successfully getting from here to there · how to lead in this change 1. provide understanding to...

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Successfully Getting from Here to There Keys to Effectively moving to VBP

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© Coleman Associates

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+Rapid Changes in Healthcare

n For years healthcare changed at a relatively slow pace. The pace has accelerated dramatically since the paper chart à EMR evolution n Changes involve all of the following:

n Evolving patient expectations n Data availability n Employee & staff expectations n Medical school output & new doctors (skills and

abilities, understanding of the field, work needs and sheer numbers)

n Payor expectations and desires n Funding and government programs and

reimbursement n Community and partner relationships


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+VBP and the Evolution

n Previous payments came primarily from Fee for Service

n Now, visits will be reimbursed in part based upon the visit with additional payments coming from quality dollars = Value Based Payment incentives

n Future? (while we cannot be sure, we do know that a more human experience and business savvy approach seems to be the one that will be rewarded by workers and government payors)


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+Triple Aim à Quadruple Aim

n Triple Aim …

n Improve Patient Experience

n Improve Quality of Patient Care

n Reduce the Cost of Delivering those patient dazzling, high quality services…

n Led to quadruple aim...

n Burnout addressed – improve work life of health care workers


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+Change is … forcing us to constantly

redefine ourselves and our goals

n What Makes a High-Performing Practice…these days?

n Preparedness for Payment Reform?

n Measures of high-quality care and outcomes for patients?

n Engaged staff and providers?

n Maximized technology?

n Strong Patient Care Team environment/culture?

n Be clear about what goals meet your mission and organizational needs


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+Impact on Primary Care

n We are unleashed from traditional Fee for Service reimbursement in some ways.

n Quality metrics and preventative care will need to be documented in a way that is consistent with reimbursement systems.

n We are accepting responsibility for quality… and are finally getting recognized for that work.


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+How is VBP System different?

n Currently:

n Fee for Service (FFS) = volume is rewarded with $

n Quality is always talked about /desired, the dollars consistently follow in office billable visit volume

n No direct link between outcomes and reimbursement

n Current bonuses for some metrics / collaborative participation

n No reward to those who are spending more time or doing “outside of the box events” to improve outcomes…only rewards for billable encounters


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+How is VBP Different?

n VBP Future Expectations:

n Payment bonus for better outcomes

n More accountability to report numbers in a way that is received by payors

n Still FFS payments….yet bigger rewards to come (?) for outcomes

n Recognition for outcomes such as PCMH recognition, decrease of unnecessary Emergency Department use, and improvements in metrics tied to chronic diseases.


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+Change in Primary Care

n Billable visit volumes have always been the staple for primary care providers…

n We have been driven by this in some components of our care plan…. like seeing a patient back rather than having a video chat or phone call with them…

n We will be rewarded more but will have to work differently to take care of the patients who are attributed to us.

n We have always looked at quality metrics yet have not gotten directly paid for that work (e.g. Care coordination).

n We will now be forced to look at this work in a non-linear wa).


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+Communicate

n With any new change, we all hear part of what we want or expect to hear.

n We often think about what we have to give up first… (Ken Blanchard).

n We need to hear, repeatedly about the potential advantages …Make the pain of changing less than the pain of staying the same.

n We need to know that we will be supported across the bridge from here to there.


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+Leading Change

n Never forget the value in communication and in your role in providing clarity along the way.


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+How to Lead in this Change

1.  Provide understanding to all stakeholders about the coming changes.

2.  Prepare to fundamentally rethink how we manage ourselves and our staff.

3.  Dramatically redesign our workflows to maximize every patient contact with us in the most efficient way possible.

4.  Be open to technology and work concepts that may mirror service industries.

5.  Foster a paradigm shift internally to consider all of the patient needs and how they become well … not just the care they get within our walls.

6.  Prepare and shift while the initial dollar rewards are at their highest.


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Operational Implications of Value Based Payment in Primary Care

+Challenges in Primary Care

n As providers of primary care services, we face a number of operational challenges that should be and will need to be addressed (at least partially) to aid our evolution to a value-based world.


