Enhancing Referrals to Loyal Specialists and Outpatient Programs

Enhancing Referrals to Loyal Specialists and Outpatient Programs Dean Kaster, FACHE, Sr. Vice President, Corporate Strategy and Business Development and Leslie Sauter, Physician Outreach Manager University of Maryland Upper Chesapeake Health Bel Air, Maryland April 15, 2015 University of Maryland Upper Chesapeake Health

University of Maryland Upper Chesapeake Health 2

Overview of University of Maryland Medical System $3.8 Billion Annual Gross Revenue 2,369 Licensed Beds 23,643 Employees 120,248 Hospital Admissions 1,602,177 Outpatient Visits 412,108 Emergency Visits 51,150 Surgical Cases Source: 2014 Annual Report University of Maryland Upper Chesapeake Health 3

University of Maryland Upper Chesapeake Health 4

UM UCH Associated Harford/Cecil Primary Care and Urgent Care Providers University of Maryland Upper Chesapeake Health 5

UM Upper Chesapeake Medical Center UM Harford Memorial Hospital Hospital Statistics 2,391 Employees 183 Licensed Beds FY15 12,589 Admissions 3,720 Inpatient Surgeries 6,828 Observations 60,476 Emergency Room Visits 114,914 Outpatient Visits* 10,504 Outpatient Surgeries 131 Average Daily Census 3.8 Average Length of Stay Hospital Statistics 830 Employees 84 Licensed Beds FY15 4,727 Admissions 647 Inpatient Surgeries 2,680 Observations 29,263 Emergency Room Visits 49,260 Outpatient Visits* 2,058 Outpatient Surgeries 59 Average Daily Census 4.58 Average Length of Stay 1,399 Births University of Maryland Upper Chesapeake Health 6

Upper Chesapeake Medical Services Physician Services: Practice Management Coding & Compliance Physician Practice Technology Provider Recruitment Lyle Sheldon UM UCH President/CEO Stephanie Dinsmore VP-Physician Services Lyle Sheldon UCMS Advisory UM UCH Council Peter LoPresti, D.O. UCMS Medical Director Adult Hospitalists UC Primary Care UC Endocrinology UC Orthopedics Pediatric Hospitalists Harford Primary Care UC Women s Care UC General/Bariatric Surgery Intensivists UC Cardiology UC Hematology & Oncology UM SOM Physicians/Practices Psychiatry Approximately 125 providers University of Maryland Upper Chesapeake Health Breast Surgery Thoracic Surgery Radiation Oncology 7

Hospital Physician Surveys Schedule Survey Title Last Survey Current Cycle Due Medical Community Development Plan (Internal) Completed 2013 Required every 2 yrs. Q4-2015 PCP to Specialist Survey (Internal) Completed in 2012 2 yrs. Q3-2014 Medical Staff Satisfaction Survey (External) Completed in 2013 3 yrs. Q3-2016 8

Primary Care Provider Survey Timetable: Tasks: Due Date: Compile and Finalize Survey Questions Jul-14 Update Reference Tables in Access Aug-14 Test Data Aug-14 Schedule Surveys Aug-14 Conduct Surveys w/providers September 1 - November 30 Thank you for participating in survey letters Nov-14 Review reference tables for accuracy Dec-14 Develop Pivot Tables and charts Dec-14 Develop Executive Summary and PowerPoint presentation - Confidential Jan-15 Present findings to Senior Leadership Feb-15 Present findings (issues, requests and opportunities to department directors, CMO and specialist offices) Feb-15 Report findings back to PCPs who participated in survey Mar-15 Awards for "Best Practices" Mar-15 "Actionable Items" letters to PCPs Sep-15 9

Survey Introduction The Physician Outreach team is responsible for gathering and reporting market intelligence, practice growth plans, identifying vulnerable practices, addressing customer service issues, promoting and selling programs and services and building and maintaining relationships centered on trust. Interviews with providers and office staff are critical to understanding what drives referrals, specialty referral patterns, customer service issues related to staffing, access, care coordination, report timeliness & specialist communication back to PCPs. This is a confidential survey and primary care providers responses are not identified or shared. 10

