Post on 16-Mar-2018
The Reality of Becoming a High Performing Health System
Parag Agnihotri, MD Medical Director, Continuum of Care
Vicki DeBaca DNS, RN VP, Health & Provider Services
Mrs. Ruiz, 82 and her daughter Maria. Unfortunately Mrs. Ruiz became ill.
Maria called Sharp; the phone was answered quickly. and Maria gave her email address for access to the Sharp Web Portal
Maria gave her email address for access to the Sharp Web Portal
Arriving at the clinic…. They used the LED directory and the patient check in kiosk.
A friendly employee called Mrs. Ruiz back quickly.
Dr. Yang arrived quickly with her complete medical history in hand. He was friendly and reassuring. He also arranged an e-consult with a cardiologist.
After the cardiologist appointment she quickly had a full treatment regime include home monitoring.
The next day her diagnostic tests were available on the web portal.
Time passes and Mrs. Ruiz starts forgetting to take her medications
Unfortunately her health declined and she was re-admitted to the cardiac unit.
After her hospital stay a Skilled Nursing Facility was recommended. The Case Manager coordinated a care plan.
Email reminders of appointments were sent to her daughter Maria.
The team at the hospital took good care of Mrs. Ruiz.
The Chronic Care Nurse reviewed her progress. The APC Nurse did home visits. The entire team was kept in the loop.
After six months Mrs. Ruiz’s condition stabilized and she is now home.
Another success story from a High-Performing Health System
How?
How do you address this in a large multispecialty medical group with … 1.2 million visits
200,000 assigned patients
445 Physicians
60 NP/PA
2000 Clinic staff
21 Clinic locations
Leading a Case for Change
Our Journey to culture change
The best place to receive care… The best place to work…
The best place to practice medicine…
Since 2010 … Our desire to become…
Relentless pursuit to build the culture and be consistent • The Sharp Experience • Leadership • Communication • Staff and Team meetings • Education • Collaboration • Compensation
2009-10
We led a Case for Change
2010 Create Change
Model & Define Goals
2011
Allocate Resources
2011
Physician Engagement
2012
Measure Patient
Engagement
2013
Demonstrate Effectiveness
with
Balanced Scorecard
2014
Add Technology
to supplement
care
Significant breakthrough
Implementation Timeline
Engage Patients
Align Stakeholders
Create Workflows
Build Teams
Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
What We Did: Making an HPHS Happen
Accountability
Care Coordination
Technology Use
Compensation Practices
Quality Measurement
Efficient Provision of Services
Organized System of Care
Our Steps to Becoming a HPHS
Align Stakeholders
Create Workflows
Build Teams
Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Sharp
Align Stakeholders
Qu
alit
y
Serv
ice
Pe
op
le
Fin
ance
Gro
wth
Co
mm
un
ity
Sharp’s Pillars of Excellence
Align Stakeholders
Create Workflows
Build Teams
Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Pillar High Performing Health System
Align Stakeholders
Create Workflows
Build Teams
Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Quality Use clinical quality measures to measure process and outcomes of care
Service Use industry survey instrument to assess patient experience and engagement
Finance Address appropriate resource utilization rates and total cost of care
Growth Increase membership and net revenue
Community Enhance community outreach
People Improve provider satisfaction and wellness
Pillars of Excellence
Pe
rfo
rman
ce M
eas
ure
me
nt
Syst
em
R
ep
ort C
ards b
y Pillar
System Strategic Plan, Five-Year Plan
System Goals/Target
Entity Strategic Plans, Five-Year Plans, Goals/Targets, Dashboard
Dept./Unit Goals/Targets, Business Plans Supplier/Partner Goals/Targets, Business Plans
Individual Goals/Target
Individual Accountability Grid, Action Plans
Individual Merit, Bonus
Align Stakeholders
Create Workflows
Build Teams
Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Align Stakeholders
Create Workflows
Build Teams
Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Our Report Care: Balanced Score Card Sample
10%
Perfect Care Diabetes Measures Achieve top decile performance on diabetes perfect care measures
4 Rating : => 51% 3 Rating : =>49% but < 51% 2 Rating : =>47% but < 49% 1 Rating : =>45% but < 47% 0 Rating: <45%
5%
Patient Satisfaction Measures
Achieve overall medical group patient satisfaction equal to or greater than 90th percentile. 4 Rating : => 90th percentile 3 Rating : =>80th but < 90th 2 Rating : =>70th but < 80th 1 Rating : =>60th but < 70th 0 Rating: < 60th percentile
Align Stakeholders
Create Workflows
Build Teams
Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
2020 Care Model
Vicki DeBaca, RN VP Health & Provider Services
Care Management Programs • Population Health • Disease Management • Chronic Care Nurses • Complex Case Management Pharmacy Refill Clinic Mental Health Integration Leveraging Technology Office Standardization
• Health Coaching • Health Education Classes • Community Resources • Healthier Living Classes • Patient Representatives
on Committees
• Peer to peer reviews
Align Stakeholders
Create Workflows
Build Teams
Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Keep Patients Healthy, Happy and at Home
Population Health Risk Stratification Interventions
Programs for Chronic Diseases Implementation of evidence based guidelines
Tier 2: Moderate Severity 20%
Walking well; need periodic screening tests Preventive Care Reminder Program
Annual wellness exam and targeted outreach
Tier 1: Low Severity 60%
Chronic Diseases with two hospitalizations; needs co-ordination of care
Reduce avoidable hospitalization
Tier 3: High Severity
15%
5%
Tier 4: Complex
Align Stakeholders
Create Workflows
Build Teams
Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Continuum of Care
SNF ALF/B+C Hospital
Hospital CM Hospitalist COC post discharge calls
Home Home Health Case Manager Extended Care Team
Outpatient
Team Based Care Disease m/m programs Healthier Living Chronic Care Nursing w/PCP Complex Case m/m Pharmacy Programs
Emergency
Room & Urgent
Care
Urgent Care Collaboration Education
Transitions - Palliative care
Align Stakeholders
Create Workflows
Build Teams
Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Align Stakeholders
Create Workflows
Build Teams
Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
30-Day All Cause Readmission Rate: Senior HMO Population
Align Stakeholders
Create Workflows
Build Teams
Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
30-Day CHF Readmission Rate: Senior HMO Population
Teamwork Who is on your team?
Align Stakeholders
Create Workflows
Build Teams Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Safe Care Requires a Team and a System
8-hour day 8-hour day
0
2
4
6
8
10
12
14
16
18
20
22
PCP Physician day(Based on a panel size of 2000 patients)
Prevention 10 hours/day
Patient Education: 2 hrs/day
Care Coordination: 2 hrs/day
Direct Patient Care 7 hours/day
Hours
Care Coordination: 2 hrs/day
Align Stakeholders
Create Workflows
Build Teams Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Roles of Continuum of Care Teams
• Hospital and SNF discharge planning
• Coordination of care to reduce readmissions
Hospital and SNF Case Management
• Catastrophic or high risk cases e.g. Organ Transplant, MVA , Multiple Comorbidities, UM, Discharge Plan
Complex Case Management
• Team work with PCP, embedded model
• Post hospital and coordinate care of high risk multiple chronic condition patients -- short term
Chronic Care Nursing
• Long term engagement and management
• CHF, COPD,CAD, Asthma, Diabetes Disease Management
• Medication therapy management
• High cost, Refill, Adherence, High risk, Reconciliation Pharmacy Program
• Group classes and peer support group
• Example Chronic Diseases, Obesity Health Coaching
Align Stakeholders
Create Workflows
Build Teams Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Have a Common EHR Platform How to find us in Touchwork
Align Stakeholders
Create Workflows
Build Teams Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Create Workflows with Automation
Align Stakeholders
Create Workflows
Build Teams Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Create Workflows with Standardization
Align Stakeholders
Create Workflows
Build Teams Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Care Team Staff Ratios
R u ervisor - are Managers R riage Referrals Month R ase Manager evel - Mem ers R ase Manager evel - Mem ers o ulation ealth ase Manager - Mem ers R ase Manager ele- ealth - Mem ers M - Mem ers MA Mem ers ommunit ealth or er Mem ers A ministrative u ort R M - Mem ers
Align Stakeholders
Create Workflows
Build Teams Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Level III
Level II
Level I
Optimize Care Team Roles
Align Stakeholders
Create Workflows
Build Teams Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Teamwork
Case Managers Social Worker
Disease Managers Care Specialists
Clinic Staff Pharmacist/Pharmacy Tech
Health Coach
OK, now you have a team, but how effective are they? Are the patients engaged?
Align Stakeholders
Create Workflows
Build Teams Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Engage the Patient: Partner with me
Form personal connection
Face-to-face interaction
Step-by-step wellness plan
Coordination of care across the system
Patient specific education material
Shared care plans
Medication adherence reporting
Use HIT to engage all patients not just present
Align Stakeholders
Create Workflows
Build Teams Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Measure the Engagement Rate
Align Stakeholders
Create Workflows
Build Teams Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Patient Engagement
• Patient engagement for Population Health Programs as high as 60% patient experience
• Top two in the state as ranked by Consumer Reports
Patient Engagement and Well Being
AMGA HPHS: Care Coordination & Efficient Provision of Services
Align Stakeholders
Create Workflows
Build Teams Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Devices that Drive Healthier Behavior
…the booming mHealth market will grow to $26 billion by 2017, with a worldwide market of 1.7 billion users looking to use their smartphones and tablets to take care of their health. Currently, there are about 97,000 mobile health applications…
---Research 2guidance 2013
88% of physicians want patients to track or monitor their health at home.
