The Green Mountain Care Board
and
VMS Education and Research Foundation
Optimizing rural care
Better quality, Better health, Lower costs
Will
Ideas
Execution
Better care, better health, lower costs
How can leaders accelerate innovation?
“You have to have the will to improve; You have to have ideas about
alternatives to the status quo; and then you have to make it real through
execution. All three have to be arranged by leaders – they are not automatic.”
Will
Ideas
Execution
1.
2.
3.
4.
Actualize 3 planned levels of care
Make VT a magnet for the workforce
Become the national benchmark for
measurement
Reduce the gap between practice and policy
Vermont Rural Physician Leaders Community
Phil Brown MD, Berlin
CVMC - Chief Medical Officer
Internal medicine, Emergency medicine
Kevin Buchanan MD, Randolph
Clara Martin Center - Medical director
Psychiatry
Ovleto Ciccarelli MD, Randolph
Gifford Health Care - Surgical Chairperson
General Surgery
David Coddaire MD, Morrisville
Community Health Services of Lamoille Valley
Medical director, Family practice
Mark Crane MD, Berlin
CVMC - General Surgery
Lou DiNicola MD, Randolph
Gifford Health Care - Pediatrics
Jeremiah Eckhaus MD, Montpelier
CVMC - Family practice
Sharon Fine MD, Danville
Northern Counties Health Care - Medic al director
Family practice
Steve Genereaux MD, Wells River
Little Rivers Health Center - Medical director
Family practice
Nikki Gewirz PA-C, Randolph
Gifford Health Care - General Surgery
Mark Heitzman MD, Berlin
CVMC - Cardiology
Will
Ideas
Execution
Sarah Kemble MD MPH, Springfield
Springfield Medical Care Services - Medical director
Internal medicine, Preventive medicine, Public health
Mike Kilcullen MD, Woodstock
Ottauquechee Health Center – Pediatrics
Dina Levin MD, Randolph
Gifford Health Care - Obstetrics and Gynecology
John Matthew MD, Plainfield
The Health Center – Executive and Medical director
Internal medicine, Family practice
Josh Plavin MD MPH, Randolph
Gifford Health Care - Medical Director
Internal medicine, Pediatrics, Pubic health
Deborah Richter MD, Montpelier
Family practice, Addiction medicine
Joel Silverstein MD, Morrisville
Copley Hospital – Chief Medical Officer
Internal medicine, Gastroenterology
Peter Thomashow MD, Berlin
CVMC – Psychiatry Chairperson
Psychiatry
Sean Uiterwyk MD, White River Junction
White River Family Practice – Independent practice
Family practice
Mark Yorra MD, Barre
CVMC - Internal Medicine
Qualitative research - Key informant interviews
What?
1.
2.
3.
4.
5.
Health resource allocation planning
Measurement of health care processes
and outcomes
Payment policy and payment reform
Communication with Board
Retention and recruitment of physicians
Who?
•
•
People who know what’s going on in
their community
Insight on the nature of problems and
recommend solutions
Advantages
•
•
•
•
•
•
•
•
Candid/in-depth
Detailed rich data
Nuanced and actionable
Trust/sensitive topics
Motivation and beliefs
Raise interest/enthusiasm
Build/strengthen relationships
Stay connected/clarify issues
Disadvantages
•
•
•
•
Difficult to selection the “right”
informants
Diversity? Bias?
Difficult to schedule
Difficult to generalize unless many
involved
Will
Ideas
Execution
Actualize 3 planned levels of care
3 levels of care by design
1.
“Our current clinical
capabilities are such that
we never lose a life
because we are missing
capacity when a life
threatening situation
presents itself; but we are
all really stressed ”
- FQHC medical director
2.
3.
