The Engelberg Center for Health Care Reform at Brookings | The Dartmouth Institute

June 6–8, 2012

Third Annual National ACO Summit

Follow us on Twitter at @ACO_LN

and use #ACOsummit.  

Physician Leadership As An Essential Capability for Transformation and

Accountable Care

Mark Werner, MD, CPE, FACPEChief Clinical Integration Officer

Fairview Health ServicesMinneapolis, MN

Fairview Overview• Not-for-profit established in 1906• Academic Health System since 1997

partnership with University of MN• Named a top 10 U.S. health system by

Thomson Reuters (2009)• 22,000+ employees• 2,500 aligned physicians

−

Employed−

Faculty −

Independent

• 8 hospitals/medical centers (1,515 staffed beds)

• 42 primary care clinics• 55-plus specialty clinics• 278-providers included in model• 55 - New Hires since fall 2009• 25 -Attrition since fall 2009

Vital Statistics•

4.8 million outpatient encounters •

80,314 inpatient admissions•

$333.6 million community contributions

•

Total assets of $2.4 billion•

$2.7 billion total revenue

2

One View of Today’s Leadership Challenge

• Creating a sustainable approach to improving health• -health disparities• -aging population• -increasing incidence of chronic diseases• -unsustainable cost increases• Responding to complexity with true system change• -clinical leadership• -sophisticated change management• -community engagement

4

Why is this change so difficult?

•Diminishing returns of existing systems

•Low productivity of new system (e.g. learning curve)

•Early signs of differentiated improvement

•BUT…High uncertainty

Car

e D

eliv

ery

Value-drivencoordinated care

Volume-drivenfragmented care

Discountedfee for service

X

TodayPresent

Episodepayment

Shared savingsmodels

Partialcapitation

Global payment

Past

Future

Payment

• With transformational change comes uncertainty

Operational challenges were expected

5

Change Experience

Change Care

Change Payment

Consumer

Employer / Plan

Provider

Building a Community Capability to Generate New Care Engagement and Payment Models

• Clinic Model Redesign

• Team-based Care

• Care Packages• Virtual Care

• New Physician Comp Models

• Risk Contracts/Gain Sharing

• Moving to Episode/Global Payments

•NetClinic•Virtual Care•Patient Activation•Panel Management

6

What Patients Expect From Physicians Negotiating a New Covenant

Then• Creativity• Intuition• Intellect• Mindfulness• Expert• Advocacy

Now• Compliance with evidence• Consistency/Uniformity• Honesty/Transparency• Understanding• Collaborator• Advocacy

Key Aspects of Culture

• Honest, Forthright, Transparent• Teamwork – about group not individuals• Shared Success – accountable to each other• Physician Leadership – Must be real and

committed • Change, uncertainty, vagueness, learning• Clinical and financial integration- physician

“owner/managers”

Being a Catalyst for Innovation

• Typically 90% of effort is on improving current operations• Need 80% of effort designing the future state- criterion,

outcomes, and performance based• Create internal structures and process that support

flexibility and rapid adaptability• Move from expert leadership to process leadership• Create the “future conversation”

Physician Leadership Effectiveness

Physician Leadership Effectiveness

Physician Leadership Skills

• Listening to diagnose vs. understand• Proactive in the setting of uncertainty and evolving

environment• Ethical centering

Collaborative Leadership Style

• Redefine success from narrow agendas to bigger goals• Involve others: move from autocratic to inclusive decision

making• Be accountable: move from blaming to taking

responsibility• Can be hard for us all, physicians and non-physicians

alike

“Collaboration” by Morten Hansen

Developing Physician Leaders

• Commitment, create authorized roles, support OJT• Create forums for conversation, shared learning, decision

making• Endless, tireless, repetitive conversations• Formal development programs- leadership, management,

finance/budgets, strategy, capital/program decisions• Dyadic model is effective• Continuous re-organizing to align work and operating

model

Not As Simple As …….

• Moving physicians to senior team• Seeking more input• Placing on governing boards• Employing and creating a physician group• Contracting networks• New vision in same old operating company

15

Must Be About …..

