Download - Peter Person

Medical Technology Leadership Forum

“The Role of Integrated Systems ……Combining Technology and

Structure…to Improve Value”

Peter E. Person, M.D.Chief Executive Officer

October 15, 2007

Overview

1. Introduction…Where has the Arms Race taken us?

2. Critical Elements of/to Successful Integrated Care

3. Overview St. Mary’s/Duluth Clinic Health System (SMDC)

4. Role of Structure/Technology and Collaborative Practice Teams to bring Value

5. Example(s) of Value Creation

6. Future Direction

Current U.S. Health Care Reality…

PatientPatient

Fragmented U.S. System…Non System

OrthopedistCardiologist

Dermatologist

Gynecologist

Gastroenterologist

Chest pain

Pap Test

Rash

Stomach Ache

Knee

ache

Health Care Costs, 2002 (in US $s)

$2,930

$2,820

$2,740

$2,520

$2,160

$2,080

$5,270U.S.

Canada

Germany

France

Sweden

U.K.

Japan

$ Per CapitaOECD, 2004

Best care in the world?

Rank of 13 industrialized nationsRank of 13 industrialized nationsLow birth weight %

Infant mortality

Years of potential life lost

Age adjusted mortality

Life expectancy @ 1 yr

Life expectancy @ 40 yrs



Average for all indicators

BestPoorest

(U.S. in Red)

WHO ranks US 3737thth out of 191 out of 191 countries in overall health measures

… With A Dysfunctional Value Proposition

“Our current reimbursement system rewards the wrong behavior……….the worst physicians get paid the

most because they see the patient more often”…Joe

Bianco, M.D. (10-8-07)

Our Belief…..Seven Critical Elements To Successful Integrated Care

(Systems of Care)

1. Mission/Vision

2. Structure

3. Strategy

4. People

5. Support/Technology

6. Incentives

7. Culture

St. Mary’s Duluth Clinic Health System (SMDC) was formed from a

partnership between St. Mary’s Medical Center and The Duluth

Clinic, Ltd in 1997

December 19, 1996

St. Mary’s Duluth Clinic Health System (SMDC)Duluth, MN (2007)

• 4 hospitals with a total of 555 beds

• 18 regional clinics• 450+ employed physicians• 6,000 employees• 850,000 annual

encounters• 40,000 emergency care

and trauma center visits• 22,000 surgeries• 9,700 cardiac procedures

• Non-profit healthcare organization serving a region of 450,000 residents

SMDC Health SystemReflecting the heritage and continuing partnership of the Health Care Ministry of the Benedictine Sisters of

St. Mary’s Medical Center and the physicians of the Duluth Clinic

MissionSMDC brings the soul and science of healing to the people we serve.

VisionSMDC, as a world-class organization, will be the best place to receive care

and the best place to work.

ValuesRespect – We regard all persons with dignity and respect.

Innovation and Excellence – We are committed to innovation and excellence in medical care, education and research.

Teamwork – Our strength is in our people, working together.Stewardship - We wisely and responsibly manage all resources.

SMDC’s Healthcare Network..A Model for Rural Health Care?

TertiaryHospital

Primary Care

Critical AccessHospitals

SpecialtyHospitals

Nursing Services

Nurse On Line

Regional Clinics

SpecialtyPhysicians

PATIENT&

RESIDENT

SMDC Integrated Vision…Bringing Technology, People, and Structure

Together to Provide Value

Building a Health Care Strategy Structured Around The IOM Six Aims

Institute of Medicine Six Aims of Quality Care:

Safe Effective Patient-Centered Timely Efficient Equitable

Internal ProcessesTo satisfy our customers, at which operational & quality processes must we excel?

FinancialTo financially sustain our Mission, on what must we focus?

Vision: SMDC, as a world-class organization, will be the best place to receive care and the best place to work

CustomerTo achieve our focus on Service, Clinical & Operational ExcellenceHow should we appearTo our internal & external customers?

Strategy Defining Value…..SMDC’s Balanced Scorecard/Strategy Map

Copyright © 2008 by St. Mary’s/Duluth Clinic Health System

Service Excellence Clinical Excellence

Operational Excellence

Learning & GrowthHow will we sustain our ability to change and improve as a system?

