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1 L7: Journey to implementing Marianne Sumego, M.D. Director of Cleveland Clinic Internal Medicine / Pediatrics IHI International Summit March 16, 2015 Disclosures No financial disclosures No patents pending No affiliations But 1

2 Objectives session 1 Describe SMA model and benefits Share best practice in the development Work sheet guides Open forum for development 2

3 Objectives session 2 Present workflow Develop adding value in chronic disease Worksheet for planning and value Open forum for questions Show data Provide our tips Lessons learned Wrap up Objectives session 3 3

4 First, Who I am.. Lake erie Where I work 8 community hospitals 20 family health centers Florida Westin Canada Toronto Las Vegas, Lou Ruvo Center for Brain Health Abu Dhabi Willoughby Hills Family Health Center 4

5 Mission The journey of medicine Traditional Office based Express locations 5

6 Current Value-Based Drivers for SMAs Population management Improve chronic disease outcomes Promote wellness Facilitate access Better utilize decreasing PCP resources Increase patient/ provider satisfaction Improve productivity Reduce cost per unit of service Payment for Quality The mission Diabetes: blood pressure Minimal change. <130/80:CDC data 6

7 Why no change? One theory.. Hurdles in Care Cost Coverage of services Logistical: geographic, transportation Increased chronic disease prevalence Access to next available appointment 2 7

8 Patient barriers to care What do our patients retain?? 1. Studies: percent of the medical information patients receive is forgotten 2. Approx. 50 % of the information retained is incorrect. References 1. Kessels RP. Patients' memory for medical information. J R Soc Med. May 2003;96(5): Anderson JL, Dodman S, Kopelman M, Fleming A. Patient information recall in a rheumatology clinic. Rheumatology. 1979;18(1): And competing priorities. Access vs. medical home Quality vs. pay 4 performance Provider shortages vs. training Complexity of healthcare vs. less time Work smarter vs. less resources EMR vs. cost of change Transforming care!!!!!! 8

9 And If we do nothing. Ideal care model would address challenges : Permits more time Provides resources and expertise Facilitates focus on self-management Leverages Peer Interaction Address barriers (access, complexity) Promotes Education 9

10 What if patients drove the care model?? SMA program overview Cleveland Clinic Individual SMA s Enterprise wide initiative began Nov.2010 Goals: Standardization of tools, process Organization of a Program Team (3) Umbrella for development of all SMA s 10

11 SMA Program Cleveland Clinic 2014 YTD Active Appointments 77 Providers 63 Locations 20 11

12 What is a Shared Medical Appointment (SMA)? 90 minute appointment patients seen together with a similar condition or chronic disease - Combines the traditional one-on-one physician visit with participation in shared discussion The Theory to SMA s Education Matters.. Managing environmental triggers Objective patient and provider measures of successful disease control Impact on compliance (device, medication) Patient involvement in disease management How information is delivered 12

13 Determine SMA Format 2 Kinds of SMAs: Annual Wellness Physical Chronic Disease Follow-Up SMA Categories(non-inclusive) Pre-Diabetes care Asthma Menopause Wellness Back Pain and pregnancy Adolescent weight Medical Weight Loss Macular degeneration Diabetes Primary and Endocrinology Bariatric: Post-surgical Osteoporosis Sleep Medicine (CPAP) Menopause CHF Discharge Weight Management: Primary care Diabetic foot care Shared Nutrition Stroke Heel pain Psychiatry : Mood Disorders 13

14 SMA Benefits Provider Improved access Leverage resources Maximize scope of practice Workflow efficiency Remove redundancy Satisfaction Quality Visits Patient Prompt Access to Care Inc. physician time Access to additional learning resources Learning enhanced through repetition Satisfaction Quality of care Who Benefits? Chronic Disease Patients needing routine follow-up care, i.e. chronic conditions: diabetes, asthma Conditions where education is critical Patients who desire additional time with their physician or healthcare professional 14

