Geographic Deployment and MultiDisciplinary Care Teams:
The Practical’s and Challenges
Jerome C. Siy, MD, SFHM
May 6, 2010
Presentation Overview
• Make the case for geographic placement of your
hospitalist practices at your hospitals
• Learn how multi-disciplinary care teams improve
communication, improve hand-offs, assist in early
discharges and improve the overall leadership and
accountability structure of hospital units
• Create an open dialogue about the challenges and
tactics to overcome those challenges in implementation
of geographic placement and multi-disciplinary care
teams
Background on our Care System
•
HealthPartners Medical Group
– Integrated care delivery system aligned with hospital, medical group and payer
– Approximately 700 physician multi-specialty practice
– Approximately 50 locations in Twin Cities and Western Wisconsin
– Hospitalist practice is 70+ providers practicing at 5 hospitals
•
Regions Hospital, St. Paul, Minnesota
– 443 licensed beds
• Regularly run 80%-90% of capacity
– 14 hospitalist daytime services caring for patients
• 4 Teaching Teams
• Palliative Care
• Medicine-Pediatrics
• Surgical co-management
• 24/7 Coverage
– Tertiary care center for smaller community hospitals
– Level I Trauma Center
– Teaching affiliation with University of Minnesota
– Inner city hospital with large proportion of uninsured, underinsured, Medicare and
Medicaid
Poll Question #1
Before Geographic
• Each hospitalist admitted to all hospital units
– ~ 8 MD’s covering a 16 bed unit
– Each MD covering on average ~6.5 units
• Problems:
– Very little nurse/MD collaboration
– Poor communication amongst the care team
– Very difficult to find a nurse or physician to talk with in person
– High number of unnecessary pages
– Lots of time wasted traveling from unit to unit
• MD’s definitely got their 10,000 Steps in per day
– No teamwork
Principles of Geographic Assignment
• Assign hospitalist service based upon location of the
patient in a unit versus “who’s up next”
– Principle of keeping fewer MD’s covering the same
unit
• 80/20 Rule – 100% geographic is not feasible
– Surgery schedule drivers
– Teaching mix
– Patient aggregation rules for nursing and other
support
• E.g. telemetry, progressive care, etc.
• Since geographic deployment in 2005, hospital expanded
in Fall 2009 moving from 12-16 bed circles to huge 36
bed “arms”
– Continue to refine our model constantly
After Geographic
Physician Team
Primary Units
R1-R4 Hospitalist Teaching
Services
HP5 and HP6 Hospitalist
HP7 and HP8 Hospitalist
HP9 and HP10 Hospitalist
HP11 Peri-Operative Team
HP12 Peri-Operative Team
HP13 Palliative Care Team
HP14 Triage / ED consults
HP15 Medicine Pediatrics
South 6, 7, 8
South 6, C63
South 7 and South 8
Central 82, 91
South 9 (Beds 9401-9518)
South 9 (Beds 9519-9636)
Hospice patients
n/a
Central 54
Geographic Practical's:
• Nighttime coverage: No geographic, pure admission service
• We too hit points of surge where there could be some teams busier
than others
– In general, seeing patients in a timely manner trumps geographic
– Transfers: in general, physician continuity trumps geographic
• Compensation is not a key driver for daily census of the MD’s
– Services are all busy enough (our overall staffing level is
appropriate)
– Productivity has remained stable for the physicians
• Physicians rotate their service in the schedule to allow for variety of
practice and patient mix adjustments
• Due to nighttime assignment and surge, often by the end of the
service week we do see slippage
– On sign outs (Tuesdays) we go back to geographic
– While not perfect, still better than the old method of covering 6+
units
Poll Question #2
Care Team Rounds
• Once you have MD’s more available on the floors, it
becomes easier to assemble the teams
• Hardwire team meetings
– All meetings occur between 9-10
• Availability for teleconferencing to accommodate
disciplines covering multiple units
– Some surgical / ICU meetings occurring again in the
afternoon to accommodate surgeons or plan for the
next day
• Each patient should only take 2 minutes to review
– All team members on the same page to progressing
care and planning for discharge
The Care Team
• Essential Participants
– Physician
– RN
– Nurse Manager
– Social Worker
– Case Manager
– Pharmacist
– Health Unit Coordinator
• Other participants may include:
– Chaplain
– Utilization Review
– Specialists
– Others
• Purpose:
– Exchange information
critical to quality patient
care
– First team to be
approached for
collaborative improvement
efforts
• E.g. Joint Commission’s
Interdisciplinary Care Plan
– Facilitate early discharge
and discharge planning
– Leverage systems, other
than the physician, to
coordinate care
Poll Question #3
Why include the pharmacist?
• Better access for dialogue between MD and
Pharmacist on medication discussions
• Decrease the number of pages between the
disciplines
• More timely therapy adjustments provide
enhanced levels of care
• Better information sharing with whole team
• Knowing the time of discharge helps align with
the discharge preparation process
– Preparing for home IV antibiotics and
assessment of other high cost discharge
medications
So, why the HUC, Case Manager
AND the Social Worker?
• These are the people with the planning skills to get the work done
– Arrange for:
• Patient education
• Ride planning
• Coordination with the family
• Arranging in advance SNF or Home Care
– Many SNFs are short on beds, often need longer lead
times to place
• Assist the patient in helping with finding financial assistance
(e.g. applying for programs)
• Coordinating transitions of care (e.g. setting up appointments
in heart failure clinic)
Content of Rounds:
Not every topic addressed due to time, only those of issue
•
•
•
Clarify demographic ambiguities
– Identify primary or working diagnosis
– Observation v. admitted status
– Basic information: barriers, language
Discharge planning
– Anticipated date/time/place
– Plan ahead: Ride, home care, follow-up
appointment needs, re-admission risk identification
Legal-Social Issues
– Holds
– POA, guardianship
– Code status addressed
Content of Rounds:
Continued
•
•
•
•
Resource utilization
–
Safety assistant
–
Telemetry
–
Isolation
–
Change in level of acuity
–
Lines and tubes (e.g. foley & central line removal)
Progression of care guidelines
–
Identifying needs related to ongoing acute care status
–
Current functional status/needs
–
Identify needs for care conference with family
Medication plan of care guidelines
–
Pain management
–
Progression to PO meds
–
Need for costly or complex medications (e.g. LMWH)
Outstanding orders that need to be completed and plan for followup
After Care Team Rounds
• Improved patient and family satisfaction through
consistent communication of plan of care and realistic
discharge expectations
• Improved flow by reducing discharge delays
– Increased discharge order entry by 9:00am to
facilitate earlier discharge (beat the ED rush)
• Improved staff and physician satisfaction
– Better access to physicians for clinical dialogue,
particularly medications
– Planful process for discharge activities that are not
always clinical, but critical to discharge
• Ride planning, SNF placement, patient education
• Potential for improved patient safety with thorough, timely
and improved communication
– Everyone owns the care of the patient
Key Measures of Success
• Patient satisfaction
– Communication scores in HCAHPS
– Willingness to recommend
• Discharge readiness
– Orders written before 9:00am
– Discharge time (earlier in the day is better)
– Decrease in Milliman Potentially Avoidable Delays
• Employee survey results
– MGMA Physician Satisfaction
– HealthPartners All Employee Survey
Questions & Discussion