Patient Experience Summit

May 20 2014

Patient Experience Summit

May 20 2014

Robert Wyllie, MDChief Medical Operations

Cleveland Clinic

Organization StructureOrganization Structure• Not for Profit

• Group Practice

• Physician Leadership

• Salaried

• Annual Professional Review

• 1 Year Contract

• Not for Profit

• Group Practice

• Physician Leadership

• Salaried

• Annual Professional Review

• 1 Year Contract

Business IntelligenceBusiness Intelligence

• If you cannot measure it, you cannot manage it.

• The less uncertainty there is about the future, the better.

Business Analysts

Information Management Information Management

Data Sources

Data Aggregation & Transformation

Internal

DataStore

DataStore

DataStore

Data Mart Financial

External

Visualization / Reporting

Data Mart

Data Mart

Data Mart External Reporting

Executive Dashboards

Internal MgtReporting

Clinical

OperationalOperational Dashboards

Population

Analysis

Infrastructure

Analytics

Other

Governance

Clinical

Operations

Other

Payer

Quality Alliance

Other

DataWarehouse

Technical Resources Data Analysts

Other

Data Stewards

Improvem

ent

Ambulatory VisitsAmbulatory Visits

Clinic VisitsClinic Visits

Prior Years

8.2%

April YTD

974,162

1.3%

Same Day VisitsApril YTD

Same Day VisitsApril YTD

5%5%3%3%

373,242

Days Wait – New Visits 2013 Compared to April 2014

Days Wait – New Visits 2013 Compared to April 2014

Days

Target

Heart and Vascular InstituteAmbulatory Clinic

Heart and Vascular InstituteAmbulatory Clinic

“We need more exam rooms & support staff”

1

2

3

4

5

6

7

HVI Ambulatory ClinicHVI Ambulatory Clinic

Improvements

- Operations• Roles of MA & RN• Room Assignments• Revised Templates

8173

9377

7500

8000

8500

9000

9500

Before After

Annual Patient Visits

15%

Team Care Practice ModelTeam Care Practice Model

Medicine InstituteKevin Hopkins, M.D.

14

TeamCare ModelHigh Efficiency Practice Design

TeamCare ModelHigh Efficiency Practice Design

• Structure- 2 Medical Assistants - Physician

• Responsibilities - Each functions highest level

• Improve throughput & satisfaction

Digestive Disease Institute

Mid – Level Clinic

Digestive Disease Institute

Mid – Level Clinic

DDI- NP/PA Clinic PilotMatch Medical Complexity & ProviderDDI- NP/PA Clinic Pilot

Match Medical Complexity & Provider

Targeted Outcomes:Improved AccessIncrease % of “Top of license” workFinancially viable (prove efficiency)Same or better patient experience

0%10%20%30%40%50%60%70%80%90%

100%

Staff Midlevel 0%10%20%30%40%50%60%70%80%90%

100%

Staff Midlevel

Mid-Level Care Path ClinicNurse Practitioners & Physician Assistants

Mid-Level Care Path ClinicNurse Practitioners & Physician Assistants

New Patient Rectal Bleeding Blood in Stool Constipation

NP/PA Clinic

• Develop Care Paths• Trained Staff

Managed in Clinic

NP/PA Clinic Pilot – Care PathNP/PA Clinic Pilot – Care Path

NP/PA Clinic - ResultsNP/PA Clinic - Results

Physician Clinic (Control)Physician Clinic (Control)

New Patient (Rectal Bleeding, Blood in Stool, Constipation)

New Patient (Rectal Bleeding, Blood in Stool, Constipation)

- Median days Wait (7 days)- Reimbursement/visit ($87)- Cost per 1hr visit ($54)

76% Managed by PA/NP or

successfully treated

- Median days Wait (15 days)- Reimbursement/visit ($102)- Cost per 1/2 hr visit ($87)

95% Managed by Physician

Margin= 38%

Margin= 14%

9.5/10Patient

Satisfaction

TBD/10

NP/PA Clinic - ResultsNP/PA Clinic - Results

Physician Clinic (Control)Physician Clinic (Control)

New Patient (Rectal Bleeding, Blood in Stool, Constipation)

New Patient (Rectal Bleeding, Blood in Stool, Constipation)

