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Engaging Patients by Automating Population Health
Jennifer Seiden, RN, MHA, CPHQDirector, Quality
Bon Secours Medical GroupRichmond, VA
Fourth National Medical Home SummitFebruary 28, 2012
The 7 Principles of the Medical Home Concept
BSMG Medical Home Clinical Transformation Project
The goal of a PCMH is to improve quality, efficiency, and satisfaction for both patients and physicians. This is done by providing prompt, cost effective, and coordinated access to a comprehensive range of services – to provide a “ System of Care”
To maintain organizational “Alignment” with new revenue lines: “Meaningful Use”, PQRI, HEDIS, ACO
To improve “Capacity and Compliance”
http://www.emmisolutions.com/medicalhome/pcpcc
Physician Time UseaMean Hours
% of Total Workday
Face-to-face patient care 4.7 54.9%Visit-specific work outside the examination roomb 1.3 14.5%
Work outside the examination room related to care of patients not currently being seenb
2.0 22.9%
Other work outside the examination roomc 0.7 7.7%
Total 8.6 100%
• Primary care physicians spend approximately 55% of the average workday on face-to-face patient care
Why Do We Need to Change?
Traditional Methods of Managing Workflow
Provider
Preventive Medicine Intervention
Chronic Disease Monitoring
Medication Refill
New Acute Complaints
Test results
Healthcare Support Team
Care/Case Management
Mental Health Providers
Referral out to Specialists
Certified Medical Assistant
Delivery System – The Care Team
Division of Labor: Use every member of team to highest level of training/licensure/ability Move all possible interventions away from the physical visit – Pre and Post visit encounterEverything comes to the patient Use of Nursing Driven Protocols
Details – Phase 1
Practice assessment and planning Bricks and Mortar review - 3 rms/MDStaff Competency/Policy reviewStaffing and Team formationEquipment and training
Including EMR Optimization and Coding for MD’s
Development of metrics
4 - 5 K Patients
Details – Phase 2
Basic Workflow rehearsalDaily Team meeting - “Huddles”Standard Patient Rooming protocolResults workflowsDisease specific Rooming Protocols
Including POC testing Medication Refill ProtocolINR Management Protocol
Details – Phase 3
Advanced Care NavigationProactive outreach to patients using a registry
we are using Phytel and individualized outreach to certain high risk populations - i.e. discharges, A1c
Use of an electronic web based patient portal for care management - MyChartCase Management/Panel Management
Embedded Case Management - RN Nurse NavigatorsVirtual Case Management RN Nurse Navigators
LPN Panel ManagerDirect Patient outreach for high risk
Fast Track Referral to CDE, MNT, LCSW, Palliative Care, etc
HRA DataHigh Risk Employee
Employee with High Risk HRA Scores and UHC Claims
Claims Data (Optima/UHC)
PCP
YesYesNo
BSMGNone
YesDoes Practice Have RN
Navigator
BSMG RN
Navigat or
Initiates Workflo
wNo
inHealthRN
Navigat or
Initiates Workflo
w
inHealthRN
Navigat or
Initiates Workflo
w
inHealth Navigator
PCP Referral
BSMG
CB
CB
Program Completion
Outcomes/Metrics
Program Completi
on
Outcome s/Metrics
Program Completion
Outcome s/
Metrics
ACO Care Coordination Workflows
Phytel Protocols for Patient OutreachProtocol Name Description Source
Chronic Conditions
DiabetesIdentify patients aged 18‐99 years with a diagnosis of Diabetes Mellitus who have not had a chronic condition
visit‐related charge in the previous 6 months and do not have a visit scheduled in the next 2 months.ADA 2009, AACE 2007,
(Joint) AMA‐PCPI (T1)
Diabetes UncontrolledIdentify patients aged 18‐99 years with a diagnosis of Uncontrolled Diabetes Mellitus who have not had a chronic
condition visit‐related charge in the previous 3 months and do not have a visit scheduled in the next 1 month.ADA 2009, AACE 2007,
(Joint) AMA‐PCPI , (T1)
AsthmaIdentify patients aged 18‐99 years with a diagnosis of Asthma who have not had a chronic condition visit‐related
charge in the previous 6 months and do not have a visit scheduled in the next 2 months.
