Coastal Annual Meeting - Rhode Island Chronic Care
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Transcript Coastal Annual Meeting - Rhode Island Chronic Care
A PCMH Journey
Lessons Learned
Al Kurose, MD
President & CEO
Meryl Moss, MPA
Chief Operating Officer
Coastal Medical
88 doctors, 25 NP’s/PA’s, 20 offices
102,351 patients
Predominantly primary care
Patient Centered Medical Home (PCMH) for 4 years
Accountable care for almost 2 years
Coastal Medical is Selected as 2012
Ambulatory HIMSS Davies Award Winner
HIMSS Davies Award recognizes excellence in use of the EHR
to successfully improve quality of care and patient safety.
All Coastal Locations are Level III Recognized
Patient Centered Medical Homes.
All Coastal Locations Have Achieved Stage 2
Meaningful Use
Patient Centered Care
Thoughtful Execution
Structure combined with flexibility
Communication, information, conversation and feedback
Allocation of correct staff resources
Design workflow that support patient focused care
You must care what patients, staff and physicians think.
Leveraging Technology
Coastal went live in 2006 with eClinicalWorks
Registry reporting
Requires structured data fields
HIT for Patient Engagement & Education
patient portal, social media, website, digital signage
Workflow Changes Begin
Structure data needs to be part of every day work flow.
Structure data required for NCQA & Meaningful Use
Technology can shift work to Physicians…need to shift it
back to staff.
Need to leverage technology to control office work.
The PCMH Team
Committed to PCMH model in 2009
Participation in CSI informed use of Nurse Care
Managers as key to success
Nurse Care Managers embedded in offices
Expanded Pharmacy Services
Pharmacists long time members of the team
Extended PCMH team to hospitals, nursing Homes
and skilled nursing facilities
Shifting Established Roles
Patient in the center of the team
Strong roles for NCMs, pharmacists, nurse
practitioners and physicians’ assistants
Medical assistants working at a higher level
All practice staff now part of patient centered team
Lessons Learned
Training, training and more training
Needed to upgrade the quality of employees
Standardization Required:
Ways to greet patients
Professional demeanor
Uniformed dress
Way to answer the phone
Lessons Learned
Monitoring and surveying everyone’s experience
Concentrate on sickest and most costly patients (5%)
Focus on Transitions
Hospital (2 NCMs, now Pharmacy connection)
Nursing homes and skilled nursing facilities
Telephonic Pharmacy phone calls work too
Improved Patient Experience
Established 1-800 “New Patient Hotline”
Uniform welcome packet for new patients
Patient panels to population management
Every patient is part of our PCMH Coastal community
Coastal 365: Weekend, evening and holiday access
Added Extenders
ER Communication required new workflow
Evaluate Progress
Patient Satisfaction Surveys
Employee Satisfaction Surveys
Provider Satisfaction Surveys
Brainstorming Sessions w/PCMH Teams
Practice Assessments
What Did We Learn?
Highly Satisfied Patients: Few opportunities for
improvement.
Highly Satisfied Employees: Opportunities for
improvement:
Increase ability for Medical Assistants and
Secretaries to contribute to the clinical team
Improve staffing ratios to allow practice staff to spend
additional time on patient care processes
Practice Assessment Results
What we Learned:
Antiquated workflows
Not enough support staff for patient centric processes.
Need for new process maps for all visits
Physician visit
Medical Assistant/Nursing visit
Laboratory visit
Need new process for pre-visit planning:
Emphasis on test and laboratory follow-up
Physicians have too much work!
Here are some comments:
Biggest Challenge is:
Finishing at a reasonable hour
Time management and flow
Time spent is arduous
Trying to meet different requirements by different
entities
Too many more tasks required to care for patients
Just completing the vast amount of work
Too many data points to worry about
Our Next Steps
Redesign of office practice work flows
Change in roles and responsibilities
Increase and realignment of staff
Roll out of new training and education
Reduction in physician only tasks
Patient Centered Programs
Lessons Learned
Al Kurose, MD
President & CEO
ER Communication Pilot:
The Program
At Miriam and RIH
UEMF, Lifespan, BCBSRI, Coastal
Wristband at registration
ER calls MD about every patient
Single 800 number for all Coastal patients
On call doctor has access to EMR
ER Communication Pilot:
Lessons Learned
It takes time for a pilot to gain traction
It’s been good to work together
Docs don’t like 3 AM calls for a sprained ankle
Every Coastal office now holds open an 11 AM
This program is improving patient care
Pharmacy Management:
The Program
4 Full time clinical pharmacists (PharmD’s)
Telephonic Cardiac Risk Reduction
In-person Medication Therapy Management
Telephonic brand to generic: $1.2 M annualized savings in
first 5 months
URI College of Pharmacy residency training site
Pharmacy Management:
Lessons Learned
Telephonic is effective
Medication Therapy Management visits are great
Brand to generic is low hanging fruit re: managing cost
It is great to work together!
