Care plans and transition in a busy primary care office

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Care plans and transition in a busy primary care office
Robert Rohloff, MD & Christopher Schwake, MD
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Five pediatricians
Eighteen nurses
1.77 FTE per doctor
5,000+ referrals to
specialist per year
31,908 office visits
last year
NO EHR!! (until May 2013)
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Parents, staff, physicians,
special needs
coordinator
Meets every 6 weeks
Recommended pursuing
care coordination
Parents-Advised on
implementation and
partnering with parents
Nurses-Advised on
workflow
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Average time on a care plan was about 4-6
hours depending on the complexity of the
patient.
Around $80-$120 dollars per care plan.
Nurses worked an average of 8 hours/week
on care coordination.
As they became more familiar with the
process they were able to make the process
more efficient, completing care plans in less
time.
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Two doctors and two nurses
Patients selected based on physician and
staff recall
Care coordination document from Special
Needs Clinic at Children’s Hospital of WI
Nurses reviewed charts and entered
patient information into a care plan
document
The physician reviewed and revised
information in the care plan
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Nurse enters the doctor’s revisions
Nurse contacts family to arrange care
coordination appointment
Care plan is sent to family for review and
input
Physician approved final draft
Care plan is updated, saved on a flash drive
and a copy is filed in the patient’s chart and
mailed to their home
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Patient satisfaction
and approval
◦ Parents loved the care
plans and wished we
had started them
earlier.
◦ Decided the care plan
could be reviewed
over the phone
instead of coming in
for a visit
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Nurses and
providers
recognized value
Providers decide to
fund ongoing
efforts: value in
cross covering,
anticipated pay
reform and EHR
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7 nurses-total of 30 hours per week-Hiring an
MA allowed for nurses to be used for other tasks.
Each nurse works about 4 hours/week-just
creating new care plans, updating ones that have
already been completed and care coordination
for the patients with care plans.
120 care plans completed over the course of the
project.
Care plans now average between 2-3 hour to
create depending on the patient.
Care plans are updated as a patient is seen by a
specialist, has lab work done or there are other
changes.
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Nurses, physicians and clerical staff suggest
patients for care coordination. Parents can also
ask that a care plan be done for their child.
The nurse does a chart review and enters the
information into the care plan template.
The doctor reviews the completed care plan
and makes changes.
The nurse updates the care plan and mails a
draft to the parents.
The nurse call the parent to review the care
plan over the phone and changes are made if
needed.
The final copy is approved by the doctor and
mailed to the family and filed in the chart.
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Incorporate care plan into Epic
Use transition document template to create a
“living dynamic document”
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Robert Rohloff, MD-Primary care pediatrician Southwest Pediatrics
Michelle Rodriguez-Quality Care Supervisor-Southwest Pediatrics
Mary Jean Green-CYSHCN Program Administrator
Julie Turkoske-CYSHCN Information and Referral Specialist
Maggie Butterfield-Director of Patient Amenities and Family Services
Josephine Camarata-Manager of Family Services and Social Work
Stacy Boyce-Social Worker for the Renal Transplant Clinic
Tera Bartelt-APN Trach. Vent. Clinic
Carole Wegner-APN Pulmonary Clinic
Terri Couwenhoven-Clinic Coordinator of the Down Syndrome Clinic
Rhonda Werner-APN Neurology Clinic
Mary McCord, MD-Special Needs Program
Kimberly Zvana, MD-Physical Medicine and Rehabilitation
Samantha Green-Project Manager for Epic Build
Tanya Skorstad-Istrategy Team Builder
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To create a care plan in Epic that will
ultimately serve as a transition document.
To make the document the lowest energy
default option for care coordination and
transition.
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By age 17
◦ Transition listed in problem list
◦ Transition document created
◦ Member of care team designated as
Transition Coordinator
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Every child will have a care plan document in
place populated from a transition checklist

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