Care Redesign and Quality Improvement Beth Averbeck, MD Senior Medical Director, Primary Care HealthPartners Medical Group
Consumer-governed, non-profit HealthPartners Medical Group Primary Care: 500,000 patients 29 locations 400 physicians Mixed payer population Integrated health care delivery and financing Clinics and hospitals Health plan Twin Cities & surrounding communities (MN & Western WI)
Minnesota Fun Facts #1 state with the worst winters #4 best state for your health #2 most bicycle friendly state Ely, MN = World s Best Towns for Outdoor Thrills by National Geographic More shoreline than California, Florida and Hawaii combined 1 recreational boat per every 6 people First open heart surgery and bone marrow transplant performed in US Average annual snowfall = 70 inches
Lead with culture
Our Physician Culture
then move to care design
Why Redesign? Inconsistent results for unsustained periods of time Poor patient access Unexplained variation Financial pressures for increased productivity EHR implementation Community transparency AMGA 25 th percentile in physician satisfaction 2005
Care Design Strategy Hope & Good Intent or System Development People (culture), Process, Tools
Care Design Work to standardize clinic workflows The right person doing the right thing at the right time with the right patient experience. Standardize to the science, customize with the patient.
Care Design Principles We use the following design principles to ensure our care achieves Triple Aim (health, experience, affordability) results: Reliability Customization Access Coordination Reliable processes to systematically deliver the best care Care is customized to individual needs and values Easy, convenient and affordable access to care and information Coordinated care across sites, specialties, conditions and time
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 Design Principles Reliability Customization Access Coordination Throughout our system we develop consistent approaches to deliver reliable, standardized care focused on the patient: Evidence-based Decision support in electronic medical record Processes are standardized Defined roles and responsibilities Every member of the care team contributes to their maximum potential Waste and rework eliminated through Lean and process redesign techniques
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
Reliability Design for Care Determined for each workflow: What - must be done the task Where - where will the task be done Who - appropriate role to complete the task How - tools needed to support the task When - what part of the visit Participants: Members of care teams, EHR, patients
Patient Story 18 year old, college bound One visit scheduled for medication refill for acne and food allergies Care team also provided asthma control assessment and asthma action plan, HPV and flu vaccines
Care Model Process: Results Pre and Post Implementation Impact All clinics improved on all measures HPMG Clinical Results Improvement from 1st Qtr 2005 to 3rd Qtr 2007 100 80 60 40 20 0 70 Mammography Screening (N=14485) 91 87 80 C&TC Preventive Visit Rate (N=4888) 10 19 Diabetes Optimal Measure (N=7583) 81 83 Pediatric Immunizations (N=1597) 1st qtr, 2005 3rd Qtr 2007 65 40 43 Depression PHQ-9 use (N=639) 81 Body Mass Index (N=51550) 80 87 Lead Screening - PCV
Results: Staffing Ratio
Care Design Principles Reliability Customization Access Coordination First we standardize to the science; then we customize care to individual patient preferences and values and unique personal characteristics
Reducing the Gap: Race Breast Cancer Screening 100% GAP is 8.2% points GAP is 5.1% points 80% 60% 40% 80.3% 72.1% 85.2% 80.1% HEDIS 2014 National 90 th Percentile = 80.3% 20% 0% 4th Qtr 2011 2nd Qtr 2016 Patients who are white Patients of color
Strategies to Reduce Disparities Same Day Mammogram Registry Outreach The Pink Ticket Program Themes: Leadership Commitment Staff Passion Systems Approach
Care Design Principles Reliability Customization Access Coordination We design ways to make care and information: More convenient Easy to access; and Affordable
Population Consultant Moving knowledge and information, not patients A new approach to diabetes care in Endocrinology: Share knowledge and best practices through the use of tele-video Discuss difficult diabetes cases with experts and other providers Build relationships with colleagues *Expanding model to Behavioral Health
Collaboration: Northwest Metro Alliance Allina Health and HealthPartners 22,000 commercial lives at risk Multi-year, evolutionary strategy 50+ initiatives implemented or expanded Mercy Hospital Allina Clinics HealthPartners Clinics
Northwest Metro Alliance (2016) Hospital focus Linking to primary care Reducing unnecessary admissions Removing communication barriers between EHR s Mental health 7-day follow-up Clinic focus: Interdisciplinary pain clinic Mental health crisis services Specialty care partnerships Generics
Year 5 Triple Aim Highlights 7% 11% Increased outpatient services lowered hospital visits by 259 fewer admissions Decreased hospital readmissions avoiding 110 unnecessary readmissions and decreasing costs by an average of $11,200 to $13,000 per readmission
Care Design Principles Reliability Customization Access Coordination We coordinate care across sites, specialties, conditions and time
Case/Disease Mgt Emergency Department Behavioral Health Primary Care Hospitals Social Work Home Is our care coordinated? Transitional Care Units Community Resources Nutrition Specialty Care Home Care Medication Therapy Management Diabetes Nurse Educators
