Health Care Transformation

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Health Care Transformation
Luncheon Panel

• The journey toward a medical home
• in Harlan, Iowa
• Don Klitgaard, MD, FAAFP
• MMC Medical Director
• With Duane Magee, patient

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Goals of our discussion

• Process of transformation what have we been
  doing in past 2 years to become a PCMH
• Physician experiences with changes
• How has this affected the patient experience?
• What have we learned so far through the process?

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Who Are We?Myrtue Medical Center Harlan, IA

• Critical access hospital/rural health clinic
  system, integrated since 1991
• Medical staff 7 Family Physicians, 1 Med/Peds,
  1 general surgeon, 3 PAs, 2ARNPs
• Nursing staff 35, Office staff - 22
• Main clinic in Harlan, community of 5200 in rural
  Iowa, and 3 satellite clinics in Avoca, Shelby
  and Elk Horn
• Full scope of practice Inpatient, ER, NH, OB,
  procedures, clinic coverage

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Harlan, Iowa
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Harlan, Iowa
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Myrtue Medical Center
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Real patients the Magee family
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Practice Demographics

• 20,787 active patient e-records
• Newborns to 107 year olds
• Wellness to acute illness to chronic disease care
• 38,000 clinic visits in last year
• 6.5 million gross clinic revenue
• 159,000 net clinic income
• Payors 39 Medicare, 30 Wellmark BC/BS, 20
  other commercial insurers, 7 Medicaid, 4
  self-pay

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Where we started in 2005-06 ripe for
practice-level change

• Interim, then new CEO
• No clinic manager
• Nurses union turmoil large nurse turnover
• Many failed practice improvement projects
• Failed EHR implementation/lost IT staff
• Stressed Medical, office, and nursing staff
• We want to improve and change but we know that we
  need help to do it!

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The Imperative to Change

• According to the Future of Family Medicine
  Report
• unless there are changes in the broader
  healthcare system and within the specialty, the
  position of family medicine in the United States
  may be untenable in a 10-20 year time-frame,
  which would be detrimental to the health of the
  American public.

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Do we really have to change?

• You dont have to change, survival is optional,
  C. Edwards Deming

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Enter the TransforMed NDP

• What is it about? (vision)
• What changes are we making through it? (process)
  
• What are we learning through the process?
  (outcomes)

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TransforMED Mission

• The mission of TransforMED is to lead and
  empower family physicians in implementing the new
  model of care

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The TransforMed Project

• AAFP-funded National Demonstration Project - 8
  million initial investment
• Applied January 2006
• Selected April 2006
• 24 month project began June 2006 and ended May
  31, 2008
• Evaluation period will end December 2008

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National Demonstration Project

• 36 sites from around the country were selected to
  study the new model.
• These practices were randomly assigned to
• one of two groups
• 18 facilitated practices will engage in a
  transformative process to fully implement a new
  model of care
• 18 self directed practices will be provided the
  information to implement the model of care in a
  self directed manner.

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Facilitated Practices
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Goals of the NDP Evaluation

• To generate and disseminate new knowledge about
  the process of practice transformation.
• To evaluate and compare the effects of two
  transformation approaches (i.e., facilitated vs.
  self-directed) on practice and patient outcomes.

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Goals of the NDP Evaluation

• To determine the effect of the New Model (PCMH)
  implementation on the following
• Patient outcomes
• Patient-centered care
• Staff/physician working relationships
• Financials of the practice

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What we agreed to

• Implementation - all aspects of the New Model
  during the 24 months
• Evaluation staff/patient satisfaction surveys,
  clinical/chart reviews, financial reviews, etc.
• Dissemination lessons learned during the NDP
  will be shared in many venues
• Staff commitment lead physician and staff
  member for learning collaboratives in KC, monthly
  phone conferences, ongoing e-mails, on-site
  visits with TransforMed staff

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What we received in return

• A worthy vision gets to the heart of medicine,
  especially FM/primary care
• Practice Enhancement Facilitator 1 for each 6
  practices
• Exposure to best practice ideas in all areas of
  practice redesign
• Ongoing consultant support
• Some specific IT product assistance

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Patient experience PCMH concept

• Concept make sense?
• Importance to patients, families, employers,
  community

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Myrtue Medical Center Clinics Projects

• Where to start?
• How do you eat an elephant.?
• Prioritized by
• Easy wins/low-hanging fruit needed practice at
  team design and needed confidence-builders
• Largest obstacles to improved care earlier
• What made sense in the big picture some
  projects built on others

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Our transformation process where and how to
start

• Team building/Vision sharing soft, but critical
• Main focus in the first 2-3 months
• Honest Self-Assessment brutal reality check
• First month
• Goal development/Timeline setting
• Started thinking about and discussing right away,
  details gradually took shape over the first 3-4
  months

