Achieving Population Health through Team Based Care Wisconsin Council on Medical Education and Workforce Conference November 12, 2015 Kathy Kerscher, Bellin Health
Overview of Bellin Health
3 MISSION Bellin Health is a community-owned not-for-profit organization responsible for the physical and mental health of people living in Northeast Wisconsin and the Upper Peninsula of Michigan. We exist to serve others through patient care excellence and community health improvement designed to positively impact the well-being of people living in our region. We are steadfast in our commitment to providing compassionate, safe, coordinated care, while striving to make that care more accessible and affordable for everyone. Our innovations and never-ending pursuit of improvement drives the evolution of healthcare in the nation. VISION The people in our region will be the healthiest in the nation, resulting in improved economic vitality in the communities we serve.
Serving a Market of 636,682 People 4 Bellin Hospital, a 220-bed community hospital with proven excellence in heart and vascular care; orthopedics and sports medicine; family programs and services; cancer care; and minimally invasive procedures including robotic surgery Bellin Health Oconto Hospital, a 10-bed critical-access hospital in Oconto Bellin Medical Group and NorthReach Healthcare, a 121-member primary care group with 32 clinic sites and proven excellence in disease management and wellness care Employer Clinics, 83 clinics located within employer facilities FastCare Retail Clinics, 4 retail clinics located in grocery and discount retail stores Physician Partners, Ltd incorporates all of Bellin Health System, their employed providers and approximately 116 independent providers Bellin Psychiatric Center, a dominant provider of in- and outpatient behavioral health services, staffed by 10 psychiatrists, 4 psychologists and 24 licensed mental health & addiction therapists Unity Hospice, providing hospice and palliative care services
Overview of Patient Care Redesign
WHAT- Population Health Strategy
Population Health Strategy Communities Segments Population Health Employees Conditions Panels Population Management THE NEW SYSTEM
WHY- Patient Care Redesign
LIFE AFTER THE ELECTRONIC MEDICAL RECORD
WHY ARE WE REDESIGNING PATIENT CARE? Increasing rates of burnout for physicians and staff Difficulty in successfully caring for patients with increasingly complex needs Current approach to patient care has achieved significant results but has plateaued in achieving quality goals Helpful to retain and recruit physicians Impending change to value based reimbursement
Our Model Population Health
Population Health- 9 Steps
NINE STEPS TO ACHIEVING POPULATION HEALTH 1. Understand the population 2. Define GOALS for the population 3 W s 3. Create high level design Match demand & capacity 4. Activate the team 5. Engage the individual 6. Measure outcomes 7. Provide feedback 8. 30 day improvement plans 9. Recalibrate GOALS
Old and New Models of Patient Care
OLD MODEL OF PATIENT CARE Paper Work Medication Refill Chronic Disease Management Test Results Acute Visits Preventative Visits Patient Orders/Triage PROVIDER Referral to Ancillary Services CMA/ LPN RN Referral to Specialist Managing Messages, Test Results, Calling Patients 16
NEW MODEL OF CARE
New Competencies For New Model of Care
Achieving Population Health Management Through Team Based Care Population Health Technical Epic Team Based Care Provider (3 days) Epic Team Based Care Staff (3 days) Prerequisite class Care Team Schegistration Patient Admission Rep Team Effectiveness Change Management Team Culture Quality Improvement Care Team Huddle/Meetings Time Management Customer Service Critical Thinking Care Manager Bridging technical and the team Care Team/Patient Interactions Coaching Motivational Interview technique Protocols/Evidence Based Guidelines Connected Patient Experience
Relationships with Colleges Bellin College Team Based Care Certification NP rotation in our clinics Northeast Wisconsin Technical College (NWTC) Team Based concepts in MA program Student rotation in our clinics
PATIENT CARE REDESIGN Core Principles and Concepts
FUNDAMENTAL PRINCIPLES FOR SUCCESSFUL TEAM-BASED CARE 1. Put the Patient First 2. Build Team Culture 3. Empower Staff 4. Encourage Critical Thinking 5. Know Your Population 22
