Primary Care Practice Redesign Newsletter
Cohort 1 | Issue 5
January 30, 2019
This newsletter is a biweekly forum to keep practices
connected and informed on the Cohort 1 Redesign efforts.
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For previous newsletters you may have missed, please visit MSHP's News and Media page .
Primary Care Redesign Updates
Recap of Learning Collaborative 2 – January 25, 2019
Cohort 1’s second Learning Collaborative began with a summary of all that has been achieved since the last Learning Collaborative, which was only a few months ago! Since then, we’ve completed practice assessments and care team wellness surveys, embedded facilitators into the practices, undergone Epic optimization, introduced a biweekly newsletter, and launched the first of our major workflow initiatives around huddles. 
Transitions of Care (TOC) Panel
Carl Jin, MS, MPA, RN-BC, CCM, Nurse Clinical Manager, Care Management, MSHP
Kristin Muzina, LCSW, Director of Care Management, MSHP
Alexandra McDonald, Population Health Manager, Lumeris
Ruchi Tiwari, PharmD, MS, Director of Pharmacy, Population Health, MSHP
Rob Fields, MD, MHA, Senior Vice President and Chief Medical Officer for Population Health, MSHP
This panel of physicians, nurses, social workers and pharmacists introduced Cohort 1 to Mount Sinai Health Partners’ care management efforts.

  • Major structural changes have been made to care management recently to align care management staff with “Pods” of providers in various neighborhoods.
  • In some practices, care management services are embedded, while in others they are remote. The care management team’s primary focus is to assist patients around transitions of care and also help to help patients who are at high risk for hospitalization.
  • New to the system are clinical pharmacy services for ambulatory care, as the health system brings disease management capabilities to practices that would benefit from clinical pharmacy support.

How do patients get identified for care management services?
MSHP collaborates with Lumeris on ADSP, Lumeris’ digital platform that identifies patients in need based on past history and present issues. In some cases, practices are referring patients directly to care management. No matter what “door” a patient enters through, the goal is the same – ensuring they get the right care from the right team member at the right time.

Transitions of Care Workflow
Practices went through an exercise to evaluate the benefits of having a TOC workflow in their practice and outlined a process for staying connected to their remote (or embedded) care management teams.

  • While a couple of practices had a robust TOC process already, many did not and all practices felt a TOC process would help build stronger ties with patients and offer greater quality and continuity of care.
  • Many practices said they would like to invite the Care Management team handling TOC into their practices or team meetings to meet face-to-face so that they may develop stronger relationships with the people caring for their patients.
Huddle Presentations
All Cohort 1 practices presented on their huddles, speaking about successes they took pride in, what got in the way, and improvement opportunities for their huddles. Many practices focused on the benefits of increased communication among staff to both patient care and practice operations. Almost all practices felt the pain of getting together when staff shortages, unexpected or pressing patient issues or misconceptions about the efficacy of huddling got in the way.
The Williamsburg practice included quotes in their presentation on the value of huddles:

“Huddling is not only effective, but a great way to communicate with a doctor prior to a busy day.”
Cassandra Nelson, MA/RA
“Huddles are good because you get more information before patients arrive, giving you the opportunity to prepare your charts.”
Rosi Estrella, MA/RA
“I like huddles because it makes the day run smoother. It makes both my medical assistant and me aware if there are gaps in the schedule and where I may need to spend a little more time with a patient. Being prepared is the key to a smooth day.”
Linda Melethil, D.O.
Plan Do Study Act (PDSA) Cycle

A rapid improvement cycle is a quality/process improvement methodology that identifies, implements, measures and standardizes changes made to improve a process or system. The group watched a video on how a mom worked through PDSA to get her kids to school on time. Through trial and error, and multiple small changes, she finally got to the point where her kids improved their timeliness. We can take the same small steps in our practices to:

