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DAY 1:  Overview of High Leverage Content Areas
Welcome and Introductions
Cindy Hupke, BSN, MBA
Transformation of the Primary Care Practice
Cindy hupke, BSN, MBA; Carolyn Shepherd, MD
The health care environment is complex and rapidly changing, constituting new challenges and opening up exciting opportunities for change.  This session will provide insight into the Clinica model and curriculum that will be offered over the next 3 days to help participating primary care practices adapt, succeed, and thrive in the current environment.   Our focus is to provide a foundation to stimulate and support substantial progress toward better-integrated care—"care that makes sense to patients and families, so that they don't feel lost and forgotten and confused as they make their way through our complex systems."   We owe it to our communities, our patients, and their families!  What would this new system look and feel like for patients and families, staff members, leadership, and the overall community?
After this session, participants will be able to:
  • Summarize the case for change from the sometimes chaotic and “treadmill” approach to primary care to a system of better integrated care that makes sense to patients and families

  • Identify the key change opportunities to help participating primary care practices adapt, succeed, and thrive in the current healthcare environment

  • Describe one organization’s transformation journey and the high leverage concepts that have contributed to their evolution

Partnering with the Patient and Family…. More than lip service
Connie Davis, MN, ARNP, Dulcie Brown, Jessie Gruman
Partnering with patients and families happens at the individual, system and community levels.  Common design principles and specific steps can help an organization build a system that is truly centered on the patient.  We have the privilege and opportunity to hear from and communicate with two patients during this session, hearing about their individual stories and evidence for patient engagement
After this session, participants will be able to:
  • Describe three levels of patient engagement: individual, system and community

  • Understand patient views of engagement

Understanding your population and processes:  Assessing the organization
Cindy Hupke, BSN, MBA, Connie Davis MN, ARNP
The process of developing a care team and developing processes within your practice is not something that you can “take off the shelf”.  It needs to be individualized for your practice, your patients, and your community.  You will learn how to take a close look into your practice to develop a greater understanding of the patient population that you serve and the processes that you use to meet their needs.
After this session, participants will be able to:
  • Identify the items you should know about your population to understand their needs and develop your care team and processes accordingly
  •  Describe methods to obtain the data
  •  Give examples on how to use these data (analyze, learn from, and react to and make changes based on)

“It takes a Village”…or at least a Team

Carolyn Shepherd, MD; Catherine Tantau BSN, MPA

“Too much work and too little time to do it”.  You may have uttered these words or heard them within your own organization.  There are increasing demands on primary care settings to meet the needs of an increasing population size seeking preventive care as well as the needs of those with chronic conditions and acute needs.  It becomes clear that most primary care clinicians in the traditional 15-minute visit can no longer do what their patients expect and deserve.  Many practices have found the answer to this dilemma in the creation of high-functioning primary care teams, with nonphysician team members taking on clinical tasks that their licenses, experience, and training support, with providers then  having quality time to spend with their patients on activities that are value-added to the patient and family.  This approach might look different in each practice, yet a common denominator for every organization is the multidisciplinary involvement and blending of unique skills that each team member can contribute toward a great patient and staff experience.  


After this session, participants will be able to:

  • Describe the imperative to change the structure and approach to primary care practice
  • Summarize methods to optimize the care team 
  • Give examples of successful approaches to care team development and structure
  • Identify strategies for assuring team designed systems to deliver evidence based indicated care
  •  List three opportunities in your own practice for improving reliability using team based approaches


Translating EHR Data into Meaningful Clinical Quality Improvement 
Carolyn Shepherd, MD


Health information technology (HIT) has the potential to enable better care for patients, and to help clinicians achieve continual improvements in the quality of care in primary care settings, but simply implementing current health IT tools will not bring about these results. To generate substantial and ongoing improvements in care, health IT adoption must go hand in hand with the implementation of a robust change package and the routine use of solid improvement methods by clinicians and other staff.  Health IT systems that support improvement of proactive population-based care need several quality characteristics related to queries and follow-up.  Those characteristics will be identified and discussed in this session, providing attendees with a solid understanding of what to look for and use in a highly functional information system that can help your organization meaningfully use your HIT.


After this session, participants will be able to:
  • Identify HIT functionality that will support improvements in primary care focused on individual patients and groups of patients.
  • List “change ideas” for implementing HIT as an improvement tool in a range of primary care settings


Understanding Access; Reducing waits and delays for all care and services
Catherine Tantau BSN, MPA
Long waits and delays for care and discontinuity are epidemic in our health care system. As we struggle to get through today, and cope with what seems to be insatiable demand we inevitably push some work into the future. This further mortgages future capacity and continuity is sacrificed. In this session we will discuss the importance of breaking this cycle and moving to models that reliably provide improved access and continuity. 
After this session, participants will be able to:
  • List the organizational attributes necessary to systematically reduce waits and delays for care in all services. 

