Building Coordinated, Patient Centered Care Management Teams

Transcription

1 Building Coordinated, Patient Centered Care Management Teams Jim Barr, MD CMO/VP Physician Network Development Optimus Healthcare Partners ACO & VP of Medical Services Aveta Health Solutions MSO

2 Patient Centered Care Management Teams Keynote Agenda Optimus Healthcare Partners ACO Overview Clinical Transformation Structures Processes Care Management Teams Engagement Models Tools & Resources Summary & Questions

3 Optimus Healthcare Partners ACO Overview Summit, New Jersey 550 Physicians Independent Physician Offices 180 PCP s (120 FM/IM) Physician Governed Directed ACO Hospital Alignment/Support CMS MSSP ACO (30,000 members) Commercial ACO Arrangements

4 Clinical Transformation Why Change & WIIFM Team Based Office Workflows Patient Centered Medical Home Model Resource: Population Care Managers Population Based Care Proactively Identify & Manage Patient Care Opportunities Tools: Aveta Patient Registry and Patient Care Plans Care Coordination & Communication ACP PCMH Neighbor Model Tool: Optimus PCP Specialist Care Coordination Guide Tool: Aveta Health Information Exchange (HIE) Program: Optimus Patient Centered Care Transitions Program

5 Patient Centered Medical Home Joint Principles Personal Provider Practice Team Whole-person orientation Coordinated care - part 1

6 TODAY S CARE PCMH CARE My patients are those who make appointments to see me Our patients are those who are registered in our medical home Patient s reason for visit determines care Care is reactive to the patient s problem and visit time available Care varies by memory or skill of the doctor We systematically assess all our patients health needs to plan care Care is proactive to meet patient needs with or without visits Care is standardized according to evidence based guidelines Patients are responsible for coordinating their own care A prepared team of professionals coordinates all patients care Slide adapted from Daniel Duffy MD School of Community Medicine Tulsa Oklahoma

7 TODAY S CARE PCMH CARE I know I deliver high quality care because I m well trained Acute care is delivered in the next available appointment and walk ins It s up to the patient to tell us what happened to them Clinic operations center on meeting the doctor s needs We measure our quality and make rapid changes to improve it Acute care is delivered by open access and non visit contacts We track tests & consultations, and follow up after ED & hospital A multidisciplinary team works at the top of our licenses to serve patients 7 Slide adapted from Daniel Duffy MD School of Community Medicine Tulsa Oklahoma

8 Preparing Your Team for Performance Based Contracts

9 Practice Requirements Provider Champion Clinical Coordinator Potential Team Members On site Off site Communications Secure E Mail, Web Based Registry, HIE Webinars & Meetings Office Project Management Plan

10 Practice Readiness Assessment Optimus Practice Readiness Assessment Assessment of progress (enter score 0 3 in box)* Prioritization of Next Steps (from date of enrollment) Action Items and Comments date practice enrolled Sept 11 Nov 11 Jan 12 Jun 12 Q1 Q2 Q3 Q4 Y2 Y3 Teamwork, leadership & practice communication Practice physician champion named Practice re design team in place & meeting regularly Clinical Coordinator named and receiving Optimus training Team utilizes Optimus performance reports, implements CQI, shares best practices and demonstrates improvement Communication plan for re design team, all practice physicians and staff

11 Clinical Coordinators Utilize the Patient Registry and HIE Develop goal directed patient care plans Outreach to patients with gaps in care Coordinate ER, hospital and home care patients Communicate with office providers & staff Communicate with other clinical coordinators Coordinate office participation in ACO clinical programs

12 Team Based Office Workflows Morning Huddle Schedule Review and Visit Preparation Care Plan Review Pre visit Activities Automated orders Screenings and testing Visit Post visit Activities Barrier Analysis & Motivational Interviewing Patient Self Management (copy of Care Plans)

13 Care Management Teams Prioritize Based On: Potential Medical Cost Savings Validated Hard Savers Feasibility of Implementation & Timelines Ability to Measure & Validate Engagement Business Case Commitment & Participation Performance Management Framework Transparency

14 Patient Access Office Visit Enhanced Access for ACO members Reserved Appointments Open Access Scheduling Extension of Hours Extended Hours Evenings Weekends After hours coverage with other offices Urgent care options Communications

15 Care Coordination & Communication PCP Specialist Care Coordination Guide Consultation Requests Hospitalizations Co Management Referral Guidelines and Management ACO Patient Centered Care Transitions Program Emergency Room, Hospital, Sub Acute, Skilled Nursing Facility (SNF), Long Term Care, Home Care Case Managers, Navigators, Vendors

16 Emergency Room Processes Appropriate Utilization Education ER Notification Process Sharing of Patient Information Involving ACO Specialists ER Patient Follow Up Office processing of ER reports Clinical coordinator role Patient medical record documentation Patient care plan modification Coordinating and communicating next steps

17 Hospital Care Notification of Admission Protocol Appropriate utilization Alternative settings (observation beds/subacute) Case Managers & Utilization Managers Optimus ACO & Aveta Health Plan Hospital Prevention of Readmission Medication reconciliation Post hospital visit coordination Home care, support

18 Imagine?? Patient Access & Communication Office Workflows Planned visits More time with patients Access to Information Appropriate and Efficient Care Transitions Trusted Patient Relationships Activated and Engaged Patients High Quality Affordable Healthcare Physician and Staff Satisfaction

19 Summary & Questions Provide Clarity & Build Culture Provide Models, Tools & Resources Performance Management Framework Team Focus Thank You, Jim Barr, MD Optimus Healthcare Partners ACO Aveta Health Solutions