# Presentation: 534969

## James B. Sutton, RPA-CClinton Family Health CenterRochester General HospitalRochester, NY

## Institute of Medicine: Crossing the Quality Chasm

- 	The problems come from poor systems ... not bad people
*In its current form, habits, and environment, American health care is** incapable **of providing the public with the quality health care it expects and deserves.*

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## Clinton Family Health Center

- Community Health Center
- 9,000 patients
- Inner city, mostly Hispanic
- High rate of uninsured, Medicaid

## Integration of Models

**1996                        1998                            2000                        2002                            2004**

**The Chronic Care Model**

**Idealized Design of the Clinical Office Practice**

**IOM Report: Crossing the Quality Chasm**

**Clinical Microsystems**

**Integration ****of Models**

## Clinical Office Redesign

**Team Formation**
**Open Access Scheduling**
**Preventive Care**
- Group Medical Visits

## Team Formation

**Daily Huddle**
**Weekly Meeting**
**Small PDSA Cycles**

## Open Access

**Do today’s work today**
**Provides Timely Care**
**Decreases ED Visits**

**Notes:**
Open Access scheduling, originally created by Mark Murray in the early 1990’s is now utilized by about 15% of healthcare centers nationwide.  Most of the VA health system is now utilizing open access.  The term can denote a variety of types of schedules, but at CFHC we interpreted it to mean that all requests for care would be fulfilled on the day of the request....... Preferably with the provider of choice, but if not available, at least with another provider in the building.  This different way of scheduling patients does not require more time, effort or money than the more traditional schedule, just a different set of protocols and mindset from the staff.  To the patent, though, it is the equivalent of having a personal physician “ on call” every day to meet your healthcare needs the day you need it, not a month later.

## Preventive Care

**Prevention at every visit**
**Team Approach to Prevention**
**Group Medical Visits**

**Notes:**
We then asked our teams to begin building prevention services into every visit.  Teams began “splitting” preventive responsibilities.  Nurses and secretaries began assessing patient’s mammogram or flu shot status for example and took a greater role and responsibility for the care of patients.  Patients began to view the team as a contiguous unit in charge of their care.  This eventually led to experimentation with the group medical visit.

## Group Office Visit

| One-on-One Office Visit | Group Office Visit |
| --- | --- |
|  Check-in 5 minutes
   (waits in waiting room 15 minutes)

 Vital signs with nurse 5 minutes
   (waits in exam room 15 minutes)

 See provider for 7-15 minutes, labs 
   ordered
   (waits in exam room another 
   15 minutes)

 Labs, check-out, next appointment 
   15 minutes |  Provider, secretary and nurse meet 
  the group patients at an assigned 
  time in the group room. 

 Check-in, vital signs, labs, provider 
   time are all done in the same room     
   at the same time on eight to ten 
   patients.

 |
|    Patient spends 1.5 hours in office
7-15 minutes with provider |   Patient spends 1.5 hours in office
  1.5 hours with provider |

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**Notes:**
Because we “close the deal” that day...... the likelihood that the patient will show for the appointment has dramatically increased.  The near perfect show rate that open access offers makes for a more predictable schedule.

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## ED visits per 1000 members per year

|   | 2003 | 2004 | Change | % Change |
| --- | --- | --- | --- | --- |
| Clinton Family Health Center | 622.66 | 475.89 | -146.77 | 24% |

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