Survey Introduction (Continued) The Physician Outreach team survey PCPs every 2 years since 2008 with a steady increase of provider participation. Fifty nine (59) PCP s were interviewed for the 2014 survey 18 (31%) employed physicians and 41 (69%) non-employed community physicians. Advanced Practice Clinicians (APC s) were invited to participate in 2014. A total of (16) APC s participated in the survey which represents 28% of the total participants. APC s were included in survey as they see their own patients and have their own preferred referral patterns while working under the guidance of sponsoring physicians. 11

Survey Evolution 2008-2014 We started the process in 2008 interviewing and surveying mostly employed Primary Care physicians. During interviews some were skeptical but curious enough to provide responses. Due to our post survey follow up activities and efforts to affect change, PCPs were more vocal during upcoming surveys. Anecdotal feedback helped to identify important trends. Some PCPs looked forward to surveys as a time to bring forth issues, requests and opportunities. Built a level of trust for keeping survey confidential. Specialists started asking for PCP Survey feedback and very responsive to resolving issues reported. 12

Introduction During the interviews, PCPs and/or their office staff were asked the following: Referral preferences for 23 specialty areas (e.g. Breast Surgery and Cardiology) and 10 outpatient services (e.g. Diabetes Education and Wound). To rate ease of access and report timeliness for each of their referral choices. To provide anecdotal feedback regarding specialists and outpatient services. Average wait time for new and urgent appointments based on third next available appointment measures. Do they accept new patients and where they refer patients if they do not. After hours coverage and where PCP s refer patients after office closes. Affiliation with PCMH s and ACO s and payor incentive program participation. Stage of Meaningful Use and Attestation Achievement and EMR system type. Practice growth and recruitment plans. 13

Survey Structure The survey form was designed by the Outreach team and included the following key areas and questions: Ask providers targeted questions about today s HealthCare, Population Health and any impact it has on providers and successfully practicing medicine. Focus on key specialties and outpatient programs that make sense to track and include in survey. Determine main driving force for referral to specialists and preferred 1 st, 2 nd and 3 rd rankings. Rate important practice indicators. i.e. Ease of Appointment Access and Timeliness of Reports. Encourage anecdotal feedback. 14

Survey Mechanics A Microsoft Access form was used for entering survey data in order to Prevent data integrity issues Improve efficiency of data gathered Improve efficiency of analyzing survey results The Outreach team used tablet devices to record survey responses during face-to-face interviews that lasted 45 minutes on average. Physicians were assured anonymity. Compiled survey responses were exported from Microsoft Access to Excel and analyzed using pivot tables and pivot charts. Microsoft Word and PowerPoint programs were used to present an executive summary. 15

Survey Participants Selection and Focus: Primary Care Providers: Survey included all employed PCPs and many community nonemployed PCPs who are predominantly loyal or seen as a splitter - using local and out of service area specialists, programs and hospitals. PCPs are within hospital service areas and comprised of solo, group and concierge practices. One large group practice employed by another hospital and has an office in our service area participated in survey. Specialists and Outpatient Departments: Specialties and outpatient departments are selected based on growth strategies within the organization. Typically areas where we need the most feedback, specifically focusing on employed, affiliated and loyal community specialties. 16

SPECIALTIES CAPTURED IN 2014 SURVEY Bariatric Surgery Breast Surgery Cardiology Colorectal Endocrine/Thyroid ENT/Otolaryngology Gastroenterology General Surgery GYN Hand Infectious Disease Nephrology Neurology Neurosurgery Oncology Ortho-General Ortho-Joint Ortho-Spine Pain Management Rheumatology Thoracic Urology Vascular Surgery 17