Mission: SMDC brings the soul and science of healing to the people we serve

We will pursue our mission and vision through a focus on Service, Clinical and Operational Excellence

C1 Quality Relationships• Patient-centered Care • Timely Care• Equitable Care

C2 Clinical Expertise• Effective Care• Safe Care

C3 Customer Value• Efficient Care

P2 Provide easy, timely, coordinated access to health care services

P1 Right patient, right care, right process, best outcome

P6 Optimize physician & staff productivity

P5 Design & implement coordinated care models to effectively manage disease

processes through teamsP7 Excel in efficient & effective operations

P4 Consistentlydemonstrate

personalized, caring,attentive interactions

P3 Investment emphasis to support clinical & financial outcomes

L3 Recruit, develop & retain talented people to outstanding levels of performance to support the Mission

L4 Engage physician leaders & managers as partners in success

L2 Grow & excel in research & education

F3 Optimize system investments F4 Be provider of choice in the Twin Ports

F2 Grow key specialty services, programs & strategic

partnershipsF5 Achieve negotiated increasing

amounts of financial risks for “covered lives”

*Cancer, Cardiovascular, Digestive, Surgery, Children’s Specialty

L1 Develop a high performance culture that delivers world-class care through innovation

F1 Achieve a 3% Operating Margin to sustain our Mission and achieve our Vision

SMDC Organizational Chart…Integrating

Physicians to Create Value

Interdisciplinary Teams At The Core of Value Delivery

Clinic VP Hospital COO

EVP Clinic Division

Physician Division

Chief

EVP HospitalDivision

Section ChairDirector orManager

Nursing Director

or Managers

Accountability- Quality- Service- P&L

Administrative Level

Care LevelAccountability- Quality- Service

Collaborative Practice Teams

Collaborative Practice Teams

• Interdisciplinary groups formed to determine best practice for an assigned patient population

• Responsible for development of tools & care processes that improve clinical quality & customer value

SMDC Collaborative Practice Teams

• Cardiology

• Cardiothorasic Surgery

• Critical Care

• General Surgery

• Medicine

• Neonatalogy

• Neuroscience

• Obstetrics

• Oncology

• Orthopedics

• Pediatrics

CardiologySMDC Heart Failure Program

• Racing to Value with Technology…(with Caveats)

• Approximately 5 million Americans have Heart Failure

• 550,000 new cases annually• Incidence of 10/1000 > 65 years of age• Estimated direct and indirect costs in U.S.

$27.9 billion• Single largest expense for Medicare

(1999-$3.6 billion)• High 1-year mortality rate with 1 in 5 dying

Heart FailureIncidence and Prevalence…

AHA. 2005 Heart and Stroke Statistical Update.

SMDC Heart Failure Program Profile

• Heart Failure outpatient services first introduced in 1999

• Program managed by nurse practitioners in collaboration with cardiologists from the SMDC Heart Center

• Model expanded to Ashland, WI in 2004; Spooner/Hayward, WI in 2005; Virginia, MN in 2007

• Currently the program coordinates care for 989 patients

Why Change Care Delivery?…Value Proposition

• Program born out of honest desire to improve care to this complicated, fragile population

• Traditional medical model did not allow time for coordination of care required of this population

• Traditional model inefficient• Maximizing the use of technology and people.

SMDC Heart Failure ProgramIntegrated Team

• Medical Director - Cardiologist oversight of program, clinical leadership

• Cardiologists-accurate diagnosis, accurate treatment plan

• Nurse Practitioners/Physician Assistant – Disease management, medication management, referral for device therapy, oversight of telescale data

• Registered Nurses- Continual patient education, management of telescale data, phone triage

SMDC Heart Failure ProgramSupporting Roles

• Primary Care Physicians

• Nurse On Line

• Emergency Room Physicians and Staff

• Pharmacy Staff

• Social Workers

• Information Services

• EPIC

SMDC Heart Failure Program Growth

1999• Initial Staff

– 1 Nurse Practitioner (NP)

