Whole System Transformation – Built on a ‘new’ Primary ... System Transfor… · Share the...

Whole System Transformation –

Built on a ‘new’ Primary Care

PlatformChanging your practice - what matters most

Douglas Eby MD MPH

February 19, 2009

Today’s Goals� Make the case for system transformation

� Evaluate current improvement strategies

� Establish that primary care is a service industry,

not a product industry – which changes everything

- how you measure success, train, hire, organize,

reward, think.

� Share the SCF Nuka model of care as one

successful redesigned model.

� Provide definition of key medical home concepts

� TIME LIMITED OVERVIEW ONLY!

The SCF Story at ANMC

� Complete system redesign on Native values

� Decrease in ER/Urgent Care over 40%

� Decrease specialty care by over 50%

� Decrease in primary care visits by 20%

� Decrease in admissions and days by over 35%

� Improved health outcomes

� Improved patient & staff satisfaction

indicators

Southcentral

Foundation

Primary Care Has Failed

� The doctor’s office medical model of

primary care has failed in its role in most

locations across the ‘westernized’ world

� The current model most prevalent will

continue to fail – wrong philosophy, wrong

use of workforce, wrong design

� There are people and places redesigned

around different thinking and design!

� Much is known – why not easy change?

What Functions are Critical

� Definitive care of basic conditions

� Health promotion, illness screening and

early intervention, illness prevention

� Primary management of most chronic

conditions

� Coordination, navigation, interpretation,

and advice related to entire health system

System’s Perspective

� Cost effective definitive management when possible

� Minimizing of need for expensive testing, procedures, specialty consultation, and institutional care (hospital, residential)

� Improved population wide health for employment and happy living

� Manage expectations and demands

Failed Primary Care = Failed System

� Medical care is too big and too complex

with way too many services, agencies, and

offerings to be left uncoordinated and

without a strong navigator/coordinator role

� Doctor-centric Medical Model primary care

has failed – need to rethink everything

� Poor ‘primary care’ = ineffective system

� Current model actually does HARM.

Potential Harms from Healthcare

� Direct Harm: The Harm of Commission

� Physical harm – over treatment, complications

� Emotional harm – dependency, failure

� Culture of Miraculous Cure

� Indirect Harm: The Harm of Omission

� The Opportunity Cost – the implications of

health care expenditures on other investment

• For workers

• For employers

• For government & society

Can healthcare do more harm than good?

� US - Huge per capita variability in Medicare costs across the country: (LA, NY, Miami, Chicago-high; Seattle, Minneapls, Denver-low).

� US - In higher-cost cities, patients received 60% more care than in low-cost cities

� Likelihood of dying from colon cancer, heart attack, hip fracture higher in higher-cost cities

� In higher-cost cities, the outcomes are no better and in many cases, worse.

� The additional “care” does more harm than good.

Fisher et al. Ann Intern Med 2003;138:273-98.

More harm than good?

� US - Treatment complications accounted for

914,000 hospitalizations in 2000 at a cost of

$19 billion

� US - Hospitalized octogenarians: only 30%

wanted care to prolong life, but 63%

received life-prolonging care including ICU

admits, vents, surgery and dialysis

Deyo and Patrick, Hope or Hype: The obsessionwith medical advances and the high cost of falsepromises 2005, p 33.


� Pulmonary artery catheters introduced 1970 - $2 billion/year. First study showing higher mortality with PA catheters was in ‘87. Use largely ended in ~’00.

� 600,000 arthroscopic surgeries per year (cost of $3 billion/year) were done on DJD of the knee until it was learned that the surgery is no better than sham surgery

Deyo and Patrick, Hope or Hype: Theobsession with medical advances and the high cost of false promises; 2005, p 193


Cardiac care

� CABG surgery

� 10% are inappropriate, and 15% more may be

� 45% of CABG patients suffer post op cognitive

deficits which often persist

� Angioplasty

� 14% of coronary angioplasties are inappropriate

and up to 50% more might be.

Brownlee, Overtreated: Why Too Much Medicine is

Making Us Sicker and Poorer Chapter 4

McKhann et al, Ann Thoracic Surg 1997;63:510-5.

Health Harm� About 64 million CT scans done in 2005, up from about

12 million in 1990.

� Perhaps 1/3 of CT scans are unnecessary; could be replaced by alternative approaches or not done at all

� CT radiation doses are about 50 times those of conventional x-rays

� 1.5 - 2% of all cancers may be attributable to CT scan radiation

� With 1.5 million new cancer cases each year, and 1/3 of CT scans unnecessary, that means 7-10,000 new preventable cancers cases yearly associated with CT

Brenner and Hall. N Engl J Med 2007;357:2277-84

The Harm of Omission:

The Opportunity Cost

� “Opportunity Cost” is the benefit that

could have been achieved had the money

been spent on something else.

� By spending billions unnecessarily on

health care, not only do we not improve

health, but we must omit those expenditures

from areas where they might actually do

some good.

The Opportunity Cost: Education

(all states, 2006)

0%

5%

10%

15%

20%

25%

Medicaid K-12 HigherEd Transport Corrections

NatNat’’l Assoc of State Budget Officers, 2007l Assoc of State Budget Officers, 2007

�State Medicaid spending (all states) has gone from $89 to $151 billion from 2000-2007.

�Rising Medicaid costs means less money for schools�Reducing grade school class sizes could save as much as

$168,000 per graduate and add QALY to each student. Woolf, JAMA 2007;297:523-6

The Opportunity Cost: Employment: Employer Share of Wages and Salaries

Spent on Health Insurance, 1960-2006

Medicalization of Life

� Cultural expectation of miracle cures from

medicine created and perpetuated in many ways

� Professionalization of clinical providers leading to

expanded dependency and passivity of population

� Expectation of medication answers to many or

most of life’s problems

� Normal range of human variation increasingly

medicalized with clinical labels and attempted to

be modified by pharmaceuticals

� Self care, management of life’s realities

minimized

This is not new news…

� We have known this for years

� The past 20 years have seen an explosion in health quality, safety, and improvement efforts.

