Patient-Centered Medical Homes (PCMH) Case Study Assessment Answers

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Assessment Details:

No. of Words: 3500

Subject: Medical

Deadline: As Per Required

Objective:  You have been assigned as the Supervisory Health System Specialist of Patient-Centered Medical Homes (PCMH) at Coventry Community Hospital and have been directed to provide a plan to the Clinic Chief as to your near term, intermediate and long-term goals and plan of action.

Background: Coventry Community Hospital is located in an urban community with high access to healthcare. There are at least 15 Urgent Care Centers within 10 minutes of the installation, and non-Active Duty patients have the choice to enroll to a private-sector healthcare provider.

The Medical Home has a current enrollment of 23,875 with a Primary Care Empanelment Tool capacity for 26,847. There is currently 2,494 Active Duty empaneled with the rest of the population made up of AD Family Members, Retirees and a small empanelment of Tricare For Life. The hours of operation are 0730-1630, Monday through Friday.  The Medical Home currently does not have an inpatient mission due to the fact that Coventry CH exclusively hires Hospitalists for this mission.

The Clinic Chief is concerned about the variability of empanelment by provider and the patient’s ability to get an appointment within a reasonable time.  Joint Outpatient Experience Survey (JOES) results indicate 22% of patients were “asked to call back” because there were no available appointments.  Additionally, there are several providers who have achieved unacceptable patient satisfaction scores for the past year. The Chief noted that one specific provider, when asked to respond to specific JOES reported complaints, remarked that “Coventry doesn’t care if we make patients happy; they just want us to make revenue for the hospital”.  He also noted that there has been a recent uptick in the number of requests from enrollees to be unenrolled from the hospital and reassigned to a private-sector provider. The Chief is concerned that the poor provider productivity may put Coventry in the position to lose primary care providers and support staff due to low enrollment.

During your in-processing, you meet with several key staff.  The administrator in Surgical Services mentioned that he was getting a fair number of complaints about referrals that were either poorly documented or were for conditions that had not been worked up to determine if a referral was indicated. “This is really impacting our surgical yield.  We are not getting enough cases from these referrals to the OR”.  He stated that Orthopedics &General Surgery were two of the services most affected by poor referrals.

You were introduced to aRadiology administrator,  who, after pleasantries, stated that she had concern about the requests for CT and MRI studies from Primary Care that do not have the appropriate supporting clinical documentation, or they do not follow the Clinical Practice Guidelines for Low Back Pain. She stated that the normal demand for these studies was already high and that these inappropriate requests were not only clinically inappropriate, but was causing a backlog for those patients who needed these studies.  You tell her that you will look into this and look forward to working with her on this issue.

Having watched several episodes of “Undercover Boss”, you decide that before you introduce yourself to the Medical Home staff, you would sit in the waiting area and see what the patient flow was like. You note that there are 4 Medical Support Assistants (MSAs) working the front desk– 3 of them appeared to be quite busy while the 4th MSA appeared to spending most of her time on her personal cellphone. Her customers appear to have to wait much longer to be assisted. You hear patients making comments amongst themselves such as “I never get seen on time! And she is always on her cellphone.” “I’ve complained about her and I get told that there is nothing they can do about her.” You take down here name and make a note to ask about her when you meet with the Clinical Nurse Officer in Charge (CNOIC).

The next day, you introduce yourself to the Medical Home staff during the Morning Huddle. You note that the Nurse Case Manager is not present for the huddle.  When you ask for her whereabouts, one of the LPNs remarks “She’s probably getting breakfast at the café. She usually doesn’t attend the huddle”.

Afterwards, you sit down with the interim Medical Home Supervisory Health System Specialist(since you are replacing her)and ask her about the staffing and the productivity of the providers. She shows you the current Provider production tools that show that you have some outstanding production from one team and that one team is doing very poorly.  She tells you that the current ratio of nurses and medics is about 1 per provider where it is supposed to be 2 per provider. She has noted that they have had difficulty hiring LPNs/LVNs and are losing the ones they have to the VA, mainly because they pay more. She also notes that there is about a 6-8 month hiring lag due to HR and waiting for security clearances.  “We’ve have lost a fair number of providers who couldn’t or wouldn’t wait that long to come on board”. You ask about the “leakage” to the hospital Emergency Medicine Department and to the network. She thinks its high but will have to get back to you with the numbers.

She tells you that one of the better Military providers has just been notified that he will be deployed down range for 9 months. She further explains that he has been a strong clinical leader who the Physician Assistants (PAs) and Nurse Practitioners (NPs) felt comfortable consulting for complex patients.  She also notes that they don’t expect that there will be a backfill for him.  They have not had time yet to figure out what to do with his empanelment.

She tells you that you should meet with the Clinical Nurse OIC (CNOIC) as soon as you can.

Later that day, you meet with the CNOIC. She tells you that while she has as many RNs as she is supposed to have, that they are feeling over-worked and dissatisfied with their current work environment. When asked to elaborate, she mentions that the RNs spend on average about 6.5 hours a day answering secure messages and T-cons from patients.  They feel that they don’t have the direct face-to-face time with their patients that they use to have and that they feel that they are responsible for staff (LPNs and medics) that they rarely get to interact with. They are concerned about patient safety– while noting that nothing serious has happened, they think it is just a matter of time until something serious happens. She asks if you would be willing to fight for some additional RNs to handle the e-mail workload.  Additionally, the nurse who was managing the clinic’s diabetic patients has been overwhelmed with answering patient e-mails; therefore, monitoring whether diabetic patients are getting their annual HgbA1C screening has been severely hampered.

You describe your observations of your time in the waiting area to the CNOIC.  When asked about the MSA you observed on the cellphone, she explains that this particular employee was going through a divorce recently and that, while the staff had been initially supportive, her behavior had not changed despite being counseled about her time on the telephone and her abrupt attitude with her customers. The employee has been placed on a 60 day Performance Improvement Period (PIP), but that her behavior, if anything, had gotten a bit worse. To compound the issue, she is a Shop Stewart for the local union who had already fought the PIP. You tell her that what you observed is unacceptable and that you want frequent updates on her performance.

At the end of the clinical day, you meet with the provider staff to introduce yourself and to communicate your expectations of them. You tell them that you feel that maintaining high HEDIS scores is a good indicator of clinic practice. When you ask how they are doing on the cancer screening measures, they tell you that they don’t know, but they think “alright”, but are not sure. You tell them you will get them the current numbers and of your intent to post each team’s score in the meeting area and make it a part of the morning huddle.

You notice during the meeting that PA Robert Fall spends most of his time looking at his watch and does not engage in the conversation. After the meeting, you ask him if there was something going on and if you could assist him. He tells you that he does not appreciate late meetings because he is going to be late for his evening shift at a local Urgent Care Center. You ask him if he has an After Hours Work Agreement and he says that he didn’t know he needed one, because his personal time was his own.

You now realize that the briefing the Clinic Chief asked for may not be as straight forward as you first thought….

Task: You shall prepare a briefing for the Clinic Chief (and other invited leaders) on your overall assessment of the Primary Care operations & the Top 3 issues you plan to address.  For each issue, you should include the following:

1. Issue: (State the problem, clearly and concisely)
2. Supporting Information: (Use the attached data, your observations, identify any additional data or information you would require if it is not provided in the case study)
3. Recommendations: (Recommend way ahead)
4. Measures of success: (How will the leadership team know the plan was successful?)

Format: You may use any presentation format you deem fit, to include but not limitedto, PowerPoint, Adobe, Excel, or Word. Supportive charts and graphs are highly encouraged. There is no minimum or maximum to the length of the presentation.