teams that work: developing models of care coordination
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Teams That Work: Developing Models of Care Coordination
Marjie Harbrecht, MD
Consultant MGHealthcare Insights, LLC
Golden, Colo.
Greg Pawson, CPA, CMA, CMPE
Chief Financial Officer
Women’s Healthcare Associates, LLC
Portland, Oregon
Marjie Harbrecht and Greg Pawson do not have any financial conflicts to report at this time.
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©2017 MGMA. All rights reserved. - 3 -
Learning Objectives
• Examine examples of how staff plans
and models can be developed
• Develop team model operational
guidelines and steps to
implementation
• Design a return on investment model
to justify new staff positions related
to population health management
US Healthcare - How Do We Compare?
©2018 MGMA. All rights reserved.
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©2017 MGMA. All rights reserved.
U.S. Health Care
Great Skills
Great Science
Poor Integration / CoordinationFragmented - Silos
Misaligned Incentives
Culture
GREAT at FIXING THINGS….NOT PREVENTING THEM
“A NON-SYSTEM OF CARE”
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PAM
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LUCILLE
Specialists - Raise your hand if these have occurred in your practice:
1. You don’t know provider that referred the patient.
2. You aren’t clear what question you’re supposed to be answering.
3. The patient doesn’t know why s/he was there.
4. You don’t get sufficient information with the referral – (i.e.,
pertinent history, workup done, etc).
5. You can’t access results from tests already performed.
6. You don’t get follow up on a patient you were concerned about.
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PCPs - Raise Your Hand if these issues are common in your practice
1. You don’t know the people you are referring patients to.
2. Specialists say they don’t get needed information with a referral.
3. Patients complain specialist didn’t know why s/he was there.
4. Tests you’ve already performed are duplicated.
5. You don’t hear back from a specialist after a consultation.
6. A referral doesn’t answer your question.
7. Your patient doesn’t come back to see you after a consultation.
8. You are unaware that your patient was seen in the ER/Hospital.
You’re Not Alone!
• 50% primary care didn’t even know patient saw specialist
• Say they received no information 60-70% of specialists
25-50% of primary care
• Dissatisfied with the information they receive 43% specialists
28% primary care
• Inappropriate referrals Unnecessary or wrong specialist
8% - average of 43 referrals /specialist/year
• Referral never completed
>20% - delayed/missed diagnosis and/or treatment1 O’Malley, A.S., Reschovsky, J.D. (2011) Referral and consultation communication between
primary care and specialist physicians: finding common ground. Arch Intern Med, 171 (1), 56-65.2 Mehrotra, A., Forrest, C.B., Lin, C.Y. (2011). Dropping the Baton: Specialty Referrals in US. The
Milbank Quarterly, 89 (1), 39-68.3 Forrest et.al Arch of Ped. Adol Med 2000
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…and then there is the Patient Experience
“I’m not sure why my doctor sent me, don’t you know?”
“I understood I was here to have the procedure today, not
just to talk about my stomach pain!”
“I had an MRI last month. Didn’t you get the information?”
“I waited 3 months for the appointment, took the day off of
work & after I was in the exam room learned I needed a
different type of specialist!”
WHY MAKE CARE COORDINATION A PRIORITY?
• Patients and families hate that we can’t make this work.
Multiple care plans - conflicting information
• Poor hand-offs lead to delays/confusion - patient safety
issues
• Enormous waste associated with unnecessary referrals and
duplicate testing
• It will make all of our work more effective
• Everyone will be happier!
Source: Ed Wagner, MD – MacColl Institute
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Some Reasons Why This Ain’t Easy… (particularly in a siloed system)
The typical primary care physician has 229 other
physicians working in 117 practices with which care
must be coordinated.
Pham et. al Ann Int Med. 2009
In the Medicare population, the average beneficiary
sees seven different physicians and fills upwards of 20
prescriptions per year
Partnership for Solutions, Johns Hopkins Univ. 2002
THE IMPERATIVE: THE QUADRUPLE AIM
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Payment Reform – Creating an ROI
• January 2015, HHS announced plan to link HALF of all Medicare FFS payments to a Value-Based Model by end of 2018
• Alternative Payment Models increasing29% of all healthcare payments
$354.5 Billion
• Majority are “blended models” Fee-for-Service + pay-for-performance or care coordination incentives
• FFS payments decreasing - 62% in 2015 to 43% in 2016
NEW PAYMENT MODELS = NEW STRATEGIES =
MARKET CONSOLIDATION
Health Care Payment Learning and Action Network (LAN)
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Market Consolidation
• Between 1983 and 2014, the percent of physicians practicing
alone fell from 41% to 17%, and percent of physicians in
practices with 25 or more doctors grew fourfold (5% to 20%).
