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Lessons Learned Transforming to a Value Care Organization While Tripling Capacity

Cástulo de la Rocha, J.D. & Martin Serota, M.D.

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• Lessons Learned• W hy?• Structural and Infrastructure Requirements• Operational changes• S ummary• Questions

The How and Why of Growth and Transformation at AltaMed

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• Be true to your mission

Lesson 1

To eliminate disparities in health care access and outcomes by providing superior quality health and human services through an integrated world-class service delivery system for Latino and multi-ethnic underserved communities in Southern California.

AltaMed’s Mission

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Lesson 2Providing Value Means Changing Models:

• Patient-centered instead of provider- or payer-centric

• Payer agnostic

• Team-based care

• Evolve from solely access to focus on quality

• Collaboration and coordination through the ACO

• Deconstructing internal and external silos

• Process-based to outcomes based

• Medical management at the core

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Lesson 3Need to be a culture of Continuous Quality Improvement:

• Pilot process

• Plan, Do, Study, Act

• Role of measurement

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Lesson 4Need to expand the role of patients:

• Patient satisfaction

• Process design

• In their care

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Lesson 5Need for payment reform:

• Role of PPS (prospective payment system)

• Financially sustainable model

• Aligned incentive

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Lesson 6Infrastructure needs to support move from “cottage” to

large–scale enterprise mentality

• Physician leadership

• Change management/acceleration

• LEAN/Six Sigma

• Succession planning

• S calability

• Robust HIT

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AltaMed Health Services and the Regional Safety Net ACN

Castulo De La Rocha, JD

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About AltaMed

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• Founded as the East Los Angeles Barrio Free Clinic in 1969, a volunteer-staffed storefront operation.

• To respond to the unmet needs of indigent populations, targeting historically underserved, uninsured, primarily Latino communities.

• Largest independent, federally-qualified community health center in the U.S.

• We deliver high quality care in “Health Professional Shortage Areas” and “Medically Underserved Areas.”

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VisionTo be the leading community-based provider of quality health care and human services.

MissionTo eliminate disparities in health care access and outcomes by providing superior quality health and human services through an integrated world-class service delivery system for Latino and multi- ethnic underserved communities in Southern California.

Core Values• Patients always come first.• Employees are our most valuable asset.• Encourage process excellence and innovation for quality outcomes. • Promote wellness and advocate for strong and healthy communities. • Integrity, honesty and respect in all of our endeavors. • Commitment to teamwork.

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West Covina

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Prospective Payment System (PPS)

• PPS is an enhanced payment to FQHC for Medicaid patients to 

provide additional support services• It has allowed us to provide PCMH‐type services to our patients for 

many years, e.g.

– Social services– Health education– Access to affordable dental, mental health and pharmacy 

services– Must provide comprehensive medical care regardless of ability 

to pay

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Why grow, transform and collaborate?

• The regions of LA and OC we serve have a large safety net population in need of an improved, coordinated model of care

• Fragmented systems of care are inefficient, costly and place patient safety & health at risk and are not financially sustainable

• Changing regulations (e.g.1115 waiver), policy changes (HCR) and market forces have finally created an opportunity to engage at a community level in patient centered care re-design

• Previous experiences working with ACN partners has led to the level of trust needed to undertake deep organizational changes and to truly partner

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Overlap View of AltaMed and ACN Service Area

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Partners

Private Hospitals: Citrus Valley Health Partners, Hollywood Presbyterian Medical Center and White Memorial Medical Center

Public Hospital: LAC+USC Healthcare Network

Federally Qualified Health Center & IPA: AltaMed Health Services

Facilitator: COPE Health Solutions

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Current Regional Need

• Within the combined service area of the ACN partner organizations, there are approximately 3.7 million residents

• Ethnically diverse population, with more than 60% of the residents in our service area represented by Latinos (2.3 million individuals)

• In our ACN service area, which represents more than 1/3 of the total LA County population (same size as state of Oregon), ACN hospitals provide approximately 25% of ED and inpatient services for our region

