Team Care Best Practices in Managing Hypertension Learning Collaborative Sponsored by AMGA and Daiichi Sankyo, Inc.

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1 2008 Best Practices in Managing Hypertension Learning Collaborative Sponsored by AMGA and Daiichi Sankyo, Inc. November 12-14, 2008, Scottsdale, AZ Great Falls Clinic, LLP Great Falls, Montana Team Care 1

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3 Medical Group Profile The Great Falls Clinic, LLP, was established in 1917 Clinics located in Great Falls (3 sites), Helena, Butte, Choteau and Fairfield 110 physicians, 38 mid-level practitioners, over 700 employees Over 40 specialties 303,000 Outpatient Visits/Year Serve 225,000 residents living in 17 counties EMR is ICChart (MED 3000/InteGreat) 3

4 Project Goal and Objectives Redesign the process of delivering primary care to patients with chronic disease to: Utilize technology to identify patients not in compliance Improve outcomes Efficiently use scarce human and fiscal resources Improve revenue 4

5 Project Goal and Objectives Solution: Team Care Medical Home Health Coach Pre-screening for gaps in care Appointments Labs Consults Short-term follow-up Behavior modification

6 Resources and Budget Internal Resources: QI Department Staff & Budget Phytel Automated Appointment Reminders Phytel Patient Outreach External Resources: AMGA Learning Collaborative ($20,000) QIO Chronic Kidney Disease Collaborative QIO EHR Care Management (Data Mining Support) Medical Home Pilot with BCBSMT ($$??) PQRI Group Measures ( $110K for 2008) CMS Medical Home Demonstration Project 6

7 Project Team Members Leadership Team: Medical Director Quality & Research Director Quality & Research Assistant Administrator Clinical Services Nephrologist Implementation Team: IM Department Chair & Physicians FP Department Chair & Physicians Clinical Managers RN Health Coaches (2-4 total, including1 RN Certified Case Manager) QI Specialist Registered Dieticians Organizational Support Team: Administrator and Chief Medical Officer Executive Committee CIO, CFO, Director of Informatics 7

8 Project Timeline Choose Balanced Scorecard Initiatives Review Literature for Clinical Initiatives Initial Program Design with Algorithms Present to Appropriate Departments Choose Pilot Sites Initial Team Meeting Agree on Design & Roles Identify Additional Resources Initiate Pilot Project - NW Clinic Baseline Data - NW Clinic Behavior Modification Training for RNs Begin Outcomes Measurement Q3 Evaluate and Modify Process as Needed Implement Process - FP Marketplace Implement Process - IM Main Implement BP Training Program - all GFC sites Begin BCBSMT Medical Home Pilot Implement Process - FP Main Outcome Measurement - All GF Divisions Implement Process - Helena Physicians Clinic Submit 2008 PQRI Measures Group Outcome Measurement - All Divisions Gantt Chart for Hypertension Disease Management Q 1 Q 2 Q 3 Q 4 Jan Feb Mar Apr May Jun Jul Aug Sept 8

9 Communication (Internal) FY07-12 Clinic Strategy Map Corporate Focus Mission: Dedicated to excellence in patient centered healthcare through teamwork and physician leadership. Vision: Montana s Healthcare Choice Customer C1 Quality Relationships Patient-centered Care Timely Care Equitable Care Clinical Excellence C2 Clinical Expertise Effective Care Safe Care Operational Excellence C3 Customer Value Efficient Care Internal Processes P1 Deliver timely access to coordinated services P3 Right patient, right care, right process, best outcome P5 Optimize physician, staff and facility productivity P2 Exceed patient expectations with individualized, compassionate interactions in a healing environment P4 Design and implement coordinated care models through an evidence-based approach P6 Leverage the best practices of our partnerships Learning & Growth L1 Recruit, develop and retain talented people L2 Ensure clinical and technical expertise L3 Develop and support physician and administrative leadership L4 Engage physicians and staff in decision making to achieve our mission F1 Achieve an operating margin that is acceptable to the partnership Financial F2 Grow key services and programs F3 Optimize Payer relationships F4 Strengthen the balance sheet F5 Demonstrate stewardship through efficient use of resources 9

10 Communication (Internal) 2008/09 Balanced Scorecard:Disease Management Target Status Perspective Measure YTD Month CUSTOMER As customers of the Clinic's services, w hat do w e w ant, need, or expect? INTERNAL As members of the Clinic's staff, w hat do w e need to do to meet the needs of the patients and healthcare community? HTN Disease Management - Patient Satisfaction HTN - % Patient Care Satisfying All Algorithm Components % Patients Counseled on Risk Factor Modification % Patients w ith Systolic Control % Patients w ith Diastolic Control % Patient w ith LDL in Target Range LEARNING & GROWTH As a Clinic, what type of culture, skills, training, and technology are we going to develop to support our processes? Number (%) of Sites/Divisions Involved In Team Care FINANCIAL As financial stakeholders, how do w e intend to meet the goals and objectives in the Clinic's mission statement? Status Adherence to Program Budget Internal Production Grow th Internal Laboratory Grow th On Plan Off Plan 10

11 Communication (External) High-risk patients are identified by the Team Health Coach sends a personal letter of introduction Non-compliant patients are proactively identified and contacted via Phytel Outreach to schedule an appointment Exploring patient assessment tools Developed HTN disease mgmt category within our EHR - Developing a patient report card Refer appropriate patients to behavior modification 11

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13 Potential Greatest Challenges Greatest Challenge: Aligning incentives and returning new revenue to the physicians. Physicians fear added cost of Health Coach Potential to Overcome: BCBSMT Medical Home $$ Cover Health Coach Costs Add physician-attributable source of revenue 13

14 Pre-Team Care Snapshot 2008 Quarter 2 NW Clinic LDL<100 71% BP<130/80 DM 46% HTN Control (non-dm) <140/90 73%

15 Outcomes Outcome Measures Patient Satisfaction % Patient care satisfying all algorithm components % Patients counseled on risk factor modification % Patients achieving BP control % Patients with LDL in target range % Sites involved in Team Care Adherence to program budget Internal revenue growth (Clinical targets based on JNC 7 guidelines) 15

16 Questions Demonstrating Captured Revenue Medical Home Dollars Increase in lab and consult compliance over baseline Aligning Incentives Directly attributable Medical Home Otherwise fairly nebulous to physicians We need to find a way to streamline our patient education materials for chronic diseases any suggestions/resources? 16

17 Tools to Share Strategy Map template Balanced Scorecard template Team Care Workflow HTN Care Algorithm Traditional vs Team Care Workflow BP Competency Training Program RN Health Coach Job Description Sample Patient Report Card