� Certification, Auditing, Compliance, Best Practices, Protocols, and host regulatory efforts have been initiated.

� Is it working? Why not?

Transformation Efforts --

A Look Back, a Look Forward

In December - 20th Annual IHI Forum on Quality

Improvement in Health Care

� A cause for celebration, and a cause for reflection

� We’ve come a long way, and we’ve not come very far

When it comes to healthcare reform…

� Would you agree that real change has been slow?

� What are the critical issues for leading real reform?

� What are you doing to drive true reform?

Previous Healthcare Fixes - US

� Think like a business – the market – ’80’s

� Managed Care – 80’s, 90’s

� Safety Movement – 90’s – now

� Case Management 2002-2007

� Some rumblings – Self Care, Community

� Now – Six Sigma, TPS, flow, reliability, spread, bundling, P4P, E.H.R

� Have they resulted in fundamental transformation of healthcare?

A Snap Shot of “Transformational”

Strategies – Current Version

1. Finance Reform2. Consumer-Driven Health Care

� Health Savings Accounts� High Deductible Health Plans� Personal Health Records

3. Information Technology� Electronic Health Records (EHRs)� Computerized Physician Order Entry (CPOE)� Regional Health Information Organizations (RHIOs)

4. Pay-for-Performance5. Competition6. Six Sigma7. The Medical Home

There is - formal or not, stated or not - theory behind each of these. What is the theory, and is it based in data?

The Hype Cycle: Impact of Irrational

Exuberance

Time

Expectations

Real Progress

Trigger Peak of Inflated Expectations

Trough of Disillusionment

Slope of Enlightenment

Plateau of Productivity

Adapted from Gartner Research

Cycles of Hype

Healthcare…. caught in cycles of hype?

WHY?

CDHC, P4P, EHRs, RHIOs, HSAs, PHRs, PCMH…

Overall: An extremely brief

statement of the problem

Healthcare in the US (and many other countries)

� Too costly – society, employers, uninsured

� Many not covered

� Not implementing best known proven care

� No system design

� No common product

� Minimal coordination of care

� Each ‘piece’ optimizing their finances

� Patient passive, family not acknowledged

The result of current efforts

� Medical Model – not questioned

� Each piece of healthcare optimizing their

financial position – very sophisticated

financially and bankrupting society

� Better, faster, safer version of what we have

– no fundamental change

� - Berwick Car Analogy -

Current State - Healthcare Reform

� No clearly articulated, shared objectives

for health care

� No agreed upon model for health system

design

� Little aggregate action focused on the

overall stewardship of both health and

healthcare

Lacking direction, healthcare reform efforts frequently proceed in opposing directions or focus on non-system solutions.

Patients

Hospital Services

Primary Care

Social ServicesSpecialists

Mental Health

Health System Design

How would you organize these components to produce optimal outcomes, and why?

Draw a diagram that shows them all in relationship to each other as an intentionally defined system.

PublicHealth

AncillaryServices

$0

$500,000

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2006, $2.2 Trillion17% of the GDP

We have a choice

� Narrow healthcare expenditures back to narrowly defined illnesses caused by infectious agents or fixed by operative cures – and give back 70% of the money

� OR

� Redesign what we are doing to affect that 70% that is neither infectious disease nor easily fixed operatively

Control: Who really makes the decisions

Acuity

“Control”

The “System”

Patient/Family

0Low High

100

1. Control – who makes the final decision influencing outcome?2. Influences – family, friends, co-workers, religion, values, money3. Real opportunity to influence health costs/outcomes – influence

on the choices made – behavioral change4. Current model – tests, diagnosis, treatment (meds or procedures)

Southcentral

Foundation

What we are Taught – Diagnosis,

Medications, Procedures

� Medical Care Process

� Signs and Symptoms – history and PE

� Leads to Differential Diagnosis

� Leads to ordering tests for more info

� Leads to Definitive Diagnosis

� Results in medications, procedures, and advice

� Then we are finished until the next visit

� This is what our work is understood to be, the product of healthcare as we learned it and as we still teach it. Southcentral

Foundation

Analogy - Hitting the target…

� If you are in a mechanical, manufacturing

environment then hitting a target is a matter

much like the throwing of a rock – figuring

out speed, trajectory, etc.

� If you are in a messy, human, complex,

adaptive environment – it is like throwing a

bird at a target – it is all about the ‘attractor’

� All of healthcare throws birds at targets and

only thinks about the throwing part…

Reality – various ‘platforms’� Healthcare has several ‘platforms’

� ICU/ER/OR – high tech, linear, mechanical

� Procedures – linear, mechanical

� Consultative – time limited, acute issue focused

� Longitudinal relationship over time – chronic conditions, outpatient, residential, behavioral health, primary care

� One size does not fit all – first two are product, manufacturing efforts – second two are service and knowledge efforts primarily

Reality� Health is a longitudinal journey

� Across decades

� In a social, religious, family context

� Highly influenced by values, beliefs, habits, and many ‘outside’ voices.

� Office visits are brief, reactive stop-gaps

� Hospitalizations are brief, intense interruptions

� MUST fix basic, underlying primary care platform first or nothing else will work well

Purpose of Primary Care

� We are a Service Industry – NOT a product

industry – coaching, teaching, partnering

are central – pills and procedures supportive

� Changes what we think we do, who we hire,

how we train, how we structure, how we

reward, and how entire system is

constructed as a system.

� We must optimize relationship – personal,

trusting, accountable – minimize barriers

Rethinking the basic platform

� If the goal is population health over time

� The major variables we can affect relate to chronic conditions, habits, choices, optimizing impact of treatments.

� Then…the backbone MUST be effective, longitudinal, personal coaching, teaching, supporting, coordinating relationship.

� Office visits, procedures, hospitalization become episodes of care only.

What’s the Data Show? Even with

medical model primary care…

“States with more general practitioners use

more effective care and have lower

spending, while those with more

specialists have higher costs and lower

quality.”

Baicker K, Chandra A. Medicare Spending, The Physician Workforce,

And Beneficiaries’ Quality Of Care. Health Affairs, 2004.

