Well deployed technology

June 22nd, 2009 | Claire Trescott, MD, Medical Director, Primary Care

Medical Home Model

Outline of Today’s Session

Why the Medical Home?

Medical Home Process & Workflows

Center for Health Studies: One Year Evaluation

Call Management – the use of Lean in ambulatory care

Why the Medical Home? From 1997-2001, Group Health was Washington’s largest group

practice, but we had shrinking membership and non-competitive pricing

From 2001-2005, Group Health implemented a series of programs to improve access & efficiency (Ralston et al, Managed Care Interface, in press)

− Advanced Access

− Direct specialty access

− Physician productivity incentives

− Patient web-access and secure emailing

− A system-wide electronic medical record

During this time we saw…– Increased Primary Care Panel Size

– Increased ER Visits

– Increased Inpatient Days

Why The Medical Home?

The new programs and larger panel sizes resulted in increased demand on Primary Care − Many providers felt the accelerated pace was unsustainable.

When asked, 74% of Primary Care physicians stated WORKLOAD was “unreasonable”

We found Primary Care physicians were retiring 5-9 years earlier than specialists

In 23 out of 27 exit interviews, physicians stated WORKLOAD was a primary reason for leaving

We weren’t making enough progress on Quality, Service, and Affordability

Medical Home Pilot

− Be patient-centered

− Deliver market leading performance in quality and service

− Be affordable

− Provide a good place to practice medicine

We decided to pilot a new primary care model designed to −

January 2007, we launched the Medical Home Pilot at Factoria Medical Center

Medical Home Principles

• Relationship based care

• Physician lead teams

• Continuous healing relationships

• Proactive care

• 24/7 patient access

• Our clinical and business systems are aligned

Applying Advanced Technology to Operations

Call Management – linking phones to electronic medical record

Clinical Decision Support Tools (Best Practice Alerts)

Picture Archiving Communication System (PACS)

Secure email messaging

Integration with Clinical Pharmacy

High Risk Outreach (predictive modeling)

Planned Care Exception Report

Make an appt. online

Email your healthcare team

Check your labs

Refill your prescriptions

After Visit Summaries

Electronic Medical Record

Health Profile

Defining the Medical Home Model:Integrated Patient-Centered Care

Point of Care Outreach

Feedback

Planned Care Exception Report(HEDIS)

Performance Reporting

Exception Reports

MyGroupHealth

Health Profile

Health Coaching

Best Practice Alerts

After VisitSummary

Huddles

High Risk Outreach(Predictive Modeling)

Residential Care RoundingCollaborative Care PlanWith Brief Negotiation

New Patient Outreach

Birthday LettersHospital/SNF/ED Outreach

Longer Appt Time

Secure Messaging

Call Management

Group Visits

Living Well withChronic Conditions

Integration with Clinical RPhHealth Maintenance Reminders

Pre-Visit ReviewAnd Outreach

Medical Home PilotCenter for Health Studies – 1 year results

Results – Changes in Utilization

We changed the way we formed and maintained relationships with our patients:

− More email

− Increased phone visits

− More group visits

− Fewer in-office, face to face visits

− Seeing patients less, but touching them more

Results – Changes in UtilizationWhat Happened…

Compared to patients in other clinics, the average patient at the Medical Home had statistically significant reductions in:− Primary care visits (in-person) – 6%− Consulting nurse calls – 10% − ED/UC visits – 29%− Ambulatory Care sensitive admissions – 11% − Specialty care referrals – 5%

(however, total specialty care visits increased 8%)

Similarly, compared to patients in other clinics the average patient had significant increases in the use of other services: − Secure message threads – 90%− Telephone encounters – 12%

Note: Utilization analyses adjusted using baseline age, sex and prior year’s prospective DxCGs using statistical model (GLM)

Call ManagementThe use of Lean in ambulatory care

Current State Pre-RPIW*:Call Flow & Messaging - Complex/Inefficient

*RPIW = Rapid Process Improvement Workshop

PCR screens and sorts calls per Call Mgmt Grid

2 M calls per year

CNS Nurse Assesses patient per Protocols

Calls patient back

regarding request

CNS -Transfer?

6%

Clinical team-

transfer?4%

Need to transfer to the clinical

team?

Need to forward to

team?

Pt available?

Clinical team-

message?20%

Need to call pt back?

Yes

No

Yes

Patient/Customer Calls -Main Appt Line

Advice LPN/RN receives Pt Call Back

Message

Complete Request

No Appointment?

47%

Make/Reschedule/

cancel appointment

Transfer to Rx, BO, Cust

Service, Provide general info

23%

Complete request

No

No

Yes

Yes,

50%of calls

get transferred

back toclinic-

HandoffRework

Inconsistent phone access

PhoneTag,

Rework

No

Yes

Yes

No

Call Center Clinical Team CNSProcess Start/End

Complete Transfer

Message to Advice LPN/

RN?

Team receives

Pt Call Back Message

No

Yes

No

YesHandoffRework

No

Yes

Handoff Patient waits1-24 hours for

call back

CNS Nurse Assesses patient per Protocols

CNS

Need to transfer to the clinical

team?

Direct Connect

CSS = Consultative Specialty Services

Learnings/Reflections:

Summary of Outcome Measures

Statewide Call Management (before & after)

2007 2009

1st Call Resolution 0 73%

Time to Resolve 9-11 hours 38 Minutes

Call Back Messages

20-150 avg per

day

23 of 26 clinics have reduced

patient call backs by 50%

MHMAdvancing Primary Care

AFFORDABLE EXCELLENCEImplementing the Medical Home Value Stream

Standard Work

Call Management

Virtual Medicine• Phone, Secured Messaging

Access : Visit Demand

MORE TIME

Disease Management

Decrease Panelse.g. 1,800

MORE TIME

Prepared for the Visit

• Enrollment Costs

• Outcomes // Patient & Staff Satisfaction

Outreach

Questions?