Test : Try alternatives
Implement : Integrate change into daily operations
Spread : Adopt a change that has been successfully implemented 
In Your Words
At the January 25, 2019 Learning Collaborative, we asked practices what changes they made in the past six months that impacted the running of their practice or the patient experience. Here’s what you had to say!
Brooklyn Heights
“We cross-trained a lot of the staff — front end and back end and it allows us to float people and utilize them where we need them. It’s helped us decrease wait times for patients because we place staff in the positions we need most on a given day. We also see that this improves the patient experience.”
“Cross training is excellent for staff because they are not pigeonholed into having one skill or one particular job they do repeatedly. They’ve broadened their knowledge base and the MAs and LPNs appreciate it and have responded positively about the cross training to their nurse manager.”
Internal Medical Associates (IMA)
“We have a Transformation Committee that performs a lot of PDSAs (Plan Do Study Act), where we do testing to see whether we can make changes in our practice’s cycle time. One thing we did in 2018 was review our late patient policy to make sure we were acting in accordance with it. We also instituted a “dot” rooming system where we change the dots when the patients are ready to be seen. It’s a team effort amongst staff and doctors and the dots let us know which patients are currently in with the doctor, which is helpful considering a doctor may be seeing multiple patients.”
West 23rd Street
“We are proud of our huddles Meeting at 7:45 AM is great and we are really making the clinic run a lot more smoothly. [Huddles] help with patient care and communication amongst our coworkers has improved greatly.”
1090 Amsterdam Avenue
"The biggest thing for us is the investment in the education and development of the staff — thinking differently and creatively on how to grow this business and treating the staff as business partners. We talk about finances, how everything impacts us, with a great focus on patient care."
"In the past year and a half, the overall ambiance of the practice has changed to one of more transparency, which helps with transitions of care and changes in culture. How can you improve if you’re not honest with each other? Our patients can tell that we are working together as one team and that changes their perspective and helps them understand that we are here for them and that they are in control of their care."
Sharing Huddle Resources
The huddles report back section showed that all Cohort 1 practices have a diverse number of ways of huddling, from the timing, data sources, and huddle check-in sheets. One thing we heard very clearly is that practices want to share best practices and resources.   Below is a list of practice leadership for each of the Cohort 1 practices. Please reach out to them directly or let us know if you’d like us to connect you (via )  
Dr. Elizabeth Enschede , Co-Medical Director
Dr. Danya Reich , Co- Medical Director 
Amber Grossman , Practice Manager
23rd Street 
Dr. Sam Altstein , Co-Medical Director 
Dr. John Chuey , Co-Medical Director
Sara Crique , Administrative Director
Sam Friedman
Jason Kindt , Medical Director 
Molly McNeil , Practice Manager
Brooklyn Heights
Dr. David Coun , Medical Director
Michelle Bekman , Ambulatory
Operations Director
Marie Figueroa , Practice Manager
Dr. Mark Gorny , Medical Director
Christine Cate , Practice Manager
1090 Amsterdam
Dr. Stephanie Wang , Medical Director
Lisa Renaud , Practice Manager
85th Street
Dr. Jennifer Kent , Co-Medical Director
Dr. Carlos Rios , Co-Medical Director
Tabitha Deynes , Practice Manager
Dr. Mary Fishman , Medical Director
Sheila Whitaker , Practice Manager
Dr. Jonathan Ripp, Senior Associate Dean for Well-Being and Resilience at the Icahn School of Medicine at Mount Sinai, joins Dr. Fields to discuss the movement in healthcare systems to promote wellness and combat burnout among providers, graduate fellows, and others. They discuss the sense among physicians of lack of control, advocating for regulations that make sense, a model of population health that doesn't contribute to burnout, and more.
Also available through  iTunes  and  Google Play
Transformation in the News
How Care Redesign and Process Improvement Can Reduce Patient Fear
We often talk about care redesign in terms of cost and efficiency. But what if patient experience was the driving force instead? Baylor Clinic in Houston did exactly that by implementing a single-day workflow for mammograms, radiology, and biopsies. When compared to the national average (33.5 days from abnormal mammogram to biopsy) it becomes clear that this is revolutionary.
The change to the same-day schedule reduces patient fears and anxieties and boosts patient experience. While reading images in real time with the patient still in the imaging room causes an initial reduction in radiology revenue, Baylor Clinic found that their patients were very likely to recommend Baylor, and saw increases in breast imaging volume relative to competing clinics and revenue growth year over year.

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