LOGISTICAL MANAGEMENT OF RAMPING BACK UP FOR RETURN …

LOGISTICAL MANAGEMENT OF RAMPING BACK UP FOR RETURN TO BUSINESS

April 23, 2020

GRATITUDE¡ AOC Celebrates its 15th year

¡ AOC Chairs & CAOs ...COVID 19 Pulse Surveys...especially from the eye of the storm Departments

¡ Membership has grown by 20+% in the last 10 days with Residents and Fellows signing up for their free memberships https://www.aoc-ortho.com/registration/

¡ 700+ Members across 128 University Based Orthopaedic programs

¡ AAOS Leadership Drs. Kristy Weber and Joe Bosco

https://www.aoc-ortho.com/registration/

GRATITUDEAOC = free memberships, free analysis, free webinars, free mentorship network, free best practice

presentations, free special interest groups (i.e. Epic, Cerner, Women’s Leadership Forum)...

This is not possible without generous support from our sponsors.... and I am delighted to announce that Brad Lee, President of Breg has signed a 5 year extension of its support to the AOC.

AOC FOCAL POINTS¡ Immediate Connections, Content, and Context during COVID 19

¡ AOC Women’s Leadership Forum (Happy Birthday to our leader Bobette Patterson!)

¡ AOC Business & Leadership Modules for Program Directors, Residents, and Fellows to prepare for the “business of orthopaedics” and ”navigating the job market”

¡ AOC Opioid Minimization Committee...identifying best practices across the AOC

¡ Due diligence around establishing high-value, cost effective: Recruitment Services; Leadership Development Programs

©BREG, INC. ALL RIGHTS RESERVED. CONFIDENTIAL. NOT FOR DISTRIBUTION. 5


Solution for facilities using telehealth who would like to continue to prescribe DMEPOS products for their patients.

Benefits of Telehealth:

Clinical support: develop workflows for your staff to provide DMEPOS items after a physician or APP telehealth visit, maintains continuity of patient care remotely

Business support: help DME departments maintain operations through logistical support (i.e. drop shipping at flat rate) and up to date communications around compliance.

Patient experience: enable and provide support of patients in the convenience of their own homes with measuring, fitting and delivering bracing and cold therapy products.

Breg Telehealth Support Offering

123


Breg Telehealth Support

Telehealth appointment with

physician

Remote brace evaluation with

specialist

Product drop-shipped to patient’s home

Remote fitting appointment with

patient and specialist

• Telehealth program options:• In-house bracing program (facility does own billing)• Outsourced inventory program (3rd party does the billing)• Direct to Patient


Products for Patient’s with Delayed SurgeriesTotal Knee Arthroplasty, Meniscal Repairs• Patient’s experiencing painful symptoms from OA and meniscus tears • Brace helps manage patient symptoms with unloader braces


Products for Patient’s with Delayed SurgeriesLigament Procedures• Patient’s experiencing some acute symptoms and instability • Brace helps with stability, proprioception, overall compression and support• Able to use post-operatively if recommended


Products for Patient’s with Delayed SurgeriesAll Elective Surgeries: Cold Therapy• In clinical studies cold therapy is shown to reduce pain, inflammation, edema and

narcotic use.¹²³⁴ • May help manage symptoms until they are able to reschedule their surgery• Continue to benefit from post-operative use of the system after their procedure.

1. The efficacy of continuous cryotherapy on the postoperative shoulder: A prospective, randomized investigation Singh H, et al. Journal of Shoulder Elbow Surgery 2001; 10:522-5

2. A randomized prospective study to assess the efficacy of two cold-therapy treatments following carpal tunnel release. Hochberg J. Journal of Hand Therapy 2001; 14:208-215

3. Continuous local cooling for pain relief following total hip arthroplasty. Saito N, et al. The Journal of Arthroplasty; Vol 19; No. 3, 20044. Continuous-flow cold therapy after total knee arthroplasty. Morsi E. The Journal of Arthroplasty; Vol 17; No. 6, 2002


Special thanks to the AOC and all

of its members!