Core community based services
• readily available
Regionalized specialty services
• reasonably available
Tertiary and quaternary care
• emergently available
Regionalized/shared general surgery
Ovleto Ciccarelli MD, Randolph
Gifford Health Care - Surgical Chair
General Surgery
Will
Ideas
Execution
Thoughts on Future
Delivery of Surgical Care
Presentation to The Green Mountain Care Board
Presented by
Ovleto Ciccarelli, MD
of Gifford Medical Center
Disclaimer: This presentation represents the personal opinions of the presenter
and does not represent an official opinion or position of Gifford Medical Center
Gifford Medical Center
Ovleto Ciccarelli, MD
TIERS OF SURGICAL CARE
CARE TO BE PERFORMED IN A TERTIARY CENTER
•
Technically complex surgery (i.e. cardiac, neuro)
•
Complex infrequently performed surgery (i.e. pancreatic, esophageal and non-cardiac open
thoracotomy)
SURGERY THAT SHOULD REMAIN IN A COMMUNITY SETTING
•
Commonly performed surgeries (i.e. breast, hernia, intra-abdominal surgery)
SURGERY THAT MAY OR MAY NOT BE DONE IN A COMMUNITY SETTING
DEPENDING ON SURGICAL SKILLS AND PERIOPERATIVE SUPPORT
•
Advanced laparoscopic and/or thorascopic surgery with short postoperative stays and the
patient with comorbid conditions that are amenable to local advanced perioperative care
Thoughts on Future Delivery of Surgical Care
Gifford Medical Center
Ovleto Ciccarelli, MD
STATEWIDE INITIATIVES TO SUPPORT A REGIONAL NETWORK OF CARE
•
Common information/technology system
•
Quality improvement system (NSQIP) to allow for comparison of surgical outcomes among
all participating surgeons
•
Statewide licensing and credentialing process
•
A central repository/inventory of available surgical skills and services
•
Centralized recruitment to meet needs of all hospitals
•
Regional surgical providers who work at more than one facility
•
Rotation of providers with advanced skills to community facilities
•
Rotation of emergency room availability
•
Centers of Excellence (i.e. metabolic and bariatric surgery)
Thoughts on Future Delivery of Surgical Care
Gifford Medical Center
Ovleto Ciccarelli, MD
EDUCATIONAL NEEDS TO FOSTER AN INTEGRATED SURGICAL
COMMUNITY
• Multi-institutional morbidity and mortality conference
• Additional training for Physician Assistants to improve operative skills
• Mini fellowships for community surgeons with respect to critical care and acute
care surgery
• Telemedicine support to allow for provision of care in local settings
Thoughts on Future Delivery of Surgical Care
Magnetize VT for the workforce
Team based care – Rethink the workforce
Planned expansion of mid–level care
New team members
“The role of mid-level practitioners must be
Community health workers
recognized; as physicians practicing in rural
communities we are extremely dependent on
having a close working relationship with midlevel practitioners. The only model that works
is a team approach”
“From the view point of a mid-level it’s very
difficult to be effective if we aren’t included in
professional, management and planning
discussions. We are expected to know
everything; we are expected to do everything,
but we don’t necessarily have access to all the
support that physicians have like CME,
newsletters and other professional
opportunities supporting lifelong learning.
Sometimes we can feel like the red-headed step
child.”
Nikki Gewirz PA-C, Randolph
Gifford Health Care - General Surgery
Will
Ideas
“We’ve taken many steps toward becoming a
patient centered medical home, but there is a
need for more community health workers,
health coaches and panel management. People
used to know how to help each other; there
were layers of support in the community; we
need trained trusted members of the
community to teach us all how to be more self
reliant”
Practice based quality improvement staff
“We need to scale up training a workforce for the
future of primary care which will include more
medical assistance level personnel to help
manage the data entry involved in monitoring
quality and controlling costs. The work keeps
increasing and the workforce stays the same!”
