Engaging Patients by Automating Population Health

Jennifer Seiden, RN, MHA, CPHQDirector, Quality

Bon Secours Medical GroupRichmond, VA

Fourth National Medical Home SummitFebruary 28, 2012

The 7 Principles of the Medical Home Concept

BSMG Medical Home Clinical Transformation Project

The goal of a PCMH is to improve quality, efficiency, and satisfaction for both patients and physicians. This is done by providing prompt, cost effective, and coordinated access to a comprehensive range of services – to provide a “ System of Care”

To maintain organizational “Alignment” with new revenue lines: “Meaningful Use”, PQRI, HEDIS, ACO

To improve “Capacity and Compliance”

http://www.emmisolutions.com/medicalhome/pcpcc

Physician Time UseaMean Hours

% of Total Workday

Face-to-face patient care 4.7 54.9%Visit-specific work outside the examination roomb 1.3 14.5%

Work outside the examination room related to care of patients not currently being seenb

2.0 22.9%

Other work outside the examination roomc 0.7 7.7%

Total 8.6 100%

• Primary care physicians spend approximately 55% of the average workday on face-to-face patient care

Why Do We Need to Change?

Traditional Methods of Managing Workflow

Provider

Preventive Medicine Intervention

Chronic Disease Monitoring

Medication Refill

New Acute Complaints

Test results

Healthcare Support Team

Care/Case Management

Mental Health Providers

Referral out to Specialists

Certified Medical Assistant

Delivery System – The Care Team

Division of Labor: Use every member of team to highest level of training/licensure/ability Move all possible interventions away from the physical visit – Pre and Post visit encounterEverything comes to the patient Use of Nursing Driven Protocols

Details – Phase 1

Practice assessment and planning Bricks and Mortar review - 3 rms/MDStaff Competency/Policy reviewStaffing and Team formationEquipment and training

Including EMR Optimization and Coding for MD’s

Development of metrics

4 - 5 K Patients

Details – Phase 2

Basic Workflow rehearsalDaily Team meeting - “Huddles”Standard Patient Rooming protocolResults workflowsDisease specific Rooming Protocols

Including POC testing Medication Refill ProtocolINR Management Protocol

Details – Phase 3

Advanced Care NavigationProactive outreach to patients using a registry

we are using Phytel and individualized outreach to certain high risk populations - i.e. discharges, A1c

Use of an electronic web based patient portal for care management - MyChartCase Management/Panel Management

Embedded Case Management - RN Nurse NavigatorsVirtual Case Management RN Nurse Navigators

LPN Panel ManagerDirect Patient outreach for high risk

Fast Track Referral to CDE, MNT, LCSW, Palliative Care, etc

HRA DataHigh Risk Employee

Employee with High Risk HRA Scores and UHC Claims

Claims Data (Optima/UHC)

PCP

YesYesNo

BSMGNone

YesDoes Practice Have RN

Navigator

BSMG RN

Navigat or

Initiates Workflo

wNo

inHealthRN

Navigat or

Initiates Workflo

w

inHealthRN

Navigat or

Initiates Workflo

w

inHealth Navigator

PCP Referral

BSMG

CB

CB

Program Completion

Outcomes/Metrics

Program Completi

on

Outcome s/Metrics

Program Completion

Outcome s/

Metrics

ACO Care Coordination Workflows

Phytel Protocols for Patient OutreachProtocol Name Description Source

Chronic Conditions

DiabetesIdentify patients aged 18‐99 years with a diagnosis of Diabetes Mellitus who have not had a chronic condition 

visit‐related charge in the previous 6 months and do not have a visit scheduled in the next 2 months.ADA 2009, AACE 2007, 

(Joint) AMA‐PCPI (T1)

Diabetes UncontrolledIdentify patients aged 18‐99 years with a diagnosis of Uncontrolled Diabetes Mellitus who have not had a chronic 

condition visit‐related charge in the previous 3 months and do not have a visit scheduled in the next 1 month.ADA 2009, AACE 2007, 

(Joint) AMA‐PCPI , (T1)

AsthmaIdentify patients aged 18‐99 years with a diagnosis of Asthma who have not had a chronic condition visit‐related 

charge in the previous 6 months and do not have a visit scheduled in the next 2 months.