For more information, please contact Jay Subbert [email protected]

TODAY’S ROCKSTAR PRESENTERS

Neil Ravitz, MBAChief Administrative Officer & COODepartment of Orthopaedics, UPENN

Yvette TehanChief Administrative OfficerDepartment of Orthopaedics, U. Rochester

TODAY’S AGENDA

Where to begin?

Quantifying the pipeline and forecasting new business in gradual return

Associating resource requirements (clinic, peri-operative, and associated staffing)

Partnering with institution, faculty, and staff to address

Q&A

Understanding the Impact of COVID-19 Elective Procedure Cancellations on Orthopaedics Surgical Volumes and Ramp Up Implications

M u s c u l o s k e l e t a l a n d R h e u m a t o l o g y S e r v i c e L i n e

April 2020

15Strategic Decision Support

Background‣ During this time nearly all elective Orthopaedic procedures have been postponed‣ Medically urgent cases continue‣ Clinic volumes have been substantially reduced and telehealth visits have been offered

Goals• Determine Impact of Cancelled Cases on the Department of Orthopaedic Surgical Volumes• Determine how long it might take to make up “lost” cases once surgeries are permitted• Understand the impact of various tactics that can be implemented• Use these estimates to start the discussion and develop plans to implement when surgeries and in-

person clinics are re-opened.


Understanding the Impact

Identify the Case Shortfall

�Develop

Scenarios for addressing the Case Shortfall

�


Considerations/Limitations‣ Various levels of retention of exiting scheduled cases are modeled but impact is unknown

• Various factors including loss of sick time, insurance, or financial hardship may prevent a patient from proceeding with surgery

‣ Assumes telehealth visits will generate surgeries at the same rate as an in person visit• Potential exists to identify and schedule patients for surgery during this time that could create additional

demand when surgery is permitted, but true rate is still unknown

‣ Assumes volume of medically urgent patients will remain constant

‣ Scenarios do not take into account the operational considerations such as:• Inpatient bed availability• Supply Availability• Ability to fill clinics if capacity is increased• Availability of clinicians to see patients


Approach – Part 1

Gather Calculate Apply Estimate Identify Project

Background Data

• Historical and current volumes and operational

metrics

Visit ratios

•Ratio of Non Urgent Surgeries

Scheduled to Visits•% Medically Urgent

Ratios

To current visits (in person and

telehealth) volumes

“Lost” Volume

Incorporate estimate of Medically Urgent

volumes into projections

Currently Scheduled Cases

Develop sensitivity analysis to account

for levels of retention of existing

scheduled cases

Generated Cases

From:• ongoing clinic

visits• ongoing

telemedicine visits

Case Shortfall


Avg Cases Per Week % Inpatient

% Outpatient

Medically Urgent% Medically Urgent

Median New Cases Generated Per WeekMedian Non Urgent Cases Generated Per Week

Scheduling Time To Surgery (Median - Days)Scheduling Time to Surgery (Median-Weeks)

Max Cases Per Week (Existing Capacity Proxy)

Gather Background Data

6

max


Background Data, Ratios, and Calculation

Median Visits Per Week (inc POVs)

Ratio of Non Urgent Surgeries Scheduled to Visits

Clinic Visits Per Week during Slowdown

Surgeries Scheduled Via Clinic Per Week during Shutdown

Telehealth Visits Per Week (Proj) during Slowdown

Surgeries Scheduled Via Telehealth Per Week during Shutdown


Background Data (FY20) – Template for UseFoot & Ankle

General Ortho Hand Joints Neuro Onc

Shoulder & Elbow Spine Sports Trauma

Ortho Total

Avg Cases Per Week 330% Inpatient% Outpatient

Medically Urgent 50% Medically Urgent 15%Median New Cases Generated Per Week 308Median Non Urgent Cases Generated Per Week

258

Scheduling Time To Surgery (Median - Days) 22

Scheduling Time to Surgery (Median-Weeks) 3.1

Max Cases Per Week (Existing Capacity Proxy) 419

DefinitionsMedically Urgent - based on allowed cases remaining on schedule from March 16- March 27 (as of 3/24)Scheduling Time to Surgery - based on the time between when a patient schedule surgery and the date of surgeryMax Cases per week - based on the maximum number of cases done in any week in 2020. Trauma and Joints adjusted since the max weeks for these specialties was substantially higher than other weeks.


