Joy At Work - BellinHealth and HealthPartners Restoring Joy in Practice through Team Based Care IHI December 2016 James Jerzak M.D. Kathy Kerscher Bellin Health Green Bay, Wisconsin 1
Agenda Crisis Emerging in Primary Care Emerging Solutions Bellin Health s Journey: Achieving Population Health through Team Based Care Restoring Joy in Practice for Physicians and Staff WHAT- Crisis Emerging in Primary Care 2
Crisis Emerging in Primary Care Clinician and staff burnout. Difficulty in successfully caring for patients with increasingly complex needs. Higher copays and deductibles leading to higher intensity of office visit. Impending change to value based reimbursement will require a new focus. Physician Burnout is a Public Health Crisis Art Caplin PhD. Division of Medical Ethics NYU 3
Our View Causes of Burnout EHR demands on the clinician during the office visit. Inefficient workflow of the in basket work with most work directed to the clinician. Challenge of providing comprehensive care to increasingly complex patients. Maximizing Our Resources PROVIDER STAFF 50 % Provider Level License 50 % Staff Level License 50 % Non Provider License Level Work 50 % Non Staff License Level Work 8 4
Life After the Electronic Medical Record http://alphaomegaalpha.org/pharos/pdfs/2015-3- Editorial.pdf The current practice model in Primary Care is unsustainable. C.Sinsky, M.D. et. al. 5
Bellin Health s Solution: Bellin Health s Solution: FIX THE PROBLEM!!!!! 6
Bellin Health s Journey Achieving Population Health Through Team Based Care Addressing Burnout: Bellin Health Solution Advanced Team Based Care A Transformational Approach to Support Population Health A comprehensive approach to health care delivery transformation including office visit redesign, in basket management redesign, and use of extended care team members and system resources to deliver effective population health management 7
Transformation to Team Based Care: The Office Visit Enhanced support from care team members Enhanced rooming procedures to address care gaps, pend refills, set agenda Full support for EHR work including documentation and pending orders Post visit support by care team members including health coaching, reviewing the plan, making future appointments Get picture of core team here 8
Transformation to Team Based Care: In Basket Management Team approach to in basket work RN/CTCs assist with in basket management Increased verbal communication with co-location decreases electronic messaging Intercept unnecessary messages to clinician Test results managed by team per protocols Panel management by core team in conjunction with Central Care Management team Expanded role of office RN in direct patient care 9
Transformation to Team Based Care: Population Health Management Ultimate goal of transformation: improved health of the population Risk stratify patient population to determine appropriate care team members needed to engage with patients Involve Extended Care Team members with high risk patients Case Managers, Clinical Pharmacists, Diabetic Educators, RN Care Coordinators, Behavioral Health, etc. Office RN involved with rising risk patients Work with employers, communities 10
Guiding Principles for Successful Team Based Care Put the Patient first Build Team Culture Empower Staff Encourage Critical thinking Know your population Core Concepts for Successful Team Based Care Planned Care Principles Enhanced rooming process Co - Location Daily Huddles Regular Care Team Meetings Maximize Use of Warm Handoffs Effective Use of Extended Care Team Members Standard Documentation and Communication Team Approach to In-Between Visit Work Start On Time 11
Our Results 3 Wins: Patient, Care Team, System Wins for the Patient 12
Patient Comments Love the team-based approach! Excellent people! The program has been so helpful. Thanks! It is much nicer that the nurse is in the room so the doctor doesn't have to look at the computer. It helps me because I understand what is happening better than before. Absolutely awesome. Treated like a person, not just a number. :) My visit today seemed a lot more efficient and beneficial that others I have had in the past. The whole team/staff also seemed to be happier. Keep up the great work! Win for the Care Team 60% Staff Satisfaction Before and After Team Based Care Launch 50% 40% 30% 20% Pre Go-Live Post Go-Live 10% 0% very dissatisfied dissatisfied neutral satisfied very satisfied 13
Provider and Staff Comments I never want to go back to the old way. I feel empowered I am finally part of a team with the focus on patient care. Work-Life balance is great. I can spend time with my family. I have enjoyed the time it has given me to build quality relationships with our patients. I feel I can support them better Win for the System 14
From Fee For Service to Managing Populations 29 Lessons Learned There needs to be strong collaboration and shared vision between administration and physicians to design a system that accomplishes the 3 Wins. Empowering staff in a Team Based Care model is the best way to accomplish effective population health management, and to share the care for complex patients. Team support for EHR work is needed to alleviate clinician burnout. Team based care is an effective way(the best way?) to put joy back into the practice of medicine, and leads to better patient care. 15
Joy in practice implies a fundamental redesign of the medical encounter to restore the healing relationship of patients with their physicians and health care systems. C.Sinsky, M.D. et. al. Do you want to be part of the future, or do you want to resist the future? Garret Camp, Founder of Uber 16
Joy in Work Beth Averbeck, MD Sr. Medical Director, Primary Care Health Plan 1.5 million members Medical Clinics 1,700 physicians 50+ primary care locations 55+ medical specialties 18 worksite health locations 22 urgent care locations Dental Clinics 60 dentists across 22 clinics 6 dental specialties Consumer-governed, non-profit Integrated health and financing 22,500 employees Hospitals 6 hospitals Level 1 trauma and tertiary center Acute care hospitals Critical access hospitals 17