• Physicians having decisional authority and its accountability

• Physicians as “owner/operators” of the enterprise• Re-organizing the company to achieve this• Steadfastly focusing on the patients’ best interests as the

core of all decisions and expecting clinical leaders to make this happen

16

Physician Leadership Messages

• Believe in what you do• Be willing to fail• Enable others• Find great mentors

Track 4: Clinical Transformation

Panel 1: Clinical Leadership Characteristics Required for ACO Success

Mark Werner, MD Chief Clinical Integration Officer, Fairview HealthJustine M. Carr, MD Chief Medical Officer and Senior Vice President of Quality and Safety, Steward Health Care System, LLCKenneth C. Wilson, MD System Vice President, Clinical Effectiveness and Quality, Norton HealthcareRandall E. Williams, MD, FACC Chief Executive Officer, PHAROS InnovationsDon Caruso, MD, MPH Chief Medical Officer, Cheshire Medical Center/Dartmouth-Hitchcock Keene (Moderator)

Building Coordinated, PatientBuilding Coordinated, Patient‐‐CenteredCentered Care Management TeamsCare Management Teams

Jim Barr, MDCMO/VP Physician Network DevelopmentOptimus Healthcare Partners ACO

&VP of Medical ServicesAveta Health Solutions MSO

PatientPatient‐‐Centered Care Management TeamsCentered Care Management Teams Keynote AgendaKeynote Agenda

Optimus Healthcare Partners ACO Overview 

Clinical Transformation • Structures• Processes

Care Management Teams• Engagement• Models• Tools & Resources

Summary & Questions

Optimus Healthcare Partners ACO OverviewOptimus Healthcare Partners ACO Overview

• Summit, New Jersey

• 550 Physicians

• Independent Physician Offices

• 180 PCP’s (120 FM/IM)

• Physician Governed‐Directed ACO

• Hospital Alignment/Support

• CMS MSSP ACO (30,000 members)

• Commercial ACO Arrangements

www.OptimusHealthcarePartners.com

Clinical Transformation Clinical Transformation 

•

Why Change & WIIFM•

Team‐Based Office Workflows▫

Patient‐Centered Medical Home Model

▫

Resource: Population Care ManagersPopulation Care Managers

•

Population‐Based Care▫

Proactively Identify & Manage Patient Care Opportunities

▫

Tools: Aveta Patient Registry Aveta Patient Registry and and Patient Care PlansPatient Care Plans

•

Care Coordination & Communication▫

ACP PCMH‐Neighbor Model

▫

Tool: OptimusOptimus

PCPPCP‐‐Specialist Care Coordination GuideSpecialist Care Coordination Guide

▫

Tool: Aveta Health Information Exchange Aveta Health Information Exchange (HIE)(HIE)▫

Program: Optimus PatientOptimus Patient‐‐Centered Care Transitions ProgramCentered Care Transitions Program

Patient‐Centered Medical Home Joint Principles

Personal Provider

Coordinated care - part 1

Practice Team

Whole-person orientation

TODAY’S CARE PCMH CARE

My patients are those who 

make appointments to see meOur patients are those who are 

registered in our medical home

Patient’s reason for visit 

determines careWe systematically assess all our 

patients’

health needs

to plan 

care 

Care is reactive

to the patient’s 

problem and visit time 

available

Care is proactive to meet patient 

needs with or without visits

Care varies

by memory or skill 

of the doctorCare is standardized

according to 

evidence‐based guidelines

Patients are responsible for 

coordinating their own careA prepared team of professionals 

coordinates

all patients’

care

Slide adapted from Daniel Duffy MD School of Community Medicine Tulsa Oklahoma 

25

I know I deliver high quality 

care because I’m well trainedWe measure our quality and 

make rapid changes to improve it

It’s up to the patient to tell us 

what happened to themWe track tests & consultations, 

and follow‐up after ED & hospital

Clinic operations center on 

meeting the doctor’s needsA multidisciplinary team works at 

the top of our licenses to serve 

patients

Acute care is delivered in the 

next available appointment and 

walk‐ins

Acute care is delivered by open 

access and non‐visit contacts

TODAY’S CARE PCMH CARE

Slide adapted from Daniel Duffy MD School of Community Medicine Tulsa Oklahoma 

““Preparing Your Team for  Preparing Your Team for   PerformancePerformance‐‐Based ContractsBased Contracts””