  • Describe where and how specific bottlenecks in your organization increase costs and decrease patient, provider, and staff satisfaction. 

  •  Identify successful strategies to transform a culture of waits and delays to smooth and timely flow for all care and services.


Networking Reception
DAY 2:  A Focus on Access, Efficiency, and Patient and Family Centered Care
Continental Breakfast
Overview of the Day
“Making Every Minute Count”:  Improving Medical Office Efficiencies and Flow
Connie Davis, MN, ARNP
Although we know how to diagnose and treat our patients’ problems, we don’t always know how to diagnose and treat our office’s problems relating to efficiency and flow.  Efficient processes require less time, effort, and resources, which is pleasing not only the patient, but also pleasing to the staff and the bottom line.  This topic is a natural complement to improving access to services and care, partnering with the patient to create a meaningful and valuable experience, financial viability, and improving staff satisfaction through the development of reliable and efficient processes.  The session will begin with the value of the patient perspective and will continue with an interactive session to flow map a process from your own organization.  You will leave with a process that you understand and can take the principles shared to apply to the redesign of the process upon your return to your facilities.
After this session, participants will be able to:
  • Describe patient journey mapping as a technique to involve patients in understanding flow and efficiency

  •  List the steps to identify where your current processes might be breaking down.

  • Create a flow map of a process from your organization

Break and Transition to Track of Interest

There are two topics that have been identified as particularly challenging for organizations that are embarking on the transformation journey:  Patient and Family Centered Care and Access to a continuous relationship.  The remainder of the day will be spent in a “deep dive” relating to those two topics.  You will leave the day with new knowledge and ideas to enhance your plans and processes already in place.    If you are present at the seminar alone, you need to choose one track to attend today.  If you are here as a team, you might want to split your team so that you can benefit from both tracks.

Lunch: 12:30-1:15

Track 1:  Patient and Family Centered Care
Connie Davis, MN, ARNP
The potential disruption of the current process and system of care when introducing patient and family centered care is clear in a quote from Don Berwick, MD, when he wrote, “Patient-centeredness is a dimension of health care quality in its own right, not just because of its connection with other desired aims, like safety and effectiveness. Its proper incorporation into new health care designs will involve some radical, unfamiliar, and disruptive shifts in control and power, out of the hands of those who give care and into the hands of those who receive it.“
This Track on Patient and Family Centered Care will be led by Connie Davis, MN, RN, ARNP, an internationally known speaker and consultant on health care design and health behavior change.  Joining her will be Dulcie Brown, Patient Voices Network member from British Columbia and Carolyn Shepherd, MD, an experienced and trusted IHI faculty member and practicing clinician and Vice President of Clinical Services at Clinica Family Health.
Track 2:  Access and Continuity
Catherine Tantau, BSN, MPA
Primary care practices face numerous challenges on their way to improving patient access. Patients continue to challenge health care by comparing the services they receive in the health system to the service they receive in other industries and clearly expect equivalent convenience.  Would your patients say that they receive the care that they need and want when they need and want it?  Can you offer your patients offer patients an appointment today for any problem with their provider of choice?
This Track on Access will be led by Catherine Tantau, BSN, MPA, an internationally recognized authority on access, efficiency and flow systems in healthcare. She led the creation and implementation of Advanced Access.  Ms. Tantau has worked with hundreds of healthcare organizations in the U.S. and Europe using this model.  Joining Catherine will be Carolyn Shepherd, MD, an experienced and trusted IHI faculty member and practicing clinician and Vice President of Clinical Services at Clinica Family Health.
Lunch: 12:30-1:15

Patient and Family Centered Care


The extended session will focus on Patient and Family Centered Care and will include:

  •  Introduction of a stepped model for self management support, focusing on honoring culture, health literacy, and patient activation.  The session will be interactive and will give attendees the unique opportunity to gain insights from the patient perspective

  • Shared Decision Making, with a comparison of tools that can be used

  •  Foundations for Self Management Support, to include actual experience in problem solving and providing information about the Chronic Disease Self Management Program from a professional and lay leader perspective

  • Advanced Self Management Support Approaches, to include motivational interviewing and group visits