Med Rec for MA’s:
The Program
Led by Sarah Thompson, PharmD at Coastal
Curriculum development w URI College of
Pharmacy
Certificate program through CCRI
Four two-hour sessions
Med Reconciliation Curriculum
1. Recognition of top 100 Drugs
2. Basic pharmaceutical calculations
3. Common prescription abbreviations
4. Process for performing medication reconciliation
5. Understanding drug information resources
6. Assessing patients for medication adherence
Med Rec for MA’s:
Lessons Learned
It was good to work with the College of Pharmacy
Separate training for pediatrics and FM
Focus more on EHR ‘basics’
More practical pharmacy calculations
Less disease state education
3 sessions instead of 4
Palliative Care and Hospice:
The Program
VNHC and HHCRI
Two in-service visits to every office
Utilization:
Q4 2011: 0 pts. in palliative care, 11 pts. in hospice
Oct. 2012: 13 pts. in palliative care; 67 pts. in hospice
Jun. 2013: 38 pts. in palliative care; 68 pts. in hospice
Length of stay in hospice:
7 days when we started; 21 days now
25-30 days is optimal
Palliative Care and Hospice:
Lessons Learned
We were underutilizing these services
In-service visits to our offices were valuable
Screening tool for palliative care is useful
It’s been good to work together
Streamlined process with a single organization
beneficial
Quality Measures:
The Program
69 measures across 5 contracts
Currently all amenable to automated queries
Monthly exception reports to every practice
“Sink or swim” as a group
Compensation is tied to performance on quality
BCBSRI Adult Quality Targets
Quality Measures:
Lessons Learned
Standardization of documentation takes effort
Closing gaps in care requires workflow and resources
Perceived performance generally exceeds actual
Full time EMR trainers are valuable assets
Quality improvement requires more staff
What is “Accountable Care”?
It’s care in pursuit of the Triple Aim:
Better population health
Better care (Quality, experience of care)
Lower per capita cost
It’s usually care under a shared savings contract
Accountability for total cost of care
Risk adjusted budget
Quality measures that impact payment
+/- Infrastructure support
ACO’s
“Public” versus “private” ACO’s
Public
Pioneer ACO’s
Medicare Shared Savings Program (MSSP)
Private:
BCBSRI Shared Savings
UHC, others
ACO Models:
Hospital centric
Multispecialty
Primary care driven
Coastal: A “Primary Care
Driven ACO”
Coastal is “all in”:
Most ACO’s still single payer
Coastal: 5 shared savings contracts
Cover the majority of our patients
Shared savings contract features
Shared savings opportunity
Quality targets that impact shared savings
+/- Infrastructure support
ACO Infrastructure
Chief Medical Officer
Directors: Analytics, Practice Management
Staff: analytics, IT, communication, EMR trainers
17 Nurse Care Managers embedded in practices
2 Nurse Care Managers in hospitals, one in SNF’s
4 Clinical Pharmacists
New Analytics and Care Registry Platform
We are building a new set of core competencies
ACO: Lessons Learned
Autonomy vs. standardization: an important trade off
Fee-for-service incentives persist in shared savings
Overhead allocation matters: more staff = less income
Understanding total cost of care is difficult
Timely actionable cost data is hard to come by
Doctors and patients need to know prices
ACO’s require new types of expertise
The new infrastructure required by ACO’s is significant
Coastal’s Perspective
Value is being redefined in healthcare. That’s good.
30% waste in the system is a huge opportunity.
Incentives matter.
We think accountable care will work for us.
Patients love it already.
The long view: Work on health, not just healthcare