The Green Mountain Care Board and VMS Education and Research Foundation Optimizing rural care Better quality, Better health, Lower costs WillIdeasExecution

The Green Mountain Care Boardand

VMS Education and Research Foundation

Optimizing rural care

Better quality, Better health, Lower costs

Better care, better health, lower costs

1. Actualize 3 planned levels of care2. Make VT a magnet for the workforce3. Become the national benchmark for

measurement4. Reduce the gap between practice and policy

“You have to have the will to improve; You have to have ideas about alternatives to the status quo; and then you have to make it real through execution. All three have to be arranged by leaders – they are not automatic.”

How can leaders accelerate innovation?

Vermont Rural Physician Leaders CommunityPhil Brown MD, Berlin

CVMC - Chief Medical OfficerInternal medicine, Emergency medicine

Kevin Buchanan MD, RandolphClara Martin Center - Medical directorPsychiatry

Ovleto Ciccarelli MD, RandolphGifford Health Care - Surgical ChairpersonGeneral Surgery

David Coddaire MD, MorrisvilleCommunity Health Services of Lamoille ValleyMedical director, Family practice

Mark Crane MD, BerlinCVMC - General Surgery

Lou DiNicola MD, RandolphGifford Health Care - Pediatrics

Jeremiah Eckhaus MD, MontpelierCVMC - Family practiceSharon Fine MD, Danville

Northern Counties Health Care - Medic al directorFamily practice

Steve Genereaux MD, Wells RiverLittle Rivers Health Center - Medical director Family practice

Nikki Gewirz PA-C, RandolphGifford Health Care - General Surgery

Mark Heitzman MD, BerlinCVMC - Cardiology

Sarah Kemble MD MPH, SpringfieldSpringfield Medical Care Services - Medical directorInternal medicine, Preventive medicine, Public health

Mike Kilcullen MD, WoodstockOttauquechee Health Center – Pediatrics

Dina Levin MD, RandolphGifford Health Care - Obstetrics and Gynecology

John Matthew MD, PlainfieldThe Health Center – Executive and Medical directorInternal medicine, Family practice

Josh Plavin MD MPH, RandolphGifford Health Care - Medical Director Internal medicine, Pediatrics, Pubic health

Deborah Richter MD, MontpelierFamily practice, Addiction medicine

Joel Silverstein MD, MorrisvilleCopley Hospital – Chief Medical OfficerInternal medicine, GastroenterologyPeter Thomashow MD, Berlin

CVMC – Psychiatry Chairperson Psychiatry

Sean Uiterwyk MD, White River JunctionWhite River Family Practice – Independent practiceFamily practice

Mark Yorra MD, BarreCVMC - Internal Medicine

Qualitative research - Key informant interviews

What?1. Health resource allocation planning2. Measurement of health care processes

and outcomes3. Payment policy and payment reform4. Communication with Board5. Retention and recruitment of physicians

Who?• People who know what’s going on in

their community• Insight on the nature of problems and

recommend solutions

Advantages• Candid/in-depth• Detailed rich data• Nuanced and actionable• Trust/sensitive topics• Motivation and beliefs• Raise interest/enthusiasm• Build/strengthen relationships• Stay connected/clarify issues

Disadvantages• Difficult to selection the “right”

informants• Diversity? Bias?• Difficult to schedule• Difficult to generalize unless many

involved

Actualize 3 planned levels of care3 levels of care by design

“Our current clinical capabilities are such that we never lose a life because we are missing capacity when a life threatening situation presents itself; but we are all really stressed ”- FQHC medical director

1. Core community based services• readily available

2. Regionalized specialty services• reasonably available

3. Tertiary and quaternary care• emergently available

Regionalized/shared general surgery

Ovleto Ciccarelli MD, RandolphGifford Health Care - Surgical ChairGeneral Surgery

of Gifford Medical Center

Ovleto Ciccarelli, MD

Disclaimer: This presentation represents the personal opinions of the presenter and does not represent an official opinion or

position of Gifford Medical Center

Thoughts on Future Delivery of Surgical

Care

Presentation to The Green Mountain Care Board Presented by

Gifford Medical CenterOvleto Ciccarelli, MD

Thoughts on Future Delivery of Surgical Care

TIERS OF SURGICAL CARE

CARE TO BE PERFORMED IN A TERTIARY CENTER

•Technically complex surgery (i.e. cardiac, neuro)

•Complex infrequently performed surgery (i.e. pancreatic, esophageal and non-cardiac open thoracotomy)

SURGERY THAT SHOULD REMAIN IN A COMMUNITY SETTING

•Commonly performed surgeries (i.e. breast, hernia, intra-abdominal surgery)

SURGERY THAT MAY OR MAY NOT BE DONE IN A COMMUNITY SETTING DEPENDING ON SURGICAL SKILLS AND PERIOPERATIVE SUPPORT

•Advanced laparoscopic and/or thorascopic surgery with short postoperative stays and the patient with comorbid conditions that are amenable to local advanced perioperative care


STATEWIDE INITIATIVES TO SUPPORT A REGIONAL NETWORK OF CARE

• Common information/technology system

• Quality improvement system (NSQIP) to allow for comparison of surgical outcomes among all participating surgeons

