These resources were developed during the EvidenceNow Southwest project which served 202 primary care practices across Colorado and New Mexico with practice transformation and quality improvement support, including on-site practice facilitation and coaching, expert consultation, shared learning collaboratives, and electronic health record support. We hope you can use these resources and adapt as needed to fit the needs of your practice and/or practice coaching.

Patient Engagement

Resources

Qualities of Successful Patient Advisors:

  • Listen well and consider other’s perspectives
  • Willing to share their individual perspectives and experiences
  • Represent different backgrounds and experiences with healthcare than each other
  • Feel comfortable giving constructive criticism
  • Are not motivated by a single personal agenda
  • Have a sense of humor
  • Have insight into different experiences of care than
  • Connect well with others
  • Motivated to be part of an improvement process within the clinic
  • Understand that healthcare is complex – some issues are easier to resolve than others.

Recruitment Methods:

  • Waiting room advertisement and sign up sheet
  • Provider referrals
  • Staff referrals
  • Spouse referrals – if a patient agrees and their spouse or friend is also a patient, ask them to bring that person along!
  • Cherry pick from a one-time feedback session – advertise a meeting in the clinic to address an issue that the clinic needs feedback on and ask those who demonstrate qualities of a strong advisor to join a PFAC thereafter. Or ask patients after their appointments to meet briefly to give in person feedback and reach out to those who were able to provide insightful, meaningful feedback.
  • Community referrals – Reach out to nearby community organizations that are highly utilized by patients to advertise the PFAB sign up or to give recommendations of known mutual patients.

 Avoid These Recruitment Pitfalls:

  • If provider/staff referrals are used, encourage providers and staff to think about the qualities listed above and avoid selecting a skewed group of patients such as former healthcare workers, those who can only sign the clinic’s praises, etc.
  • Recruiting patients that accurately represent the different backgrounds and experiences of your clinic is most helpful, but you do not need to wait until you have the perfect sample to start. A 30 minute wait to schedule an appointment is a problem for everyone!

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PFAC MISSION:

To promote and support patient-and family-centered care at [clinic] by personalizing, humanizing and demystifying the healthcare experience.

GENERAL INFORMATION:

 Vision:

The PFAC strives to promote respectful, effective partnerships among patients, families

and healthcare professionals in the clinic/health system/community.

 Scope:

To actively promote and create new and unique opportunities for communication and

collaboration emphasizing responsible and personalized patient-and family-centered

care.

 Objectives:

The primary objectives of the PFAC are:

  • To provide ongoing feedback that aids in establishing organizational priorities and in addressing patient service issues.
  • To assist in promoting highly effective practices in response to patient/family needs and priorities.
  • To improve the patient experience as measured by patient satisfaction survey scores, personal letters, and other data-gathering tools.
  • To educate PFAC membership so they can become ambassadors to and for the [health system] and the community.
  • To strengthen communication and collaboration among patients, families, caregivers and staff.
  • To promote patient and family advocacy and involvement.

 Membership:

  • Must be an active patient at the [clinic name]
  • A member of the board may resign at anytime by submitting a written notification to the facilitator
  • A member may be removed from the board if it is in the best interest of the PFAC, which will be determined by [clinic] staff involved with the board
  • Board representation will be comprised of 1/3 staff and 2/3 clinic patients

Membership Qualifications:

Consistent effort shall be made to ensure the board membership reflects on diversity in

culture, gender and healthcare experiences found in our community.

  • Share insights and information about their experiences in ways from which others can learn.
  • See beyond their own experiences
  • Show concern for more than one issue or agenda
  • Respect the perspectives of others
  • Speak comfortably and candidly in a group

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Description of Job Positions within the Clinic

Front Desk Person – This person answers phones, performs scheduling tasks, assists with medical records.  They are frequently the people who greet patients when they check in for an appointment.  If needed, an MAs can also perform a CTA’s role.

MA (medical assistant) – This person can perform both clinical and administrative duties.   They are the people that room patients and take their vitals.  They also can draw labs.  They sometimes help with the CTA roles if needed.

