Team-based Care Fuels Patient Self-management Success

Previsit Planning Means More Face Time With Patients

July 17, 2013 04:15 pm Sheri Porter Menomonie, Wis. –

In a busy family medicine practice, it often is difficult to get patients to engage in and contribute to their own health care, a concept popularly labeled patient self-management, but one family physician in Wisconsin found that changing some basic processes and empowering his nursing staff resulted in more patient-self management, better patient care and more face time with his patients.

FP Dave Eitrheim, M.D., gives Mary Knops his full attention and all the time she needs as he draws out the patient's health concerns during a relaxed office visit made possible by the implementation of clinic efficiencies.

Patient self-management, which can include team-based care, health coaching, motivational interviewing and patient goal setting, resonates with many family physicians, who routinely provide health care for millions of Americans who suffer from diabetes and other chronic diseases.

It also likely will be an integral component of future health care as the Patient Protection and Affordable Care Act is expected to create a surge of new patients in 2014. That increase likely will create a need for more efficient clinical processes to deal with the increased patient volume.

A Patient Self-Management Case Study

One physician who already is working to incorporate more patient self-management into his practice is Dave Eitrheim, M.D., who for 26 years has practiced family medicine at the Mayo Clinic Health System -- Red Cedar in Menomonie, Wis.

Story Highlights
  • A family physician in a large Wisconsin clinic spearheaded new clinic protocols in 2008 that stressed previsit planning and team-based care.
  • The role of nurses throughout the larger clinic was expanded to include new patient responsibilities.
  • The changes gave physicians more face time with patients and the entire clinical team opportunities to work on engaging patients in their health care.

AAFP News Now recently visited the Red Cedar Clinic to observe firsthand how the clinical team there engages patients and supports patient self-management. Eitrheim saw 23 patients that day -- a typical caseload -- but the pulse of the office flow felt measured and calm.

"Family medicine is a team sport. I couldn't feel relaxed seeing that many patients in a day -- and have patients feel like I listened to their concerns -- without the two nurses who work with me every day," said Eitrheim. He recalled a three-week period back in 2007 when his only registered nurse was absent for three weeks. "I was an hour behind and frazzled" the entire time, said Eitrheim.

That experience was the catalyst for change. In 2008, Eitrheim requested that a second nurse, an L.P.N., be added to his clinical team. The two-nurse team assumed responsibility for preventive care measures, including the scheduling of mammograms, Pap smears and immunizations. They counseled patients about tobacco use. "Those things are no longer on my radar. The nurses own that," said Eitrheim.

When the nurses added diabetic foot exams to their to-do list, the clinic's "miss rate" dwindled to just three diabetic patients out of 70, according to a report from the organization's quality assurance staff. "No way -- we never miss one," was the nurses' response to the report, and, as it turned out, all three misses could be traced back to slight glitches in the clinic's proven protocol.

Jill Hartung, R.N., spends a full hour conducting a Medicare annual wellness visit with patient Peggy Kothmam. The visit includes motivational interviewing and goal-setting and elicits information that will guide FP Dave Eitrheim, M.D., in his care decisions.

Eitrheim, who is president-elect of the Wisconsin AFP, told AAFP News Now that the clinic also instituted a patient previsit planning process that includes ordering each patient's lab work ahead of his or her appointment. "In the past, I'd order lab work, and then the results would come in 'who knows when,' and I'd send the patient a letter with the results. It wasn't very satisfactory," said Eitrheim, especially for patients with chronic conditions that require close monitoring.

"Patients like to talk about their lab work. Honestly, when they got a letter and didn't have the ability to ask a question or to clarify, it didn't sit quite right with them," said Eitrheim. For the past six years, however, he and other clinical staff members have used patient lab results as a starting point for conversations about healthy lifestyle changes.

Eitrheim said patients with diabetes are particularly easy to track. These patients have lab work drawn within three days of their scheduled visit, and Eitrheim uses their hemoglobin A1c lipid profile -- past and present -- as a motivator for change.

The previsit planning process also allows nurses to compile patient data, including a list of diagnoses and medications, so Eitrheim has all the necessary information at his fingertips when he greets each patient. "We sit down together and go through it all," he said. "I would never go back to the old way of doing things."

Eitrheim's successful plunge into practice transformation spread throughout the Red Cedar Clinic and inspired all of the 20-plus internal medicine and family medicine physicians employed there to follow his lead.

Changes that have smoothed operations throughout the larger clinic and resulted in more time for the physicians and enhanced patient care include establishment of

  • four care-coordination nurses who, among other things, now cover all previsit planning duties, including issuing reminders to patients to bring their patient self-management data (e.g., exercise and peak flow logs) to appointments;
  • an expanded nurse advice line that includes additional duties, such as handling medication refills, the clinic's message center and symptom-based calls;
  • a protocol that allows a registered nurse to conduct all Medicare annual wellness visits; and
  • a diabetes "hot list" that enables nurses to follow up with patients whose names are highlighted in red and are overdue for an office visit.

The clinic also makes use of a handy diabetes score card, a one-page template that holds a summary of the patient's labs and keeps tracks of the top five diabetes goals associated with management of diabetes -- namely, hemoglobin A1c, blood pressure, LDL cholesterol, tobacco use and aspirin use, when indicated.

Diabetes Educator Plays Role

In terms of working with patients on their care, "motivation has to come from within," according to Heidi Mercer, R.N., a certified diabetes educator at the Red Cedar Clinic. Mercer is trained in motivational interviewing and health coaching. Every patient newly diagnosed with diabetes has an opportunity to work with her.

Jackie Weber, L.P.N., will add vital signs to the cadre of information collected on Orval Gabriel during previsit planning so the primary care physician will have all the patient information he needs when he steps into the exam room.

"There are more than 1,400 patients diagnosed with diabetes in this clinic, and I see 350 a year," said Mercer. "Diabetes education is not a visit; it's a lifelong process. I work with patients (in conjunction with the rest of the clinical team) to help them discover and overcome their barriers to good choices."

A typical visit goes something like this: "I allow 90 minutes for a patient's first appointment. I do a thorough assessment; it's like peeling back layers on an onion," said Mercer. Each visit thereafter, Mercer spends about 10 minutes "peeling the onion" and another 15 minutes describing the metabolic chaos going on inside the patient's body. She devotes the final 20 minutes to goal-setting.

Patients set their own goals, with Mercer serving as their guide.

"I want every patient to succeed. If a patient agrees to set the oven timer and walk five minutes in the house, that's huge," said Mercer. "When the patient comes back happy and successful, I'll say, 'Let's try for 10 minutes.'"

Mercer shuns patient-education handouts, opting instead for human contact. "I do a lot of talking and looking in patients' eyes," she said. "I am making a difference in the lives of patients with diabetes because I give them the confidence and the knowledge to live healthier."

Mercer has a reputation around the clinic of success with the most difficult of patients, and her data back that up: Patients under her tutelage reach their goals anywhere from 70 percent to 100 percent of the time.

Hard Work Reaps Positive Results

"The main reason family physicians don't have time to do motivational interviewing and patient goal-setting is that they don't have efficient office practices," said Eitrheim, who admits that back in 2007, his work/life balance was out of whack.

"I love my work now because I get the patient information I need and have the time to spend with patients and develop relationships," he said. The team feels empowered, physician leadership is strong and outcomes are improving, he added.

The impact on patients also is positive. "Their wait time is much less, and patient satisfaction is through the roof. Patient engagement starts with having a trusting relationship with the physician and a good experience during the visit." Otherwise the patient isn't going to buy into anything, said Eitrheim.