NAEPP/NHLBI/NIH
2007,(Joint)
AMA‐PCPI,
NCQA (T1)
HypertensionIdentify patients aged 18‐99 years with a diagnosis of Hypertension who have not had a chronic condition visit‐
related charge in the previous 6 months and do not have a visit scheduled in the next 2 months.JNC7 2004, (Joint) AMA‐
PCPI, NCQA (T1)
Hypertension, Malignant Identify patients aged 18‐99 years with a diagnosis of Malignant Hypertension who have not
had a chronic
condition visit‐related charge in the previous 3 months and do not have a visit scheduled in the next 1 month.JNC7 2004, (Joint) AMA‐
PCPI, NCQA (T1)
High CholesterolIdentify patients aged 18‐99 years with diagnosis indicative of hypercholesterolemia who have not had a chronic
condition visit‐related charge in the previous 6 months and do not have a visit scheduled in the next 2 months.ATP III Update 2004rev,
NCQA (T1)
Thyroid DisordersIdentify patients aged 18‐99 years with a Thyroid Disorder diagnosis who have not had a chronic condition visit‐
related charge in the previous 6 months and do not have a visit scheduled in the next 2 monthsAACE 2006rev, NCQA
(T1)
Severe Thyroid DisorderIdentify patients aged 18‐99 years with a severe thyroid disorder diagnosis who have not had a chronic condition
visit‐related charge in the previous 3 months and do not have a visit scheduled in the next 1 month.AACE 2006rev, NCQA
(T1)
Chronic Obstructive
Pulmonary Disease (COPD)Identify patients aged 18‐99 years with a COPD diagnosis who have not had a chronic condition visit‐related
charge in the previous 6 months and do not have a visit scheduled in the next 2 months.
ATS 2005, NHLBI 2005,
GOLD 2008, ICSI 2009,
(Joint) AMA‐PCPI, NCQA
(T1)
Coronary Artery Disease
(CAD)Identify patients aged 18‐99 years with a diagnosis of Coronary Artery Disease who have not had a chronic
condition visit‐related charge in the previous 6 months and do not have a visit scheduled in the next 2 months.
ACC/AHA 2006,
ACC/AHA 2007, (Joint)
AMA‐PCPI, NCQA (T1)
Heart Failure (HF)Identify patients aged 18‐99 years with a diagnosis of Heart Failure who have not had a chronic condition visit‐
related charge in the previous 6 months and do not have a visit scheduled in the next 2 months.
ACC/AHA 2009, HFSA
2006, AMA‐PCPI, NCQA
(T1)
BSMG Dashboard Phytel
May 2010 – April 2011
Total # successful contacts
77,909
# appts scheduled 16,651
% success 21%
Detail on Case Management – Nurse Navigators
1 RN “Nurse Navigator” for every 4-5K pts.Active Case load = 125 – 150“Bat Phone - Beeper” access
Case Management Admission Criteria:Per MDPer Hospital based Case ManagerPer Insurer’s Case Management
Frequency of Touch determined by Level of ManagementDepending on severity index (i.e. RRI) and/or MD
Manage TransitionsDischarge Criteria
Stabilization, goal attainment, MD decision
Nurse Navigator Activities
Hospital Discharge f/uSNF f/uChronic Disease RegistriesHome O2/LabDVI/Lovenox managementSoft CP work upHome IV antibioticsCare/Life Coordination – transportation, housing, food, insurance, etc.
Where can a guy get a little help around here?
