Dr. Thomas Spain, primary care physician and Director of Practice Transformation at the Midsouth PTN, and Kirkland Ahern-Jones, Director of Operations for the Midsouth PTN, take the opportunity to look back at the Best Practices podcast series as TCPi comes to a close.

The Best Practices podcast was inspired by a vision to create an active, living legacy of the work that has been done over the last years by 4,500 clinicians in over 100 practices across the midsouth. The podcast series aims to look more deeply at the work practices have done in moving through the phases of transformation as part of the seven aims of TCPI. The overarching project was to aid practices in preparing for APMs (alternative payment models), and this living legacy has been created with the aim of inspiring other practices to participate, succeed, and thrive in the APM space.

The Best Practices podcast series focuses on high impact change. We interviewed practice leaders as well as subject matter experts to outline some of the best quality improvement practices in the TCPI toolkit. The Best Practices podcast tells the best stories about the best work done by the best practices. We hope you will join us for the entire series on our YouTube channel.

Podcast Episode Resources

To learn more about the resources referenced in this episode, please see the following links:

MidSouthPTN: https://midsouthptn.com/

Daily Practice Huddles: https://tinyurl.com/dailypracticehuddles

Collaborative Care Model: https://tinyurl.com/collabrotivecaremodel

Behavioral Health Integration: https://tinyurl.com/bhiama

QI Toolkit: https://tinyurl.com/qitoolkit19

IHI LEAN Model: https://tinyurl.com/goinglean

PDSA Cycle: https://tinyurl.com/pdsa19

Steps Forward: www.stepsforward.com

CDC Medication Management: https://www.cdc.gov/medicationsafety/

3 Step Screening: https://tinyurl.com/3stepscreening19

What is Shared Decision Making: http://tinyurl.com/shareddecisionmaking19

Mayo Clinic Decision Making: https://shareddecisions.mayoclinic.org/

Patient Activation Measure: https://tinyurl.com/patientactivation19

AHRQ Website: https://tinyurl.com/ahrq19

Reducing ER Visits: https://tinyurl.com/ervisit19

High Value Care Coordination Toolkit: https://tinyurl.com/HVCC19

AMA Steps Forward: Forming a Patient and Family Advisory Council: https://tinyurl.com/AMAPFAC

Open Notes: https://www.opennotes.org/

Lane Stiles, Director of Patient Education for Vanderbilt University Medical Center, joined our Best Practices hosts to “SHARE the Knowledge” about shared decision making. Shared decision making is a patient engagement strategy that focuses on creating collaborative conversations between the patient and provider.

The current healthcare climate places patients in a reactive role, but shared decision making is an invitation to patients, offering them a reason to actively participate. When patients are involved in their healthcare and own their decisions, studies have shown that patients are more likely to follow a care plan, to take their medications as prescribed, to be satisfied with their care, and to accept outcomes, even adverse ones.

This approach to engage patients solves numerous downstream issues and allows providers to personalize and communicate risk. Shared decision making places the patient at the center of their healthcare team.

Shared decision making is a simple concept, one that makes sense and is a rational patient engagement strategy, but it requires practice for providers and teams to do it well.

Podcast Episode Resources

To learn more about the resources referenced in this episode, please see the following links:

CMS: https://www.cms.gov/

TCPI: https://tinyurl.com/tcpi19

MidSouthPTN: https://midsouthptn.com/

Vanderbilt University Medical Center: https://ww2.mc.vanderbilt.edu/

What is Shared Decision Making: http://tinyurl.com/shareddecisionmaking19

Mayo Clinic Decision Making: https://shareddecisions.mayoclinic.org/

High value healthcare is safe healthcare, and studies estimate upwards of 90% of patients seen in an outpatient setting have medication errors in their record. Dr. Amanda Mixon from Vanderbilt University Medical Center in Nashville, TN, joined our Best Practices hosts to discuss the quality improvement efforts and patient safety intervention methods of medication management.

It is important for practices to understand that every time an additional medication is prescribed, there is an inherent risk. Medication management should be patient-centered, and patient education plays a pivotal role. The patient should be educated on why he or she is taking the medication, on how the medication should be taken, and on when the practice should be notified if problems arise.

The three main steps of medication management in an inpatient setting can be translated to an ambulatory setting. The first critical step in the beginning of the process is obtaining a medication history for the patient. The next step is one of reconciliation: practices should take the medication history and compare it to what the provider wants to change. Finally, the provider needs to both document changes to the medication list in the medical record and communicate any changes to the family and caregiver.

The best data collected thus far in estimating the magnitude of medication errors and the downstream repercussions still underestimate the problem because it is underreported. Studies show that roughly two-thirds of patients being discharged from inpatient care to outpatient care are at risk for having medication errors.

Time and staffing present the biggest challenges in this transformation effort, but Health Information Exchanges, investing in an on-site pharmacist to monitor and intervene, and a concerted de-prescribing effort can play a critical role in medication management.