Background (FY20) and Projections – Template for UseFoot & Ankle

General Ortho Hand Joints Neuro Onc

Shoulder & Elbow Spine Sports Trauma

Ortho Total

Median Visits Per Week (inc POVs) 2,460

Ratio of Non Urgent Surgeries Scheduled to Visits

10%

Clinic Visits Per Week during Slowdown 478

Surgeries Scheduled Via Clinic Per Week during Shutdown

48

Telehealth Visits Per Week (Proj) during Slowdown

123

Surgeries Scheduled Via Telehealth Per Week during Shutdown

13

DefinitionsClinic Visit Per Week During Shutdown based on Completed and Scheduled Visits for 3/16/2020-4/03/2020Telehealth Visits based on 5% of Median Visits per Week

Italics represent calculated metric


Scheduled Cases

Currently ScheduledFoot & Ankle Hand Sports

1 16-Mar 3 132 23-Mar 4 10 303 30-Mar 18 44 534 6-Apr 15 52 235 13-Apr 17 29 206 20-Apr 5 19 157 27-Apr 5 19 98 4-May 5 14 179 11-May 7 17 310 18-May 3 3 411 25-May 3 412 1-Jun 10 913 8-Jun 2 014 15-Jun 3 3 415 22-Jun 2


Ortho Total100% Retention

Retention Scenarios90% Retention 80% Retention 70% Retention 60% Retention 50% Retention

1 16-Mar2 23-Mar3 30-Mar 234 211 187 164 140 1174 6-Apr 440 396 352 308 264 2205 13-Apr 612 551 490 428 367 3066 20-Apr 714 643 571 500 428 3577 27-Apr 825 743 660 578 495 4138 4-May 900 810 720 630 540 4509 11-May 967 870 774 677 580 48410 18-May 996 896 797 697 598 49811 25-May 1020 918 816 714 612 51012 1-Jun 1052 947 842 736 631 52613 8-Jun 1059 953 847 741 635 53014 15-Jun 1083 975 866 758 650 54215 22-Jun 1090 981 872 763 654 54516 29-Jun 1094 985 875 766 656 547

Cumulative Demand ScenariosThe current situation will likely impact the ability of patients to proceed with surgery. To date only 70% of surgeries have been rescheduled which may be a starting point for the impact.


Estimate Ungenerated (“Lost”) VolumeAverage Number of SurgeriesMedically Urgent .Missed Cases Per Week

Cumulative Demand (based on the schedule)Surgeries Generated from In person visits during ShutdownSurgeries Generated from Telehealth visits during ShutdownQueue

Case Shortfall=

++

-


Understanding the Impact

Identify the Case Shortfall

�Develop

Scenarios for addressing the Case Shortfall

�


Approach – Part 2

� � �Identify Operational Changes that can be

made

• Clinic Capacity• OR Capacity

Develop Scenarios based on levels of operational change

1. Increase Clinic Capacity by 20%

2. Achieve Max OR volume (may require in crease in Clinic Capacity)

3. Increase OR capacity by 15% (requires increase in Clinic Capacity)

Factor in Patient Retention

• 100%• 90%• 80%• 70%• 60%• 50%

Sensitivity AnalysisScenariosLevers


Scenario 1

Scenario 2

Scenario 3

Make Up VolumesAvg Cases Per Week 330 330 330Max Cases Per Week (Capacity) 419 419 419Clinic Capacity Needed Per Week 1.20 1.36 1.57Cases Generated Per Week 396 419 482

IP Cases Generated 196 207 238OP Cases Generated 200 212 244

Incremental Cases Per Week 66 89 152IP Incremental Cases 33 44 75OP Incremental Cases 33 45 77