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+1. Medical Home Standing

n Given that PCMH recognition is rewarded by most providers, ensure that your PCMH recognition remains secure.

n Get educated on PCMH changes and work across the board to adopt the concepts that will not only meet the check box but that will help evolve your culture, update your operations and increase your quality.

n Pay attention to additional changes: Behavioral Health Distinction


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+2. Documentation

n Review your current reporting with your payors with an eye toward metrics that they receive.

n Look for opportunities --where you believe you are doing the work, but the results are not making it through the system.

n Ensure that all providers know how to code for all services (the work involved here varies by EMR).

n Teach team members where to document details about the patient’s preventative care (this varies by EMR).


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+3. Patient Ownership

n In many clinics today, patient ownership can be elusive with a large group of the patients.

n What is your rate of empanelment?

n How many patients are attributed to you and not seen?

n Steady team assignments allow the patient to belong practically speaking to a team of staff, and not just a provider (remember the quadruple aim).


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+4. Starting Small with Test Groups

n Familiarize your staff with PDSA (Plan Do Study Act) or RRT (Rapid Redesign Tests) in which they create new processes and then test out those systems.

n Increasing your staff’s ability to pilot ideas and create ideal solutions will not only increase your overall Continuous Quality Improvement abilities (PCMH) but will also create a platform to being testing on outcomes-based processes.


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+Test Groups of Patients

n Think about your expensive patients....

n Think about your shared patients...

n Where are the best reimbursement opportunities?

n Adult Hypertension

n Cervical Cancer Screening

n Pediatric Immunizations

n What roles does Care Coordination play in referral management, hospital follow up?

n How does care management of specific populations help?


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+5. Deliver Quality Care and Outcomes

n Since VBPs are coming from meeting measures and improving upon measures, provide direction to your teams around the metrics that your organization is most ready to impact.

n Tests in implementing process best practices will help your team to deliver those outcomes.

n Practical Note: How do staff access data on their patients?


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+What do Patients Want?


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What Patients

Want

Let me in

Don’t waste

my time

Care about me

more than I do

Figure me out &

fix me

Give me the

best

+What We See in Meeting Quality

n We often see that one of the biggest barriers to meeting outcomes can be access.

n If patients are unable to access their primary care provider and team readily, then their ability for that provider to provide teaching, order tests, and influence care is minimized.


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+“Let Me In!” The Access System


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What Patients

Want

Let me in

Access

Just say “YES”

Patient Portal

Visits

Email Phone

Texting

Website Health

Info

+6. Raise the Level of Quality through Operational Improvements

n Some of the suggested items include consistent teams, pre-visit preparation and planning, easy access to care for patients, systems to call patients directly rather than waiting for their next appointment and a steady stream of team-based data.

n All of these components are a direct result of operational systems and processes that support this type of work.


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+Initial Operational Steps Within the Teams

n Provide a team-based care environment and team access for patients

n Develop a framework to provide quality care

n This can keep evolving…

n Ensure documentation of work done


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+Some Foundational Operational Improvements

n Some of the suggested items include

n consistent patient care teams,

n pre-visit preparation and planning,

n easy access to care for patients,

n  steady stream of team-based, reliable data,

n processes and permissions call patients directly rather than waiting for their next appointment.

n All of these components are a direct result of operational systems and processes that support this type of work.


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+Who is on a Team?

n Provider

n MA

n Nurse

n Front Office

n Behavioral Health

n ????


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+Steps In The Team Dance

1.  Visit Prep

2.  Robust Confirmation Calls

3.  PCT Huddle

4.  QuickStart

5.  Jockey the Schedule

6.  Red Carpet the Patient

7.  Robust Intake

8.  30-Second Report

9.  Midway Knock

10.  Charting at the Time of Visit

11.  Sheep and Shepherd

12.  SoftLanding

13.  Over Communicate

See the Team Dance Article on ColemanAssociates.com for specifics.


