Among PCDC’s in-house experts is Shivani Patel, senior project manager in the Performance Improvement group. Patel joined PCDC in 2015 and provides Patient-Centered Medical Home (PCMH) consulting services.
In her own words below, Patel describes helping a client transform in light of the Delivery System Reform Incentive Payment (DSRIP) program, a New York State initiative designed to restructure the health care delivery system.
“This particular practice saw an opportunity, sought out PCDC, and took full advantage,” she says.
A small Brooklyn-based health center (two providers, front-desk staff, and minimal clinical support staff).
A big part of the DSRIP initiative for primary care practices is achieving PCMH recognition. Although PCMH recognition has been available to practices since 2008, New York State primary care sites are now being required to transform, rather than volunteering to do it on their own. It’s a different dynamic, and there is hesitation and concern among practices.
Ultimately, there’s always a bottom line. Practices have to stay open. A consulting agent can’t go in recommending change that it is unsustainable. All of us at PCDC are mindful of the needs and nuances of a small practice. Patient care is first and foremost — but we’re also mindful of everything that comes after that.
We really “hand-hold” our clients — we’re there for them as much as they need us to be. For example, I was on many vendor calls with the physician; I was at the practice for several half-days.
Sometimes it’s the little things; we ask them to let us know about matters that are out of the ordinary so we can do a quick case conference.
Our approach with clients is to “meet them where they are,” and not push them too hard, too quickly. We want them to really transform along the way.
My colleagues and I provide as much support as needed, sometimes meeting with EMR vendors even without practice staff present, if they need that level of support.
During hour-long, biweekly coaching sessions with the client, we talked through each PCMH process, identified areas of improvement, and trained staff on their role in the activity. Practice team members were encouraged to voice their concerns ongoing in order to design the best process for each staff role at the practice.
Throughout the engagement they also did many quick improvement studies using the Plan-Do-Study-Act model to determine what would work best for their practice.
As an example, when our work began, one of the medical assistants was performing only patient intake, including patient vitals and some administrative work. She had a limited role at the front desk and did not check patient insurance information.
By the end of our engagement, the medical assistant “owned” multiple roles in quality improvement as leader of the daily huddle, head of internal meetings, lead of the quality reports and meaningful use reports — which had previously been performed by one of the two physicians.
In fact the physician had been doing many tasks — including depression screenings and care coordination efforts — that took time away from his primary role. When the medical assistant took on these important responsibilities instead, the entire workflow shifted.
Prior to our involvement the practice had a high no-show rate. While staff scheduled appointments and sent reminders, patients who’d scheduled two months earlier were not keeping their appointments; instead they’d walk in later in the week, whenever they had time.
Having front-desk staff as part of our process was critical. As in most practices, staff were “siloed;” but in this case they were brought in for a lot of PCMH activities, all of it team-based.
The staff gained a new understanding of what access should look like. For example, they modified their schedule to reserve same-day appointments to accommodate a high volume of walk-in patients in an organized way.
They also ran a campaign about why it’s so important for patients to call to cancel appointments rather than not show up, in order to open the appointment slot to another patient.
Consequently, the practice saw a major reduction in its no-show rate and an increase in same-day utilization. This made a huge difference in the daily work by reducing time spent calling patients that do not show. It also boosted staff morale.
Staff not only “owned” the changes, but also lived by them. Every single individual at the practice said they were happier as a result of clear responsibilities. People felt invested. They didn’t mind more work, because the work was theirs.
The practice hadn’t considered this perspective at all. While staff were doing relatively well [in this area], it’s always helpful to have some real feedback.
By placing a suggestion box in the waiting room, the practice learned of many unexpected requests — like offering some materials in other languages or putting forms online to reduce time at registration. And then there were the little questions that people might not otherwise feel compelled to ask — minor requests such as “Can you turn the fan on?” Staff were happy to receive this kind of feedback, because it was the first time they’d accessed it.
Electronic Medical Records (EMR)
A lot of practices — especially smaller ones — don’t know all that an EMR can do. They don’t have an IT department that can tell them how.
PCDC helped the Brooklyn practice learn the functionalities they hadn’t been tapping into — for example, how to create disease-specific templates or a care plan embedded into the EMR, which is often very difficult to do.
Referral tracking had been nonexistent at the practice; staff just needed to learn advanced functions, none of which are typically discussed in the standard training that practices receive from the EMR vendor.
The practice had been using only 50 percent of the EMR’s capabilities. Now they’re using at least 75 percent.
At the beginning of the process, the providers’ mindset was along the lines of, “We’ll get it done, we’ll get it done” — checking off boxes, rather than truly “transforming” as a practice. Having worked in a practice setting, I have found that physicians are open to delegating; they just don’t always feel confident doing so.
Once PCDC began training all staff to “own” their tasks, it became a joint effort that involved everyone, including the two physicians.
They were able not only to delegate, but also to feel comfortable delegating. It became a much more even distribution of work.
First, all of us at PCDC have worked at primary care practices including private practices, small independent practices, FQHCs, and hospital-based clinics. Because we’ve worked with such a wide range of clients, we understand how to provide solutions for various environments. I’m not certain every consulting company is always able to do that.
Two, we have an incredible depth of knowledge among our staff. For example, behavioral health is not necessarily my own area of expertise, but I work alongside two clinical social workers. Having such a breadth of skills in such close proximity helps me provide immediate help to my clients.
It’s great, because I don’t think there’s one practice I’ve worked with without my having accessed the wealth of expertise around me. I don’t think other consulting agencies necessarily have that advantage.