Make Up Cases

Scenario 1: Increase Clinic Capacity 20%Scenario 2: Reach Max OR Volume every weekScenario 3: Increase OR Capacity 15% above Max OR Volume

Scenario 1: Increase Clinic Capacity 20%Scenario 2: Requires Clinic time to increase 36%Scenario 3: Requires Clinic time to increase 57%


Clinic Starts:

Missed Cases

In Person Visits

Tele-medicine

CumulativeSchedQueue

Case Shortfall

Weeks to Make Up Volume

CumulativeSchedQueue

Case Shortfall

Weeks to Make Up Volume

Sc 1 Sc 2 Sc 3 Sc 1 Sc 2 Sc 330-Mar 840 95 26 234 485 7.3 97.0 8.8 164 555 8.4 111.0 10.0

6-Apr 1120 143 39 440 498 7.6 99.7 9.0 308 630 9.6 126.1 11.413-Apr 1400 191 52 612 546 8.3 109.2 9.9 428 729 11.1 145.9 13.220-Apr 1680 238 64 714 663 10.0 132.6 12.0 500 877 13.3 175.5 15.927-Apr 1960 286 77 825 772 11.7 154.3 14.0 578 1019 15.4 203.8 18.44-May 2240 334 90 900 916 13.9 183.2 16.6 630 1186 18.0 237.2 21.5

11-May 2520 381 103 967 1069 16.2 213.7 19.3 677 1359 20.6 271.7 24.618-May 2800 429 116 996 1259 19.1 251.8 22.8 697 1558 23.6 311.6 28.225-May 3080 477 129 1020 1454 22.0 290.9 26.3 714 1760 26.7 352.1 31.9

1-Jun 3360 524 142 1052 1642 24.9 328.4 29.7 736 1958 29.7 391.5 35.48-Jun 3640 572 155 1059 1854 28.1 370.9 33.6 741 2172 32.9 434.4 39.3

15-Jun 3920 620 168 1083 2050 31.1 410.0 37.1 758 2375 36.0 474.9 43.022-Jun 4200 667 180 1090 2262 34.3 452.4 40.9 763 2589 39.2 517.8 46.929-Jun 4480 715 193 1094 2478 37.5 495.5 44.8 766 2806 42.5 561.2 50.8

Ortho Total

Scenario 1: Increase Clinic Capacity 20%Scenario 2: Reach Max OR Volume every weekScenario 3: Increase OR Capacity 15% above Max OR Volume

Scenario 1: Increase Clinic Capacity 20%Scenario 2: Requires Clinic time to increase 36%Scenario 3: Requires Clinic time to increase 57%

Cumulative:Queue

Generated By 100% Retention: 70% Retention:

COVID-19 ResponseYvette Tehan, Chief Administrative Officer

Christopher Blankenberg, Director of Operations

University of Rochester Medical Center

Greater Rochester Area COVID-19 Tracker

Greater Rochester Area COVID-19 Tracker

URMC Ortho Outpatient Clinic Locations weekly volume then and now

LocationsTypical Weekly

VolumeCurrent Weekly

Average Total

Current Weekly Average In-

Person

Current Weekly Average

TelemedicineBuilding D 2,679 1,015 519 496Penfield 354 67 22 44Victor 334 117 77 40Highland Hospital 237 92 12 80Strong West 236 56 24 32Webster 226 18 0 18Greece Ortho 149 42 34 8Brighton Podiatry 134 62 56 6Greece Podiatry 124 29 28 1

33.5% 17.3% 16.2%

Initial Steps• Cancel elective surgeries (1,400+ from 3/13-5/4)• Cancel non-essential outpatient clinic visits (11,000+ from 3/16-4/17)

• Somewhat concurrent launch of phone then Zoom telemedicine visits• Inconsistent mix of in-person and telemedicine visits

• Not efficient, but not a problem while the volume is low

• Initiatives • Re-launched Orthopaedic Injury Clinic in conjunction with Emergency Medicine

• Initial planning for the Building D Procedure Room to accommodate minor trauma cases• Staff Re-deployment cover critical needs

