Transformation of Primary Care

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1 Transformation of Primary Care Shane H. Peng MD VP/Senior Medical Director Sentara Medical Group June 8, /31/08 1

2 Sentara Healthcare Mission We improve health every day. Values People, Quality, Patient Safety, Service, Integrity Vision Be the healthcare choice of the communities we serve. 2

3 Sentara Healthcare 123-year not-for-profit mission 9 hospitals; 2,173 beds 3,000 physicians on staff 10 long term care/assisted living centers Extended stay hospital 520-provider Sentara Medical Group 432,600-member health plan Sentara College of Health Sciences Approximately 20,000 employees Virginia North Carolina 3

4 This image cannot currently be displayed. Integrated Health System Health Insurance End-of-life Care Prevention & Early Detection Long-term Care Family & Community Services Continuum of Care Primary & Specialty Care Home Care Pharmacies Mental Health Care Emergency Care Medical Transport Hospital Care Rehabilitation 4

5 Presentation Outline Review Goals Review Guiding Principles Approach to Change and Practice Redesign Current State of the Project Future State of the Project Discussion 8/31/08 5

6 Goals of Transformation of Care QUALITY CARE DELIVERY Processes & practice Optimized Patient Experience ALIGNMENT & ACCOUNTABILITY Incentives & expectations COST CUSTOMER SERVICE KNOWLEDGE MANAGEMENT Informatics & decisions 8/31/08 6

7 Guiding Principles Patient Centered Standardization Working to the Highest Level of Licensure Data Driven 8/31/08 7

8 Key Processes Scheduling Between Visit Check-In Post-Visit Pre-Visit Existing Process Visit Future Process 8/31/08 8

9 Pilot Structure Five Pilot Locations Project Team with Executive Sponsors Governing Physician Body Physician Clinical Protocol Committee Physician Leads and Clinical Chiefs Operations Committee Key Operations Leads IT Committee Key IT Leads 8/31/08 9

10 July 1, 2010 January 1, 2011 First Colonial Kempsville Providence Road Chimney Hill Independence Jason Alper, DO Robert Bademian, MD Norman Gonzalez, MD Robert Callahan, MD Shirly Chai, MD Steven Choi, MD Dennis Hufford, MD Michael Charles, MD Louis Croteau, MD Robert Dowdy, MD Anthony Hardt, MD Ted Kubicki, MD Daniel Dickinson, MD Beaumont Hodget, MD Dana Keys-Frezzell, MD Ravi Kahatapitiya, MD Charlene Britt, MD Nicola Davies, MD Francis Javier, MD Benita Jones, MD Eric Lipton, MD Lisa Jefferson, DO Katherine Law, MD Meredith Rose, MD Nancy Robbins, NP Joanna Roberts, MD Karen Sullivan, MD Bradford Tisdale, MD Amanda Mitchell, NP Paul Wenzel, MD David Woods, MD Wave 1 Leilanie Tuanquin- Gonzalez, MD Wave 2 8/31/08 10

11 Scheduling Visit Project Highlights Same Day Appointment Increase Same Day Appointment Scheduling through Patient Portal MyChart (Patient Portal) Over 54,000 Patient and 30% of Practices have Adoption Rates Greater Than 20% Alternative Visits Group Visits Between Visit evisits (July 1, 2011) Hospital and ED Follow-Up Overall NCQA PCMH Recognitions Level 3 8/31/08 11 Integrated Practice Meetings with Optima Health

12 Standardization Across All of SMG Spread of Best Practices/NCQA Across SMG Early Adopters 3 Additional Pilot Sites Jan May 2011 Cutting Edge 2 Pilot Sites Jan 2011 July

13 Why? Pre-Visit Planning Organize Patients Needs and Concerns Frame the Visit and Set Expectations Proactive Rather than Reactive Care Improve Referral Process Integrate Preventative Care with Acute Care Get the Team Involved!!!!! 8/31/08 13

14 Coordinating Quality and Care Disease Registries Diabetes (NCQA) Heart/Stroke (NCQA) Heart Failure Asthma (Fall 2011) Preventative Care Adult Wellness Bundle Pediatric Wellness Bundle 8/31/08 14

15 Pre-Visit Planning Highlights Check-In Pre-Visit Planning Document Preparation Demographic Insurance Patient Portal Activation Notices Medication List Staff Responsibility Patient Care Representatives (Administrative) Patient Commitment Letter Pilot Small Targeted Diabetic Populations 8/31/08 15

16 Pre-Visit Planning Highlights Care Team Huddles 5-7 Minutes Participants Provider Clinical Staff Administrative Staff Review Admission/Discharge/Transfer List Review Clinical Schedule Discuss Patient Needs 8/31/08 16

17 Pre-Visit Planning Highlights After identifying the patient as a diabetic, the snapshot view on the clinical schedule to review Health Maintenance. All indicators that are overdue are highlighted on the clinical schedule. These tests/screenings will then be ordered and pended during the rooming process 8/31/08 17

18 Clinical Schedule Properties The Clinical Schedule can be manipulated to show HgbA1c and LDL columns which will assist with identifying Diabetic patients. (Prep Orders is blank for notes). 1/10/2011

19 Pre-Visit Planning Review the Disease Registries/Proactive care Preload Outstanding Tests, Referrals, Scheduling, etc. Nurse Chart Review Optimize Patient Wait Time Medication Lists Depression Screenings Maximize Provider Time Improve Patient Satisfaction 8/31/08 19

20 Post-Visit Planning After Visit Summary (AVS) Every Patient Receives an AVS Also Available on the Patient Portal AVS Highlights Updated Medication List Next Steps/Follow-Up Upcoming Appointments Health Maintenance Reminders 8/31/08 20

21 After Visit Summary 8/31/08 21

22 After Visit Summary 8/31/08 22

23 Post-Visit Planning MyHealth Champions 2 Embedded Care Coordinators Focusing on Heart Failure and Diabetes 8/31/08 23

24 Post Visit Planning In Process Identify Evidence Based Protocols Patient Schedules through MyChart or Automated Phone System Generate Patient List System/Pract ice Revenue for Current Model Enhanced Quality and Centralization for Future Model Patient Contact Tracked and Repeated, If necessary Contact Patients via Preferred Means 8/31/08 24

25 8/31/08 25

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