0

0.5

1

1.5

2

1000 2000 3000 4000

Per Capita Health Care Expenditures

Pri

mary

Care

Sco

re

Primary Care Score vs. Health Care

Expenditures, 1997

Starfield 10/0000-133

US

NTH

CANAUS

SWEJAP

BEL FRGER

SP

DK

FIN

UK

Starfield 10/00IC 1731

Relationship between Strength of Primary Care

and Combined Outcomes

0

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10

12

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Outcomes Indicators (Rank)

Pri

mary

Care

R

an

k* USA

GER

BEL

AUS

SWE

SP

CAN

FIN

UK

NTHDK

*1=best11=worst

Starfield 1999IC 1433

Individual/Family

Consultants

Social Services

Hospital Services

Public Health

Evidence-Based Health System Design

Community Resources

Medical Home/Care Team

Note: The “Medical Home” is likely not the “primary care” that we currently have. The Trust for Healthcare Excellence’s Better Health Initiative

Whole System Design

� Changed, effective primary care is needed

to make basie healthcare better, BUT it is

also THE critical step to transforming the

entire healthcare system.

� All other components of healthcare MUST

then redesign themselves in coordination

with, and in support of, primary care.

� This is NOT the primary care we currently

have in most health systems.

Individual/Family

Consultants

Social Services

Hospital Services

Public Health


Community Resources



‘Medical Home’ – is it enough?

� AAP, AAFP, ACP, AOA – ‘The patient centered medical home is an approach to providing comprehensive primary care for children, youth, and adults. The Patient Centered Medical Home is a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family.’

NCQA Medical Home

� Personal physician

� Physician directed medical practice

� Whole person orientation

� Care is coordinated or integrated

� Quality and Safety

� Enhanced Access

� Payment Change

Huge advance, but incomplete?

� Pt as individual, family not emphasized

� Physician emphasis, limited integrated team description

� Process more than functions or outcomes

� ‘Primary care’ not defined in much detail – no real change required!!

� Little on the role relative to rest of the system – relatively unaddressed

IHI Triple Aim – ‘new’ focus

� The Triple Aim

� Improved health of a defined population

� Reduced per capita cost

� Improved experience of care

� Structure

� Macro system Integrator (Health Plan, HMO,

employer, government)

� Micro system Integrator – primary care,

medical home – coordinate care

Three Dimensions of Value

Population

Health

Experience

of Care

Per Capita

Cost

Design of a Triple Aim EnterpriseDefine “Quality” from

the Perspective of an Individual Member

of a Defined Population

The “Triple Aim”

Health Care, Public Health,

Social Services

Per Capita

Cost Reduction

Integration

System-LevelMetrics

$E

PH

Definition of

Primary Care

50

Patients and

Families

Population Health

Management

Triple Aim Struggles

� Health of a population over time

� Current Medical Model will not succeed –requires complete redesign of primary care

� Triple Aim Teams struggling with:

� US Teams – defined population addressing health over time

� All - Effective whole system design

� All - Redefining backbone as longitudinal relationship – service industry

Triple Aim Design Components

1. Individuals and families

2. Redesign of “primary care” services and

structures

3. Population health management

4. Cost control platform

5. System integration

Who will be the Macro-

Integrators?

� Macro-Integrators – responsible to see that the

overall system has all services needed.

• Employer

• Government Agency

• Health Plan

• Community, County

• School

• State, City, County

Who will be the micro-

integrators?

� Micro-Integrators – coordinators and

integrators of care for the individual patient.

• Primary Care clinician

• Behavioral Health clinician

• Social Worker

• Lay Worker

• Family Member

• Self

• Church? School? Community Center?

TA - Redesign of “Primary Care” Services

and Structures

� Core Purpose – longitudinal relationship – service - teaching, coaching, partnering

� Have a team design for basic services that can deliver at least 70% of the necessary medical and health-related social services to the population.

� Deliberately build an access platform for maximum flexibility to provide customized health care for needs of patients, families, and providers.

� Cooperate and coordinate with other specialties, hospitals, and community services related to health.

Components of Medical Home� Level One: Caring for a defined population or list – new goal

� Defined list – patient panel, registered list – and responsibility for the list of patients;

� Ability to generate disease registries (ideally computerized); ability to track requirements for effective intervention; longitudinal coordinating relationships

� Level Two: Delivering barrier free team-based care – new structure� Care delivered by a team – not all doctors; all working at the top of their license;

� Same day access – delays in access will divert to other care locations. Provision for ‘ad hoc’contacts – e.g. after hours phone access, urgent-care/walk-inn visits, email?

� Mind and Body back together – imbedded behaviorists

� Level Three: Redefining relationship to specialty care – new relating� Redefinition of role of specialists relative to primary care;

� Movement of care from just illness care to include secondary prevention (optimal management of already existing health issues).

� Level Four: Shifting to delivering “health” rather than “disease care”� Effective incorporation of primary prevention, including connectivity to other community

resources.

� Becoming truly customer driven more completely, self-care, family-care

Now IHI has a model to generate

real system discussions…

And the possibility of real system transformation….

But it is still not easy at all….

Just Do It… Why not?

� Why not take the best known practices and

design a system?

� Why not spread this system everywhere and

reap the benefits?

� Why has this not already occurred?

�Why is this so hard?

Difficulties

� Unquestioning belief in the medical model and professionalism

� Firm basis in science, technology, industrial manufacturing models, body as physical

� Many people making a whole lot of money in current system – as independent pieces

� Current system allows/supports/rewards independence and entrepreneurial thinking – no common purpose, framework, principles

� Very weak workforce and management theory, knowledge, skill in healthcare

So, then isn’t the answer…

� Standards, Protocols, Best Practices

� Decision support, information availability

� Financial systems that pay for the right

thing

� Limiting access to expensive things

� Single payer, Proven single model of

delivery

Complex Adaptive Systems

� Simple grid – Certainty and Complexity

� High Certainty and low to medium complexity

– agreement possible, protocols defined –

assembly line approach usually works

� High complexity and low certainty (most of

healthcare) – manufacturing approaches do not

work – protocols ignored

Complex Adaptive Systems� Theory says – reality is often complex and human

and messy. That the number of variables and how

they interact is nearly infinite. That humans as the

deliverers of the product (service) are imperfect and

variable.