An online database of resources pooled from Bon Secours facilities
19
helpgood
Care Team: New Workflow Redesign
Healthcare Support Team
Care Management RN/LPN/MA
Provider Medical Assistant
Behavioral Health
Medical Nutrition Therapy
Diabetes Educator
Nurse Navigator
Medication Refill
Chronic Disease Monitoring
Test results
New Acute Complaints
Preventive Medicine Intervention
Point of Care Testing
Acute Mental Health Complaint
Chronic Disease Compliance Barriers
Totals By MonthTotals For Whole Year
January February March April May June July AugustSeptember
October 2011
Num of Pts139 182 249 550 848 1105 1086 1057 1173 1168
Num of Pts7,557
Already Sched 45 40 74 93 98 40 126 161 248 287
Already Sched 1,212
Appts Sched 59 89 115 271 328 95 103 144 123 162
Appts Sched 1,489
Readmits4 4 8 10 10 22 7 14 13 25
Readmits117
Percentages By MonthPercentages For
Whole Year
January February March April May June July August September October 2011Already Sched 32.37% 21.98% 29.72% 16.91% 11.56% 3.62% 11.60% 15.23% 21.14% 24.6%
Already Sched 16.04%
Appts Sched 42.45% 48.90% 46.18% 49.27% 38.68% 8.60% 9.48% 13.62% 10.49% 13.87%
Appts Sched 19.70%
Readmits2.88% 2.20% 3.21% 1.82% 1.18% 1.99% 0.64% 1.32% 1.11% 2.14%
Readmits1.55%
Nurse Navigator Contacts
BSMG Dashboard: Epic Adoption # E-Prescriptions
Jan 2011 65,536April 2011 73,841May 2011 76,339June 2011 81,686Aug 2011 90,547Sept 2011 94,907Dec 2011 104,438Jan 2012 116,214
BSMG Dashboard: MyChart Patient Portal
Number of “Activated Patients”(Given but not Activated= 94,993)
38.028
Number of “all” messages/week 1427
eRx TAT 11h 37m
Appointment Request TAT 6h 15m
Messaging TAT 9h 24m
Review - The Big Picture
The PCMH, due to its “value” proposition, is gaining momentum
Major role in health care reform legislation under President Obama
Memorial was the first of three practices in Bon Secours to gain NCQA recognition as a Level 3 PCMH
TODAY’S CARE MEDICAL HOME CAREMy patients are those who make appointments to see me
Our patients are those who are registered in our medical home
Patients’ chief complaints or reasons for visit determines care
We systematically assess all our patients’ health needs to plan care
Care is determined by today’s problem and time available today
Care is determined by a proactive plan to meet patient needs without visits
Care varies by scheduled time and memory or skill of the doctor
Care is standardized according to evidence-based guidelines
Patients are responsible for coordinating their own care
A prepared team of professionals coordinates all patients’ care
I know I deliver high quality care because I’m well trained
We measure our quality and make rapid changes to improve it
It’s up to the patient to tell us what happened to them
We track tests & consultations, and follow-up after ED & hospital
Clinic operations center on meeting the doctor’s needs
A 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
Slide from Daniel Duffy MD School of Community Medicine Tulsa Oklahoma
25
Patient & Family
Advanced Primary CareUnder Patient-Centered Medical
Home
Medical Group & Health Care SystemEnterprise Level Activities
Accountable Care OrganizationHospitals• Service Line Integration• Medical Staff Alignment• Incentives for Efficiency & Lean Six Sigma• Quality (SCIP, Leap Frog)• Safety
Medical Groups &Health Care System• Enterprise Level Activities• PC-MH FunctionsSkilled Nursing Facilities
• SNFists• On-site Case
Management• Efficiency Rating Systems
“Preferred Facilities”Ancillary Services• Free-Standing ASC &
Diagnostic Testing Centers
Home Care• Home Safety Visits• Post Discharge Visits• Home Health
Coordinator of Services
Hospice• Transitions
(CHF, COPD, Frailty Syndrome, Dementia)
• PCP/SCP Incentives & Clinical Guidelines• Pay for Performance Initiatives and
Outcomes Measurements• Hospitalists, Post Discharge Follow-Up
Programs
DME• Integration &
Oversight with Care Management
• Outcomes & Evidence Based Medicine
• Call Coverage• Consult Services (Stroke,
STEMI)
• ER Avoidance Programs• Urgent Care• End of Life (Palliative Care)• Patient Satisfaction & Loyalty
• Personal Health Record• Patient Portal• Health Risk Assessment• Patient Engagement &
Activation
• Prevention & Wellness• Point of Care Analytics &
Clinical Decision Support• Gaps in Care• Population Management &
Chronic Care Registries• Home Visiting Teams• Generic Prescribing
Program
• Cost Effective Medical Management & Utilization of Services (SCP, Ancillary)
• Access, Same Day Appointments, e-Visits
• Patient Satisfaction & Loyalty• Provider & Office Staff
Satisfaction
• Care management (Acute, Chronic, Inpatient, SNF)
• Health Coaching (Shared Decision Making)
• Transition of Care• Provider Satisfaction• Behavioral & Mental
Health
Maturing ACOs Payment Mechanism
Questions?
Contact: [email protected]