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+Work Aggressively to Provide Access

n What and Why access measures matter:

n No Show Reduction

n Low Third Next Available Appointment (TNAA)

n Phone Access/ Watch Abandonment Call Rate – conduct your own Mystery Shopper Calls


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+Engage Staff in Data

n Staff who collect data understand it and can better use it to make decisions.

n Allows for more engagement

n Teams can track operational and quality metrics


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+Deeper Care Follow Up

n Develop a model for Care Management and Care Coordination ideally within each team

n Care Coordination involves leveraging community relationships and following up on patients referred out, admitted/discharged, etc.,

n Care Managements may involve Community Health Workers and nurses as well as the care team to follow patients who you have identified as being at a higher risk for troubles.


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+Initial Steps


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+Agenda

n Engaged or disengaged in QI

n What does it look like?

n When does it happen?

n Where do you see it?

n Solutions

n Shared goals

n Data

n Leadership

n Start with ‘Why’


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“If you could get all the people in an organization rowing in the same direction, you could dominate any industry in any market, against any competition, anytime.”

Patrick Lencioni Business author Five Dysfuctions of a Team, Founder The Table Group


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+What does it Look Like?

n Engaged? n Disengaged?


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+Remember, Change Does Not Happen By Consensus

n Stop trying to make everyone happy… Everyone will not agree to everything all the time. It’s ok.

n Patrick Lencioni in his 5 Dysfunctions of a Team training says that human beings don’t always have to get their way, but “they do have to weigh in to buy in”


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+Three Signs of a Miserable Job Patrick Lencioni’s

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+From The Key to Employee Engagement…

“Human beings need to be needed, and they need to be reminded of this pretty much every day. They need to know that they are helping others, not merely serving themselves.”

– Patrick Lencioni

“See management is an everyday thing. Strategy & financial reporting are not.”

– Patrick Lencioni

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Data

We couldn’t talk QI, If we didn’t talk data


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+Data Should Be…

n Public

n Transparent

n Simple – one page

n Understandable – even to a novice

n Not anonymous

n Up-to-date

n ** MOST IMPORTANTLY… it stirs to action

… Not responding is the same as accepting results


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The Approach

Drawing the Line from Here to There


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+Provide Visible Leadership


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+Timebox the QI Work

n TimeBox – Michael Hammer

n Break work into chunks so it’s not a never ending process… No one can staff engaged infinitely

n The slower you go, the more likely it is you will fail.

n Momentum is key to victories.


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+Don’t Saddle Your…

n High Performers with Low Performers – Jim Collins

n Put Stars with Stars – David Cottrell

n Everyone loses engagement working with others who are not pulling the oars as strongly.


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+Eliminate Ambiguity

n Your role as a leader is to clarify the mission and set expectations.

n Address head-on the typical communication gap between admin and clinical staff.

n You are responsible for helping your employees see how what they do affects the goals.

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+Follow Through on Success and Failure…

n Support a culture of failure : “Fail often so you can succeed sooner.”(IDEO)

n But don’t allow stagnation…

n Or Project ADD

n Quint Studor’s the Wall


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+Stop Moving the Goal Posts

n Set hard to attain goal and then when they are achieved… celebrate.

n Changing what defines success makes us feel like we are never able to succeed.

n Celebrate victories sufficiently before setting new goals.


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+Make Sure you can Articulate…

n …What is in it for them?

n If it’s not compelling, they won’t be engaged.

n Communicate, Communicate, Communicate – often & with a sense of urgency every chance you get.

n Address resistance to change.


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+Thank You!

“We always hope for the easy fix: the one simple change that will erase a problem in a stroke. But few things in life work this way. Instead, success requires making a hundred small steps go right—one after the other, everyone pitching in.”

Dr. Atul Gawande, from his book

Better: A Surgeon’s Notes on Performance


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