� Theory says – the best you can do - a simple set of

rules/principles that are strongly adhered to.

� Healthcare – ultimate complex adaptive system – sick

people that are highly variable, service as main

product, human delivery system.

So…where are we? Established…

� New Platform – Service Industry Primary

Care – longitudinal relationship – partnering

� New Models for whole system designing

� We don’t need a ‘better car’ only or mostly

� Care Model Redesigned, Triple Aim

� Understanding of Complex Adaptive

Systems and consequences for managing

and designing

� And one more – Customer IS in Control

What is in our way…

� Low certainty, high complexity

� No agreement on purpose, principles

� Tinkering won’t do – fundamental, transformational change required – inertia

� Huge money incentives to not change

� Customer and system belief in medical model, science, physical cures, professionals

Reality – various ‘platforms’� Healthcare has several ‘platforms’

� ICU/ER/OR – high tech, linear, mechanical

� Procedures – linear, mechanical

� Consultative – time limited, acute issue focused

� Longitudinal relationship over time – chronic

conditions, outpatient, residential, behavioral health,

primary care

� One size does not fit all – first two are product,

manufacturing efforts – second two are service

and knowledge efforts primarily

� WE MUST fix the backbone first – primary care

– and optimize the size of the first three

Patient and Family Perspective…� Customer-owner – they give me what I and my team

have defined I need when, where, and how I want and

need it.

� Customer-owner – they really know me and care

about me

� Customer-owner – they listen to me, advise me, and

support me on my entire health journey

� Customer-owner – my questions and concerns are

answered, my care is coordinated, my values and

goals are what drive my health plans

The SCF Nuka Model - briefly� Defining the purpose – relationship over time

� Understanding complexity science - principles

� Moving from product to service as the

fundamental base of entire system

� Optimized primary care with redefined entire

system on that ‘new’ backbone/platform

� Customer driven design – reallocation by

design of power and control at every level

� Optimizing messy human relationships

Alaska Native Medical Center

� 150 Bed Hospital

� Over 400,000 outpatient visits last year

� Local primary care, regional community

hospital, and tertiary care statewide hub

� Level II Trauma Center, Magnet Status

� Combined project of SCF and ANTHC

� Full system – includes medications, etc.

Southcentral

Foundation

Southcentral Foundation� 25 years of history

� Innovative, relationship based, customer driven systems

� 1,400 staff

� 45,000 local clients plus 10,000 in over 50 remote villages, some statewide services for population of 145,000

� Poorly funded by I.H.S. with no increases

� Rapidly expanding population (7%/yr)

Southcentral

Foundation

Southcentral Foundation

� Medical Services – Primary Care, Women’s Health, Pediatrics, Optometry, Urgent Care

� Dental

� Behavioral Health – clinics, residential treatments, after-care, youth, elders

� Family Wellness Warriors – abuse and neglect treatment and prevention

� Tribal and Traditional Services

Southcentral

Foundation

Where we used to be…1997

� Comprehensive budget, employed staff

� Weeks to months to get appointments

� Most acute care in ER – with 4-8hr waits

� Little coordination of care in system

� Impersonal treatment by staff often

� Different provider each visit – retelling

story over and over

� Sent all over the facility for services Southcentral

Foundation

Old System – unhappy patients

� Doctors giving confusing and sometimes

contradicting advice

� Lots of medicine

� Sent to different locations all over the

hospital for one visit

� Had to retell health history every visit

� Appointments weeks before being seen

� Health is not improving

Doctors & nurses complaints

� Patients don’t follow instructions very well

� Patients don’t seem to pay attention well

� Often want natural or traditional herbal medicines

� Government programs don’t pay enough for the visit and doesn’t pay for the ‘right’ medications.

� No time in the visit to deal with all issues

� Friction between primary care and specialists

� In-hospital care disconnected from office care

� Health status getting worse

SCF VISION

A Native community that enjoys emotional,

physical, mental, and spiritual wellness.

SCF MISSION

Working together with the Native community to

achieve wellness through health and related

services.

SCF KEY POINTS

Shared Responsibility

Commitment to Quality

Family Wellness Southcentral

Foundation

SCF Operating Principles

� Relationships between the customer/owner, the family, and provider must be fostered and supported

� Emphasis on wellness of the whole person, family, and community including; physical mental, emotional, and spiritual wellness

� Locations that are convenient for the customer/owner and create minimal stops for the customer/owner to get all of their needs addressed

� Access is optimized and waiting times are limited

� Together with the customer/owner as an active partner

� Integration of services throughout all of SCF. No more islands

Southcentral

Foundation

Operating Principles (cont)

� One seamless system

� No duplication of services or roles and responsibilities

� Simple and easy to use systems and services

� Hub of the system is the family

� Interests of the customer/owner are placed first and the system is created around what works best for the customer/owner

� Population-based systems and services

� Services and systems are culturally appropriate and build on the strengths of Alaska Native cultures.

Southcentral

Foundation

SCF – thinking differently

� Population based premise

� Intentional rethinking of purpose and design of entire system of care

� Implementation of entire integrated system

� Definition as a service industry

� Refocus of core of system on longitudinal relationships partnering over time.

� Public health, prevention, wellness, and medical care in one system

Southcentral

Foundation

Some of our Improvements� Microsystem Optimization -teams

� Primary Care: Physician, RN, Certified Medical Assistant, CM Support, Behaviorist, Dietician, Pharmacist, office redesign

� Behavioral Health: Physician, Master Level Therapist, Case Manager

� Human Resources: HR Generalist and Assistants – Same day service, etc.

� Behavioral Health Consultants

� Standardize Improvement Processes and Tools

Southcentral

Foundation

Parallel Work Flow Redesign

Southcentral

Foundation

Alternatives to Medical Model

� Escape the tyranny of the provider based one on one office visit

� Move beyond professional centric planning

� Move away from linear, sequential activity to parallel, circular, multidirectional thinking

� Integrated teams where each person works at the top of their license.