- Median days Wait (7 days)- Reimbursement/visit ($87)- Cost per 1hr visit ($54)

76% Managed by PA/NP or

successfully treated

- Median days Wait (15 days)- Reimbursement/visit ($102)- Cost per 1/2 hr visit ($87)

95% Managed by Physician

Margin= 38%

Margin= 14%

9.5/10Patient

Satisfaction

TBD/10

Ambulatory ManagementKey Takeaways

Ambulatory ManagementKey Takeaways

However…

• Learned – greater efficiency- Same day appointments- Efficient space utilization- Physicians - Team Care Model - Top of license: Mid-levels Clinics

Population ManagementPopulation Management

Integrated Care Model

Care Paths

Care System

Cleveland Clinic Integrated Care ModelCleveland Clinic Integrated Care Model

Retail Venues Home

CC ClinicCommunity- Based

Organizations

Ambulatory D&TIndependent Physician

Offices

Hospitals

Rehab

Skilled Nursing Facilities

MyChart

EmergencyPost-Acute(other)

26

CarePath Development Cycle

Care Guide Analysis AlgorithmPractice

TransformationEMRBuild

Training and Implementation

Transform the Guide into an algorithm - defining the critical

steps and episode

27

Light Bulb MomentLight Bulb Moment• It’s not just about guide content “the What”

• It’s all about flow and model of care … the Who and the Where

• “I wish I’d had a chance to think through this before beginning to build the EMR-enabled Care Path.”

• … which is currently being implemented and we will share with you…

Neurological Institute

Low Back Pain Care Path

Neurological Institute

Low Back Pain Care Path

Case Study – Back PainCase Study – Back Pain

• Common and expensive conditions• Favorable natural history - majority • Tremendous variation - care and expense• Care givers – ED, primary care, therapists and surgeons• Impacts – multiple facilities and service lines• Focus of Payers and employers

JAMA 7/29/13

8 Surgical Locations 17 Outpatient Sites

Lakewood - 61 Lakewood Lorain/Avon

Fairview - 66 Fairview BroadviewHeights

Medina - 61 Medina Strongsville

Lutheran - 317 Lutheran Wooster

Hillcrest - 791 Hillcrest Twinsburg

Main Campus - 1774 Main Campus Solon

South Pointe - 15 South Pointe Willoughby Hills

Marymount - 62 Marymount Lake West

* Lake West/St. John’s - 118

Current State Locations

Visits = 39,000Intervention = 4,000Surgery = 3,400

Analysis of Base CaseAnalysis of Base Case

Reviewed 1,000 cases•Supply & labor costs•Fixed, variable expenses•Direct, indirect charges

Analysis of Base CaseAnalysis of Base Case

•Results

•Imaging – 40%•Opioids – 23%•Physical Therapy – 33%s

My Care: Spine AppMy Care: Spine App

Lower Back Pain Care PilotLower Back Pain Care Pilot

• Twinsburg and Strongsville FHC- Physician Lead: Dr. Mazanec

• Results:- Initial pilot: 40 patients pre/40 patients post - results: reduced cost per patient

• 57% - from $554 to $237- 513 pts per month qualify – care path

Lower Back Pain Care Path Pilot

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

Visits Therapy Imaging

Total Cost by Service

Pre

Post

Lower Back Pain Care Path Pilot

Cost Reduction

Pre - Post Per Patient $316

Projected Year $1.9 M

Full Year Potential $2.5 M

Population Management Key Takeaways

Population Management Key Takeaways

• Care Paths - “What”- Reduced variability – medical care

• Need to consider- “Who” – provide the care- “Where” - “Right Patient, Right Place”

However…

Reference PricingReference Pricing

Reference Pricing Health Affairs - August 2013

Reference Pricing Health Affairs - August 2013

• How it works…- Employers - Financial Upper Limit on Procedures

• Classified providers - Value and Non-Value- Patients - Freedom of Choice

• More Financial Responsibility

• Implemented in 2011- California Public Employees Retirement System

• Knee and Hip Replacement Data

Source: Health Affairs 2013

Reference PricingReference PricingKnee and Hip Replacements

Market Share - CalPERSKnee and Hip Replacements

Market Share - CalPERS

Source: Health Affairs 2013

Facilities

* Implemented in 2010