PCP Referrals for All Specialties by 1 st Ranking 18

Pay for Performance (PFP) Incentives 12 (20%) of PCPs surveyed do not participate with any PFP Program. 45 (76%) participate with CFBCBS PCMH Program. 2 (less than 1%) participate with Medicare Shared Savings Programs only. 12 (20%) participate with all PFP programs. Pay for Performance PFP Contract Choices Count % of Ttl FALSE Does not Participate 12 20.3% FALSE Total 12 20.3% TRUE CareFirst PCMH 45 76.3% Medicare Shared Savings Program 2 3.4% TRUE Total 47 79.7% Grand Total 59 100.0% Note: 12 providers participate with all PFP programs 19

After Hours Office Coverage Where PCPs refer patients after office is closed. Less that 10% of providers surveyed state they refer patients to either Urgent Care or Emergency Departments. On-call provider: 71.2% Call providers cell phone: 20.3% Emergency Department: 5.1% Urgent Care Center: 3.4% 20

Ease of Access Best Practices Received scores of 4.5 and higher on a scale of 1-5 Ease of Access Scores 4.5 & > Pain Management ENT Vascular General Surgery Bariatrics Ortho, Spine Ortho, non-emp Urology Breast Ortho, non-emp Orthopedic Cardiology 4.5 4.5 4.5 4.5 4.5 4.5 4.5 4.6 4.6 4.7 4.7 4.9 4.3 4.4 4.5 4.6 4.7 4.8 4.9 5 21

Ease of Access Opportunities Received scores lower than a 4.0 on a scale of 1-5 Ease of Access - 4.0 & < OBGYN Orthopedic, employed Cardiology, employed Neurosurgery Nephrology Neurology Endocrine Center Gastro I.D. Endocrine Rheumatology 2 2.2 2.6 2.6 2.5 3.1 3.3 3.5 3.9 3.8 3.8 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 22

What We Heard/Learned Top priority of PCPs: Ease of Access to specialty care for patients Coordination of care and communication with specialists Timely report turn-around Identified Primary Care practices who are in the process of recruiting which ties into our Medical Community Development Plan initiatives Identify which Primary Care practices who are in need of recruitment support Identify which specialties Primary Care providers believe should recruit additional providers (APC s included) to address ease of access issues. Identify roadblocks to care between Primary Care providers and specialists which often times lead to patients being sent to Emergency Departments for care that otherwise was appropriate in a different care setting. 23

What We Heard/Learned (Continued) Acknowledge physician groups that represented Best Practices Identified opportunities for coordinating medical staff introductions of UM UCH employed specialists and other physicians (e.g. affiliates and loyalists) Identified opportunities for driving referrals to UM UCH employed physicians/loyalists and outpatient programs and services. Gained market intelligence regarding what UM UCH competition does best When and why patients are referred outside of Harford County for services available within the county to better manage leakage Outpatient programs and services patient and provider satisfaction 24

Sample Table Specialty Cardiology PCP Status Employed Practice Primary Referral Specialist Employed Not Employed Grand Total Employed Practice 1 100.0% 57.5% 71.2% Employed Total 100.0% 57.5% 71.2% Not Employed Practice 2 Practice 3 Not Employed Total Grand Total 0.0% 40.0% 27.1% 0.0% 2.5% 1.7% 0.0% 42.5% 28.8% 100.0% 100.0% 100.0% Tables were created for targeted specialties and outpatient programs. Statistics were broken down and comparisons were made to 2012 data. Anecdotal comments were embedded on slides within presentation. University of Maryland Upper Chesapeake Health 25

High Level Findings Best Practices: Non-employed Cardiology practice received highest scores for customer service, ease of access and communication w/pcps. Employed Hematology/Oncology practice: All 59 PCPs surveyed chose UM UCH Hematology/Oncology practice due to providing excellent customer service, ease of access, communications back to PCPs and patient anecdotal feedback. Non-employed Urology practice: Majority of PCPs surveyed chose and rate local urology practice high in areas of service, access, report timeliness and access to specialists. Employed Endocrinology practice: Received high marks when compared to competition for diabetes education program, physician services and customer service. Employed OBGYN practice: Gained market share since last survey due to providing PCPs with timely reports. PCPs report other OBGYN offices still don t send reports. Some PCPs have shifted referral patterns as reports are needed to demonstrate compliance for Pay for Performance measures and Meaningful Use requirements (i.e. mammograms and pap smears). 26