Southcentral

Foundation

Redefine Work

� Move from episodic, reactive care to long-term relationship

� Move from only one-to-one visits to use of groups, phone, email, fax, home visitors

� Move from doctor-centric to team based approach in relationship

� Move to team based meetings, problem solving

Group Office Floor Plan

Some Improvement Specifics� Advanced Access – appointments when the

customer wants – same day primary care

� Max Packing

� Service Agreements

� Behavioral Health Redesign

� Hospitalists in Pediatrics and Internal Medicine

� Integration of Social Services

� Integration of Health Education

� Optimization of Access to specialists

Some of our Improvements

� Integration of Complementary Medicine and Traditional Healing

� Clinical Pathways

� Case management and chronic illness management� Depression

� Asthma

� Chronic Pain

� Diabetes

� HIV

Workforce Development� Workforce Development

� Up front training for CMAs and Admin Support

� Native professional development

� Hiring Practices – Same Day, behavioral

� Orientation and Mentoring intentionally

� Employee Development Center

� PAP’s, Job progressions, career ladders

� Summer and winter interns

� Key – all staff ‘expert’ in improvementSouthcentral

Foundation

Micro System Optimization

� Example - Front Office• Group Hiring, Same Day Hiring

• Orienting, Training, Mentoring, Career Ladders

• Booking Guidelines and Scripting

• Mystery Shopping

• Open Environment

• Case Management Support Role

• De-Officing Managers

Southcentral

Foundation

Improvements – Data - Information� Measurement and Analysis

� Development of Balanced Scorecards and Dashboards for every department coordinated and connected throughout the organization

� Data walls, Data Mall

� Provider Packets and reports monthly

� Patient Registries

� Web based tools: Health information website for customer/owners and employees; committee manager; planning tool; and training center

Listening to the Customer–10 ways

� Pt driven rather than Pt Centered

� Examples of really listening� Tribal Advisory Groups – VSMT, Nilavena

� Elders Council

� Diabetes, H. Ed, Head Start Advisory

� Traditional Healing Elder’s Council

� Customer Service Reps

� Surveys, focus groups, public forums

� Board, staff, friends, family

� Industry standard written surveysSouthcentral

Foundation

Taking this further….

� What we do now…..

� Vision, Mission, KP’s, Principles lead to….

� Four Corporate Goals lead to…

� Corporate Initiatives lead to….

� Division, committee, dept initiatives lead to…

� Annual plans lead to…

� Individual Performance Action Plans….’

� And all lead to ongoing reporting, dashboards, and

scorecards….Southcentral

Foundation

Every patient has a right to…� Coordinated, integrated, safe, optimized basic health

care services

� Individuals who know them who they can rely on to

answer questions, advise on care issues, and help

navigate the system

� Clear, personalized health plans

� Support in achieving health goals and optimizing

medical treatments, including coordinating care

across boundaries

� All done building upon values and assets of pt.

A robust medical home looks like…

� Customer-owner – they give me what I and my team


need it.


about me


support me on my health journey




Side issue…

Disparities - Cultural Competency� Fundamental Flaw

� System has not changed – inherent values conflicts

� Culture competency is still just a veneer applied to a health system that is based on values that are in fundamental conflict with the cultures in the communities being served.

� In order to truly be Culturally Competent MUST put culture in the center/core and add services to it – not the other way around

Cultural Competency� Characteristics of true cultural competency

� Staff make-up is representative of community – phone, front desk, professionals

� Leadership are from the community – Board, executives, managers

� When, where, how, and by whom services are delivered are mostly determined by the individual and family receiving them

� Self & family care is central

� Individual and family define goals/success

Words matter

� Patient – full of historical baggage

� Patient compliance, non-compliance,

adherence – judgmental, demeaning

� Guilt, Shame, Harassment as motivators

� Techno-lingo – medical-ese

� Impersonal labeling – diagnosis, number

� Arbitrary labeling – diagnosis – BP, gluc

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000F

eb-0

0

Apr-

00

Jun-0

0

Aug-0

0

Oct-

00

Dec-0

0

Feb-0

1

Apr-

01

Jun-0

1

Aug-0

1

Oct-

01

Dec-0

1

Feb-0

2

Apr-

02

Jun-0

2

Aug-0

2

Oct-

02

Dec-0

2

Feb-0

3

Apr-

03

Jun-0

3

Aug-0

3

Oct-

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Dec-0

3

Feb-0

4

Apr-

04

Jun-0

4

Aug-0

4

Oct-

04

Dec-0

4

Feb-0

5

Apr-

05

Jun-0

5

Aug-0

5

Oct-

05

Dec-0

5

Feb-0

6

Apr-

06

Jun-0

6

Num

ber

Em

panele

d .

Family Medicine Pediatrics Total

Primary Care Provider Empanelment Project

Patient Enrollment


Southcentral

Foundation


Visits per 1,000 PCP PatientsUCC Patients

15.0

25.0

35.0

45.0

55.0

65.0

75.0

85.0J

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Day UCC Night UCCSouthcentral

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Visits per 1,000 PCP PatientsER Patients

5.0

10.0

15.0

20.0

25.0

30.0

35.0Jan-0

0

Apr-

00

Jul-

00

Oct-

00

Jan-0

1

Apr-

01

Jul-

01

Oct-

01

Jan-0

2

Apr-

02

Jul-

02

Oct-

02

Jan-0

3

Apr-

03

Jul-

03

Oct-

03

Jan-0

4

Apr-

04

Jul-

04

Oct-

04

Jan-0

5

Apr-

05

Jul-

05

Oct-

05

Jan-0

6

Apr-

06

Nu

mb

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isits

.