• More than half of U.S. physicians are now employed by
hospitals or integrated delivery systems.
• ~ 1,000 ACOs nationwide, using a shared savings and/or risk
arrangement
• Large systems gobbling up smaller systems. Deloitte predicts
50% of current integrated systems will be gone.
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Integrated Community Care(Patient-Centered Medical Home to Accountable Care Organizations)
Payer Partners
► Insurers
► Employers
► States
► CMS
Provided Courtesy of
Premier Healthcare Alliance
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HUGE OPPORTUNITIES
• Shared Space• Shared Medical Records• Shared Care Plans• Aligned Incentives
WORKING TOGETHER IN TEAMSTo Help Patients Achieve Their Best Outcomes
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CATEGORY 2CATEGORY 1 CATEGORY 3
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SPECTRUM OF COLLABORATIVE CARE
BUILD A STRONG BRIDGE
OF COORDINATED CARE
WITH REGULAR, EFFECTIVE
COMMUNICATION WITH
THOSE OUTSIDE YOUR
PRACTICE
WORK SIDE BY SIDE IN THE
SAME PHYSICAL LOCATION,
SHARING INFORMATION
WITH SOME WARM HAND-
OFFS
WORK AS AN INTEGRATED
TEAM, WITH ROLES AND
CULTURES THAT MERGE,
WITH HIGH LEVELS
COORDINATION
COLLABORATION CO-LOCATION INTEGRATION
COMMUNICATION PHYSICAL PROXIMITY COMPREHENSIVE
CHANGE
INSIDE PRACTICE OUTSIDE PRACTICE
Getting to “WE”
Healthcare - A Team Sport?
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WORKING IN TEAMS
INSIDE THE PCMH
• Primary Care Physicians
• Nurses/MA’s
• Care Managers
• Front Office Staff
• Back Office Staff
• Patients/Families
OUTSIDE THE PCMH
• Specialists
• Behavioral Health Professionals
• Educators
• Home Health
• Skilled Nursing Facilities
• Pharmacists
• Patients/Families
REALLY??
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When Teams Work Well…
MGHealthcare Insights, LLC - © 2016
“Culture eats strategy for lunch
…over and over again.”
– Anonymous
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TO HAVE CONNECTED CARE BETWEEN PRACTICES, NEED TO HAVE CONNECTED CARE WITHIN
PRACTICES
Everyone getting their own “houses” in order then building connections with our neighbors
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INSIDE THE PATIENT-CENTERED MEDICAL HOME (PCMH)
An approach to providing high-quality, safe,
continuous, coordinated, comprehensive care,
with a partnership between patients
and their personal health care team…
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From Practice Point of View
From Patient Point of View
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NEW PAYMENT MODELS ALLOW NEW WAYS OF THINKING!
Population Management- Transition from FFS “Treadmill Medicine” to coordinated
planned management of entire panel, with extra care for those who need it
Redefine “VISITS” – enhance access- 40 – 60% don’t need to be in person- Save in-person visits for higher need patients (FFS)
RIGHT CARE – RIGHT TIME – RIGHT PLACE - Kaiser Permanente: emails, phone appointments, urgent care,
emergent care
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Building a Solid Infrastructure - Fundamentals for Transforming
Technology & Outcomes Reporting
Leadership &
Team Based Care
Practice Viability
& Efficiency
Care Mgmt,
Coordination &
Communication
Patient
Engagement &
Access
Patient Centered
Medical Homes
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EMPANEL AND RISK STRATIFY YOUR POPULATION TO PRIORITIZE RESOURCES
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Multiple
Chronic
Conditions
&
Complex
Patients
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PATIENT CENTERED PLANNED CARE
Before, During, and After Visit
Develop Customized Care Plan- Shared-decision making
- Prevention, Chronic Conditions, Acute Care Issues
Warm Handover to your TEAM depending on patient needs
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TEAM BASED CARE & STAFFING
Key Elements• Clear Roles/Responsibilities with accountability• Highest level of licensure• Use team to help patients reach goals
Consider 2 to 1 ratios – MA/Nurse to provider
Consider additional co-located or integrated team members • Care Coordinators/Care Managers• Behavioral Health Professionals• Pharmacists• Others depending on population
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Collaborative Care Model – in PCMH
Essential Elements
• TEAM-DRIVEN CARE
• EVIDENCE-BASED CARE
• MEASUREMENT-GUIDED CARE
• POPULATION-FOCUSED CARE
• ACCOUNTABLE CARE (Results Driven)
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Team-Driven with Behavioral Health
Spring 2016 - APA/APM REPORT ON DISSEMINATION OF INTEGRATED CARE
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Psychiatric Providers Supporting Teams
Care Manager/BHP 1
Care Manager/BHP 2
Care Manager/BHP 3
Care Manager/BHP 4
• 50-80 patients/caseload
• 2-4 hrs psych/week/care
manager
• A lot of patients getting
care!