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Our transformation process - Overview of the
projects

• Projects the work starts in earnest
• Staff empowerment/redesign
• Advanced Access Scheduling
• EHR Implementation Oh, the pain.
• Clinic process review
• Chronic Disease Management
• Clinical decision support/Point of care reports
• Wellness integration

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Myrtue Medical Center ClinicsCurrent Projects

• Staff redesign/empowerment
• Daily nursing huddles easy/effective
• Lead nurse selection and development
• Clinic manager critical missing element
• Immunization nurse improved efficiency
• Health coaches/Chronic Disease Management nurses
  manage registries, proactive care

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Myrtue Medical Center ClinicsCurrent Projects

• Open Access/Advanced Access Scheduling
• Accurately matching supply with demand
• Started with a 2 week internal study of
• Supply hours available by provider by day
• Demand appointments requested by provider and
  as a whole
• Gave us an accurate picture of problem times
  supply/demand mismatches
• Made changes in scheduling to help opened more
  open slots on busiest days/times, added evening
  hours
• Continual reassessment and revision process
• This can now drive good decisions on need for
  more staff as well as how to handle holidays,
  vacations, crunch times better

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Patient experience - access

• Open/Advanced access
• Extended hours
• Saturday hours
• Impressions of access changes?

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Myrtue Medical Center ClinicsCurrent Projects

• EHR implementation/use go live was 2/07
• HUGE change for all, especially Med Staff
• Planning, planning, more planning crucial 2 yrs
• Many benefits
• Intraoffice e-messaging
• E-prescribing
• Real-time documentation with templates
• Expanded access to information
• Allows for a new level of population-based care,
  point of care improvements, etc
• An extremely useful tool, but not an end

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Patient experience Technology

• EHR
• E-prescribing
• Change in patient experience laptops,
  information access, rxs

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Myrtue Medical Center ClinicsCurrent Projects

• Clinic process review - started asking many hard
  questions
• How does information flow around our office? How
  should it flow in an efficient, effective medical
  home? Who does what process, and should they?
• rx refills, NH questions, phone messages, lab
  results
• How can we as a Medical staff make group
  decisions to make our staffs days (and patients
  care) better?
• Standardized care - templates, flow sheets,
  standing orders
• Moving towards true team care of patients
  especially those with chronic diseases
• Not easy, but big returns in efficiency!

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Myrtue Medical Center ClinicsCurrent Projects

• Chronic Disease Management /Population
  Management/Health Coaches
• Diabetes, asthma, hypertension, CHFwho?
• First had to develop disease registries not
  easy
• Foster a true team approach to care OUR team of
  physician, nurse, scheduler, health coach (as
  opposed to calls from insurers nurse, CMS
  reviewer, etc.)
• Allows flexibility simple reminder calls to
  lengthy face-to-face interventions, either
  planned or opportunistic
• Health Coaches to monitor populations of patients
  get them in for needed care, provide proactive
  interventions, help give patients more
  empowerment and control
• HUGE potential for improved care

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Patient experience Chronic disease management

• See value with family, as employer?

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Myrtue Medical Center ClinicsCurrent Projects

• Clinical decision support/Point of care (POC)
  reports 2008?
• Offers enhanced disease registry functions not
  available in EHR
• POC reports based on EHR data run through a
  protocol engine
• Single page report
• Makes visits much more productive
• Easily identifies needed care
• Can delegate which things nursing can do by
  standing order and which a physician should
  discuss with the patient
• When paired with CDM, much potential for large
  improvements in patient/population care quickly
• However, another level of technology
  cost/interface barriers

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Patient experience Point of care reminders

• Would you like this?
• See benefits as patient?

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Myrtue Medical Center ClinicsCurrent Projects

• Financial review
• Individual physician and group finances evaluated
• Offer insights into possible areas of improvement
  
• Highlights the need for ongoing dialogue and
  education of the medical staff about business,
  billing and coding issues
• Emphasizes the underlying inherent conflict in
  many physicians between the business of medical
  practice and the practice of medicine just let
  me take good care of my patients

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Myrtue Medical Center ClinicsCurrent Projects

• Office Redesign in process
• Satellite clinic remodels
• Plans for major clinic overhaul to optimize care
  under the PCMH model
• Wellness integration in process
• MMC funding/leading community Wellness Center
  project open late 2009
• Will offer many opportunities to encourage
  wellness and integrate into our practice

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Patient experience Wellness

• Impressions from a parent, school administrator,
  individual

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Continuing toward a PCMHFuture Projects

• Website enhancement/Patient portal
• Scheduling and refill requests
• Electronic bill pay
• E-visits/e-mail communication
• Secure lab results
• Collect PMH on-line
• Referral tracking Trudy
• Enhanced communication with hospitals/specialists
• Kiosks in office check-in, update demographics,
  enter symptoms, instant claims adjudication
• The list keeps growing!