---PricewaterhouseCoopers– HRI Physician Survey, 2010
Align Stakeholders
Create Workflows
Build Teams Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Sometimes, people like talking to computers
Align Stakeholders
Create Workflows
Build Teams Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Outreach in Multiple Ways Outreach using MySharp web portal
and Nuance telephonic outreach messages
Goal: Minimize the number of lists to the Physicians and Clinic sites
Align Stakeholders
Create Workflows
Build Teams Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Medication Therapy Management
AMGA HPHS: Use of Information Technology & Evidence-Based Medicine
Align Stakeholders
Create Workflows
Build Teams Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Medication Therapy Management Program aids prescription refills
• 60,000 Rx refills completed in 2013
• 140,000 medication related
tasks addressed • Projected volume of 120,000
refills
Physician Involvement and Engagement
Parag Agnihotri, MD Medical Director, Continuum of Care
Physician Engagement Strategy
1. What do you want your Physicians to do?
2. Do they know how to do the work?
3. Do they have the resources to do the work?
4. Are physicians motivated to do the work?
Ralph Jacobson, Leading for a Change: How to Master the Five Challenges Faced by Every Leader. he ea er’s ool ox
Align Stakeholders
Create Workflows
Build Teams Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Physician Satisfaction with Leadership
Align Stakeholders
Create Workflows
Build Teams
Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Compensation Practices
AMGA HPHS: Compensation Practices
• Reduction in the complications of heart disease by 22%
• Stroke reduced by 11%
Compensation practices that reward management of chronic diseases
$
Align Stakeholders
Create Workflows
Build Teams Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Leadership of the Culture
• Commitment to Standards of Care
• Transparency
• Peer reviews
• Mandatory quarterly training
• Sharing best practices
Align Stakeholders
Create Workflows
Build Teams
Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Two-Year Physician Leadership Academy
• Develops emerging Physician leaders
• Continuous learning, innovation, teamwork, sharing and personal growth
• Accountability
Align Stakeholders
Create Workflows
Build Teams
Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Group Specific Clinical Guidelines
Align Stakeholders
Create Workflows
Build Teams Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Address Practice Variation: Peer Review
Dr. A Dr. B Dr. C Dr. D Dr. E Dr. F Dr. G Dr. H Dr. I Dr. J Dr. K Dr. L
Align Stakeholders
Create Workflows
Build Teams Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Continuous Improvement Process ‘All or none’ Diabetes bundled care
30.0%
34.0%
38.0%
42.0%
46.0%
50.0%
Centralized process
52% have advanced perfect care
Change in BP criteria
48% Goal
Align Stakeholders
Create Workflows
Build Teams Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Measure Effectiveness
Quality Results: Diabetic Eye Exam
Diabetic Eye Exam Rate: Senior HMO Population
Align Stakeholders
Create Workflows
Build Teams Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Quality Results: Glaucoma
Glaucoma Screening Rate: Senior HMO Population
Align Stakeholders
Create Workflows
Build Teams Engage Patients
Use Technology
Engage Physicians
Quality Results: Chlamydia Screening
Chlamydia Screening Rate in Women 16-24 Years: Commercial HMO Population
Align Stakeholders
Create Workflows
Build Teams Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Quality Results Overall
Align Stakeholders
Create Workflows
Build Teams Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
AMGA: Quality Measurement and Improvement Activities
Clinical Quality Top performing Medical Group status in California for 10 years in a row
Awards and Recognition
Acclaim Award Honoree Top 10% Nationally for Patient Satisfaction 2014 Doyle Award : CHF program; recognition by mcg guidelines with its highest honor Number two medical group state score in 2013 by Consumer Reports based on patient experience among 170 medical groups Top Medical Group 2014; 2013 and 2012 ranked #2 by local newspaper based on local resident votes Baldridge Quality Award Winner
CAPG Elite Status for seven years in row IHA state Top Performing Medical Group status for 10 years in row State’s Office of Patient Advocate 2013 4/4 stars rating: 207 groups In top 90% of scores for all the medical groups across the specific quality measure Our program has received 2013 C.O.R.E. award recognition by organization under the People Pillar AAAHC accredited for 32 years.
