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Team Care at The Cleveland Team Care at The Cleveland ClinicClinic
Team Care at The Cleveland Team Care at The Cleveland ClinicClinic
Kevin D. Hopkins, MDKevin D. Hopkins, MDSection Head-Family MedicineSection Head-Family Medicine
Strongsville Family Health CenterStrongsville Family Health CenterCleveland ClinicCleveland Clinic
AgendaAgenda
• Planning for Change
• Program Overview & Structure
• Outcomes
• Taking it to “the next level”
It’s All About Increasing ValueThe Right Thing to Do in Any Payment Methodology
It’s All About Increasing ValueThe Right Thing to Do in Any Payment Methodology
• Focus on maximizing value delivered to patients• Explore strategies that increase value• Enter into contracts that share in value created
Value = Quality
Cost
Introduction to Value-Based Operations:
The Industry is Changing
Volume-Volume-Driven Driven
HealthcareHealthcare
VALUE-VALUE-Driven Driven
HealthcareHealthcare
Cost
Quality
• Fragmented• Fee-for-service
• Connected• Bundled• Accountable
Managing Population HealthManaging Population Health
Today:The FFS model
Tomorrow:The Value-Based
model
Care of the individual
Payment for each service we provide
Predictability!
Care of a population
Payment based on the quality and efficiency of our care
Uncertainty and risk!
6
“Care Transformation” is Critical“Care Transformation” is Critical
•Transform clinical operations
•Assemble the right care team
•Reward added value with sustainable payment models
•Support with the correct Analytics
17
Patient-Centered Medical HomeThe Key to Success
Patient-Centered Medical HomeThe Key to Success
“Patient-centered medical home (PCMH) is a model of care where patients have a direct relationship with a provider who coordinates a cooperative team of healthcare professionals, takes collective responsibility for the care provided to the patient and arranges for appropriate care with other qualified providers as needed.”
NCQA
There’s No Place Like a “Medical Home”
There’s No Place Like a “Medical Home”
Physician Directed Practice
Comprehensive and Coordinated
Care
Payment for Added Value
En
han
ced
A
cces
s
Patient Engagement
Safety and Quality
Treatment of Patient as a
“Whole”
Transform Clinical OperationsTransform Clinical Operations
Standardized Care Paths
Proactive, targeted outreach
Patient follow-up & engagement
Enhanced access
Engage other
providers
Pre-visit planning
Chronic disease
management
The Time Problem The Time Problem
• Time needed for chronic illness care for 2,500 patients1
• Time needed for preventive care for 2,500 patients2
• Time needed for acute care1
• 10.6 hours/d
• 7.4 hours/d
• 4.6 hours/d
1. Østbye TH, et al. Ann Fam Med. 2005;(3)209–214.2. Yarnall KS, et al. Am J Pub Health. 2003;93(4)635–641.
Based on various analyses:
Assemble the Right TeamAssemble the Right Team
MD Medical Assistant
Care
CoordinatorPharmacist
Patient
Strongsville FHCStrongsville FHC
BackgroundBackground
• There are many factors exerting considerable pressure on our healthcare system:
- Reimbursement for care is static and uncompensated care is increasing
- Increased level of acuity of outpatient office visits
- Primary Care Physician utilization rates are 90-95%
- Healthcare Reform-ACA provisions
BackgroundBackground
• Press Ganey data for appointment convenience
- 50% “very good” (median: 51%, 90th percentile: 59%)
• Leakage
- This is lost-opportunity for higher-quality care for the patient, and revenue for the organization.
Team Care
“Team Care” is a higher-efficiency practice
style designed to:
• Increase accessibility
• Improve quality of clinical care
• Increase patient throughput
• Improve satisfaction at all levels (physician, employee, and patient)
Team CareTeam Care
A “Team Care” model utilizes a team-approach in caring for patients
• Responsibilities are delegated and shared
• Each individual in the chain of patient care functions to the highest level of their qualifications.
Team CareTeam Care
Outpatient Visit:
• Stage 1: Gathering data
• Stage 2: Physical exam and synthesis of data
• Stage 3: Medical decision-making
• Stage 4: Patient education and
plan-of-care implementation
Team Care WorkflowTeam Care Workflow
• With a “Team Care” model, the clinical assistant gathers and documents the data.