Care Coordination Support Consistent approach across clinics & hospitals: Identify those most at risk Proactive outreach Care Plans Shared visits (MD & RN) Access for mental health Link to health plan and community resources % of Population 9% % of Total Healthcare Expense 1% 29% 39% Data Source: Thomson Reuters Market Scan Database National Sample of 21 million insured Americans, 2003-2007 20% 70% 21 % 11%
Care Coordination Support 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
Fire Department/Paramedic Partnerships Home visit the day after hospital discharge Key elements of the visit: Physical exam Vital signs Medication checks and reconciliation Home safety/food security evaluation Patient education Physician orders Resource referrals
Care Coordination Outcomes Readmissions Acute inpatient admissions Average length of stay Total Cost of Care Results ER count index below metro average Inpatient total cost index below metro average
Improvement structure & approach
Improvement Structure Improvement Group Expert Panels FIT Teams
Continuous Improvement New Idea Redesign based on learning's from all sites Research & Development By Expert Panel or Team Audit Implement Spread central or site training train-the-trainer Pilot 1-3 Sites Test Small
CMP engagement for enhancements System Level 29 primary care locations 5-6 pilots at one time at 3 clinics each, 2x per year = 1 clinic per year in at least 1 pilot Oversight Committee = 50 clinicians/staff/leaders Clinic Level 2x a year training with all care teams Quarterly care team meetings
Care Model Process: Upgrades Clinic upgrade training sessions 2X yearly - Two, 4 hour sessions - Re-evaluate & reduce - Improvement requires change - Train everyone! 7 Core Modules 12 Resource Modules 8 Population Health Modules 10 Clinical Content Modules Module Overview
Core Modules: Visit scheduling Check-in Pre-visit planning Visit (rooming, check-out) Test results Patient communication Medication refills Care Model Process Modules (Primary Care) Resource Modules: Prior authorization Scheduled telephone visits InBasket folder definitions InBasket flags InBasket coverage for out of office clinicians External records Forms Advance directives Clinician to clinician communication Paperwork and RightFax flow REF order module Hospital and emergency department discharge follow-up Population Health: Patient care coordination Disease registry Opioid management Care plan documentation Centralized anticoagulation clinic Co-management between D&CM and primary care patients Social services tackle box Behavioral health How to access guide Pediatrics: Adolescent mental health screening ASQ-SE (12 & 36 months) Expert Panel: Pediatric ADHD Expert Panel: Child and Teen Check-up clinical content Clinical Content: Expert Panel: Diabetes and vascular clinical content Expert Panel: Hypertension clinical content Expert Panel: Asthma clinical content Expert Panel: Immunization clinical content Expert Panel: Preventive services Depression care management (no formal expert panel) Other: Collaborative documentation
Practice Efficiency 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
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
Cascading Results HealthPartners June 2016 Summary Report
Care Team Scorecard Meeting 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
One Clinic Example Clinic A: Hypertension Improvement 84% 79% 74% 69% 71.52% 80.06% Measure: Patients age 18 to 85 years who have at least two qualifying visits for hypertension in the last 2 years and at least one qualifying visit in the past year for any reason, and whose blood pressure is adequately controlled. Blood pressure goals vary by age and co-morbidity: HTN Only Age 18 to 59 years with blood pressure <140/90 HTN Only Age 60 to 85 years with blood pressure <150/90 HTN Age 18 to 85 with Diabetes and/or Ischemic Vascular Disease (IVD) with blood pressure <140/90 64% Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 n = 3079 3094 3108 3095 3168 3158 3152 3182 3200 3094 3119 Local leaders accountable Individual discussion between Medical Director and physicians HP Internal Goal: 84% 2015 MN Statewide Average: 76.2% Nursing leader RN visits, LPN records blood pressure and notes abnormal Registry outreach
System Results
Dimension Percentile Ranking Preauthorization AMGA Physician Satisfaction Survey 2005 75th Computers Colleagues Quality 50th Compensation Resources Compensation 25th 2005 Staff Admin Patients Time Working Leadership AMGA Correlation with Overall Satisfaction
Dimension Percentile Ranking AMGA Physician Satisfaction Survey 2016 Preauthorization Computers Paper Work Staff Resources Colleagues Quality Administrators Compensation Leadership 75th Patients Time Working 50th 25th 2016 AMGA Correlation with Overall Satisfaction HealthPartners
System Results 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 l = Medical Group rate and confidence interval fully above average Blank = measure reported but rate was average or below average
How to get started Define your reason to change Why before what Culture, culture, culture Team Delegate, trust and verify Transparency Look for the early wins Test small, tolerate failure (non-critical), spread what works
Lessons Learned Standardize to the science and customize to the patient Take your work seriously, but not yourself Improving care for patients improves joy in work for physicians and care teams
Thank You!