Community Outreach
• Proactive patient outreach for preventive and chronic care
• Partner with organizations that address priority health needs such as cardiovascular and senior health organizations
• Inspire San Diego county residents to take action and responsibility for their health, safety and well-being
Align Stakeholders
Create Workflows
Build Teams Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Measure Effectiveness
Sharp ACO Collaborations
Commercial PPO Patients
SCMG and Sharp Rees-Stealy
Medical Group “SRSMG”
Pioneer ACO
Medicare Fee-for-Service
Beneficiaries
Sharp HealthCare, SCMG, SRSMG
Commercial PPO Patients
SCMG and Sharp Rees-Stealy
Medical Group “SRSMG”
Align Stakeholders
Create Workflows
Build Teams Engage Patients
Use Technology
Engage Physicians
Track Effectiveness: Population Health
14.55%
10.19%
6.52%
10.23%
7.05%
5.31%
7.61%
0%
2%
4%
6%
8%
10%
12%
14%
16%
Q1 2012 Q2 2012 Q3 2012 Q4 2012 Q1 2013 Q2 2013 Q3 2013
30 Day CHF Readmission Rate SRS Senior HMO Population
(Source: Claims)
9.09%
4.55%
11.76%
0.00%
4.76%
0.00%
0%
2%
4%
6%
8%
10%
12%
14%
Q1 2012 Q2 2012 Q3 2012 Q4 2012 Q1 2013 Q2 2013
30 Day COPD Readmission Rate SRS Senior HMO Population
(Source: Claims)
Align Stakeholders
Create Workflows
Build Teams Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Aligning Community Stakeholders: Sharp Extended SNF Care
• Contracted network of 60 SNFs
• Collaborators 10 SNF
• Reduced length of stay by 20%
• Improved 30 days readmission rate to be < 12%
Per Capita Cost of Care
Align Stakeholders
Create Workflows
Build Teams Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
AMGA HPHS: Accountability
Reduce per capita cost of healthcare
12% reduction in internal points used under the shared responsibility with hospital measuring post-acute care and ancillary funds
University of Best Practices Medical Group Collaboration to adopt best practices
The campaign to make San Diego a heart attack and stroke free zone
Continuous Improvement Process
58.7 58.1 57.3
52.2 49.8
45.5
30
35
40
45
50
55
60
65
2008 2009 2010 2011 2012 2013
Year
CAD Hospitalizations per 1,000 Senior HMO Members
per Year Data Source: Claims
2.9
3.3
3.1
2.9
2.7 2.7
1.5
1.7
1.9
2.1
2.3
2.5
2.7
2.9
3.1
3.3
3.5
2008 2009 2010 2011 2012 2013
Year
Stroke Hospitalizations per 1,000 SRS HMO Members
per Year Data Source: Claims
Align Stakeholders
Create Workflows
Build Teams Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
The Best Place to Work The Best Place to Practice Medicine
The Best Place to Receive Care
2009-10
We led a Case for Change
2010 Create Change
Model & Define Goals
2011
Allocate Resources
2011
Physician Engagement
2012
Measure Patient
Engagement
2013
Demonstrate Effectiveness
with
Balanced Scorecard
2014
Add Technology
to supplement
care
Implementation Timeline
Challenges and Opportunities
Align Stakeholders
Create Workflows
Build Teams Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Challenge: Moving from Individual to Team Based
Align Stakeholders
Create Workflows
Build Teams Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Challenge: Becoming an ACO
Align Stakeholders
Create Workflows
Build Teams Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Continuing Challenges and Opportunities
• Create transparent culture with good communication
• Increase accountability for better results
• Change management: The emotional and practical impact
• Engage everyone in the patient experience
• Create a better place to work • Integrate the EHR and technology • Continue to maintain visible,
passionate leadership to keep focus and energ on what’s im ortant
• Reward success
Align Stakeholders
Create Workflows
Build Teams Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Lessons Learned
Change is Hard: Share best practices
• Organization scorecard Align stakeholders
• Keep it simple and centralized Patient care workflows
• Highest scope of license Team based healthcare
• Measure Engage Patients
• Integrate and leverage it Use Technology
• Address practice variation Engage Physicians
• Demonstrate the ROI Measure Effectiveness &
Performance
What I Shall Do on Monday
We are lifelong learners too…
It is all about Teamwork!
In Summary: Process to Become a HPHS
Align Stakeholders
Create Workflows
Build Teams
Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Align Stakeholders
Create Workflows
Build Teams Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Sharp Experience video
We now welcome your questions…
Parag Agnihotri, MD Medical Director, Continuum of Care
Align Stakeholders
Create Workflows
Build Teams Engage Patients
Use Technology
Engage Physicians
Measure Effectiveness
Vicki Debaca, RN, VP Health Services