Day ER Night ER Southcentral

Foundation


1,400

2,400

3,400

Ja

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Vis

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PCP Patient Cohort Visits to Specialty Clinics

Current Cohort Count:

Cohort: patients empaneled since January 2000

Specialty Clinics: DM, ENT, IM, MH, Ophthalmology, Orthopedics, Surgery, WHC

11,229

Admits per 1000 PCP

2

3

4

5

6

7

8

9

10J

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Ad

mit

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00

Excludes Admits for patients age 0-4 days (newborn) and deliveries within 4 days of admit date

Average Appointments open at 8am

Family Medicine Clinic

0%

10%

20%

30%

40%

50%

60%

70%

80%

Clinic Average

PCP Asthma Patient Hospitalizations

Rate for Patients Age < 18

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

10.0%

19

97

19

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19

99

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ate

# of Hospitalizations among Asthma Pts divided by All Asthma Pts (thus # hospitalizations per person)

Asthma patients are identified by having both an asthma diagnosis and asthma Rx during a given period

Ryan White Program Hospitalizations

0

5

10

15

20

25

2001

2002

2003

2004

Patients Admitted to

Hospital

Family Treatment Visits

Families in Treatment Together

0

20

40

60

80

100

120

140

Ja

n-0

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Fa

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Childhood Immunizations

PCP Patient Immunization Rate

87%

88%

89%

90%

91%

92%

93%

94%

Oc

t-0

2

Ja

n-0

3

Ap

r-0

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Impaneled Patients age 3-27 months immunization rate for DTAP, Hep B; HIB; IPV; MMR

Finishing up...learning in story

� At SCF we are an Alaska Native

organization and talking story, learning in

story, and connecting in story is

fundamental to how we teach and learn.

� Let’s look at the story of two individual

stories given to us by the IHI Triple Aim,

Frank and Darryl, who are very common in

all health systems…

FrankFrank is a 79 year old widower with Chronic

Obstructive Pulmonary Disease (COPD), Heart Failure and Diabetes. He lives alone. Frank is very anxious as he is often very breathless and feels unable to manage. He has phoned the practice of his primary care physician on several occasions requesting a home visit and over the last year he has frequently been taken to the local emergency department, after he has dialled 911. He has been admitted to hospital on 7 occasions in the last year and now keeps a small packed suitcase by his chair.

Frank’s Diagnosis

� COPD

� CHF

� Diabetes

� Frank’s Healthcare providers

� Primary Care, Cardiologist, Pulmonologist,

Endocrinologist, Nutritionist, Physical

Therapist, Pharmacist, Home Health.

Realities about Frank

� Frank IS in control� Getting and taking meds

� Using inhalers

� Eating, sleeping, exercising, socializing

� Calling 911

� Frank is costing a great deal of money

� Frank is getting worse

� No one ‘knows’ Frank

Nuka – a different look at Frank� Primary Diagnosis

� Anxiety, Loneliness/isolation, insecurity,

confusion, dependency, lack of confidence

� Secondary Diagnosis

� COPD, CHF, Diabetes

� Primary interventions

� Personal care coordination, integration of care by

PCP team, determination of motivators,

behavioral based motivational interventions,

consolidation of meds/tx.

Frank - In Hospital

� Visit by PCP

� Coordination by PCP or team of care

transition from inpt

� Medications provided in Mediset

� Learn Frank’s story – identify

motivators, values

Frank - Upon Discharge

� Home Health – front loaded visits

� Home visitor

� Enrollment in day program

� Phone follow-up by PCP

� Begin self monitoring – home scales, log of

activity, etc.

Frank - Clinic Visit

� Customized encounter - health maintenance

reminders, meds, recent history, likely diagnosis

� Personal clinical information

� Clarification of expected future communications –

some ‘push’, some ‘pull’.

� Inclusion in appropriate registries

� Medication Preview by pharmacist

� Track PCP performance and produce timely

individual reminders

Darryl

117

Darryl’s Diagnosis – the ‘usual’

� Diagnosis - Asthma

� Darryl’s Healthcare ‘Issues’

� Parent’s who don’t care

� Parents and child who are ‘non-compliant’

� Family who are probably ‘hopeless’

Nuka - A Different Look At Darryl

� Health experts giving advice and prescriptions

� Darryl’s parents/grandparents really making all

the critical decisions about what really happens

treatment-wise

� All are influenced by their current beliefs, values,

personal understandings of illness and disability,

personal life experiences, gender role

expectations, TV, Internet, family, values, culture

A different look at Darryl� Primary Diagnosis

� Parental inconsistency, lack of unified understanding of cause (incomplete information, differing views of illness), system messaging incomplete and inconsistent

� Secondary Diagnosis

� Asthma

� Primary interventions

� Personal care coordination, integration of care, family caregiver coordination, determination of motivators, use of behavioral based motivational interventions, tx. consolidation

Darryl - In Hospital

� Visit by outpatient provider(s)

� Coordination by PCP

� Whole family care conference with

consensus on cause and treatment and

roles and responsibilities

� Learn family’s story – identify priorities,

motivators, values

Darryl - Upon Discharge

� Phone follow-up

� Begin self care and self monitoring - log

of activity, peak flows, etc.

� Begin self care process involving all

adults, esp father - home measures and

self adjusting of meds

� Identify primary contact over time

So how is Frank…

His life now..

Frank’s life now� Frank attend elder’s lunches, plays bingo, and

teases his elder worker/visitor

� Frank gets his meds in a Mediset and can

describe what each are for

� Frank understands his symptoms, his weight

changes, etc. and knows what to do and when

to call

� Frank knows his doctor and other providers by

name

Frank’s Life Now

� Frank has an end of life plan and has even planned is own memorial service

� Frank has a health plan stating his wants and wishes even when not critically ill –and laying out the way forward

� Frank knows he can get answers for questions he has today

� Frank has not called 911 in nine months and has had only one admission during that time.

Frank

� Frank has a health system where his control

is recognized, encouraged, facilitated and

supported.

� The healthcare system builds on what is

important to Frank.

� He has personalized access designed to

meet his needs and wants

Frank’s Report

� They give me what I and my team have

defined I need when, where, and how I want

and need it.

