Team Care at The Cleveland
Clinic
Kevin D. Hopkins, MD
Section Head-Family Medicine
Strongsville Family Health Center
Cleveland Clinic
Agenda
• Planning for Change
• Program Overview & Structure
• Outcomes
• Taking it to “the next level”
It’s All About Increasing Value
The Right Thing to Do in Any Payment Methodology
Quality
Value =
Cost
•
•
•
Focus on maximizing value delivered to
patients
Explore strategies that increase value
Enter into contracts that share in value
created
Introduction to Value-Based Operations:
The Industry is Changing
Cost
• Fragmented
• Fee-for-service
VolumeDriven
Healthcare
• Connected
• Bundled
• Accountable
VALUEDriven
Healthcare
Quality
Managing Population Health
Today:
The FFS model
Tomorrow:
The Value-Based
model
Care of the individual
Care of a population
Payment for each
service we provide
Payment based on the
quality and efficiency of
our care
Predictability!
Uncertainty and risk!
“Care Transformation” is Critical
• Transform clinical
operations
• Assemble the right
care team
• Reward added value
with sustainable
payment models
• Support with the
correct Analytics
6 17
Patient-Centered Medical Home
The Key to Success
“Patient-centered medical home (PCMH) is
a model of care where patients have a
direct relationship with a provider who
coordinates a cooperative team of
healthcare professionals, takes collective
responsibility for the care provided to the
patient and arranges for appropriate care
with other qualified providers as needed.”
NCQA
There’s No Place Like a “Medical
Home”
Patient
Engagement
Treatment of
Patient as a
“Whole”
Comprehensive
and Coordinated
Care
Enhanced
Access
Safety and
Quality
Physician
Directed
Practice
Payment for Added Value
Transform Clinical Operations
Patient follow-up
& engagement
Proactive, targeted
outreach
Engage
other
providers
Enhanced
access
Chronic
disease
management
Pre-visit
planning
Standardized
Care Paths
The Time Problem
Based on various analyses:
• Time needed for
chronic illness care
for 2,500 patients1
• Time needed for
preventive care for
2,500 patients2
• Time needed for
acute care1
1. Østbye TH, et al. Ann Fam Med. 2005;(3)209–214.
2. Yarnall KS, et al. Am J Pub Health. 2003;93(4)635–641.
• 10.6 hours/d
• 7.4 hours/d
• 4.6 hours/d
Assemble the Right Team
MD
Medical
Assistant
Patient
Care
Coordinator
Pharmacist
Strongsville FHC
Background
• There are many factors exerting considerable
pressure on our healthcare system:
- Reimbursement for care is static and
uncompensated care is increasing
- Increased level of acuity of outpatient
office visits
- Primary Care Physician utilization rates are
90-95%
- Healthcare Reform-ACA provisions
Background
• Press Ganey data for appointment
convenience
- 50% “very good” (median: 51%, 90th
percentile: 59%)
• Leakage
- This is lost-opportunity for higher-quality
care for the patient, and revenue for the
organization.
Team Care
“Team Care” is a higher-efficiency practice
style designed to:
•
•
•
•
Increase accessibility
Improve quality of clinical care
Increase patient throughput
Improve satisfaction at all levels (physician,
employee, and patient)
Team Care
A “Team Care” model utilizes a teamapproach in caring for patients
• Responsibilities are delegated and
shared
• Each individual in the chain of patient
care functions to the highest level of
their qualifications.
Team Care
•
•
•
•
Outpatient Visit:
Stage 1: Gathering data
Stage 2: Physical exam and
synthesis of data
Stage 3: Medical decision-making
Stage 4: Patient education and
plan-of-care implementation
Team Care Workflow
•
With a “Team Care” model, the clinical assistant gathers
and documents the data.
•
The clinical assistant:
- Takes a competent history
- Presents to the physician
- Remains in the room with the physician and patient
- Completes all documentation of the visit
- Implements the treatment plan
- Gives patient instructions (AVS), ensures
understanding, and completes the visit
Medical History
Medication Review
• Medication refill requests discussed
• Allergies
• Health Maintenance
• Smoking/Substance abuse
• Changes to medical/surgical history
•
Medical History
• Reason for visit
• Note template is loaded in the
progress note
• Collect and document the History of
Present Illness and ROS
Team Care Workflow
•
With a “Team Care” model, the clinical assistant gathers
and documents the data.