• Statewide licensing and credentialing process

• A central repository/inventory of available surgical skills and services

• Centralized recruitment to meet needs of all hospitals

• Regional surgical providers who work at more than one facility

• Rotation of providers with advanced skills to community facilities

• Rotation of emergency room availability

• Centers of Excellence (i.e. metabolic and bariatric surgery)



EDUCATIONAL NEEDS TO FOSTER AN INTEGRATED SURGICAL COMMUNITY

• Multi-institutional morbidity and mortality conference

• Additional training for Physician Assistants to improve operative skills

• Mini fellowships for community surgeons with respect to critical care and acute care surgery

• Telemedicine support to allow for provision of care in local settings


Magnetize VT for the workforce Team based care – Rethink the workforce

Planned expansion of mid–level care“The role of mid-level practitioners must be

recognized; as physicians practicing in rural communities we are extremely dependent on having a close working relationship with mid- level practitioners. The only model that works is a team approach”

“From the view point of a mid-level it’s very difficult to be effective if we aren’t included in professional, management and planning discussions. We are expected to know everything; we are expected to do everything, but we don’t necessarily have access to all the support that physicians have like CME, newsletters and other professional opportunities supporting lifelong learning. Sometimes we can feel like the red-headed step child.”

New team membersCommunity health workers“We’ve taken many steps toward becoming a

patient centered medical home, but there is a need for more community health workers, health coaches and panel management. People used to know how to help each other; there were layers of support in the community; we need trained trusted members of the community to teach us all how to be more self reliant”

Practice based quality improvement staff“We need to scale up training a workforce for the

future of primary care which will include more medical assistance level personnel to help manage the data entry involved in monitoring quality and controlling costs. The work keeps increasing and the workforce stays the same!”

Nikki Gewirz PA-C, RandolphGifford Health Care - General Surgery

Jeremiah Eckhaus MD, MontpelierCVMC - Family practice

Become the national benchmark for measurement

Checking little boxes versus meaningful measurement

Design valid trusted metrics“As an organization we can produce significantly

different rates based on the methodology we use to collect the data.

If we use a manual chart review process on a random sample of 70 patients to determine if we documented tobacco use status we score 100%; the same rate calculated through the Meaningful Use methodology using our EMR is 85%.

Similarly, manual method results in 45% of our patients being counseled about stopping tobacco use, where the Meaningful Use method shows a 15% counseling rate and for some practitioners the rate is as low as 4%”

Reduce the administrative burden“I’ve practiced primary care in other parts of

the country; Vermont is the best place for primary care

that I’ve been;But, if the administrative burden continues to

increase, the good intentions underlying the

documentation requirements and other administrative burdens will ruin the appeal of VT for primary care”


Reduce the gap between practice and policyBetter care, better health, lower costs

1. Actualize 3 planned levels of care2. Make VT a magnet for the

workforce“If you don’t know where you’re going, any

road’ll take you there”

3. Become the national benchmark for measurement

“Our shared goal should be improvement of value as defined by the outcomes that matter to patients and costs over meaningful episodes of care”

Tom Lee MD, Sept 2012

4. Reduce the gap between practice and policy

“Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it's the only thing that ever does”

Margaret Meade


Vermont Rural Physician Leaders CommunityPhil Brown MD, Berlin

CVMC - Chief Medical OfficerInternal medicine, Emergency medicine

Kevin Buchanan MD, RandolphClara Martin Center - Medical directorPsychiatryOvleto Ciccarelli MD, RandolphGifford Health Care - Surgical ChairpersonGeneral SurgeryDavid Coddaire MD, MorrisvilleCommunity Health Services of Lamoille ValleyMedical director, Family practiceMark Crane MD, BerlinCVMC - General SurgeryLou DiNicola MD, RandolphGifford Health Care - PediatricsJeremiah Eckhaus MD, MontpelierCVMC - Family practiceSharon Fine MD, DanvilleNorthern Counties Health Care - Medic al directorFamily practiceSteve Genereaux MD, Wells RiverLittle Rivers Health Center - Medical director Family practiceNikki Gewirz PA-C, Randolph

Gifford Health Care - General SurgeryMark Heitzman MD, BerlinCVMC - Cardiology


Mike Kilcullen MD, WoodstockOttauquechee Health Center – Pediatrics

Dina Levin MD, RandolphGifford Health Care - Obstetrics and Gynecology

John Matthew MD, PlainfieldThe Health Center – Executive and Medical directorInternal medicine, Family practice


Deborah Richter MD, MontpelierFamily practice, Addiction medicine

Joel Silverstein MD, MorrisvilleCopley Hospital – Chief Medical OfficerInternal medicine, GastroenterologyPeter Thomashow MD, Berlin

CVMC – Psychiatry Chairperson Psychiatry

Sean Uiterwyk MD, White River JunctionWhite River Family Practice – Independent practiceFamily practice

Mark Yorra MD, Barre

CVMC - Internal Medicine

Documents

The Green Mountain Care Board and VMS Education and Research Foundation Optimizing rural care Better quality, Better health, Lower costs WillIdeasExecution