– 1 Physician (MD)

– 1 Registered Nurse (RN)

– 1 Certified Medical Assistant (CMA)

• 100 Patients Served

2007• Current Staff

– 6 NPs/PAs

– 2 MDs (Directors)

– 6 RNs

– 6 CMAs3 teams in Duluth

3 teams in regional sites

• 989 Patients Served

SMDC Heart Failure Program

• Patients have a cardiology consult prior to entering the program

• 7- 10 office visits with a nurse practitioner in first year (0, 2, 4, 6 weeks; 3, 6, 9 months)

• 4 office visits annually thereafter with an NP

• AT LEAST an annual office visit with a cardiologist and their primary care physician


• Structured educational content

• Team approach to clinic visits

• Quality of life, functional status and depression screening

• In home scale tele-monitoring program for vigilance between office visits

SMDC Heart Failure ProgramCommunity Outreach

• Quarterly Heart Failure Support Group/Educational Sessions

– Designed by Heart Failure Focus Group

– 100+ attendees, patients and relatives

– Various clinical presentations /clinicians

• Quarterly Heart Failure Newsletter – 2000 copies printed


• Tele-monitoring (Telescales)• Home based electronic scales. Patients send

daily weights and survey data to Heart Failure staff

• 175 scales in use. Assigned to the most frail patients

• Staff calls patients when triggers occur• Hold patients accountable for their own care

plan


• RN calls patient – Completes the following:– Nursing assessment – Medication list review– Dietary adherence– Educational needs– Follows diuretic protocol as indicated/or talks with

NP– Makes followup recommendations– Initiates office visit or primary care referral– Care plan monitoring; hospitalization initiation


• Tele-monitoring advantages– Facilitates early intervention and minimizes ER visits

and re-hospitalizations– Improves patient adherence with care plan– Patients get immediate feedback on life style choices– Provides high patient satisfaction– Provides family reassurance– Provides additional opportunity to educate patients– Builds trust between patient and provider

Type of Care Pre-Program6 months

Post-Program6 months

Percent Change

Inpatient $1,149,080 $185,134 -84%

Outpatient $124,884 $125,498 0%

ER $379,852 $66,318 -83%

Prof. Fees $674,428 $706,298 5%

Lab/Radiol $138,781 $118,064 -15%

Pharmacy $124,229 $137,312 11%

Total $2,591,254 $1,338,624 -48%

SMDC Heart Failure ProgramFinancial Outcomes

Pilot with payer N=29 patients $1.25M cost savings

SMDC Heart Failure ProgramFinancial Outcomes

Tele-Monitoring makes financial sense:

• Yearly charges for a remote scale– Rental + Professional Fees

$2,820/year– Compared to 1 hospitalization for heart failure

$6,000/admission

–CONCLUSION: Paying for preventive care and wellness reduces downstream hospital charges and payer costs. Resources are used more efficiently.

SMDC Heart Failure ProgramClinical Outcomes

Sample Study in 200025 patients in the Heart Failure Program

• 82% Reduction in Heart Failure hospitalizations

• 81% Decrease in Length of Stay

• 88% Decrease in ER Visits

SMDC Heart Failure ProgramClinical Outcomes

2006 Data (Currently 815 Patients)

• 7% Yearly Admission Rate

• 2.8% 6-month Re-admission Rate

National 6 month Re-admission Rate is 40-50%

SMDC Heart Failure Program Total Uncompensated Services (n=800)

• Staff $781,750• Research 15,000• Community Outreach 10,000• Telescales 398,800

Total Direct Cost $1,205,550

…The Caveat

Payor “Savings” (n=29 patients) $1,250,000

Total Unreimbursed Costs (n=800 patients)

• Staff $781,750• Research 15,000• Community Outreach 10,000• Telescales 398,800

Total Direct Cost $1,205,550

TertiaryHospital

Primary Care

Critical AccessHospitals

SpecialtyHospitals

Nursing Services

Nurse On Line

Regional Clinics

SpecialtyPhysicians

PATIENT&

RESIDENT

SMDC Future Vision

Questions???