Engagement How do we partner with and engage our physicians/clinicians and staff to help us improve experience, health, affordability and joy in practice? 18
Strategy Hope & Good Intent or Culture & System Development Process, People, Tools Cultivating Culture Behaviors Values How we behave Head + Heart, Together Behaviors Values: What guides our actions Excellence Compassion, Partnership Integrity Vision Mission : Why we are here To improve health and well-being in partnership with our members, patients and community. Mission Vision: Where we are headed Health as it could be, affordability as it must be, through relationships built on trust. 19
Common Beliefs/Values/Behaviors Partnership Agreement/Compact Refresh Guiding Coalition Direction to department/site leaders Local meetings to discuss: What do you want for the future of our organization-wide Group Practice culture? For our patients? For each other? For yourself? What do we need to do to help this culture move forward? What do we need from our organization? From each other? From you? What can you do to help us succeed in achieving this future? How can you help us be successful? What s critical to you to have in this new culture? Outcome: New document with practice commitments (instead of gives and gets ) 20
Themes Care Design: Care Model Process Work to standardize primary care clinic workflows The right person doing the right thing at the right time with the right patient experience. All conditions for all patients at every visit. 21
Designing Care Model Process DESIGN WORKSHOP TO CREATE WORKFLOWS Use existing staff and not assume added resources Be condition neutral Ensure the right person is doing the right work Increase provider efficiency Support Patient- Provider relationship Focus on the full Care Team PILOTS TO TEST AND FINE-TUNE DESIGN Start small begin with just 2-3 pilots Charge site leadership to take ownership of pilot Iterate on the design real-time until you get it right Celebrate small victories along the way Provide organizational support PLAN TO SPREAD Create a roll-out plan that balances speed with effectiveness Plan includes a standardized curriculum and approach with defined timelines Don t lose sight of your pilot practices Identify upgrades as you implement Care Model Process Before The Visit During the Visit After the Visit Between Visits Visit Scheduling Pre-visit Planning Check-in Visit Follow-up Between Visits Reception Insurance verification Check-in Scheduling Message triage Forms CMA/RMA/LPN Registry Message triage LPN standing orders Test results Immunization RN s Phone triage Protocol driven care Warfarin management Medication refill Abnormal test triage Care Coordination Action Plan Clinician Leader of care team Diagnosis and treatment Engaging patients in their care Directing members of care team Care plans 22
Care Model Process: Upgrades Clinic upgrade training sessions 2X yearly - Two, 4 hour sessions - Re-evaluate & reduce - Improvement requires change - Train everyone! Module Overview 7 Core Modules (visit cycle, test results, med refill, etc.) 12 Resource Modules (prior authorization, forms, advance directives, etc.) 8 Population Health Modules (registry, care plans, etc.) 10 Clinical Content Modules (diabetes, hypertension, preventive services, etc.) Using data as information Transparency What Data Data is Wrong Our Patients are Sicker Measuring the wrong condition Data could be right Data is never perfect and it s good enough 23
Cascading Results: System Minnesota Community Measurement High Performing Medical Groups in 2015 (Primary Care) Total Cost of Care 10% lower than state average ADHD Measure HealthPartners Clinics 16 out of 20 Park Nicollet Health Services 15 out of 20 Stillwater Medical Group 13 out of 20 Allina Health 12 out of 20 Essentia Health East Region 11 out of 20 Fairview Health Services 11 out of 20 Mankato Clinic, Ltd. 11 out of 20 Adolescent Immunizations Breast Cancer Screening Bronchitis Childhood Immunization Status (Combo 3) Chlamydia Screening Colorectal Cancer Screening Controlling High Blood Pressure COPD Depression Remission at 6 months Depression Remission at 12 months Maternity Care: Primary C- Section Rate Pharyngitis Optimal Asthma Care - Adults Optimal Asthma Care - Children Optimal Diabetes Care Optimal Vascular Care Pediatric Mental Health Screening Pediatric Overweight Counseling URI = Medical Group rate and confidence interval fully above average Blank = measure reported but rate was average or below average Cascading Results HealthPartners June 2016 Summary Report 24
Care Team Scorecard Meetings Structure Meet every 90 days with site leadership Physician/Clinician, LPN/CMA, RN Process Celebrate & share Identify opportunities and learn Test improvements: care teams and leaders partner Site Leaders send plans to division leaders Identify best practices Reward and recognize Share with others 25
Building Relationships Care Coordination Primary Care to Specialty Care Specialty assumes accountability for appointments and access Hotline Urgent Care and ED to Primary Care Scheduled orders for follow-up Pro-active outreach to patients Home to Hospital Physician notified of admission Hospital or TCU to Home RN calls Supporting Leaders Leader Standard Work Cohort developed Standard processes Tools Sharing best practices 26
Decreasing Time Spent Working Call, Click, Come in E.Visit Phone Visit Schedule Template Documentation Efficiency EHR Tools Voice recognition Collaborative documentation Screen Size Exam Room Agenda Setting Establish Boundaries EHR Efficiency Closing the Visit Use of Interpreters Care Team Care Model Process Flow Stations Proximity to Care Team Printer Location Inbasket Efficiencies Wider Screens 27
Keys to Success Assume best intent Stay curious Transparency of results Co-design The whole is greater than the sum of the parts. 28