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Medicare Payments
• Short Term Behavioral Health Services In a Primary Care Setting
• Starting July 2018 – new CPT Codes
• 6 visits – for BHP to assess, track progress, review weekly caseloads with
psychiatric consult, evidence-based treatments
• Documentation parameters - reasonable
• Others likely to follow
• Performance Metrics
• Process and outcome measures
• Satisfaction – patient and provider
• Functional –work, school, homelessness
• Utilization/Cost - ED visits, 30 day readmits, med/surg/ICU, overall cost
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A Medical Home Without An
Integrated Medical Neighborhood
Is Just An Island
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Building The Medical Neighborhood
Shared Resources – Expand “TEAM”• Complex Care Managers, Clinical Pharmacists, Social Workers,
Educators, Mental Health Providers, Home Health…
Specialists
Compacts
Hospitals Identification, Notification, Communication
Mental/Behavioral Health– Overcoming HIPAA, Carve Outs
Community Resources– Awareness and Connections
PCMH-Neighbor Model - Framework
www.acponline.org/hvcc-training
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“Won’t You Be My Neighbor?”
Medical Neighbor (PCMH-N)
A clinician that collaborates with a PCMH or another medical neighbor to participate in the
care team to enhance bi-directional communication and collaboration on behalf of
the patient.
Otherwise Stated
A framework so patients neither fall
through the cracks nor get duplicated
services
Safe – Efficient – Effective
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First Step: Create A Shared Vision
Identify Pain Points – Work Toward Solutions and Common Goals
• Determine what’s working well…..and what’s not
• Use consensus-driven decisions
• Beware: the lure of the “status quo” is powerful Have a preset strategy / plan for change
Identify “champions” - help gain consensus on difficult issues
Consider using outside facilitator
• Work through misconceptions & wrong assumptions PCP thought it best to make the appt for patient but specialist knew that
was associated with high No Show rate.
Specialist thought they were helping by referring on to another…..
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THE DISCUSSION
Mutual respect of what each brings to the table
Recognition of the value of role differentiation
Appreciation of primary care as foundation
Specialty skill sets as complimentary
Acknowledgement of a flawed system
Longing for more “professionalism”
Better communication, consideration, cooperation and integration
Always return to: Patient Centered Care
A “High Value” Referral Process
Care Coordination Agreements (Compacts) - tool for better communication & safe transitions:
- Clarifies roles and responsibilities
- Clarifies expectations and timelines
- Provides core elements for the transition record
Develop policies & procedures that outline the way you want it to work
- See if it works
-Make improvements/changes as needed
- Report cards
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Patient-Centered Extension Of Care Team
Access – appropriate and timely consultations
Coordination
• Define roles - clarify who’s doing what?
Clear Communication
• Define expectations
• Ensure effective flow of information - pre/post referral
• Ensure ALL understand, including patients/caregivers
Culture
• Support each other in reaching individual patient and
population goals
• Regular get togethers
Expectations for High Value Referrals
Referral Request
• Prepared Patient
• Type of referral
• Clinical question
• Urgency
• Core Data Set
• Pertinent Data set
• Answer the clinical question
• What specialist will do
• What patient is instructed to do
• What does the referring
physician need to do & when
• What follow up is needed & with
whom
Referral Response
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Clarify The Specialist’s Role