•
The clinical assistant:
- Takes a competent history
- Presents to physician
- Remains in the room with the physician and patient
- Completes all documentation of the visit
- Implements the treatment plan
- Gives patient instructions (AVS), ensures
understanding, and completes the visit
Team Care Workflow
The physician (with the assistant still in
the room):
• Confirms the history
• Performs the physical exam
• Makes medical management decisions
• Articulates diagnostic/treatment plan
Team Care Workflow
• The physician leaves the exam room of
the completed patient.
• Orders pended by the clinical staff are
filed by the physician.
• The physician signs any prescriptions that
are not electronically transmitted.
• Physician starts the process with the next
patient prepped by the other medical
assistant
Team Care Workflow
• The medical assistant reviews the After
Visit Summary with the patient along with
any prescriptions or ordered tests.
• Patient education is given and reviewed.
• The patient is escorted to the appointment
desk by the clinical staff.
Care Coordination
• RN Care Coordinator embedded
• Hospital Discharges
- DM-2
- CHF
- COPD
- Pneumonia
- MI
- CKD
Clinical Pharmacist
• Referrals for:
- Polypharmacy
- Medication compliance
- Medical literacy
Key Metrics
• Increase volume of patients seen
• Increase efficiency/decrease scheduling wait
time
• Increase accessibility to quality physician care
• Increase patient satisfaction
• Improve quality of patient care
• Increase clinical employee satisfaction
• Increase physician satisfaction
Access – Patients Added
May 2011 – August 2013
Ramp Up
Team Care
140
137
130
130
123
116
113
106
106
104
97
100 101 98
94
85
83
80
72
66
53
100
99
66
Missing MA
32
30
24
32
Patient Satisfaction 20112013 (Q1)
Sum of 2011
94
92
93
93
Sum of 2013
97
96
96
95
Sum of 2012
95
94 94
95
94
93
93
91
88
Care Provider CP respect for Likelihood of
Patients'
questions* recommending confidence in
CP
CP
88
Rating of CP* Time CP spent
with patient
Total Visits Normalized per Clinical
FTE 2010-2013 (2013 Projection)
6000
4946
4761
5000
4382
4000
3894
3881
4058
3984
3633
3000
2000
1000
0
Total Visits
Total Visits
Hopkins
Kaesgens
WRVU’s normalized for Clinical FTE
2010-2013 (2013 Estimation)
Sum of 2010 Norm
Sum of 2012 Norm
5608
Sum of 2011 Norm
Sum of 2013 Norm Est.
6649
6008
5074
4791
4869
4968
4970
WRVU's
WRVU's
Hopkins
Kaesgens
Productivity WRVU's 2010-2011-2012
619
576
570
569
554
536
526
519
539
522
510
505
494
488
WRVU's
469
466
432
406
460
488
474
470
440
438
419
489
414
400
424
414
407
2010
2011
383
369
371
370
2012
366
350
336
328
319
303
283
269
252
219
Month
*Days not worked not considered
Outcomes
Quality Indicators Chosen for Improvement
Q1
2011
Q2
2011
Q3
2011
Q4
2011
Q1
2012
Q2
2012
Q3
2012
Blood
Pressure
Control
74%
76%
81%
79%
79%
78%
78%
A1c
Diabetics
96%
96%
98%
96%
98%
97%
99%
Diabetes
Screening
89%
90%
90%
90%
91%
91%
93%
Hyperlipidemia
Screening
79%
80%
80%
74%
77%
79%
81%
Mammogra
m
Completed
77%
78%
78%
75%
78%
79%
78%
Team Care started 2Q 2011
Sensitivity Analysis
Potential Financial Impact
Per Day
6
8
10
1,338
1,784
2,230
Revenue
$156,546
$219,024
$273,780
Expenses
$61,992
$61,992
$61,992
EBIDA
$94,554
$157,032
$211,788
Annual Add
BIO Cards
Bio Cards so
Patients can put a
face with a name
and to promote our
Team!
Taking It to the Next Level
• Expand Team Care at Strongsville to include
6 Family Medicine Physicians
- 6 MA/MA/MD Teams
- 1 more in 2014
• Transform 1 in 4 primary care practices to
TeamCare to increase volume; fund care
coordination and PreVisit MAs
• Care coordinators and PreVisit MAs (pre-visit
planning, health maintenance and wellness) support
all providers