Enhancing Patient Care Through Better Data
Wayne Pan, MD, MBA, Chief Medical OfficerThe Individual Practice Association Medical Group of Santa Clara County Inc. (SCCIPA)
IHA’s Tenth Annual P4P Stakeholders Meeting • September 22, 2011 • Los Angeles
What I Did During My Summer Vacation
ourperspective
retrospectoscope
whoweare
Santa Clara County1,304.01 sq. miles
1,781,642 (2010)$74,335
5 PCP80 Specialists
57 PCP104 Specialists
173 PCP343 Specialists
11 PCP30 Specialists
SCCIPAfounded in 1986physician-owned, physician-governed800+ physicians - 240+ PCPs, 550+ specialistsall 9 hospitals - including a tertiary care center9 health plans (Commercial and Medicare Advantage)
ourjourney
theneed
it’snottechnology
signalvsnoise
it’saboutthepatient
peopleprocessesplatform
peopleprocessesplatform3P’s
peopleprocessesplatformCbig
culturepeopleprocessesplatform
culture?
patientcentered
efficient
evidencebased
promotequality
makeiteasy
4processes
communication
collaboration
coordination
PCPs
Specialists
Patients
CaseManagers
anticipation
it’snottechnology
technology 1st
designphilosophy
put hot triggers in the path of
motivated peopleBJ Fogg, PhD
Director, Persuasive Technology LabStanford University
work with humannature
BJ Fogg, PhDDirector, Persuasive Technology Lab
Stanford University
lazysocialhabitsBJ Fogg, PhD
Director, Persuasive Technology LabStanford University
ourplatform
common web-based communication platformfacilitates administrative functionsrules-based management of processesintuitive user-interfaceembed quality reminders into office/provider workflowprovider feedbackprovide actionable clinical data at point of care
platform
common web-based communication platformfacilitates administrative functionsrules-based management of processesintuitive user-interfaceembed quality reminders into office/provider workflowprovider feedbackprovide actionable clinical data at point of careallow patients to access their own dataallow patients to provide feedback and enter their own data
platform
anticipation
4dimensionaldata
financial
administrative
clinical
retrospective
reactivecare
behavioral+
predictive
proactivecare
provideactionabledata
@pointofcare
@home
thecareteam
thecarecontinuum
ourplatforms
ACCESSEXPRESS
peopleprocessesplatform
hospitalistsSNFistsonsite case managerscomplex case managersutilization review staff
people
hospitalistsavailable 24/7evaluation of patients for possible redirection to SNFaggressive use of observation statusannual coding/documentation training for risk adjustmentnotification of PCP of admission/dischargedischarge summary faxed to PCP
peopleprocesses
SNFistsongoing evaluation of patients to reduce rehospitalizationnotification of PCP of admission/dischargedischarge summary faxed to PCP
peopleprocesses
onsite case managersdaily review of patients based on Milliman guidelinesactively involved with discharge planningall discharge needs authorized/arranged prior to dischargepost-discharge follow-up on all patients with DME/HHC needs
peopleprocesses
complex case managerswarm hand-off between onsite and ccmuse of clinical and non-clinical staff to assist patient and family caregivers with care coordinationinsure follow-up with PCP/specialist within 2 weeks
peopleprocesses
utilization review staffall authorizations/referrals reviewed using Milliman guidelinesworking closely with PCPs/specialists/ccm to facilitate care coordinationcompliance with regulatory guidelinesgenerate member/provider letters regarding medical necessity decisionsphysician performance and quality reportingidentification of potential quality issuescontinuous process improvement
peopleprocesses
thepatientjourney
thepatientjourney
dischargeplanning
hosspitaldischargeplanner
IPA onsitecase
manager
hospitalist
patient family
thepatientjourney
dischargeplanning
hosspitaldischargeplanner
IPA onsitecase
manager
hospitalist
patient family
Rx
patient
medicationreconciliation
hospitalist
thepatientjourney
dischargeplanning
hosspitaldischargeplanner
IPA onsitecase
manager
hospitalist
patient family
Rx
patient
medicationreconciliation
hospitalist
dischargeinstructions
patient
outpatientphysicianfollow-up
hospitalist
thepatientjourney
dischargeplanning
hosspitaldischargeplanner
IPA onsitecase
manager
hospitalist
patient family
Rx
patient
medicationreconciliation
hospitalist
dischargeinstructions
patient
outpatientphysicianfollow-up
hospitalist
Rx
discharge
dischargeinstructions
patient family
thepatientjourney
dischargeplanning
hosspitaldischargeplanner
IPA onsitecase
manager
hospitalist
patient family
Rx
patient
medicationreconciliation
hospitalist
dischargeinstructions
patient
outpatientphysicianfollow-up
hospitalist
Rx
discharge
dischargeinstructions
patient family
outpatient physician follow-up
dischargeinstructions
patient
discharge
hospitalistIPA
onsitecase
manager AE
outpatient physician follow-up
dischargeinstructions
patient
PCP
IPA onsitecase
manager
48hr call
AE
outpatient physician follow-up
dischargeinstructions
patient
PCP
internalnon-clinical
staff
post pcpvisit call
AE
thepatientjourney
dischargeplanning
hosspitaldischargeplanner
IPA onsitecase
manager
hospitalist
patient family
Rx
patient
medicationreconciliation
hospitalist
dischargeinstructions
patient
outpatientphysicianfollow-up
hospitalist
Rx
discharge
dischargeinstructions
patient family
medication reconciliation
admissionorders
patient
admission
hospitalist
medication reconciliation
new Rx
patient
discharge
hospitalist
admissionorders
medication reconciliation
reviewmedlist
patient
pcp visit
pcp
new Rxadmissionorders
“new” medication reconciliation
new Rx
patient
discharge
retailpharmacy pcp
thepatientjourney
preventivecare
diabeticpatient
meds
self-testing
dieteducation
exercise
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er
hosp
snf
endo
preventivecare
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preventivecare
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preventivecare
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preventivecare
meds
self-testing
dieteducation
exercise
pcp
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snf
endo
pAE
preventivecare
diabeticpatient
meds
self-testing
dieteducation
exercise
pcp
er
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peopleprocessesplatform
culturepeopleprocessesplatform
it’saboutthepatient