___Pre-consultation/ pre-visit assistance/preparation
___Medical Consultation: Evaluate and advise with recommendations for management and send back to me
___Procedural Consultation: Specialist to confirm need for and perform requested procedure if deemed appropriate.
___Shared Care Co-management: I prefer to share the care for the referred condition (PCP lead, first call)
___Principal Care Co-management: Please assume principal care for the referred condition: (Specialist assumes care, first call)
___Please assume full responsibility for the care of this patient (Complete transfer of care)(e.g. Pediatric to Adult Care transition)
MAKE SURE YOU CLOSE THE LOOP
• Referral Tracking
o Response Note
o Follow-up needed
o Notification of No Show or Cancellation
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31 30
4953
32
25
3632
2015
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49
57 59
42 41
51
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3033
54
0
20
40
60
80
100
AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US
Medical home No medical home
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COORDINATION GAPS WITH AND WITHOUT MEDICAL HOMES
Percent*
Test results/records not available at time of appointment, doctors ordered test that had already been done, providers failed to share
important information with each other, specialist did not have information about medical history, and/or regular doctor not informed
about specialist care.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
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BOTTOM LINE
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Ideal State
Shared “community” vision
Shared data – timely, actionable, in usable format
-All patient information available at point of care
-List of those needing services - for outreach
-Aggregated across community to identify target
areas for improvement and monitor progress
Shared Care Plans
-Everyone that touches patient on the same
page…including the patient/family
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Ultimately, working together to assist
patients in achieving the highest level of
health they can, preventing problems
BEFORE they occur!
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With Our TEAM
Building Accountability to Each Other
and Our Communities
With Our NEIGHBORS
With Our PATIENTS!
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Thank You.
Marjie G. Harbrecht, MD
MGHealthcare Insights, LLC
Case Study: Teams That Work: Developing Models of Care Coordination
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©2017 MGMA. All rights reserved. - 59 -
©2017 MGMA. All rights reserved. - 60 -
Women’s Healthcare Associates, LLC
• Serving women in the Portland, Oregon metropolitan
area since the 1940s
• 15 offices, 110+ providers
• Obstetrics, gynecology, maternal-fetal medicine,
preventative women’s healthcare, birth center
• Issues:
• Evolving reimbursement model
• Cost pressure (including lowering C-Section Rate)
• Demonstrating quality and value to consumers and payers
• Improving health literacy
Background
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©2017 MGMA. All rights reserved. - 61 -
Problem solving approach
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• Researched/tested different care models (group,
internal/external support, etc.)
• Developed into a prenatal care model known as
Pathways
• Hybrid group/one-on-one visits
• Team of 4 OB/GYNs, 1 nurse practitioner and clinical support (internal
and external, including behaviorists)
• Well Being Assessment (WBA) form
Identify Opportunities
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©2017 MGMA. All rights reserved. - 63 -
PathWays model overview
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Program Goals and Metrics
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How is it different?
• Early entry/needs identification
• MA collect information (WBA) and provider reviews
• Custom pregnancy PathWay
• Questionnaire administered at 12 and 36 weeks
• Primip needs reliable information; multips need assurance
• Comprehensive education
• Healthcare utilization, etc.
• Pediatrician involvement
• Specialized needs
• Behavioral health, nutrition
©2017 MGMA. All rights reserved. - 66 -
Overcoming the challenges
• Standardization (forms,
terminology, data
gathering)
• Communication,
coordination w/care
partners
• Evidence based
• Skill development
(facilitation, teaching
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©2017 MGMA. All rights reserved. - 67 -
Success measures – cost/utilization
©2017 MGMA. All rights reserved. - 68 -
Success measures-quality/satisfaction
• Lower no show rates
• Do they like it?
• When asked if they found the group visit helpful, 95% of those surveyed responded “yes.”
• Overall
• Meets or exceeds patient satisfaction cores vs other models
• Quality – yes (but consider sample size)
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Providers and staff love it!
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Where to go from here
• Integration of other care providers
• OB (hospital or other providers),
GYN, other
• Expansion of WBA
• Moderate to high risk
• Annual exams
• Migration to new EMR
• Data, forms, standardization
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- 71 -©2018 MGMA. All rights reserved.
Continuing Education ACMPE credit for medical practice executives…………... 1.5
*AAPC Core A credit ………………….………………………… 1.5
ACHE credit for medical practice executives…………..…. 1.5CME AMA PRA Category 1 Credits™……………………….. 1.5CNE credit for continuing nurse education …………….... 1.5
*CPE credit for certified public accountants (CPAs)……….. 1.8
CEU credit for generic continuing education………..……. 1.5
*AAPC CODE: 5 8 7 6 0 A Y Y*CPE CODE: 3 0 2 C C
Let the speakers know what you thought!Evaluations will be emailed to you daily.
Thank You.
Gregory S. Pawson, CPA, CMA, CMPE
503-601-3611
Women’s Healthcare Associates LLC
7650 SW Beveland St.
Ste 200
Portland, OR 97223