High Level Findings Opportunities for Specialists: Orthopedic, Spine: (Affiliated) Look for ways to partner with Pain specialists and work with Ortho Spine surgeons on how to incorporate non-surgical options into practice. Cardiology: ( Employed) Provide Customer Service assessment of practice, reassess office phone system, continue to look at ways to improve physician communication with PCPs and appointment scheduling process to accommodate same day requests. Breast Surgery: (Employed) Look at process for improving time between abnormal mammogram findings and visit to breast surgeon and ways to schedule same day biopsies. This had the tendency of slipping out two weeks which increases patients anxiety levels and impacts primary care referral patterns to breast center. Thoracic Surgery: (Employed) Look at lung screening flow process. PCPs get Radiology report first, then handwritten note from Nurse Practitioner in the office. The handwritten is the final and comes 2 weeks later. Patients and PCPs would like final reports sooner. Five Specialty Practices: (Employed and Community Practices) Recommendations are to recruit specialists to provide more coverage and aid in improving ease of access issues, timeliness of performing procedures and keeping the care local. 27

Outpatient Departments Presentation includes identical sections for outpatient department responses and feedback: What we Heard / Learned High Level Findings Best Practices Opportunities 28

PCP Referrals for All Outpatient Service The table below illustrates PCP s primary referrals for outpatient services. Outpatient departments receiving a high percentage of PCP primary referrals were Diabetes Education (92%), Infusion (94%), and Wound/Ostomy (97%). Affiliation: Advanced Imaging Joint Venture 29

OUTPATIENT SERVICES Diabetes Education Imaging Infusion Lab Rehabilitation Sleep Study Wound Care 30

Wound Care PCP Status Count of Surveyor Wound Center Surveyed Employed Status OP Program Prim Ref OP Not Grand Employed Employed Status Program Employed Total Employed HMH 100.0% 95.0% 96.6% Employed Total 100.0% 95.0% 96.6% Not Employed Hospital 1 0.0% 2.5% 1.7% Hospital 2 0.0% 2.5% 1.7% Not Employed Total 0.0% 5.0% 3.4% Grand Total 100.0% 100.0% 100.0% Wound Center at UM HMH received 96.6% of PCP primary referrals which is up slightly from 94.7% in 2012. The Wound Center at UM HMH received 100% of all employed PCP referrals. Only two PCPs chose the competition which is most likely due to their affiliations with those centers. Comments included: Terrific program, specialists are excellent, providers and staff are very knowledgeable, wounds healed when patients return to office, great outcomes, good patient feedback 31

Structure and Communication of Survey Results An Executive Summary (word) document is created to illustrate tables, charts, graphs and essay summaries of survey findings. The summary is approximately 45 pages in total. This takes 60 days on average to finalized. The document has a table of contents and pages are numbered. The document is blocked, password protected and marked confidential across all pages. Focus is on Best Practices, trends specific to process related issues, customer service, communication or access related issues, report timeliness, opportunities & requests. A PowerPoint presentation is created and presented to Senior Leadership highlighting the Executive Summary. 32

Executive Summary - Table of Contents: Introduction Overview of Survey Results Survey Results by Specialties Bariatric Surgery Breast Surgery Cardiology Colorectal Endocrine/Thyroid ENT/Otolaryngology General Surgery Gynecology Hand Surgery Infectious Disease Nephrology Neurology Neurosurgery Oncology Orthopedic Surgery Pain Management Rheumatology Thoracic Surgery Urology Vascular Surgery Survey Results by Outpatient Service Lines Diabetes Education Imaging and Lab Services EEG Services Infusion Services Rehabilitation Services Sleep Study Services Wound Care Services Appendices 33

Post Survey: The Work Doesn t Stop Here! The survey will be utilized to drive these efforts: 1. Send thank you letters to survey participants. 2. Identify opportunities to grow business. 3. Address access issues by recruiting additional specialists. 4. Acknowledge Best Practices. 34