NAEPP/NHLBI/NIH 

2007,(Joint)

AMA‐PCPI, 

NCQA (T1)

HypertensionIdentify patients aged 18‐99 years with a diagnosis of Hypertension who have not had a chronic condition visit‐

related charge in the previous 6 months and do not have a visit scheduled in the next 2 months.JNC7 2004, (Joint) AMA‐

PCPI, NCQA (T1)

Hypertension, Malignant Identify patients aged 18‐99 years with a diagnosis of Malignant Hypertension who have not

had a chronic 

condition visit‐related charge in the previous 3 months and do not have a visit scheduled in the next 1 month.JNC7 2004, (Joint) AMA‐

PCPI, NCQA (T1)

High CholesterolIdentify patients aged 18‐99 years with diagnosis indicative of hypercholesterolemia who have not had a chronic 

condition visit‐related charge in the previous 6 months and do not have a visit scheduled in the next 2 months.ATP III Update 2004rev, 

NCQA (T1)

Thyroid DisordersIdentify patients aged 18‐99 years with a Thyroid Disorder diagnosis who have not had a chronic condition visit‐

related charge in the previous 6 months and do not have a visit scheduled in the next 2 monthsAACE 2006rev, NCQA 

(T1)

Severe Thyroid DisorderIdentify patients aged 18‐99 years with a severe thyroid disorder diagnosis who have not had a chronic condition 

visit‐related charge in the previous 3 months and do not have a visit scheduled in the next 1 month.AACE 2006rev, NCQA 

(T1)

Chronic Obstructive 

Pulmonary Disease (COPD)Identify patients aged 18‐99 years with a COPD diagnosis who have not had a chronic condition visit‐related 

charge in the previous 6 months and do not have a visit scheduled in the next 2 months.

ATS 2005, NHLBI 2005, 

GOLD 2008, ICSI 2009, 

(Joint) AMA‐PCPI, NCQA

(T1)

Coronary Artery Disease 

(CAD)Identify patients aged 18‐99 years with a diagnosis of Coronary Artery Disease who have not had a chronic 

condition visit‐related charge in the previous 6 months and do not have a visit scheduled in the next 2 months.

ACC/AHA 2006, 

ACC/AHA 2007, (Joint) 

AMA‐PCPI, NCQA (T1)

Heart Failure (HF)Identify patients aged 18‐99 years with a diagnosis of Heart Failure who have not had a chronic condition visit‐

related charge in the previous 6 months and do not have a visit scheduled in the next 2 months.

ACC/AHA 2009, HFSA 

2006, AMA‐PCPI, NCQA 

(T1)

BSMG Dashboard Phytel

May 2010 – April 2011

Total # successful contacts

77,909

# appts scheduled 16,651

% success 21%

Detail on Case Management – Nurse Navigators

1 RN “Nurse Navigator” for every 4-5K pts.Active Case load = 125 – 150“Bat Phone - Beeper” access

Case Management Admission Criteria:Per MDPer Hospital based Case ManagerPer Insurer’s Case Management

Frequency of Touch determined by Level of ManagementDepending on severity index (i.e. RRI) and/or MD

Manage TransitionsDischarge Criteria

Stabilization, goal attainment, MD decision

Nurse Navigator Activities

Hospital Discharge f/uSNF f/uChronic Disease RegistriesHome O2/LabDVI/Lovenox managementSoft CP work upHome IV antibioticsCare/Life Coordination – transportation, housing, food, insurance, etc.

Where can a guy get a little help around here?

An online database of resources pooled from Bon Secours facilities

19

helpgood

Care Team: New Workflow Redesign

Healthcare Support Team

Care Management RN/LPN/MA

Provider Medical Assistant

Behavioral Health

Medical Nutrition Therapy

Diabetes Educator

Nurse Navigator

Medication Refill

Chronic Disease Monitoring

Test results

New Acute Complaints

Preventive Medicine Intervention

Point of Care Testing

Acute Mental Health Complaint

Chronic Disease Compliance Barriers

Totals By MonthTotals For Whole Year

January February March April May June July AugustSeptember

October 2011

Num of Pts139 182 249 550 848 1105 1086 1057 1173 1168

Num of Pts7,557

Already Sched 45 40 74 93 98 40 126 161 248 287

Already Sched 1,212

Appts Sched 59 89 115 271 328 95 103 144 123 162

Appts Sched 1,489

Readmits4 4 8 10 10 22 7 14 13 25

Readmits117

Percentages By MonthPercentages For 

Whole Year

January February March April May June July August September October 2011Already Sched 32.37% 21.98% 29.72% 16.91% 11.56% 3.62% 11.60% 15.23% 21.14% 24.6%