• APP’s to Access Center for phone triage• APP’s and Clinic Staff to cover COVID Screening at clinic entrances• Access Center and Physician Support Staff – WFH• Limited number of staff sent home with pay

• Developed Telephone/Video Workflow with Walk-in X-ray• Walk-in X-ray workflow vital for maintaining Telemedicine volume

• Developed reporting capabilities to track Department, Locations, and Providers

Orthopaedic Injury ClinicIn coordination with

• Med Center Sr. Leadership • Emergency Medicine

Objective• Keep MSK injuries out of the ED

Orthopaedic Injury Clinic • 3 locations

• Central – Building D• Westside – Greece Ortho• Eastside – Victor Ortho/FF Thompson

APP’s Redeployed to manage phone triage

• 600 calls per day – Ortho Access Center• 55 per day - Injury line

Telephone/Video Workflow with Walk-in X-rayTelephone and Video Workflow

Provider PSS In-person Visit Check-OutVideo/Telephone VisitWalk-in X-ray

Review Schedule

Mark each patient with either IP, C, T

V, or X

If X, then indicate what the next visit should be T,

or V

Submit schedule to APP, PSS, and AA

PSS contacts patients

PSS directs patient to CCO, Gre Ortho , Vic.

Walk-in Hours 8:00AM to 4:00PM

Then, schedule either a Video or Telephone visit for after the X-

ray is complete

Is x-ray requested?

Schedule Video or

Telephone visit

Is Video or Telephone requested?

Confirm in-person or

cancelation with patient

Yes

No

Yes

No

Patient Arrives in clinic

Check-in and Rooming actions

completed

Provider evaluates patient and completes

Disposition Notes

Video or Telephone Visit

Arrived

Chart and Zoom/Phone

meeting opened

Provider evaluates patient and completes

Disposition Notes

If in-person

Patient arrives at CCO, Gre Ortho, or

Vic for X-ray

COVID screening is

performed at front door

Rad Tech completes X-

ray

Patient exits clinic

Initially X-rays will be performed as Walk-In visits. The volume will be monitored and a

scheduling mechanism put in place if needed

OAS Reviews Disposition

Notes

Is an in-person or Telephone

follow up requested?

Schedule visit and perform

check out workflow

OAS sends PSS in basket

message

Is Video or X-ray requesed?

Yes

No

Yes

Place order if X-ray or specialty

imaging is needed

Place order if X-ray or specialty

imaging is needed

APP reviews schedule and places order

for any patients with

an X

Patient is directed to

Ortho Check-in Desk

Ortho Check-in performs

eRecord Registration and notifies X-ray that patient has

arrived

Enterprise-Level Reporting

Home-grown Reporting

Recovery Steps• Surgical Case Stratification/Scheduling Algorithm

• Relating 3 types to 4 conditions• Emergent, Urgent, Elective case types• Community prevalence of COVID19, Hospital COVID19 burden, supply chain, staff availability• Red, yellow, green scheduling pattern

• Estimated timeframe for backlog given all unknowns ranges 12-18 months• OR and Staffing Capacity, Pipeline Capacity, Shift in Socioeconomic Status

• Outpatient Clinic Scheduling• Redefine “normal” and “essential” visits• Non-COVID patients where continued delay in care may cause harm or worsening health• Reconfigure Patient Care Schedules

1. Stable scheduling methodology and clinical operations with scheduled blocks of in-person and telemedicine visits• Needed for efficient appointment scheduling by Access Center, Front Office, PSS• Promote consistent availability for in-person care 5 days/week by Division

2. Production leveling of clinical throughput – set at 2 patients/hour for in-person visits/provider• Minimize the patients’ total time in clinic• Provide appropriate social distancing

