Welcome to Care Coordination and Interoperable Health IT Systems, Team-based Approach to Patient Care. This is Lecture c Evidence-based Clinical Practice. This unit will explore evidence based clinical practice guideline resources. The objective for this unit Team-based Approach to Patient Care Lecture c is to identify evidence based clinical practice guideline resources. The following slides provide a general overview from change management and project management perspectives of managing transformation to team-based care coordination. There is no one complete proscriptive approach to this process. This guidance should be considered in the context of your organization's setting and scale. A change plan for team-based care transformation requires planning phases of assessment and reassessment through transformation to a collaborative team based care model. Phases should include opportunities for gap analysis, milestones measurement, and examination from baseline to current milestone progress monitored and tracked for optimum adaptation during the transformational change process. Phases should include opportunities for gap analysis, milestones measurement and examination from baseline to current milestones progress, monitored and tracked for optimum adaptation during the transformational change process. Refer to Component 18, Unit 10 for more information on Change Management. In the assessment phase, start to create an effective measurable plan by assessing the collaborative team leadership and team roles and responsibilities to establish a baseline related to the transformation team-based care key elements, standards and criteria defined in the patient centered medical home team-based models. This allows leadership to target and prioritize where to most easily begin transformation to yield the highest results, gain early momentum and maximize experience satisfaction. Planned measurement and gap analysis during transformation plan phases, strategically reveal when, where, and how to analyze and adapt plans to efficiently move towards establishing high- functioning team-based care. Planned measurement and gap analysis during transformation plan phases strategically reveals when, where, and how to analyze and adapt plans to efficiently move towards establishing high- functioning team-based care. Systems technology provides capabilities and opportunities for identification and prioritization of managing clinical conditions with an emphasis on managing population health, wellness promotion, disease prevention, chronic disease management and patient activation and engagement. Health information technology systems designed to support health condition registries, chronic disease management and population health management, measurement and analytics capabilities can improve opportunities for predictive modeling, risk assessment and patient population stratification. High-risk or high acuity patient population data can be analyzed and used to identify and prioritize the patient population in a given population of patients or a provider panel. This is done in order to measure the highest stratification for the most needs and most increasing needs for healthcare utilization. High-risk patients have three or more chronic diseases, poorly controlled chronic diseases, demonstrated difficulty with care recommendations and compliance, three or more hospitalizations and / or emergency department visits in the past year, identified high health care cost and services utilization according to health plan or payer historical data, risk associated to social determinants of health, SDOH. The most common chronic diseases worldwide are heart disease, stroke, diabetes, asthma, cancer, and chronic obstructive pulmonary disease or COPD. There are many risk factors associated with chronic illness. However, at all ages the vast majority of chronic disease deaths in men and women can be explained by the following common modifiable risk factors that can benefit from team-based intervention. Unhealthy diet, physical inactivity and tobacco. Although death rates from chronic disease are falling the prevalence of chronic disease is rising. This is due to changes in population demographics, in particular, the aging of the population, as well as increased exposure to risk factors, resulting from social, and environmental changes. Refer to Component 21, for more information on Population Health and Health IT Systems. Developing a culture of proactive care management depends on providing adequate evidence-based, best practice tools into systems. Historically, evidence-based clinical guidelines have been cause for apprehension for primary care providers. Primary care physicians fear evidence-based guidelines can create a cookbook approach that is overly formulaic and standards dependent. Primary care physicians often prefer an individualized approach that allows for nuance in care. However, in recent years, physicians have become more accepting of evidence-based guidelines. They have the ability to discuss, agree upon, and choose their own evidence-based guidelines EBG and measures. Furthermore, primary care providers can also use EBGs embedded in electronic health record systems to realize the value for establishing standardization of care and continue to support unique individualized interaction in clinical management of patients. They can find that after implementing structured guidelines for population management, they have more time for individual clinical management because their team is attending to the minimal standards of care. PCPs can develop protocols and guidelines to delegate authority and responsibility to teams, integrate decision support mechanisms, reduce fragmentation, improve safety and quality outcomes, and use data driven measurement for decision making and management. Listed on the next few slides are recognized resources for evidence-based guidelines. Evidence-based guideline resources may be embedded within health information technology systems and or in addition to systems and support preventive health, chronic diseases or other health conditions as agreed upon by clinicians choosing the guidelines. Clinical researchers and or clinical organizations are responsible for performing research and rigorous development processes to provide resources for the highest quality scientific evidence. Some of these resources include the Institute for Clinical Systems Improvement, the Michigan Quality Improvement Consortium, The American College of Physicians, ACP, the US Preventative Task Force, NQF Diabetes, The American Diabetes Association, ADA, and the American Association of Clinical Endocrinologists, AACE. The Centers for Disease Control and Prevention, National Heart, Lung and Blood Institute, The American College of Cardiology. Agency for Healthcare Research and Quality AHRQ. US Department of Health and Human Services National Guideline Clearinghouse. Agency for Healthcare Research and Quality AHRQ. US Department of Health and Human Services Innovations Exchange. The references to these resources are listed in the references section at the end of the lecture slides. This concludes Lecture c, Evidence-Based Clinical Practice of Unit 2, Team-based Approach to Care Coordination. In summary, this lecture covered a change plan for team-based care transformation requires planning phases of assessment and reassessment. Properly designed health IT systems hold potential. The primary care physicians, PCPs can utilize evidence-based clinical practice guidelines. And there are a variety of evidence-based clinical practice guideline resources available. To summarize the unit team-based approach to care coordination, team-based care is a proven, preferred model. Foundational elements for successful transformation to team-based care, are, leadership, communication and teamwork. There are various recognized resources for evidenced-based guidelines.