Post Survey (Continued) 5. Work with our employed network leaders 6. Work with Senior Leadership/Chief Medical Officer to share appropriate feedback with specialists identified in survey, while assuring anonymity. 7. Offer and/or provide Customer Service Assessments & training. 8. Create Post Survey Actionable Items Report. 35

Thank You Letters Thank primary care providers (PCPs) for taking the survey. Remind PCPs survey is confidential and trends captured in data across all surveys will be scrutinized. Include service recovery steps taken to address reported issues obtained by PCPs during the survey to ensure provider satisfaction and patient experience. Insert marketing collateral to grow referrals, such as; a service brochure or new physician biography flyer to promote areas of inquiries discussed during the survey. Demonstrate you are listening by thanking them for providing ideas & opportunities for gaining new referrals. Remind PCPs the survey will be repeated every two years. 36

Opportunities to Sell and Secure New Referrals Gain insight into what drives referrals, preferred practice referral patterns and why PCPs prefer the competition. Survey results provide opportunities to sell outpatient programs and services and specialists. Survey findings provide liaisons the framework needed to: Coordinate follow up visits with PCPs. Develop pre-call planning activities which may include taking departmental content experts on visits. Conduct Needs Based Assessments specifically for PCPs who refer out of the county and/or to the competition. Drill down further into why PCPs prefer the competition to better manage leakage and gain access to lost and new referrals. 37

Address Access Issues by Recruiting Additional Specialists Use anecdotal feedback from surveys for specialties noted as needing to recruit. Compare anecdotal findings to hospital Market Community Development Plan for recruitment strategies and to better manage leakage and preserve market share. Collaborate with targeted non-employed specialty practices to aid with recruitment efforts. Budget for recruiting employed specialists. 38

Best Practices Formally acknowledge Best Practices by: Send letters to specialists who meet the criteria for Best Practices which includes high scores in areas for Ease of Access and Timeliness of Reports and received positive anecdotal comments during the survey. Display Best Practice Award posters in hospital physician lounges to share with medical staff. Deliver plaques with certificates for Best Practice awards. Deliver lunch or dessert trays to employed and loyal nonemployed practices to acknowledge staff for their contributions. 39

Work with Employed Network Leaders Follow-up with employed practices in areas of: Best Practices. Opportunities for process and service improvements. Review summary of anecdotal feedback. Opportunities to introduce new specialists to PCPs. Provide Customer Service Audits. 40

Senior Leadership Involvement Assign clinically sensitive issues to leadership to address as peer to peer (e.g. CMO) Leadership meets with targeted specialists to review survey findings. Leadership works collaboratively with specialists on action plan to address and resolve issues reported. Steps taken to close issues, when appropriate, are reported back to PCPs. 41

Provide Customer Service Practice Assessments For practices identified with low customer satisfaction scores by focusing on employed practices as priority. Customers include physicians and patients. Assessments include: Pre-assessment survey. Mystery Shopper survey. Audit checklist reviewing office processes. Real time patient surveys. Customer Service Training to staff and providers. 42

Post Survey Actionable Items Report Start by using an automated system for tracking and assigning issues & requests to individuals responsible for seeing task through the process of completion. Report includes work done collaboratively with specialist offices and outpatient departments to address: Improvements in areas of access & report timeliness. Communication back to PCPs Other trends captured during the survey. Send final report 60 90 days post survey to survey participants and consider sending to all medical staff. Validates we heard PCPs during the survey and aids in improving PCPs satisfaction, experience and loyalty. 43

Key Take-Aways Survey is conducted internally vs. third party. Assuring anonymity and confidentiality is critical. Conduct face to face interviews vs. mailed or online surveys. Validation of other survey tools such as data repositories. PCP engagement in survey process. Willingness to do every two years. PCPs and Specialists see the value of the survey data. Data collected can be used for other projects involving sales for growing volumes, building and maintaining relationships, improving physician satisfaction and patient experience, managing leakage, securing provider referrals, loyalty and trust. 44

Discussion and Concluding Remarks University of Maryland Upper Chesapeake Health 45