Nurse – A nurses’ job description varies significantly based on the environment in which he/she works.  At our clinic, our nurses answer MANY triage phone calls throughout the day addressing things like medication refill requests and guiding patients to come to clinic vs. go to the emergency room for their issues.  They also help in clinic if IVs or certain medications need to be given.

Nurse Practitioner – A nurse practitioner is a nurse who has received additional advanced training such that they are skilled to take a patient’s history, perform an exam, make a diagnosis and offer treatment.  In our clinic, our nurse practitioners serve as the primary care provider for many patients.

Physician Assistant – A physician assistant is another type of provider that can take a patient’s history, perform an exam, make a diagnosis and offer treatment, similar to a nurse practitioner or a physician.  Their job descriptions vary based on their work environment, as some PAs choose to work in the hospital.  Like nurse practitioners, the physician assistant position was created in the 1960s to help meet the need for more healthcare providers.

Doctor of Psychology – At our clinic, we have several behavioral health providers who have received doctorate level training in psychology.  Similar to the psychology intern, they see patients independently, in co-consultation visits with medical residents, and on the fly after a patient’s appointment, if desired.

 Pharmacist – Pharmacists complete college, four years of pharmacy school, +/- residency training specific to the type of environment in which they hope to practice.  Retail pharmacists (aka, the person behind the counter at the local drug store) does not need to complete a residency.

 Family Physician – aka doctor, this person has completed 4 years of medical school, 3 years of family medicine residency and has passed the Family Medicine boards to become “board-certified

Behavioral Health – A lump term for all the psychology providers within the clinic.

Care Manager – Care managers are trained professionals who are skilled at helping patients navigate the healthcare system.  At our clinic,  our care manager has been a huge help in launching our quality improvement efforts.  She helps arrange care for complicated patients and helps providers understand what resources are available to a patient.

Provider – This is a generic term that is used to describe any of the higher trained fields including medical resident, nurse practitioner, physician assistant or physician.  We sometimes include behavioral health providers under this term.

Primary Care Provider – A patient’s main provider.  This can be a doctor, nurse practitioner, or physician assistant. 

Care Team – This term refers to all the staff members a patient typically sees.  Because we are broken into three pods, a patient usually only sees care team members within their pod.  This includes MAs, providers, and sometimes a care manager.

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Adapted from: http://www.mclaren.org/MPHO/glossaryoftermsmpho.aspx

  1. PCMH – Patient Centered Medical Home
A health care setting that facilitates a philosophy of a strong patient-physician relationship which actively engages the patient in their healthcare provides comprehensive healthcare and works towards achieving wellness.
  2. PCMH-N – Patient Centered Medical Home-Neighborhood
An extension of Patient Centered Medical Home into Specialties and Sub-specialist fields which includes a strong PCP/Specialist relationship to ensure communication and outcomes of mutual patients.
  3. PO – Physician Organization 
An organization that partners with physicians or is a group of physicians that works with health plans on contracts and other mutual interests (i.e. incentive programs, transition programs, etc.) of their organization.
  4. PHO – Physician Hospital Organization
An organization that partners with physicians and hospitals in order to obtain payer contracts and to further mutual interests (i.e. incentive programs, transition programs, etc.) within integrated delivery systems.

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Template for patient advisory agenda topics, blank meeting minutes and a Patient and Family Advisor Confidentiality Contract

Also includes a form to assist with evaluating an Advisor-Provider collaboration in systems change.

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Quality Improvement

Resources

This document includes an extensive ENSW resource list.  Topics covers clinical guide summaries for the ENSW ABCS as well as resources on the 10 building blocks of high performing primary care.

ENSW ABCS Clinical Guideline Summaries

Aspirin Primary and Secondary Prevention of Cardiovascular Disease -Guidelines on the use of aspirin and other anti-thrombotics

Blood Pressure Management Hypertension Control – Action Steps for Clinicians An article from the Centers for Disease Control addressing strategies to optimize blood pressure control. Visit Checklist: Supporting Your Patients with High Blood Pressure A one page checklist from the CDC for health care professionals to use when assisting patients with hypertension control.

Cholesterol Management The Patient With Difficult-to-Treat Hypercholesterolemia: Is Everything Under Control? Panel discussion video on lipid management in difficult to treat patients.

