyourreportifdesired.Tonarrowyoursearch,thefollowingselectionscouldbemade:month,Dualvs.Non-Dual, ageandpopulation.

3.Click“ViewReport”intheupperrighthandcornerand caneitherviewinformation withinthereportorexporttoExcel.

4.Columntitled“Total EDVisitsper100Pts” allowsyourpracticeto benchmarkagainst CCWJCandCCNCasawhole.Othermeasurescanbe gleaned from thisreportaswell.

Usecaseexample:

•Graphingyourpractice’stotal EDvisitsonaquarterlybasistomonitortrends

*Since it takes 3weeksto3 monthsfor90% ofhospitalclaimstobe paid,thesereports willhaveincomplete dataforthemostrecent 3 monthsofservice

dates.Useit tolookfortrendsovertime ratherthanfor timely patientdata.

References:

Goodman,Robert.EmergencyDepartmentUseAssociated WithPrimaryCareOfficeManagement,May2013.TheAmerican JournalofManagedCare.Vol. 19,No. 5.

Coleman,Eric A. The Post-HospitalFollow-Up Visit: APhysicianChecklisttoReduceReadmissions,October2010.CaliforniaHealthCareFoundation:IssueBrief.