• The clinical assistant:- Takes a competent history- Presents to the physician- Remains in the room with the physician and patient- Completes all documentation of the visit- Implements the treatment plan- Gives patient instructions (AVS), ensures
understanding, and completes the visit
Medical History
Medical History
• Medication Review• Medication refill requests discussed• Allergies• Health Maintenance• Smoking/Substance abuse• Changes to medical/surgical history
Medical HistoryMedical History
• Reason for visit
• Note template is loaded in the progress note
• Collect and document the History of Present Illness and ROS
Team Care WorkflowTeam Care Workflow
• With a “Team Care” model, the clinical assistant gathers and documents the data.
• The clinical assistant:- Takes a competent history- Presents to physician- Remains in the room with the physician and patient- Completes all documentation of the visit- Implements the treatment plan- Gives patient instructions (AVS), ensures
understanding, and completes the visit
Team Care WorkflowTeam Care Workflow
The physician (with the assistant still in the room):
• Confirms the history
• Performs the physical exam
• Makes medical management decisions
• Articulates diagnostic/treatment plan
Team Care WorkflowTeam Care Workflow
• The physician leaves the exam room of the completed patient.
• Orders pended by the clinical staff are filed by the physician.
• The physician signs any prescriptions that are not electronically transmitted.
• Physician starts the process with the next patient prepped by the other medical assistant
Team Care WorkflowTeam Care Workflow
• The medical assistant reviews the After Visit Summary with the patient along with any prescriptions or ordered tests.
• Patient education is given and reviewed.• The patient is escorted to the appointment
desk by the clinical staff.
Care CoordinationCare Coordination
• RN Care Coordinator embedded• Hospital Discharges
- DM-2- CHF- COPD- Pneumonia- MI- CKD
Clinical PharmacistClinical Pharmacist
• Referrals for:
- Polypharmacy
- Medication compliance
- Medical literacy
Key MetricsKey Metrics
• Increase volume of patients seen
• Increase efficiency/decrease scheduling wait time
• Increase accessibility to quality physician care
• Increase patient satisfaction
• Improve quality of patient care
• Increase clinical employee satisfaction
• Increase physician satisfaction
Access – Patients AddedMay 2011 – August 2013
Ramp Up Team Care
Missing MA
Patient Satisfaction 2011-Patient Satisfaction 2011-2013 (Q1)2013 (Q1)
Patient Satisfaction 2011-Patient Satisfaction 2011-2013 (Q1)2013 (Q1)
Total Visits Normalized per Clinical Total Visits Normalized per Clinical FTE 2010-2013 (2013 Projection)FTE 2010-2013 (2013 Projection)
Total Visits Normalized per Clinical Total Visits Normalized per Clinical FTE 2010-2013 (2013 Projection)FTE 2010-2013 (2013 Projection)
WRVU’s normalized for Clinical FTE WRVU’s normalized for Clinical FTE 2010-2013 (2013 Estimation)2010-2013 (2013 Estimation)
WRVU’s normalized for Clinical FTE WRVU’s normalized for Clinical FTE 2010-2013 (2013 Estimation)2010-2013 (2013 Estimation)
*Days not worked not considered
OutcomesQuality Indicators Chosen for Improvement
OutcomesQuality Indicators Chosen for Improvement
Team Care started 2Q 2011
Q1 2011
Q2 2011
Q3 2011
Q4 2011
Q1 2012
Q2 2012
Q32012
Blood Pressure Control
74% 76% 81% 79% 79% 78% 78%
A1c Diabetics
96% 96% 98% 96% 98% 97% 99%
Diabetes Screening
89% 90% 90% 90% 91% 91% 93%
Hyperlipid- emia Screening
79% 80% 80% 74% 77% 79% 81%
Mammogram Completed
77% 78% 78% 75% 78% 79% 78%
Sensitivity AnalysisPotential Financial Impact
Sensitivity AnalysisPotential Financial Impact
Per Day 6 8 10
Annual Add 1,338 1,784 2,230
Revenue $156,546 $219,024 $273,780
Expenses $61,992 $61,992 $61,992
EBIDA $94,554 $157,032 $211,788
BIO CardsBIO Cards
Bio Cards so Patients can put a face with a name and to promote our Team!
Taking It to the Next LevelTaking It to the Next Level
• Expand Team Care at Strongsville to include 6 Family Medicine Physicians
- 6 MA/MA/MD Teams
- 1 more in 2014• Transform 1 in 4 primary care practices to Transform 1 in 4 primary care practices to
TeamCare to increase volume; fund care TeamCare to increase volume; fund care coordination and PreVisit MAscoordination and PreVisit MAs
• Care coordinators and PreVisit MAs (pre-visit Care coordinators and PreVisit MAs (pre-visit planning, health maintenance and wellness) planning, health maintenance and wellness) support support allall providers providers