|Care Management |
The Importance of Huddles In Primary Care (taken from the Center of Excellence in Primary Care)
Huddles are short, daily meetings in which a teamlet (a Primary Care Provider and a Medical Assistant or other support staff) reviews their patient list for the day. They usually last no more than 10 minutes. Huddles enable a team to anticipate care needs and special situations, so that members of the care team can support each other through the day.
In addition to care team huddles, all-staff huddles are used at some clinics to alert everyone to staffing issues, upcoming events, or important policy updates. They are usually no more than 5 minutes/day. Sometimes, all staff huddles are followed by care team huddles.
There is not one right way to conduct a healthy huddle. Huddles can range from a few minutes to twenty minutes. They may be held daily or at the beginning of a clinic session, and the agenda varies depending on the team needs. The goal is for a huddle to be an effective and efficient tool for communicating about patients and the flow of the clinic session.
The most effective huddles involve some preparation in advance. For example, in some clinics a medical assistant “scrubs the charts” or does pre-visit prep work in advance, identifying preventative care gaps, chronic disease management needs, screening alerts, or patients with recent hospitalizations. The person who does the most visit preparation will often lead the huddle as they know what is ahead of the teamlet for the clinic session or day.
Huddles often result in great improvements for relatively small time investment. Clinics often report that staff are more likely to show up on time and communication is quickly improved.
For additional tools to implement huddles in your practice. Please visit https://cepc.ucsf.edu/healthy-huddles#:~:text=Huddles%20enable%20a%20team%20to,events%2C%20or%20important%20policy%20updates.
Erica Ross, Clinical Services Manager
|Patient Centered Medical Home |
Welcome to the Blue Cross Blue Shield of Michigan Patient Centered Medical Home (BCBSM PCMH) monthly newsletter update! Each month we will bring together all relevant PCMH news and updates for our participating provider community. This month we will discuss the requirements for new capabilities 2.29 and 3.23.
2.29 Registry is being used to manage all patients that are identified as taking one of these 5 oral anticoagulants (warfarin, apixaban, dabigatran, edoxaban, rivaroxaban) for such conditions as atrial fibrillation, venous thrombosis and after a myocardial infarction
PCP and Specialist Guidelines:
a. Registry may be paper or electronic
b. Practices using anticoagulation clinics are excluded from this capability
c. Collection information must include the following 3 components:
i. Name of anticoagulation
ii. Date and result of last serum creatinine – Direct Oral Anticoagulant (DOAC) patients
iii. Concurrent antiplatelet use
d. Other optional collection components:
i. Indication for anticoagulation
ii. Start date of anticoagulant
iii. Estimated anticoagulation stop date
▪ To identify patients that should be taken off anticoagulant
iv. International Normalized Ratio (INR) target range (warfarin only)
v. Dates and results of INRs (warfarin only)
vi. Dates of emergency department (ED) visits for bleeding
vii. Dates of ED visits for ischemic stroke (atrial fibrillation pts) or recurrent venous
thromboembolism (VTE) for VTE patients
viii. Date of last clinic visit assessing anticoagulation (adverse events, need for continued
anticoagulation, dose, etc.)
3.23 Performance reports are generated for the population of patients taking one of these 5 oral anticoagulants (warfarin, apixaban, dabigatran, edoxaban, rivaroxaban)
PCP and Specialist Guidelines:
a. Required anticoagulants metrics:
i. % of patients on DOACs with last serum creatinine test > 1 year ago
ii. % of patients on combination anticoagulant-antiplatelet therapy without history of heart valve replacement, recent myocardial infarction, CABG, or PCI (within past year), or other clear indication for combination therapy
b. Optional anticoagulants metrics:
i. % of patients in which <50% of International Normalized Ratio (INR) were in-range over the past 6 months
ii. % patients with 2 or more ED visits for bleeds in the past 6 months
iii. % of patients with 1 or more ischemic strokes (atrial fibrillation patients) or recurrent
venous thromboembolism (VTE) for VTE patients within the past year
iv. % of patients in which last clinic visit assessing anticoagulation was > 6 months ago
Kathryn Correll-Rice, Manager of Quality Improvement Strategy