Smoking Cessation Management Behavioral and Pharmacotherapy Interventions for Tobacco Smoking Cessation in Adults, Including Pregnant Women: U.S. Preventive Services Task Force Recommendation Statement This article is an evidence review of smoking cessation of the effectiveness and safety of pharmacotherapy and behavioral tobacco cessation interventions among adults, including pregnant women and those with mental health conditions.

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The e-Learning modules offered on this website, developed by faculty at the University of Colorado Department of Family Medicine, support the work of practices participating in ENSW.

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A: Aspirin- Patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period and who had documentation of use of aspirin or another antithrombotic during the measurement period.

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The EvidenceNOW Southwest (ENSW) Practice Improvement Plan is the beginning of your work with
your practice facilitator to improve outcomes related to cardiovascular health for your patients.

Review and Discuss

This planning document is a guide for a multidisciplinary practice team to review and discuss:

  • Strength to build on
  • Opportunities for improvement
  • Priorities that will help to improve the cardiovascular health of your patients

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This interactive document is for Clinical Health Information Technology Advisors (CHITAs) to work with a practice to

institute sustainable quality improvement. The Data Quality Improvement Plan (DQIP):

  • Allows your practice’s CHITA to understand results from your Practice Survey.
  • Focuses on the data elements and clinical quality measure (CQM) reports that support care for patients with cardiovascular
    disease or those who are at high risk.
  • Will help your CHITA to work with your practice team to identify opportunities and barriers for implementing the
    EvidenceNOW Southwest project.

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Heart Health

Resources

Flow chart depicting the inclusion and exclusion criteria for both the numerator and denominator for the high blood pressure measure.

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Description: Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90mmHg) during the measurement period.

Methodology: Population identification is accomplished via a query of a practice management system or Electronic Medical Record (EMR) to identify the population of eligible patients (denominator). Data elements are either extracted from an EMR system or abstracted through medical record review.

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Denominator Flow chart depicting the inclusion and exclusion criteria for both the numerator and denominator for the cholesterol measure.

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Description

Percentage of high-risk adult patients aged >= 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR adult patients aged >=21 years with a fasting or direct LowDensity Lipoprotein Cholesterol (LDL-C) level >= 190 mg/dL; OR patients aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL; who were prescribed or are already on statin medication therapy during the measurement year.

Methodology

Population identification is accomplished via a query of a practice management system or Electronic Medical Record (EMR) to identify the population of eligible patients (denominator). Data elements are either extracted from an EMR system or abstracted through medical record review. Measurement Period January 1 through December 31, 20xx

Eligible Population

Eligible Specialties Family Medicine, Internal Medicine, Geriatric Medicine, Endocrinology, Cardiology Eligible Providers Medical Doctor (MD), Doctor of Osteopathy (DO), Physician Assistant (PA), Advanced Practice Registered Nurses (APRN) Ages 21 years and older as of January 1 of the measurement period Event At least one face to face visit (Value Sets: Annual Wellness Visit; Face-to-Face Interaction; Office Visit; Preventive Care Services – Established Office Visit, 18 and Up; Preventive Care Services – Initial Office Visit, 18 and Up) with an eligible provider in an eligible specialty for any reason during the measurement period.

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Flow chart depicting the inclusion and exclusion criteria for both the numerator and denominator for the smoking cessation measure.

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Description:

Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user.

Methodology:

Population identification is accomplished via a query of a practice management system or Electronic Medical Record (EMR) to identify the population of eligible patients (denominator). Data elements are either extracted from an EMR system or abstracted through medical record review.

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Flow chart depicting the inclusion and exclusion criteria for both the numerator and denominator for the aspirin use measure.

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Description
Percentage of patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antithrombotic during the measurement period.

Methodology: Population identification is accomplished via a query of a practice management system or Electronic Medical Record (EMR) to identify the population of eligible patients (denominator). Data elements are either extracted from an EMR system or abstracted through medical record review.

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*These resources were created as part of the AHRQ funded ENSW initiative that ended in May 2019. The information on this page and the associated documents have not been updated since the conclusion of the initiative.