15 Who is here??? Group introductions Hospital vs. private practice Primary care vs. specialist Have an SMA concept or experience Concepts: Where To Start??? 15

16 Why Consider??? Opportunity. Decrease Repetition Maximize scope of staff Add service (i.e. nutrition, CDE) High Quality Improve access Additional education opportunities Staff and provider satisfaction Cleveland MetroParks 16

17 Best practice for SMA development Phases Discovery Development Operations Implementation Measure and Feedback 17

18 Getting started Component: Provider Large Volume Long wait time/back-log Interest in a concept Desire to add Say the same thing everyday Love to teach Engaged provider Treating our Patients The good physician treats the disease, the great physician treats the patient who has the disease. Sir William Osler 18

19 Component: concept What conditions? SMA goals; Access? Ease of scheduling High Volume/patient demand Resources/strengths (extenders, adjunct staff) Then select a condition Condition: Add details Involve engaged provider Areas of interest Ease of Scheduling Current resources Patient benefit Impact on quality of care? 19

20 Component : team Know team strengths Identify resources Engage representation: clinical, clerical, facilitator, provider Add Value!!!!! Can do with no additional staffing!!!! Optional: scribe Define team SMA goals i.e. Metabolic syndrome Chronic Disease : improved management, lower HgA1C Target: all patients with abnormal glucose Value: patient education Tools : (use of food charts, adding PT) Available time: evenings 20

21 Component: patient Current scheduling process Patient identification/triage New vs. established Determine patient exclusions (minimal) Ability to recruit Define patient goals i.e. Diabetes Exposures toresource expertise in DM; Nutrition Complimenting primary care OV Increase self-management Goal: increase use of additional resources for a more focused DM visit 21

22 SMA: Men s Minority Health M Worksheets Complete Regroup to share Open forum: Answer questions 22

23 Continuing our Concept: Operations What does your team look like? Cleveland Browns Stadium and football team 23

24 Best practice for SMA development Phases Discovery Development Operations Implementation Measure and Feedback Operations: Building blocks Identify resources needed Workflow logistics Team Roles/responsibility Adding value 24

25 Building block: resources Staffing Billing Provider Physician, APN, PA, etc Facilitator RN, Nutritionist, etc Other Clinical MA Clerical Operational Scheduling IT SMA Room: Computer Comfortable chairs Access to exam rooms Display Educational Information A view from on the ground 25

26 Building block: work flow 9-12 patients check in with vitals 10 minutes early Facilitator reviews HIPAA and notes each patients questions / concerns Physician / primary provider addresses each patient individually Documentation during visit Private exams 5-10 minutes Facilitator : wrap up Facilitator Provider SMA Set-up 26

27 Building block: team Team Members: Who? Clerical: Scheduler Clinical Intake: medical assistant PrimaryMedicalProvider:MD,DO,NP,PA Facilitator: NP, RN, PA, Nutritionist, Social Worker Administration: Coordination and Support 27

28 Clerical: Scheduler Identify patients Scheduling Verbiage, answer questions Encourage/reassure Need: Training, additional support Clinical: MA, LPN Name tags (first name) Chart review/preparation Room setup Vitals/check in Data entry/ front load/questionnaires Need: education, training, peers 28

29 Facilitator (NP, RN, PA, Nutritionist, Social Worker) Chart and room prep Privacy review HPI gathering Shared documentation Add expertise/education Manages time Wraps up Facilitation: Adding Value The doctor of the future will give no medicines, but will interest his patients in the care of the human frame, in diet, and in the causes and prevention of disease. ~Thomas Edison 29

30 Sample Privacy Statement 30

31 Provider (Physician, APN, PA, midwife) Conducts visit Documents of exam Assessment Develop care plan Billing/close chart CHAMPION!!! Exam 31

32 Leverage Resources Illustration Per 2 Hour Time Block (Minutes) Staffing 1:1 SMA Difference APN/Physician Medical Asst. (2) Facilitator/RN PSR (2) Staff Availability gained: 150 minutes Summary: SMA team Handout for referencing 32

33 Building blocks Identify resources needed Workflow logistics Team Roles/responsibility Build value Building block: Add Value Expertise (medications, nutrition ) Understanding of disease Education (comprehensive) Provide self management tools Group dynamic creating peer support Guide the interactions (positive) Support Chronic Disease Management 33

34 Tools: Value IT (pre-questions, documenting) Education materials Materials (Data board, 2 nd computer, printer) Materials: flip charts, name tags, privacy form Administration support: critical Worksheets Complete Focus on team and goals Regroup to share Answer questions 34

35 Home stretch Metrics and tips Best practice for SMA development Phases Discovery Development Operations Implementation Measure and Feedback 35

36 Great Lakes Science Center Does it work? SMA metrics Access to care change Census trends Satisfaction Chronic disease transformation Quality impact Sustainability 36

37 Quality is not an act, it is a habit Aristotle Metric: Quality Diabetes: Average HbA1c SMA +/ Non SMA +/ Linear (SMA +/- 1.47) Linear (Non SMA +/- 2.17) Data not for reuse: preliminary 37

38 Patient Satisfaction Press Ganey Ability to schedule SMA Satisfaction with primary provider Did you feel additional benefit from the SMA Visit? Would you recommend an SMA to other patients? Will you participate in another SMA? SMA Non SMA

39 Internal Patient Satisfaction Total # Surveys Returned : 44 Questions Average Rating # of Responses on a Scale of Strongly Disagree 2- Disagree 3-Neutral 4- Agree Scheduling the Shared Medical Appointment was easy I gain valuable info from the other patients & their questions at the SMA. 5-Strongly Agree I feel there is adequate time for my questions at the SMA I gain a sense of group support from the SMA I feel my patient follow-up needs are being met at the SMA I would participate in the SMA again I would recommend the SMA to other patients OVERALL AVERAGE Weight Mgmt.: Comments: Enjoy Hearing others' stories I feel it helps with encouragement I find it very helpful Love listening to everyone Love the "sharing" environment Not comfortable with weights posted Really Enjoy hearing from others Thanks very much for the opportunity. Great help. Would love to get more information and linkages between food and health. (impacts and consequences) Verbatim Is always informative my son really has enjoyed meeting the other kids and it is great to compare experiences Very valuable - teenage girls feel comfortable that they are not alone I love it. I enjoy it much more than regular appts 39

40 Pediatric Diabetes: TIPS AND WRAP UP 40

41 Change takes work Technical Engaging all staff Training/education Designing your quality metrics Implementation curve Competing priorities (Our job!!!!) Operational Scheduling Leveraging staff Patient recruitment Develop work flow Exclusions It is new!! Chihuly in the Garden Traditional and New can Intersect 41

42 Tips The care is the same There are ways to keep the group moving Difficult patients are few Motivated patients are more Have an SMA cart. (equipment, nametags) Education is the benefit, not the basis Be flexible Lessons Learned Target high volume conditions Provide ongoing feedback Identify common points: education Scheduling is critical Set quality, chronic disease goals Facilitator: add value Pilot and engage staff Work efficiently, Add value, Have fun and adjust!!!! 42

43 Remember: Overcoming Barriers? The ideal care model Permits more time Includes resources and expertise Facilitates focus on lifestyle Leverages Peer Interaction Address barriers (physician and patient) Promotes Education 43

44 Top 10 Reasons to conduct an SMA 10) Efficient documentation 9) Added resources for our patients 8) Patients want them 7) Added time with our patients 6) Opportunity to add quality to our care 5) Variety for our care teams 4) Customizable, every SMA is unique 3) Patients centered 2) Improved access 1) They are fun!!!!! "The way a team plays as a whole determines its success. You may have the greatest bunch of individual stars in the world, but if they don't play together, the club won't be worth a dime." - Babe Ruth 44

45 Jennifer Muehle: Program Coordina Anne Maggiore: Program Manage Annette Zeldin: Clinical Resource Expert 45

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