� They really know me and care about me

� They listen to me, advise me, and support me

on my health journey

� My questions and concerns are answered, my

care is coordinated, my values and goals are

what drive my health plans

Primary Care Redesigned

� Rethinking purpose, workforce, system design, use of data, reward and recognition, technology, setting – everything

� Understanding that control already lies in the hands of the patient and family

� Understanding setting in community, culture, values

� Understanding responsibility to community and consequences of actions and expenditures

Characteristics of a Medical Home

� Level One: Caring for a defined population-list – new goal� Defined list – patient panel, registered list – and responsibility for the list of patients;

� Ability to generate disease registries (ideally computerized); ability to track requirements for effective intervention; longitudinal coordinating relationship

� Level Two: Barrier free team-based care – new structure� Care delivered by a team – not all doctors; all working at the top of their license;



� Level Three: Relationship to specialty care – new relating� Redefinition of role of specialists relative to primary care;


� Level Four: Delivering “health” rather than “disease care”� Effective incorporation of primary prevention, including connectivity to other community

resources.


Level 1 Discussion of What

� Level One: Caring for a defined population-list� Defined list – patient panel, registered list – and

responsibility for the list of patients – longitudinal relationship

� Ability to generate disease registries (ideally computerized); ability to track requirements for effective intervention

� Ability to measure progress against standards� Ability to create call-lists for engaging individuals not

at standards� Ability to be an ‘attractor’ – creating an attractive

enough service that those within the population choose to use your services

� Ability to engage the defined population and create long term relationship with them.

Level 1 Measures

� Number on panel or list

� Number of contacts per year per person

� Match Rate – number of times seen by PCP or Case Manager

� Number of pt driven PCP changes

� Registers or Number per panel with key diagnosis – DM, CHF, Cancer, HIV, Obesity, Tobacco, Learning disability

Level One Questions

� Questions:1. Do you currently have a defined list or population?

How could you move toward this?2. Can you generate disease registries for your population,

and track your effectiveness in delivering optimal care to groups of patients? What would move you closer?

3. How do you prepare your workforce to deliver care for a defined population? How do you propose to do case management and care coordination?

4. What other challenges/opportunities need to be addressed? What measures should be in place?

5. What skills does your system need that it does not have?

6. What could you test by next Tuesday?

By Next Tuesday…

� Defined Population for each care provider

� Disease Registries launched

� Multi-faceted access expanded – add email, phone, extenders

� Define performance standards – create data mall

� Begin process of daily or monthly run charts with performance on key population health measures.

� Make it easy to always see the same provider and/or case manager

� Make it so the care team only sees their assigned patients

Level 2 Discussion of How

� Level Two: Delivering team-based care� Care delivered by a team – not all doctors; all working

at the top of their license; CMA, Nurses, behaviorists, educators, dieticians

� Same day access – delays in access will divert to other care locations. Provision for ‘ad hoc’ contacts – e.g. after hours phone access, urgent-care visits (walk-in center), email?

� Mind and Body back together – behaviorist integrated

� Extenders – home visitors, lay workers, others

� Patient Portal – optimal use of email, self-care

� Development of self-care, family member care coordination, etc.

� Parallel processing rather than rate limiting step

Compilation ‘08 Office Summit� The Integrator (M Home) must -(functions)

� Facilitate self care

� Facilitate care across the continuum

� Be made up of integrated teams capable of

managing physical, mental, spiritual aspects.

� Optimize roles of each team member

� Provide optimal, multifaceted Access

� Listen to customer and act on what is said

� Measure and act on findings

The SCF Nuka Model� Defining the purpose – relationship over time

� Understanding complexity science - principles

� Moving from product to service as the

fundamental base of entire system

� Optimized primary care with redefined entire

system on that ‘new’ backbone/platform

� Customer driven design – reallocation by

design of power and control at every level

� Optimizing messy human relationships

Southcentral

Foundation

Parallel Work Flow Redesign

Southcentral

Foundation

CareOregon Distillation

Looking at SCF Medical Home, CO defined the 5 critical components as:

1. Customer driven care

2. Team based care

3. Barrier free access

4. Integrated behaviorists in primary care

5. Proactive panel management

*The order of implementation was variable*

Level 2 Measures

� Access – same day? 3rd next available?

� % virtual visits

� PMPM visits to ER? Urgi-care?

� Satisfaction ratings

� % on target for prevention and screening – immunizations, cancer screening, other

� % in target for chronic conditions – DM measures, HTN, Chol, CHF, HIV

� BH measures – depression, anxiety, referrals

� Total cost PMPM

� Ambulatory Sensitive Conditions admission rate

Level Two Questions� Questions:

1. Who is on this team? What are their roles?

2. How is the family seen as a member of the team?

3. How important is the idea of mind and body back together – behaviorists on team, etc?

4. Provide same-day access? Alternatives to in-person visits?

5. What other challenges/opportunities need to beaddressed? What measures should be in place?

6. What skills does your system need that it does not have now?


By Next Tuesday…

� Flow diagram of current processes…

� Evaluation of flow diagram for current roles and responsibilities – and evaluation of possibility of changing these – rule: everyone doing only those things that only they can do – work at the top of your license.

� Open discussion as to the co-location and integration of:� Behaviorists, Dieticians, Social Workers, Pharmacists

� Case Managers – and – Case Management Support

� Consider all phone calls directly to care team

Level 3 Discussion of system

� Level Three: Redefining relationship to specialty care – coordinating across the system� Redefinition of role of specialists relative to primary

care – including single backbone of care coordination based in primary care

� Movement of care from just illness care to include optimal management of already existing health issues.

� Service Agreements – written, signed documents between specialties/practices

� Redefining role of specialist to be only consulting, advising, teaching, coaching – seamlessly available

� Implications for locations, availability, care coordination for specialists

� Expand primary care role in hospital discharges

Patients

Hospital Services

Primary Care

Social ServicesSpecialists

Mental Health

Health System Design

How would you organize these components to produce optimal outcomes, and why?

Draw a diagram that shows them all in relationship to each other as an intentionally defined system.

PublicHealth

AncillaryServices

Individual/Family

Consultants

Social Services

Hospital Services

Public Health


Community Resources



Level 3 Measures

� Hospital Re-Admissions w/in 30 days

� PMPM visits to specialists

� Number of service agreements with specialists –and performance measures?

