Bridge 2 Excellence: Patient Centered Medical Home

Implementation A joint venture with GIM and RISE

Patient Perspective

Wait!Wait!

2

Patient Acute Service Utilization

3

No Show Impact

4

61% of patients arrive for scheduled appointments

~20% are materially late

Impact not planned for and used effectively

Results in average of 20 minute gap in schedules in nearly 1 of 4 appointments

BMC GIM Physician Productivity

5

Productivity higher than expected at 8 visits / session

Significant process barriers prevent higher productivity

Patient no-show and reschedule rates are material

Low average sessions per provider per week result in limited access for patients

All identified barriers are addressable, and expect 12 visits per session is attainable

Future State of Primary Care

Key Drivers Payor Consolidation Continued downward pressure on

costs Payment Reform

Move from transaction based payment to payment based on outcomes

Global payment demonstrations, ACOs

Penalties for readmissions, admissions for ambulatory sensitive conditions

Accountability for health of population Fewer publicly insured patients in

FFS arrangements Once insured, patients have choices

and vote with their feet Clout matters – volume brings scale

and negotiating leverage

Future Requirements Primary care should be “front door” to

system; must be welcoming and responsive to patient needs

Practices should be patient-centric Need capacity in practices to see new

patients and existing patients with urgent needs

Patients need continuity when their physician is not available; care teams become critical

Teams can be accountable for a panel of patients; they have to be a size that people know one another and patients know who to call

Need short cycle information and metrics

Need system of leadership and accountability that is supported by training, tools and measurement

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Transforming Primary CareA Comprehensive Approach

What Is Needed

Create Capacity

Measure and improve clinical quality and enhance patient experience

Design and organize care to improve outcomes and lower costs

How Is It Achieved

Extend the physician through allied professionals and “virtual visits”

Move tasks to the most appropriate member of the care team

Use technology to eliminate work

Continuous data analysis leading to proactive patient outreach

Consolidated data leads to more effective and focused visit

Focus on patient experience at every point of contact

Create and manage to a customer-specific Medical Cost Action Plan

Build evidence-based protocols into the process

Inform patients so they are active participants in care decisions

What does all this mean?

First emphasis should be on unleashing capacity Improvements in quality and cost will follow Improvements occur primarily as a result of focusing on process and

accountability Unwarranted variability must be eliminated to support effective flow

Will require a fundamentally different process Incremental change will not yield the transformation needed Leadership development is key to transformation and sustainability May need to evaluate reward and incentive structures In this unique environment, patient panels must be owned by care teams, not

individual physicians

Possible to substantially increase visit and patient volume Double capacity of visits and 50% increase in patients not inconceivable Of value today and in ACO environment

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Two initial areas of focus

Create a dedicated care team with clear accountability and goals

Team means more than group of people sharing rooms

Team is accountable for a panel of patients

Each team a has part-time medical director, full-time practice manager, practice assistants, check in-check out, and nursing resources available

Team held accountable for clearly identified metrics

Create technology-enabled team designed to contribute to the care experience and support the practice

Emphasis on completing as much as possible in advance of visit

Optimized scheduling

Pre-visit prep including eligibility and insurance verification, history of present illness, and med rec

Most of the follow through and care planning activities completed by this team

9

Proposed Scorecard

Stop Light Version

Operationalize Decision• Order Entry • Prescriptions• Pt education

• Letters• Calls• Refill Rx• Results Management

15 min 5 min

• Daily Huddle• Arrive Patient• Collect Copay• Manage Patient Wait• Vital Signs• Room according to Protocol

• Optimized Schedule• Verify Eligibility• Verify Insurance• Med Reconciliation• History of Present Illness• Select Family and Social History• Care Gaps (TBD)• Wellness Gaps (TBD)• Virtual Visits (TBD)

Operationalize Decision• Prior Authorization• Referrals

EMR Optimization• Clinical Protocols (Initial)Existing

support roleNew

extender rolePhysician

Operationalize Decision• Order Entry • Prescriptions• Prior Authorization• Referrals• Pt education

Documentation• Complete Note• Coding

• Letters• Calls• Check Labs• Refill Rx

PatientVisit

20 min 4 min (Est)9 min (Est)

• Presenting issue• Med Reconciliation• History• Physical Exam• Plan• Decide• Update EMR• Begin Referrals

• Verify Eligibility• Verify Insurance• Collect Copay• Arrive Patient• Vital Signs

CarePlanning

Follow-Through

Registration& Room

Pre-visitPrep

• Schedule• Transfer to Practice

15 min 4 min9 minPatientVisit

CarePlanning

Follow-Through

Check-in& Room

Pre-visitPrep

CarePlanning

AFTER Hands on and

dedicated care team focused on efficient patient flow

New Patient Coordinator role takes work off rest of care team

Predictable provider process more readily accommodates patient fluctuations

Provider able to complete “today’s work today”

BEFORE Support team not

focused on effective patient flow

Provider process unpredictable

Provider schedules not flexible to daily patient fluctuations

Provider has significant work carryover beyond scheduled session

A Day in the Life of the Practice (Phase 1)7 min4 min

15 min

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The Extended Care Team

Project Timeline

The Case for Transformational Change

TRAINING KICK-OFF

• 28 New Rise Employees Trained