Practice RequirementsPractice Requirements

••

Provider ChampionProvider Champion••

Clinical CoordinatorClinical Coordinator

••

Potential Team MembersPotential Team Members••

OnOn‐‐sitesite

••

OffOff‐‐sitesite••

CommunicationsCommunications▫

Secure E‐Mail, Web‐Based Registry, HIE

▫

Webinars & Meetings

••

Office Project Management PlanOffice Project Management Plan

Optimus Practice Optimus Practice 

Readiness AssessmentReadiness Assessment

Assessment of progress                                   

(enter score 0‐3 in box)*Prioritization of Next Steps                                    

(from date of enrollment)Action Items and Comments

date practice enrolled Sept‐11 Nov‐11 Jan‐12 Jun‐12 Q1 Q2 Q3 Q4 Y2 Y3

Teamwork, leadership & practice 

communication

Practice physician champion named

Practice re‐design team in place & 

meeting regularly

Clinical Coordinator named and 

receiving Optimus training

Team utilizes Optimus performance 

reports, implements CQI, shares best 

practices and demonstrates 

improvement

Communication plan for re‐design 

team, all practice physicians and staff

Practice Readiness Assessment

Clinical CoordinatorsClinical Coordinators

•

Utilize the Patient Registry Patient Registry and HIEHIE

•

Develop goal‐directed patient care planscare plans

••

OutreachOutreach

to patients with gaps in care

•

Coordinate ER, hospital ER, hospital and

home care home care patients

••

CommunicateCommunicate

with office providers & staff

••

Communicate Communicate with other clinical coordinators

••

Coordinate Coordinate office participation in ACO clinical  programs

TeamTeam‐‐Based Office WorkflowsBased Office Workflows••

Morning HuddleMorning Huddle▫

Schedule Review and Visit Preparation 

▫

Care Plan Review

••

PrePre‐‐visit Activitiesvisit Activities▫

Automated orders                            

▫

Screenings and testing

••

VisitVisit

••

PostPost‐‐visit Activitiesvisit Activities▫

Barrier Analysis & Motivational Interviewing

▫

Patient Self‐Management (copy of Care Plans)

CareCare

Management TeamsManagement Teams••

Prioritize Based On:Prioritize Based On:

•

Potential Medical Cost Savings 

•

Validated “Hard Savers”

•

Feasibility of Implementation & Timelines

•

Ability to Measure & Validate

••

Engagement Engagement 

•

Business Case

•

Commitment & Participation•

Performance Management Framework

•

Transparency

Patient Access Patient Access 

•

Office Visit Enhanced Access for ACO members  •

Reserved Appointments

•

Open Access Scheduling•

Extension of Hours

•

Extended Hours•

Evenings

•

Weekends

•

After hours coverage with other offices•

Urgent care options

•

Communications

Care Coordination & CommunicationCare Coordination & Communication

••

PCPPCP‐‐Specialist Care Coordination GuideSpecialist Care Coordination Guide▫

Consultation Requests

▫

Hospitalizations▫

Co‐Management

••

Referral Guidelines and ManagementReferral Guidelines and Management

••

ACO PatientACO Patient‐‐Centered Care Transitions ProgramCentered Care Transitions Program▫

Emergency Room, Hospital, Sub‐Acute, Skilled 

Nursing Facility (SNF), Long Term Care,Home Care

▫

Case Managers, Navigators, Vendors

Emergency Room ProcessesEmergency Room Processes•

Appropriate Utilization Education

•

ER Notification Process•

Sharing of Patient Information

•

Involving ACO Specialists•

ER Patient Follow‐Up•

Office processing of ER reports

•

Clinical coordinator role•

Patient medical record documentation

•

Patient care plan modification•

Coordinating and communicating next steps

Hospital CareHospital Care•

Notification of Admission Protocol•

Appropriate utilization

•

Alternative settings (observation beds/subacute)•

Case Managers & Utilization Managers•

Optimus ACO & Aveta 

•

Health Plan•

Hospital

•

Prevention of Readmission•

Medication reconciliation

•

Post‐hospital visit coordination•

Home care, support

Imagine??Imagine??•

Patient Access & Communication

•

Office Workflows•

Planned visits

•

More time with patients•

Access to Information

•

Appropriate and Efficient Care Transitions•

Trusted Patient Relationships

•

Activated and Engaged Patients•

High‐Quality Affordable Healthcare

•

Physician and Staff Satisfaction

Summary & QuestionsSummary & QuestionsProvide Clarity & Build Culture

Provide Models, Tools & Resources

Performance Management Framework

Team Focus

Thank You,Jim Barr, MD

Optimus Healthcare Partners ACOAveta Health Solutions

Track 4: Clinical TransformationPanel 2: Building Coordinated, Patient‐Centered Care Management 

Teams

James E. Barr, MD CMO and VP Physician Network Development, Optimus Healthcare Partners, VP of Medical Affairs, Aveta Health SolutionsNancy Boerner, MD, MBA CMO, Monarch HealthcareJames Dold, RN, BSN Director of Clinical Performance, New England Quality Care Alliance Susan Kendig, JD, MSN Principal, Health Policy Advantage, LLC; Outside Counsel, Missouri Center for Patient SafetyNeil Calman, MD President and CEO, The Institute for Family Health, Inc., Clinical Professor of Family and Social Medicine, Albert Einstein College of

The Engelberg Center for Health Care Reform at Brookings | The Dartmouth Institute

June 6–8, 2012

Third Annual National ACO Summit

Follow us on Twitter at @ACO_LN

and use #ACOsummit.