2021-03-12 UCSF PSC Pop Health Outreach team

Notes

20210312 UCSF OPHAC Outreach morning huddle

Agenda
- Outreach team progress report
  - Madison
    - Sneha outreaching by herself a week ago, comfortable with well-care and diabetes workflows for QIP
    - Then moved her to next topic
  - Mauricio
    - Sneha shadowed Mauricio and Katrina
    - Cancer screening and depression
    - Followed calls on depression with Katrina
  - Dianne
    - Debriefed with Sneha after independent work – able to do workflow on her own, comfortable
  - Madison
    - Giving Sneha my phone number as call-back
    - If they’re not here, patient can call back – but then I’ve never spoken to the patient
    - Have Excel docs that we take notes, and take notes in a telephone encounter in patient’s chart
      - APeX won’t show same detail as Excel chart
  - Mauricio
    - Cancer and depression – have Cipher platform – so documentation
    - Sneha now has access to Cipher, could access dashboard, can share documentation across navigators for follow up, handoffs, continuity of care
  - Madison
    - Don’t use Cipher all the time – working towards that (e.g. for well care checkups) – especially for diabetes, rely on Excel
- JB understanding of progress, from student internship side
  - Reports from Sneha
  - Upcoming call with Gina and Michael
  - PSC plan for student internships
    - Andrea co-President of student group next year
- JB proposals for internship job description and career ladder
  - Job description
    - Workflows for QIP diabetes, pediatric well child patients, hypertension, cancer screening
      - Data scientist runs report on patient care gaps
      - Navigators look at report in Excel file (name, MRN, blood pressure, HBA1C lab, eye exam)
      - For each patient, go to chart, look at labs, look at upcoming appointments
      - For patients with observed care gaps, call patient to inform patient that they’re due for health maintenance exams
        
        Generalized outreach script in Box folder
      - Hypertension: some health coaching – do you have blood pressure cuffs; instructing patient to take blood pressure measurements to discuss with doctor
        
        Coaching script in Box folder
      - Schedule the patients
      - Document calls and actions (e.g. scheduling) on CipherHealth Screening tool (or Excel)
        
        To generate reports on QIP contracted outcomes
      - Document calls in patient record in APeX
        
        For clinical collaborators
      - Some patients have multiple conditions – handle them all in one call
      - Navigators also pend (prepare/draft) orders (e.g. for labs, referrals for an eye exam, mammogram) in patient record, that the doctor signs off on
    - Discussion
      - Mauricio – Sneha portrayed a good picture
      - Kristin – good summary of various programs
  - Career ladder for students
    - Early
      - Training – shadowing, observing via Zoom (semester 1)
      - [Side by side – case find and build final list of patients to call (semester 2) – for Outreach]
    - Medium
      - Supervised practice – being observed via Zoom (semester 3-4)
    - High
      - Independent practice within one clinical area (semester 4-5)
    - Mastery
      - Independent practice with multiple clinical areas (semester 5-6-7-8)
  - Career ladder discussion
    - Mauricio – early admin tasks – and yes, at highest level, knowledge of multiple conditions
      - Start with one condition – QIP – Well Check – simplest interaction
      - Later, be cross-trained in hypertension, more sophisticated areas, requiring health coaching etc
    - Madison
      - Like them shadowing students early on
      - Should get early access to APeX, practice on systems
      - Before they do actual scheduling, need lots of practice/facility with programs
    - Dianne
      - As students go up the ladder, start doing independent work
      - Will need training on motivational interviewing
      - JB: heading in direction to collaborate on training
      - Dianne – attended external workshops; had multiple in last few years on motivational interviewing; emotional intelligence
  - Scheduling
    - Second week of April – April 9th
    - Agenda
      - JB updates about overall agreements and direction with Pop Health
      - Kristin – update on integrating internship program into description of outreach program goals and navigator roles