Already Sched 16.04%

Appts Sched 42.45% 48.90% 46.18% 49.27% 38.68% 8.60% 9.48% 13.62% 10.49% 13.87%

Appts Sched 19.70%

Readmits2.88% 2.20% 3.21% 1.82% 1.18% 1.99% 0.64% 1.32% 1.11% 2.14%

Readmits1.55%

Nurse Navigator Contacts

BSMG Dashboard: Epic Adoption # E-Prescriptions

Jan 2011 65,536April 2011 73,841May 2011 76,339June 2011 81,686Aug 2011 90,547Sept 2011 94,907Dec 2011 104,438Jan 2012 116,214

BSMG Dashboard: MyChart Patient Portal

Number of “Activated Patients”(Given but not Activated= 94,993)

38.028

Number of “all” messages/week 1427

eRx TAT 11h 37m

Appointment Request TAT 6h 15m

Messaging TAT 9h 24m

Review - The Big Picture

The PCMH, due to its “value” proposition, is gaining momentum

Major role in health care reform legislation under President Obama

Memorial was the first of three practices in Bon Secours to gain NCQA recognition as a Level 3 PCMH

TODAY’S CARE MEDICAL HOME CAREMy patients are those who make appointments to see me

Our patients are those who are registered in our medical home

Patients’ chief complaints or reasons for visit determines care

We systematically assess all our patients’ health needs to plan care

Care is determined by today’s problem and time available today

Care is determined by a proactive plan to meet patient needs without visits

Care varies by scheduled time and memory or skill of the doctor

Care is standardized according to evidence-based guidelines

Patients are responsible for coordinating their own care

A prepared team of professionals coordinates all patients’ care

I know I deliver high quality care because I’m well trained

We measure our quality and make rapid changes to improve it

It’s up to the patient to tell us what happened to them

We track tests & consultations, and follow-up after ED & hospital

Clinic operations center on meeting the doctor’s needs

A multidisciplinary team works at the top of our licenses to serve patients

Acute care is delivered in the next available appointment and walk-ins

Acute care is delivered by open access and non-visit contacts

Slide from Daniel Duffy MD School of Community Medicine Tulsa Oklahoma

25

Patient & Family

Advanced Primary CareUnder Patient-Centered Medical

Home

Medical Group & Health Care SystemEnterprise Level Activities

Accountable Care OrganizationHospitals• Service Line Integration• Medical Staff Alignment• Incentives for Efficiency & Lean Six Sigma• Quality (SCIP, Leap Frog)• Safety

Medical Groups &Health Care System• Enterprise Level Activities• PC-MH FunctionsSkilled Nursing Facilities

• SNFists• On-site Case

Management• Efficiency Rating Systems

“Preferred Facilities”Ancillary Services• Free-Standing ASC &

Diagnostic Testing Centers

Home Care• Home Safety Visits• Post Discharge Visits• Home Health

Coordinator of Services

Hospice• Transitions

(CHF, COPD, Frailty Syndrome, Dementia)

• PCP/SCP Incentives & Clinical Guidelines• Pay for Performance Initiatives and

Outcomes Measurements• Hospitalists, Post Discharge Follow-Up

Programs

DME• Integration &

Oversight with Care Management

• Outcomes & Evidence Based Medicine

• Call Coverage• Consult Services (Stroke,

STEMI)

• ER Avoidance Programs• Urgent Care• End of Life (Palliative Care)• Patient Satisfaction & Loyalty

• Personal Health Record• Patient Portal• Health Risk Assessment• Patient Engagement &

Activation

• Prevention & Wellness• Point of Care Analytics &

Clinical Decision Support• Gaps in Care• Population Management &

Chronic Care Registries• Home Visiting Teams• Generic Prescribing

Program

• Cost Effective Medical Management & Utilization of Services (SCP, Ancillary)

• Access, Same Day Appointments, e-Visits

• Patient Satisfaction & Loyalty• Provider & Office Staff

Satisfaction

• Care management (Acute, Chronic, Inpatient, SNF)

• Health Coaching (Shared Decision Making)

• Transition of Care• Provider Satisfaction• Behavioral & Mental

Health

Maturing ACOs Payment Mechanism

Questions?

Contact: Jennifer_Seiden@bshsi.org