  • Action Planning with an opportunity to consult with faculty

Access and Continuity


The extended session will focus on Advanced Access and Continuity and will include:

  • Establishing and Maintaining Panels and Continuity

  • AA:  How to make it work, Part 1  

    • Balancing Demand and Supply

    • Reducing Backlog

  • AA:  How to make it work, Part 2

    • Reducing appointment types and times

    • Reducing demand for unnecessary visits

    • Contingency planning

    •  Optimizing the Care Team

  • Action Planning and Consult with Faculty:  Refining aims, measures and planning tests of change

The Patient as Common Denominator
Connie Davis, MA, ARNP; Cindy Hupke, BSN, MBA, MD; Betsy Stapleton, RN, FNP
This session will be an interactive small group discussion and brainstorming, with synthesis and report out expected.  It will help participants amalgamate the content of the seminar and will generate ideas for prioritization and plans for the future.  Each group will be encouraged to bring their discussion back to the driver of health and wellness in their communities...the patient.
Day 3:  Speeding Down the Transformation Highway
Continental Breakfast
Overview of the Day
The Pit Crew:  Care Coordination and Management
Connie Davis, MN, ARNP, Carolyn Shepherd, MD
Patients in our health care systems often receive fragmented care that is delivered across multiple providers and organizations. Care is not systematically coordinated, and, as a result, can be confusing for patients, families, and referral organizations and can result in suboptimal outcomes and satisfaction.  Care coordination helps ensure a patient’s needs and preferences for care are understood, and that those needs and preferences are shared between providers, patients, and families as a patient moves from one healthcare setting to another. This session will introduce a toolkit prepared by Group Health’s MacColl Institute for Healthcare Innovation, (supported by The Commonwealth Fund), in April 2011.  Teams will be coached in the four key concepts identified by the MacColl Institute to enable change, and pragmatic examples from faculty and peers will be shared in this interactive session.
After this session, participants will be able to:
  • Define care coordination and care management

  • Describe approaches to care coordination and care management

The Design Team:  Engaging Patients and Families in Redesign
Connie Davis, MN, ARNP, Carolyn Shepherd, MD, Dulcie Brown
In an effort to better satisfy consumer demands and expectations, patient-centered organizations are increasingly turning to the voice of patients and families to guide their efforts. There is not a better way to understand what patients want from their healthcare team that to ask, and then listen and respond to what they have to say.  Clearly, transformation of the organization to become a patient and family centered organization requires visionary leadership and a commitment to changing the organizational culture to view patients and families as equal members of the team with the right to participate in decisions affecting the planning, delivery, and evaluation of care.  The session will introduce the broad spectrum of patient and family engagement and provide pragmatic tips to recruit, orient, monitor and evaluate the patient and family engagement process.  In addition, the value and importance of identifying and partnering with effective community programs and using the patient and family experience to design care will be addressed. 
After this session, participants will be able to:
  • Describe the spectrum of patient and public engagement
  • Determine engagement approaches possible for their setting
  • Define coalitions
  • Describe key features for successful coalitions
The Dashboard:  Using Data for Meaningful Change
Carolyn Shepherd, MD
Organizations find that the “health” and use of its EMR data has direct and strong ties to the financial and operational health of the organization and patient outcomes. By using data for meaningful change, an organization can be poised to provide the best possible care to its patients and thrive as an organization during this rapidly changing and challenging time in healthcare.  When data is used effectively and meaningfully, the system will have accurate and complete information about a patient’s health, the ability to better coordinate the care given, a way to securely share information with patients and families, greater efficiency, and cost effectiveness.
After this session, participants will be able to:
  • Describe the differences in the use of data for improvement, accountability, and research
  • List evidence based medicine supports and clinical decision support tools that should be readily available
  • Identify useful attributes of a clinical information system and/or registry
  • Describe the importance and use of accurate and assessable data when building a culture of improvement within your organization
Making a Pit Stop:  Application for Medical Home Recognition
Carolyn Shepherd, MD
Patient centered medical home recognition is not a destination in itself, but instead could be seen as confirmatory sign on the pathway to organizational transformation.  This session will describe Clinica’ s 10 year transformative and ongoing journey and will describe how their improvement initiatives paid off when deciding to apply for PCMH recognition.   The session will be a blend of didactic and interactive activities, allowing all participants to benefit from the experience of others in the room.
After this session, participants will be able to:
  • Identify key elements to have prepared when applying for Patient Centered Medical Home certification
  • List at least 3 pragmatic ideas for the certification process
Closing Remarks and Next Steps
Cindy Hupke, BSN,MBA