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Patient experience Website, etc

• Would you use and anticipate other to also?

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Our transformation process

• Ongoing assessments metrics
• Metrics, common in business, are largely unused
  in most smaller practices
• Wait times, staff satisfaction, patient
  satisfaction, billing/coding reviews and
  improvements, individual physician and practice
  level financial assessments
• Very helpful internally to identify
  opportunities, gauge process change effectiveness
• If not understood completely and used punitively,
  will derail progress measuring complex process

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Practice
NDP
Practice
NDP
March, 2008
June, 2007
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Sowhat have we learned?(at MMC and in the NDP)

• Change is hard and slow
• Transformation on many levels
• of practices culture change
• of physicians personal change
• of patient expectations
• Practices not used to system-level changes
• Personally, I think this will be a 3-5 year
  process, even with a motivated, unified practice
  with adequate resources

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What have we learned?

• Relationships matter
• Practices capacity for change and ability to
  follow through is heavily dependent on strong
  relationships within the practice
• Need to build and foster strong relationships on
  all levels to be successful with changes
• Especially important at times when practice under
  much stress i.e. EHR implementation

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What have we learned?

• Medical practices are extraordinarily complex
• Small changes often have large impacts
• Large, difficult changes may be necessary but
  have small impacts overall
• Change management is an essential skill that
  practices need to be successful
• Eidus theorum of change difficulty

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What have we learned?

• Leadership is Key
• Need strong leaders in all areas
• Physician/mid-level
• Clinic manager/nursing
• Administration/financial
• IT systems
• If not all on the same page, ability to make
  changes hampered or halted

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What have we learned?

• Transformation has to happen on the personal
  level also
• Is a gradual change from physician-centered
  thinking and office practices to team-based,
  patient-centered care
• This is just as hard as (or harder than ) the
  practice-level process changes

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What have we learned?

• Technology has great potential, but several
  problems limit its current usefulness and
  widespread implementation.
• lack of interoperability
• Expense
• amount of resources and energy needed to make
  things work together

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What have we learned?

• PCMH is more than the sum of its individual parts
• Measurements (NCQA, etc) are important and get at
  many parts of the PCMH, but not the full essence
• Medicine is art in addition to science
• Patients want healing, not just diagnosing or
  curing

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The old model of care doesnt make sense in the
PCMH context

• Coordinated, not just episodic care
• Proactive, not just reactive care
• Emphasis on achieving and maintaining wellness,
  not just treating illness
• Team-based care
• Comprehensive care
• We need high tech and high touch

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The Case for The Medical Home
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Many current national trends align well with the
PCMH model

• Emphasis on quality and transparency
• Patients, employers, CMS, payors, health systems
• Emphasis on patient-centered care
• Convenient, timely, patient-friendly
• Emphasis on technology not just in our
  practices but in individual patients lives
• Google Health, Revolution.com, WellMark/UHC,
  etc. will change health care perceptions and
  expectations
• Emphasis on practice redesign/innovation
• PCPCC, TransforMed/AAFP, IHI
• Emphasis on wellness promotion/disease prevention

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Where does that leave us?

• Buyers of care should find what they have been
  buying unacceptable
• Providers of care should find it unethical and
  even immoral to continue to provide episodic,
  uncoordinated care
• Patients should be at the center of a redesigned
  system that needs both
• Transformation of medical practice
• Reformation of payment for care to support it

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How do the participating practices feel about the
TransforMed NDP?

• Extremely excited and encouraged
• Much harder than we thought initially
• Absolutely worth it and imperative!
• Privileged to be part of the process

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How can stakeholders help?

• Support/fund pilot projects
• Need to include PCPCC blended payment model
• Continued fee-for-service
• CDM fee
• Additional P4P incentives
• Support those working to affect change
• Funding educational efforts, learning
  collaboratives
• Tap into national/state primary care academies
• Support innovators/early adopters
• Technology improvements
• Support for PCMH concept in your sphere of
  influence
• Support Primary Care education
• In medical schools, primary care residencies

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Website Resources

• Patient-Centered Primary Care Collaborative
  www.pcpcc.net
• TransforMed www.transformed.com
• AAFP www.aafp.org
• Center for HIT www.centerforhit.org
• Institute for Healthcare Improvement
  www.ihi.org
• Iowa Healthcare Collaborative www.ihconline.org
• Myrtue Medical Center www.myrtuemedical.org

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Why I want to see the PCMH succeed in the U.S.
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Contact information

• Don Klitgaard, MD
• 1220 Chatburn Avenue
• Harlan, IA 51537
• 712-755-5130 (PCMH)
• 712-579-1911 (cell)
• Dklitgaard_at_myrtuemedical.org