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