� Rating by specialists off quality and appropriateness of referrals.

� Quality of care measures for specified chronic conditions??

� PMPM high end tests or procedures??

Level Three Questions� Questions:

1. How does a primary care practice determine what services it will provide (make) and what it will refer elsewhere (buy)?

2. Does primary care ‘do’ transitions or is it specialized?

3. How can a primary care practice engage specialty care in addressing the needs of a population? Providing services closer to the community? Co-located?

4. What is the role of the family in integrating care?

5. What needs redesigning in primary care to do this well?

6. Can primary care manage hospital discharges?7. What other challenges/opportunities need to be

addressed? What measures should be in place?6. What could you test by next Tuesday?

By Next Tuesday…

� Open discussion with key, large volume specialists about discussion relative roles and responsibilities

� Begin writing at least one service agreement with one specialist you work with well already.

� Invite one key specialist to open conversation about them doing at least part of their daily/weekly work at your primary care site.

� Identify primary care role in hospital discharges

Level 4 Discussion of Community

� Level Four: Shifting to delivering “health”rather than “disease care”� Effective incorporation of primary prevention,

including connectivity to other community resources.

� Public health measures and responsibilities built into practice

� Primary Care taking lead role for individual, family, and community ‘health plans’ including measures, outcomes, and ongoing responsibility.

� Scope and shape of practice is determined significantly or largely by community through conversations.

� Fully redefining via customer-driven design & priority

� Understanding and acting upon reality that nearly all health funding is community funding

Level 4 Measures

� Quality of Life measures

� Service agreements in place

� Pt reported obstacles due to money, transportation, child care, etc.

� PMPM referral rate ‘in’ or ‘out’.

� % reporting active exercising

� % reporting regular helmet use

� PMPM rate of change in home location

Level Four - Questions� Questions:

1. What works in terms of connecting to community resources?

2. What activities belong in a practice versus other structures/locations?

3. How should the effectiveness of primary care be measured/rewarded?

4. What is the ‘responsibility’ of a private practice to the community? How should the community ‘shape’ it? Is all health money a community good?

5. What other challenges/opportunities need to beaddressed? What measures should be in place?


By Next Tuesday…

� Open discussion with key community leaders and/or organizations about discussing relative roles and responsibilities

� Begin writing at least one service agreement with one community you should work with closely.

� Invite one key community member or organization to open conversation about them doing at least part of their daily/weekly work at your primary care site.

� Identify primary care role in community conversations on funding/planning priorities

Characteristics of a Medical Home

� Level One: Caring for a defined population-list – new goal� Defined list – patient panel, registered list – and responsibility for the list of patients;

� Ability to generate disease registries (ideally computerized); ability to track requirements for effective intervention; longitudinal coordinating relationship

� Level Two: Barrier free team-based care – new structure� Care delivered by a team – not all doctors; all working at the top of their license;



� Level Three: Relationship to specialty care – new relating� Redefinition of role of specialists relative to primary care;


� Level Four: Delivering “health” rather than “disease care”� Effective incorporation of primary prevention, including connectivity to other community

resources.


Workforce – new realities

� Complex Adaptive Systems – all staff must

be engaged, skilled, and ‘owning’ system

� Principle driven management and design

� Human interaction, teaching, motivating,

supporting – partnering – main skill!

� Different managers/leaders needed

� Training, rewarding, advancement changed

Workforce: Nuka Skill Development

Three Areas of Competency for All:1. Connecting Deeply in Story - Relationship

1. Nuka Core Concepts (Senge S.O.L)

2. Technical Improvement Skills - Improvement

1. Nuka – basic analysis, problem solving, data –PDSA, run charts, control charts, ADLI, dashboard

2. (Brent James ATS training, IHI Imp. Advisor)

3. Alignment, Big Picture, Context

1. Nuka – 4 Ovals, Operational Principles, Scorecard, Annual plan, PAP’s, cascade of functions.

2. (Baldrige Understanding and application)

Workforce: Nuka Team Skills

� Meeting to design, improve, review and

learn – all done in integrated teams

� Job Progressions, Career Ladders

� Formal Mentorship with curricula, goals,

measures, forms, advancement defined

� Network of Directors, Improvement

Advisors, Improvement Specialists,

Program Coordinators

� Work at top of your license

Struggles - ongoing� What is the community responsibility of

health systems to listen? Be designed by

the community? Set priorities for

expenditures?

� One size does not fit all. How do we

customize to population segments?

� Balancing personal choice and care

optimization, balanced with population

driven design

Primary Care MUST change� The entire medical system depends on

primary care working well

� Primary care is a set of functions, roles and responsibilities – not a specific medical discipline

� Most Medical Home designs will not transform the system

� Quality, Safety, Cost, Satisfaction, Outcomes – and Health - depend on PC

� Society’s well being also depends on PC

Ultimately primary care must…

� Have the ability to meet the individual where they are – in terms of self care, family care, values, culture, education, literacy level, social complexity.

� Have the ability to identify motivators, values, impediments to change.

� Have the ability to motivate, inspire, inform, organize, listen, partner.

Ultimately primary care…

� Will not be a ‘Medical Home’ – but a set of

functions and relationships built optimally

into everyday life.

� Will allow for there to be various ways of

providing these functions and relationships

and they will continually improve and

evolve

� Will be learning entities…

Remember…

� THEY ARE in control

� We are a service industry in primary care

� We only have hope in team based

approaches – or v. small pt. panels

� Longitudinal relationship only works with

unimpeded access – time, place, language,

attitude, culture, gender, etc.

� They must define and ‘own’ the goals,

success, what is of value

‘We’ want…

� Optimized overall costs and optimized uses

of all the modern medicine offers

� Good population and individual health

outcomes over time

� Excellent Experience of Care

� Quality, Safety

� Satisfaction, Delight

� Expanded self confidence and pride

In their words…� Customer-owner – they give me what I and my team


need it...in a safe, effective, and optimized way…


about me


support me on my entire health journey




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