Podcast Episode Resources

To learn more about the resources referenced in this episode, please see the following links:

CMS: https://www.cms.gov/

TCPI: https://tinyurl.com/tcpi19

MidSouthPTN: https://midsouthptn.com/

CDC Medication Management: https://www.cdc.gov/medicationsafety/

3 Step Screening: https://tinyurl.com/3stepscreening19

Quality by Design: https://tinyurl.com/qualitybydesign19

The Best Practices podcast explores the exemplary work done by practices in the MidSouth Practice Transformation Network over the last three years. Throughout the episodes, the podcast explores quality improvement efforts, but what are these continuous process improvement methods? Kirkland Ahern-Jones, Director of Operations for the Midsouth PTN, interviews her cohost, Dr. Thomas Spain, primary care physician and Director of Practice Transformation at the Midsouth Practice Transformation Network, to explore the continuous process improvement methods and why they are needed.

The efforts of the MidSouth PTN were underpinned by the knowledge that to thrive in a value-based payment environment, practices needed to learn how to continually improve and how to use data to drive that improvement. There are a number of continuous process improvement methods, but the two most common in healthcare are Lean Process Improvement and the IHI Model for Improvement. Each method includes preparation practices need to make before they undertake improvement and before they begin making changes. Continuous process improvement methods are essential when striving to enact change, because these methods provide a feedback cycle that enables practices to learn from the changes being put in place and to allow what they have learned to influence the changes made in the future.

The IHI Model for Improvement is simple and universal. The Institute for Healthcare Improvement provides a wealth of resources online, and their Model for Improvement begins with two parts. The first part is a trio of questions that aid a practice in setting aims, establishing measures, and selecting changes. A practice’s aim should be quantifiable; it should be specific, measurable, attainable, relevant, and time-frame bound. How a practice will measure to know a change is an improvement is a step that is often left out, but it is pivotal to the use of data to drive improvement. The second part of the first step of the IHI Model for Improvement is the Plan-Do-Study-Act (PDSA) method for testing change.

For those interested in quality improvement, we invite you to explore the continuous process improvement methods. Dr. Spain’s best advice for those just beginning their healthcare improvement journey: Start small.

Podcast Episode Resources

To learn more about the resources referenced in this episode, please see the following links:

CMS: https://www.cms.gov/

TCPI: https://tinyurl.com/tcpi19

MidSouthPTN: https://midsouthptn.com/

IHI LEAN Model: https://tinyurl.com/goinglean

PDSA Cycle: https://tinyurl.com/pdsa19

QI Toolkit: https://tinyurl.com/qitoolkit19

How do you break down the barriers to better mental health in a pediatric setting? Dr. Julie Peek from Terrace Pediatrics in Nashville, TN, joined our Best Practices hosts for our latest podcast episode discussing behavioral health integration.

Terrace Pediatrics has been treating generations of patients since the 1960s, but only since joining TCPi has the practice worked toward enhancing care in a way that gives providers a broader picture of the influences on a young patient’s health. The practice began by incorporating post-partum and adolescent depression screenings, but the providers were left figuring out what to do with the results of those screenings. Working with TCPi offered Terrace Pediatrics the opportunity to partner with a local chapter of the Mental Health Co-Op to bring a mental health professional into the clinic.

Behavioral health integration, Dr. Peek advises, has to begin with a physician advocate, with clinical involvement and leadership, and with open lines of communication for a practice to successfully enhance their care in treating the whole patient.

Podcast Episode Resources

To learn more about the resources referenced in this episode, please see the following links:

CMS: https://www.cms.gov/

TCPI: https://tinyurl.com/tcpi19

MidSouthPTN: https://midsouthptn.com/

Terrace Pediatric Group: https://www.terracepediatricgroup.com/

MidSouthPTN YouTube Channel:

Siloam Health faced the hurdle of improving efficiency and effectiveness of the patient flow process. Claire Reagan, Nurse Manager at Siloam Health in Nashville, TN, joined Dr. Thomas Spain, primary care physician and Director of Practice Transformation at the Midsouth Practice Transformation Network, and Kirkland Ahern-Jones, Director of Operations for the Midsouth PTN, to discuss the effort the practice made to implement team huddles and the difference huddles made in the practice’s workflow and experience as part of their TCPI work.

By initiating a clinical team huddle, Siloam Health moved to the next level of team based care. Taking the time to establish the huddle habit and to encourage providers to collaborate about patient care, Siloam Health improved both the team and the patients’ experiences and further developed relationships between patients and the entire team.

Team huddles led to a 20% improvement in colon cancer screening over baseline, moving the practice performance above the national MIPS benchmark in just 18 months. The practice improved dramatically on mammogram screenings, showed a 15% over baseline in administration of Pneumovax to elderly and diabetic populations, and better incorporated behavioral health in patient care. With the implementation of daily huddles, Siloam Health is able to work as a more organized team to serve each patient’s unique needs.

Podcast Episode Resources

To learn more about the resources referenced in this episode, please see the following links:

CMS: https://www.cms.gov/

TCPI: https://tinyurl.com/tcpi19

MidSouthPTN: https://midsouthptn.com/

Siloam Health: https://siloamhealth.org/

Team/Daily Practice Huddles: https://tinyurl.com/dailypracticehuddles

MidSouthPTN YouTube Channel: