Davis Medical Center Population Health Preparing for the Future of Medicine

Transcription

1 Creating Clinically Integrated Health System-Based Medical Groups Collaborative Case Study Davis Medical Center Population Health Preparing for the Future of Medicine

2 Creating Clinically Integrated Health System-Based Medical Groups Collaborative Case Study Davis Medical Center Population Health Preparing for the Future of Medicine Organizational Profile Davis Medical Center (DMC) is a comprehensive, not-for-profit, integrated, rural healthcare delivery system serving a population of 85,000 in five primary counties. Davis Health System (DHS) formed in It is comprised of Davis Medical Center and Broaddus Hospital. DHS constructed a physician clinic in neighboring Upshur County, WV, in Buckhannon Medical Care also provides specialty care in the areas of podiatry, pediatrics, nephrology, and gastroenterology. In 2000, DHS opened a Cancer Care Center on its campus in Elkins bringing medical and radiation oncology services to a regional population. In 2014 Davis Memorial Hospital changed its name to Davis Medical Center with the construction of a 75,000-square-foot primary care and specialty physician office building. The center also provides outpatient radiology and lab services and pre-admission offices. We operate a 90-bed community hospital, a critical access hospital, and a number of health services including urgent care clinics, retail pharmacies, long-term care, year-round emergency services, cancer care, endoscopy center, home health, diagnostics, family practice and specialty clinics, sleep services, rehabilitation and therapy, and more recently have partnered with West Virginia University Hospitals and have opened a Heart and Vascular Institute on our campus. We employ more than 800 people and an affiliated medical staff of 70. More than half of these physicians belong to our multispecialty group practice, which represents family practice, pediatrics, obstetrics and gynecology, surgery, urology, oncology, podiatry, hospitalists, otolaryngology, orthopedics, anesthesiology, emergency medicine, psychology, and pain management. We currently serve approximately 88,000 patients, many of whom are elderly, live in rural areas, and have low incomes. We also serve a population with high rates of the problems that cause chronic disease, including smoking, obesity, and excessive drinking. Executive Summary As an organization in the past year, we instituted many initiatives in order to improve our quality of care. We began by instituting a monthly population health meeting where physicians are able to come to the table and discuss standards of care. From that meeting, we have developed a handbook for primary care physicians, entitled Standards of Excellence in Primary Care, to which we add material on a monthly basis. We also established the role of chief medical officer to work hand-in-hand with the administration in a triad-type model to help more closely align the concerns of the medical staff with those of operations and financial decision makers. Any changes in the operations of the clinic are now made with the input of all three members of the triad. We also hired a nurse navigator, a health coach, and an annual wellness nurse to assist with the medical and social needs of the Medicare population. Additionally, we have instituted team nursing for our primary care physicians in an effort to streamline the care of patients and to give them a touchstone person whom they can contact if needed. We have begun transitional care not only for Medicare patients, but for all patients at risk for readmission. We also have begun chronic care management and have experienced some real results, including a patient whose hemoglobin A1c went from 11 to 6 with the help of the health coach. We have instituted the use of 2

3 huddle boards as a means of communicating successes and failures in real time. As a system, we have begun to explore a PHO model for streamlining care within risk-based insurance models, and have begun discussions with local insurance companies to institute risk-based contracts. Finally, we have begun discussions about incentive-based contracting for providers. We have gotten some good ideas about this from participating in the collaborative. Program Goals and Measures of Success Our goal for this fellowship was to define what success looks like for a high-performance health system and a high-performance medical group. Upon beginning the fellowship, we had just become part of a rural ACO and needed both the guidance and tools for developing a clinically integrated health system-based medical approach which would be the foundation of successful ACO participation and the transition to other future healthcare change. We were seeking new approaches to practice management, including group performance, care coordination, and incentives designed to engage physicians. We were hoping to discover innovative ideas for operational success factors such as clinical quality measures, resource utilization, and practice improvement initiatives. Our goals are aligned with our True North goals of quality/safety, employee engagement, patient experience, and sustainability. Our move toward population health aligns completely with these goals. We are striving to increase quality and safety by allowing our staff to now work to the highest level of their licenses. Our patients feel that they are being better cared for because they have a person besides the physician to touch base with. Examples such as this improve safety because the nurse helps the provider to find any discrepancies in studies and charts. Employee engagement has improved with the population health meetings. Providers have a seat at the table when clinical decisions are being made for the organization. This is also empowering to the providers and improves satisfaction. Additionally, the providers have been encouraged to join the huddle boards so as to be actively engaged in the process changes. Despite patient satisfaction survey rates being quite low, we are hoping that the patient experience has improved, though we do not have data to support this. Finally, we hope that by improving and expanding our population health program, we will be able to offer more services to more people and to keep our communities healthier. This should allow us to be sustainable over the next several years. We were able to measure the amount of annual wellness visits (AWVs) being completed and the subsequent generated income. We are hoping to be able to measure patient satisfaction over the next couple of years. Otherwise, success with this particular project will have been defined not by metrics, but by monthly meetings to discuss how the changes are working and what needs to improve. Intervention Background: Our action plan developed originally in conjunction with becoming part of a rural ACO. DMC s primary goal at the beginning was to increase the number of AWVs that were being done and to get the providers excited about doing it. This was the primary focus of the first couple of population health meetings with providers. Clinical Standards and Algorithms: We created a handbook, Standards of Excellence in Primary Care, which is an ongoing standard that has been distributed to all of the providers in primary care in our network. In it are the standards of care for common medical problems based on evidence throughout the literature. As of the time of this case study, we have sections on prevention over age 65, diabetes, hypertension, atherosclerotic heart disease, systolic congestive heart failure, concussion, dementia, and anticoagulation. 3

4 We originally started by trying to work in the AWV during 15-minute follow-up visits, but found that this was not enough time to do a thorough job with cognitive exams, depression, and end-of-life care. While it was possible to do a cursory discussion and get the pay for it, such action didn t feel like it fit with trying to improve quality, safety, and patient experience. This approach was decreasing provider and patient satisfaction, so a new approach had to be generated. A marketing blitz was taking place during this time as well. We took out ads, sent out postcards, and discussed this with our patients to make them aware that this was very important. We also hired a nurse navigator when we originally started this process, someone who could scour the schedules and look for opportunities for AWVs. Every day, she presented providers with a list of AWVs that needed to be done. Eventually, she also was able to fill out some of the forms for the AWV and take some of the burden off the provider. Next, we hired a health coach whose primary role is to help coordinate care for higher risk patients. She works with the ED and the inpatient discharge planners to set up transitional care, facilitate home health, and follow up ED visits. She also works to get these patients in with their providers in a timely manner in order to decrease readmits and overuse of the ED. This has been helping with our sustainability. The third step was to start retraining nurses in the concept of team nursing. With each of these initiatives, we began with the CMO to work out process errors, which would then rollout to providers in a stepwise fashion. Fourth, we hired another health coach for one of our outreach clinics. She is also working with the ED and inpatient, providing follow-up to an area that generally does not have much in the way of medical care. The people in this area generally have to drive 45 minutes to see a provider. She is acting as a liaison between provider and patient to decrease the amount that the patient has to travel for care. Fifth, we hired a respiratory navigator who is aiding in identifying patients in need of sleep studies and PFTs, serving as a facilitator to get these tests ordered and approved. Finally, we hired an annual wellness nurse to aid in making AWVs as thorough as possible. During this entire year, we continued with the population health meeting and instituted the huddle boards in order to keep interest and engagement piqued. In regard to financing and payment, we added one FTE and reassigned two LPNs to health coach roles. Otherwise, financing was minimal. To achieve buy-in, we began with a general education on population health and then followed up with education on the annual wellness visit. Buy-in took some time, and it is something that we are still working on and struggling with. The financial incentive associated with the AWV helped the providers to buy in. We have really pushed the burning platform of payment reform and loss of income if these metrics are not met. We also had to educate the health coaches, navigator, and nursing staff in AWVs and in team nursing. Regarding how our EHR and registry were used to facilitate the care process, this is an area that needs much more work. Luckily, the AWV is built into the EHR, so that makes it much easier to document. Unfortunately, our ability to mine data in real time is non-existent at the time. This has led to the creation of a CMIO position to work as a clinician with IT. It is the CMIO s goal to utilize the multiple systems that we have available to make the data as accurate as possible. We do have TCM and CCM templates built into the system, and this has improved documentation in these areas. Unfortunately, these templates were not installed until mid-year. Although we were doing the work, we were unable to bill for it in the first and second quarters. 4

5 Measurement As mentioned, we sent out postcards and flyers to inform patients of the AWV. As providers, we also have the conversation with the patients when appropriate. When more education is needed, the patient is referred to either the health coach or the respiratory navigator to discuss disease management and correct utilization of meds. They also discuss barriers to health with the patients and help to educate them on ways to get around those barriers. YTD Wellness Visits (January 2016 December 2016) 1018 Wellness Visits Completed 140 In 2016 to date we have completed wellness visits on 62.5% of our known Medicare population G0402 G0438 G Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Outcomes and Results Following is an example of some the improvements made by individual patients: 1. T.C. hemoglobin A1C (A1c) from 6.4 mg/dl to 6.2 mg/dl 2. M.S. A1C from 8.6 mg/dl to 8.2 mg/dl 3. D.M. A1C from 10.8 mg/dl to 8.5 mg/dl 4. V.S. A1C from 13.6 mg/dl to 11.5 mg/dl 5. R.P. A1C from 9.1 mg/dl to 8.3 mg/dl 6. W.E. A1C from 10.4 mg/dl to 8.0 mg/dl 7. C.T. A1C from 14.9 mg/dl to 6.9 mg/dl 8. P.S. A1C from 13.9 mg/dl to 11.5 mg/dl Our readmission rate has significantly decreased. In 2016, we had no Medicare penalty for readmissions. Patient satisfaction rates have gone up since these measures were instituted, resulting in some truly amazing success stories. As you can see from the charts below, we have done very well compared to other organizations in our ACO. Our overall score falls just below the leaders, and we will see that number come up as our transitional care and chronic care management get into full swing. 5

6 Due to increased screenings with low dose CT lung screenings, we have found two lesions that were suspicious in otherwise asymptomatic patients. We also have found an operable abdominal aortic aneurysm in an asymptomatic patient. The potential devastation for these families if these processes had not had early intervention cannot go unrecognized. In rural West Virginia, getting people out to the doctor is generally difficult, whether it be due to financial, weather, or simply cultural reasons. The fact that this project has allowed us to increase our attributable lives, especially compared to other rural hospitals in our ACO, is testament to the kind of quality care that a population health approach can accomplish. Many of these patients would not have seen a doctor had they not come in for their free Medicare AWV. Despite having a relatively more ill population based on our risk-adjusted scores, we also managed to have a lower cost of care than many others in our organization. We are now one of the top performers in our ACO on all metrics (the minimum to get a bonus this year was three). Unfortunately, the ACO as a whole did not make the bonus. See the most recent information from the ACO below: Quarterly Dashboard Category Metric Broaddus Davis and FTMC and Grant Jersey Knox Reynolds SJMH Van Wert Total Valley Bellevue Shore Leading Indicators Care Coordination Key Billing Indicators Outcomes Self Engagement Physician Lead RN Care Coordinator in place Physician Leader in place Lightbeam Interface Status Demographics as of 5/15/17 Development QA Process QA Process QA Process QA Process QA Process QA Process Prod. QA Process % of patients with AWV - full credit for over 50% % of patients in CCM - full credit for over 10% % of patients in TCM - full credit for over 10% 9.2% 30.3% 21.1% 20.3% 10.4% 26.8% 7.6% 5.5% 25.9% 0.7% 0.8% 0.7% 1.1% 0.2% 1.0% 0.6% 1.2% 1.2% 3.1% 3.6% 20.6% 1.4% 14.2% 6.6% 1.4% 1.5% 5.3% Billing AWV Billing CCM Unknown X 3 3 X Unknown X 3 3 Billing TCM Unknown Unknown X X 3 Patient Satisfaction Tablet Utilization Rate Opt-Out Opt-Out Opt-Out 7.2% 0.0% 14.7% 8.3% 31.7% 14.3% 2016 Quality Score B/w 25%ile & Avg. > CH Avg. B/w 25%ile & Avg. B/w 25%ile & Avg. < 25th%ile B/w 25%ile & Avg. 25th%ile B/w 25%ile & Avg. B/w 25%ile & Avg Total Cost Did not meet Did not meet Did not meet Did not meet Met 90% CI Met 90% CI Did not meet 2016 ED Utilization Met 90% CI Did not meet Did not meet Met 90% CI Met 90% CI Met 90% CI Did not meet 2016 SNF Utilization Met 90% CI Met 90% CI Met 90% CI Met 90% CI Met 90% CI Met 90% CI Did not meet 2016 IP Utilization Did not meet Did not meet Did not meet Did not meet Met 90% CI Did not meet Did not meet Representative at Board Meeting ACO Champion at Road Map Call Practice Manager at Road Map Call Care Coordinator at Road Map Call Attend Q/W Attend Care Coordinator Cohort Calls Attend Quarterly Steering Committee Meeting Attend Cohort Calls Points Earned - Site Level 61.5 Points Possible 88 Site Score 69.9% ACO Medical Director Attend April EBM Webinar 3 Attend July EBM Webinar 3 Attend March Cohort Call 3 Attend June Cohort Call 3 Attend Physician Leader 3 Cohort Calls 3 Points Earned - ACO Medical Director Level Points Possible ACO Medical Director Score Total Score (Site + ACO Medical Director) % 81.0% 80.7% 67.0% 65.0% 70.0% 71.5% 73.0% 72.8% % 74.3% 6

7 Van Wert SJMH Reynolds Knox Jersey Shore Grant FTMC Davis and Valley Broaddus Bellevue Caravan Health Attributed Only Q Q % 27.6% Van Wert 20.0% 24.6% 3.5% 5.6% SJMH 3.6% 5.5% 5.4% 9.0% Reynolds 5.1% 8.8% 35.0% 28.3% Knox 22.7% 20.3% 5.3% 10.3% Jersey Shore 4.7% 9.5% 32.7% 24.5% Grant 22.4% 16.9% 24.8% 23.3% FTMC 22.2% 21.1% 35.1% 30.4% Davis and Valley 34.4% 29.4% 10.8% 8.4% Broaddus 9.6% 7.5% 4.5% 9.9% Bellevue 4.5% 9.6% 29.0% 25.1% Caravan Health 26.1% 23.2% All Medicare 0% 10% 20% 30% 0% 10% 20% 30% Care Coordination: Chronic Care Management, All Medicare Q Q % 2% 1% 0% 1.1% 1.4% 0.9% 0.9% 0.8% 0.8% 0.6% 0.6% 0.4% 1.8% 0.1% 0.2% 1.1% 1.2% 1.0% 0.7% 1.3% 1.2% 0.9% 1.5% 2.8% 3.1% Bellevue Broaddus Davis and Valley FTMC Grant Jersey Shore Knox Reynolds SJMH Van Wert Caravan Health 7

8 Care Coordination: Transitional Care Management, All Medicare Q Q % 15% 10% 5% 0% 0.0% 0.0% 3.9% 4.7% 3.8% 4.0% 15.1%22.9% 2.2% 1.1% 12.6%12.0% 6.2% 6.5% 1.4% 1.2% 0.7% 1.2% 5.0% 7.1% 7.0% 8.1% Bellevue Broaddus Davis and Valley FTMC Grant Jersey Shore Knox Reynolds SJMH Van Wert Caravan Health Attribution and Risk Van Wert SJMH 559 Reynolds Knox 1,216 3, Jersey Shore 1,055 Grant FTMC Davis and Valley 3,808 1, Broaddus Bellevue % By 2013 By 2014 By 2015 By Q Aged/dual Aged/non-dual Disabled ESRD 8

9 Community Breakdown: Total Expenditures per Assigned Beneficiary per Year, Unadjusted Q Q $12,000 Total PPPY Expenditures $8,000 $4,000 $10,188 $10,838 $12,043 $11,405 $9,672 $10,434 $10,555 $11,086 $7,376 $7,205 $8,516 $9,030 $12,007 $12,377 $12,220 $11,625 $8,134 $8,261 $9,010 $9,113 $10,613 $10,971 $0 Bellevue Broaddus Davis and Valley FTMC Grant Jersey Shore Knox Reynolds SJMH Van Wert Caravan Health Community Breakdown: Total Expenditures per Assigned Beneficiary per Year, Risk Unadjusted Q Q $7,500 Total PPPY Expenditures $5,000 $2,500 $7,494 $7,972 $7,592 $7,189 $6,897 $7,440 $8,308 $8,726 $6,450 $6,300 $7,918 $8,396 $8,487 $8,749 $8,513 $8,098 $6,416 $6,517 $8,050 $8,142 $8,495 $8,781 $0 Bellevue Broaddus Davis and Valley FTMC Grant Jersey Shore Knox Reynolds SJMH Van Wert Caravan Health 9

10 At baseline, we did not have any population health department or initiatives in our organization. In one year, we have transformed our clinical flow, care of Medicare patients, and overall culture where population health is concerned. The populations that have benefitted the most are those that needed the most help, primarily Medicare patients with three or more chronic illnesses. With the initiation of the AWV nurse position, we are now tracking the number of packets and calls sent out against the number of visits and no-shows. This has only recently begun, however, so we do not have data on it. We are also tracking the ancillary services that have been generated from the AWV since starting. First and foremost, the triad management model has been profoundly successful. The providers feel that they have someone sitting at the table that has their best interest at heart. Also, we have learned that we must speak a different language and see things through very different blinders. The collaboration has allowed us to see things through others eyes and understand why certain needs must be met and why others cannot. Team nursing is working wonderfully. The addition of the AWV has been very nice as well. We have had decreased readmission rates because of the health coach addition. The thing that was the biggest failure was trying to do the AWV in a 15-minute follow up visit. It simply was not a satisfying experience for the patient or the provider. We chose the AWV nurse approach after visiting another organization in the collaborative and seeing how well it was working for them. Another big pitfall was the waning of cooperation from providers as the year went on. We neglected to keep the platform burning. As a result, AWVs as well as interest fell off. There was also the pitfall of not having minable data yet. It has been difficult to keep providers engaged without real results to show them. We are currently working on this. The biggest challenge, of course, has been convincing the providers that this is important and convincing the board that the upfront cost is worth it. It is difficult to convince an organization to pay out for more FTEs for a payment that will not be made for another three years. The initiation of the positions of nurse navigator, health coach, and annual wellness nurse has been immensely helpful in the journey. If we could have done something differently, it would have been to utilize these positions more from the start. Our main challenge is the same challenge everyone has, which is, how to financially support outcomes-based medicine while living in the fee-for-service world. Ideally, we would have multiple health coaches for all of our populations, and our providers would have more time to spend with each patient truly addressing all of their needs. This year has certainly been full of growth and education. We have learned so much, and looking at the systems that we have come to know through the collaborative, we know that it certainly has a long way to go. Moving forward, we are planning on expanding our health coach team as we enter into risk-based contracts with other insurers. We will be working with the providers to develop some outcomes-based incentives and adding this to the contracts. We will also be partnering with some local non-employed physicians and some rural critical access hospitals in a PHO/CIN environment to expand our population health model to more of the community. We also plan to start to develop our outreach clinics staffed with either mid-levels or health coaches in some surrounding, very rural, underserved counties. The next big project is to institute telemedicine in our outreach clinics and add a travelling APP so that we can take the AWVs and quality care to our more rural patients. We are teaming up with WVU hospitals in order to expand our local service lines, including the cancer care center and the cardiovascular institute. Finally, we are planning to institute eicu as well as other means of telemedicine in order to provide more comprehensive care to patients. 10

11 Appendix This was recently sent out to our providers: Hey everyone! We have all spent countless hours discussing population health, and we re doing a great job at it. We talk a lot about numbers and metrics and annual wellness visits, but we don t always see the effects of our efforts in action. I wanted to share today a story about a real patient who has benefitted from our efforts. Patient N. is an elderly woman who presented to me today with increased falls and some occasional confusion. She has been my patient for years probably since we opened the office 14 years ago. I have seen her children over the years abuse her, take advantage of her, and overall be horrible people. Today, she came to me sobbing. She knows that she isn t safe living by herself. She is having trouble managing her bills and her medications. She is falling and hurting herself. And she has NO ONE at all to help her. Her children have flat out told her that she can t come and live with them. She has very little concept of what her finances are like, and doesn t know what will happen to them if she goes into placement. She wants to go to ERCC, but doesn t have any idea how to go about doing it. I sat with her for some time while she cried, and I listened to her. We all know, however, that providers don t have those answers, or the time to procure them. When she settled down, she said she wanted to go to ERCC. I asked her to wait a minute, and I called the inpatient discharge planning team. They agreed to help. I also asked Melissa to come in and meet with the patient. Melissa got her some coffee and held her hand while she cried more. The discharge planner came downstairs and sat with Melissa and Mrs. N. for over an hour helping to plan out her next steps. Melissa then contacted an organization that goes into homes (Melissa knows the name I don t) to help people like this. She is going to have a nurse come out weekly to keep an eye on her, help with her bills, and help with her medications until she can be placed. Orders were placed for NH placement, and Mrs. N. went home on the van feeling that she had some people looking out for her for the first time in a long time. We all work very hard. We all get overwhelmed. We ve all had to undergo a lot of change in the way that we practice. We all get frustrated when processes break down. BUT, what happened today is hope. It is my hope that we can continue to grow as an organization focused on the health of our population so that every patient will leave here with the experience that Mrs. N. had. Have a good weekend everyone! Give your family a hug. Mindy 11

12 Project Team Carl Nichols, M.B.A., FACHE, Vice President of Professional Services, Davis Medical Center Catherine Chua, D.O., FAAFP, FMNM, ABAARM, FAARM, Chief Medical Officer, Davis Medical Center 12