In-Person and Telemedicine Schedule Matrix

Phone/Video BlockIn-PersonName Division Designation Location AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PMBAUMHAUER, JUDITH F Foot and Ankle MD H&F 3 3 3 3BOWEN, CHRISTIE L Sports APP H&F 2 2 2 2 2 2 2BRADT, CARIE E Shoulder APP H&F 2 2 2 2 2BUCKLAEW, TIMOTHY Foot and Ankle APP H&F 2 2 2 2 2 2BYRNE, STACY L Foot and Ankle APP H&F 2 2 2 2 2 2 2 2COOPER, JAYNE L Adult Reconstruction APP H&F 2 2DIGIOVANNI, BENEDICT Foot and Ankle MD H&F 3 3 3 3 3 3FLEMISTER, ADOLPH S Foot and Ankle MD H&F 3 3 3 3 3OH, IRVIN C - FOOT FELLOWFoot and Ankle MD H&F 3 3GARDNER, LISA ANN Non-op Sports APP H&F 2 2GEORGE, CHRISTOPHER Sports APP H&F 2 2 2 2GOON, STEPHEN C Non-op Sports APP H&F 2 2 2HERBERT, MEGHAN Sports APP H&F 2 2JANNELLI, KIMBERLY ANN Adult Reconstruction APP H&F 2KETONIS, CONSTANTINOSHand and Wrist MD H&F 3 3 3 3KETZ, JOHN P Foot and Ankle MD H&F 4 3 3 4 3 3 3 3KINGSLEY, G SCOTT General APP H&F 2 2 2 2 2KLEEHAMMER, DANIEL G Sports APP H&F 2 2 2 2MCDONALD, STEPHANIE Non-op Sports DO H&F 2 2MAHMOOD, BILAL Hand and Wrist MD H&F 3 3 3 3 3 3 3 3MCHENRY, LINDA L Hand and Wrist APP H&F 2 2 2 2 2 2MILLER, RICHARD J Hand and Wrist MD H&F 3 3 3 3 3 3 3 3OH, IRVIN C Foot and Ankle MD H&F 2 2 2 2 2 2 2 2 2REAVEY, PATRICK Surgery - Plastics MD H&F 3 3RIZZONE, KATHERINE H Non-op Sports MD H&F 2SNIDER, JANET M Foot and Ankle APP H&F 2 2 2 2 2 2 2 2 2WASSERBAUER, DIANE Hand and Wrist APP H&F 2 2 2 2

Thur FriWeek 1 Week 2

Mon Tues Wed Thur Fri Mon Tues Wed

Recovery Steps - continuedStaffing/Operations• Update base staffing models per location by functional workgroup

• Priority – adequate staffing expedite workflow (no waiting)• Volume driven metrics for how to ramp number of staff by functional area

• Investigate a call system for patient arrival• Patients to wait in cars until they can enter the workflow process

• Investigate alternative staffing models and technology to minimize 1:1 in-person transactions (MyChart and Welcome)

Recovery Steps - continuedCost Containment• Suspension of annual merit raise program• Hiring freeze and furloughs• Hold on

• Capital spending• Business expenses• Electronic purchases

Essential Question• How can we do business differently to gain

efficiencies?

Thank you

Orthopedic Groups Use SocialClimb

❖ AAOE membership rely on SocialClimb

❖ OrthoForum – 3,000+ surgeons use SocialClimb

❖ 3rd Year with AOC – Covering 2,500 Surgeons Reputations

Now What? How To Get Patients Flowing Again

❖ A marketing recovery plan you can follow

❖ Marketing tools available to all

❖ What we see others doing

Google Listings

❖ Setup new Google Link❖ Own and optimize your listings

Google Posts

❖ Use Posts

❖ Be found (website, listings, email/text)

Proactive Messages

❖ Send open announcement & options❖ Collect patient feedback

Public GMB ViewLeverage Google’s Free Google My Business Pages

Proactive Messages To Patients

Ø Message previous patients

Ø Text Messages Best

Ø Email is also effective

Ø Stay in contact

Here To Help

Ø Let software & SocialClimb help

Ø AOC special free offer

Ø Recovery plan https://socialclimb.com/three-phase-covid-19-recovery-plan-for-medical-practices/

Ø Ty Allen - [email protected]

https://socialclimb.com/three-phase-covid-19-recovery-plan-for-medical-practices/

http://socialclimb.com

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LOGISTICAL MANAGEMENT OF RAMPING BACK UP FOR RETURN …