CORE CONCEPTS FOR SUCCESSFUL TEAM-BASED CARE 1. Planned Care Principles 2. Colocation 3. Daily Huddles 4. Regular Care Team Meetings 5. Maximize Use of Warm Handoffs 6. Standard Documentation and Communication 7. Effective Use of the Extended Care Team 8. Team Approach to In Between Visit Work 9. Start on Time 23
The 3 W s! 1. Win for the Patient 2. Win for the Care Team 3. Win for the System 24
THE TRIPLE WIN Win for the Patient Improve patient experience during office visit by maximizing direct provider engagement via reduction in clerical and computer tasks. More resources to support the needs of the patients via extended care team. Improve patient engagement and self-management skills by maximizing involvement of the health care team. Outcome measures Likelihood of recommending Access to care team 25
THE TRIPLE WIN Win for the Patient (Continued) Patient requested a picture of my care team! 26
THE TRIPLE WIN Win for the Care Team Improve provider experience by assistance with refill management, documentation, order entry, in basket management, and help with high-risk patients via the extended care team. Improve staff experience by providing direct patient care at the top of their skill set. Improved efficiency of the office visit allows for improved access and more time to deal more effectively in meeting patient needs. Improved satisfaction of all staff by working together as members of a health care team. Outcome Measures Pre and post staff satisfaction survey Employee engagement score Pulse Survey 27
THE TRIPLE WIN Win for the System Improved patient experience and engagement. Retain existing staff and providers and effectively recruit due to improved care team experience and engagement. Generates confidence in participating in risk-based contracts as a result of improved quality measures and team-based care. Improve financial viability in both current and future health care environments. Outcome Measures ROI Quality/Financial targets Value based contracts Risk Adjustment Factor 28
Financial Results Win for the System Care Team Operating Margin prior to Go-live Operating Margin Target 1-2.2 3.3 5.7 2 10.5 10.4 17 3 7.9 8.4 18.1 4 9.5 4.8-11.1 5-9.5-1.2-4.6 6 49.2 50.3 46.1 Operating Margin Actual
Quality Results Win for the Patient, Careteam, and System Measure Baseline Actual Percentage Improvement Breast 55.37% 64.01% 8.64% Cervical 69.61% 77.57% 8.26% Colorectal 79.71% 84.38% 7.97% LDL @ TARGET (<100) 65.79% 65.43%.36% BLOOD PRESSURE @ TARGET (<140/80) 50% 50.53%.53% A1C @ TARGET 48.95% 57.98% 9.03% A1C POOR CONTROL (>9%) 6.11% 4.37% 1.74% RENAL PROTECTION 62.11% 68.62% 7.40% FOOT EXAM 21.05% 73.94% 52.89% RETINAL EXAM 32.63% 38.30% 5.67% PNEUMOVAX COMPLETED 54.21% 64.89% 10.68% HEP B COMPLETED 6.32% 7.45% 1.13%
Scale and Spread Infrastructure and Timeline
Scale and Spread
Milestones 11/3/14 Dr.Jerzak Go-Live TBC 2/23/15 Dr. Wozney Go-Live TBC 10/19/15 Generations Go-Live Today 1/18/16 Dr. Singh Go-Live TBC 3/21/16 Ash Go-Live TBC 5/18/16 Ash 2 Go-Live TBC 7/25/16 Dr. Bedi Go-Live TBC 9/26/16 11/21/16 Dr. Wilson Howard Go-Live TBC Go-Live TBC 5/18/15 Dr.Lasecki/ Dr. Bongiorno Go-Live TBC 10/5/15 Dr. Meyer Go Live 2/22/16 Green Bay Clinic Go-Live TBC 4/18/16 Dr. Gerzak Go-Live TBC 6/22/16 Ash 3 Go-Live TBC 8/22/16 Dr. Gauthier Go-Live TBC 10/24/16 Dr. Boyd Go-Live TBC
Comparisons Some systems have addressed office visit redesign. Some have addressed population health management. Few if any have taken the comprehensive approach as we have Cleveland Clinic has a very similar model as we have. Had 7 Physicians on TBC after 2 years After 4 years, has 20 providers We have 15 providers in TBC in less than 1 year Systems that fail in spreading TBC Why? - Lack of administrative commitment - Lack of physician willingness to change - Too aggressive a spread plan
QUADRUPLE AIM Improving the health of the population Enhancing the patient experience of care Reducing the cost of health care Improving the work life balance of health care clinicians and staff 35
36 THANK YOU!
References From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider Annals of Family Medicine November/December 2014 Volume 12 No. 6 Corresponding Author Thomas Bodenheimer M.D.