Jeremiah Eckhaus MD, Montpelier
CVMC - Family practice
Execution
Become the national benchmark for
measurement
Checking little boxes versus meaningful measurement
Reduce the administrative burden
Design valid trusted metrics
“I’ve practiced primary care in other parts of
“As an organization we can produce significantly
the country;
Vermont is the best place for primary care
that I’ve been;
But, if the administrative burden continues to
increase,
the good intentions underlying the
documentation requirements and other
administrative burdens will ruin the
appeal of VT for primary care”
Sarah Kemble MD MPH, Springfield
Springfield Medical Care Services - Medical director
Internal medicine, Preventive medicine, Public health
different rates based on the methodology we
use to collect the data.
If we use a manual chart review process on a
random sample of 70 patients to determine if
we documented tobacco use status we score
100%; the same rate calculated through the
Meaningful Use methodology using our EMR is
85%.
Similarly, manual method results in 45% of our
patients being counseled about stopping
tobacco use, where the Meaningful Use
method shows a 15% counseling rate and for
some practitioners the rate is as low as 4%”
Will
Ideas
Execution
Reduce the gap between practice and policy
Better care, better health, lower costs
1. Actualize 3 planned levels of care
2. Make VT a magnet for the
workforce
“If you don’t know where you’re going, any
road’ll take you there”
4.
Reduce the gap between
practice and policy
“Never doubt that a small group of thoughtful,
committed citizens can change the
world; indeed, it's the only thing that
ever does”
Margaret Meade
3. Become the national benchmark
for measurement
“Our shared goal should be improvement of
value as defined by the outcomes that
matter to patients and costs over
meaningful episodes of care”
GMCB
Rural
physician
leaders
Better care
Better health
Lower costs
Tom Lee MD, Sept 2012
Josh Plavin MD MPH, Randolph
Gifford Health Care - Medical Director
Internal medicine, Pediatrics, Pubic health
Will
Ideas
Execution
Vermont Rural Physician Leaders Community
Phil Brown MD, Berlin
CVMC - Chief Medical Officer
Internal medicine, Emergency medicine
Kevin Buchanan MD, Randolph
Clara Martin Center - Medical director
Psychiatry
Ovleto Ciccarelli MD, Randolph
Gifford Health Care - Surgical Chairperson
General Surgery
David Coddaire MD, Morrisville
Community Health Services of Lamoille Valley
Medical director, Family practice
Mark Crane MD, Berlin
CVMC - General Surgery
Lou DiNicola MD, Randolph
Gifford Health Care - Pediatrics
Jeremiah Eckhaus MD, Montpelier
CVMC - Family practice
Sharon Fine MD, Danville
Northern Counties Health Care - Medic al director
Family practice
Steve Genereaux MD, Wells River
Little Rivers Health Center - Medical director
Family practice
Nikki Gewirz PA-C, Randolph
Gifford Health Care - General Surgery
Mark Heitzman MD, Berlin
CVMC - Cardiology
Will
Ideas
Sarah Kemble MD MPH, Springfield
Springfield Medical Care Services - Medical director
Internal medicine, Preventive medicine, Public health
Mike Kilcullen MD, Woodstock
Ottauquechee Health Center – Pediatrics
Dina Levin MD, Randolph
Gifford Health Care - Obstetrics and Gynecology
John Matthew MD, Plainfield
The Health Center – Executive and Medical director
Internal medicine, Family practice
Josh Plavin MD MPH, Randolph
Gifford Health Care - Medical Director
Internal medicine, Pediatrics, Pubic health
Deborah Richter MD, Montpelier
Family practice, Addiction medicine
Joel Silverstein MD, Morrisville
Copley Hospital – Chief Medical Officer
Internal medicine, Gastroenterology
Peter Thomashow MD, Berlin
CVMC – Psychiatry Chairperson
Psychiatry
Execution
Sean Uiterwyk MD, White River Junction
White River Family Practice – Independent practice
Family practice
Mark Yorra MD, Barre
CVMC - Internal Medicine