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Goals1.Improve access to care, quality of care, patient safety and satisfaction, efficiency and cost effectiveness of care delivery 2.Improve long term financial viability of providers within the network 3.Provide strong clinical leadership and resources to the network 4.Drive advocacy and policy development to improve access to care for the safety net population 5.Provide the best practice opportunities for physicians who want to care for all patients in a community

Goals1.Improve access to care, quality of care, patient safety and satisfaction, efficiency and cost effectiveness of care delivery2.Improve long term financial viability of providers within the network3.Provide strong clinical leadership and resources to the network4.Drive advocacy and policy development to improve access to care for the safety net population5.Provide the best practice opportunities for physicians who want to care for all patients in a community

PrinciplesFocus on the PatientEase of Use

Capacity & Capability for Population ManagementAccountability & TransparencyPartnership & TrustAdaptability

PrinciplesFocus on the PatientEase of Use

Capacity & Capability for Population ManagementAccountability & TransparencyPartnership & TrustAdaptability

Shared Vision, Goals and Principles

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Benefits to AltaMed and Partners

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• Improved access and quality of care for patients

• Enable development of risk-sharing and innovative payment models based on quality and cost- effectiveness for managing challenging populations

• Increased opportunities to access federal and state funding to expand and strengthen the resources available for the safety net population in Los Angeles County

• Enhanced ability to engage in population health and community-based research

• Provide opportunities to grow market share

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ACN Strategy

• Collaboration• Shared IT• Clinical Integration• Shared medical management• Financial Integration

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Establishing clinical integration

(12-18 months)

Establishing clinical integration

(12-18 months)

Engaging in financial integration (2-3 years)

Engaging in financial integration(2-3 years)

Path to Clinical & Financial Integration

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• AltaMed will triple capacity by- Growth at each site- Increasing the number of sites - Expanding the IPA- Collaborating with the ACN

• ACN will improve access and quality, reduce disparities

A Five-Year Strategy…

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Infrastructure change as a part of transformation

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Physician Leadership

• Medical Leadership Council

• Chief Medical Officer

• Physician Leadership Development

• Physician Mentorship and Coaching

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Quality Team• Medical Director• Director of Quality• Business Analysts• Clinical Quality Analysts• Clinic Team• Patients

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Professional HR Team

• Hiring• Competencies• Staff Development• Leadership Training• Succession planning

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Management Resource Review

• Identifies leadership pipeline• Identifies gaps• Guides training and mentoring

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Office of Project Management• SPD integration

• ADHC/PACE Conversion

• Clinical Integration Engine (Unity) Implementation

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Operational Requirements Overview• Patient-centered• Physician-led• Transformation• Integration• Collaboration• Clear Goals

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How do you eat an elephant?

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Many bites at a time!

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TRANSFORMATION THROUGH INTEGRATION AND THE PCMHStandard Work/ LEAN

Patient Portal

Medical ManagementDisease ManagementCare Management

IPA/Regional PODs

Operational-Clinics-Med Refill-Advanced Access-Pre Visit/ Post Visit-Cycle time

Operational-Enterprise-Call Management-Auth/Referral-Patient Outreach -Integrate Medical Management

Clinical Integration Engine(Unity)

PCMHJuly 2011

Clinics: PCP, HIVSenior Services: PACE, ADHCIPA

1115 Waiver-SPD-Dual eligible

Health Care Reform Market Forces

Safety Net ACN

Patient Centered Care

Improved Quality and Outcomes

Reduced Disparities

-Health CoverageInitiative

Behavioral Health

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1.Choose Your Accrediting Body: The Joint Commission and/or NCQA

2.Choose Your Primary Focus: patient experience, quality outcomes, patient connectivity and empowerment, intense medical management

3.Build Accordingly: staffing; measurement, reward the right behavior

4.Utilize Valuable Tools: PDSA, Huddles, Measurement, Data boards

Primary Care Medical Home

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1st in the Nation Primary Care Medical Home

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• AltaMed primary care doctors work with an interdisciplinary team to support the patient and ensure comprehensive and coordinated care

• AltaMed underwent a rigorous unannounced on-site survey the week of July 11, 2011

• PCMH creates an environment of teamwork where we treat the whole patient

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QUALITY DEPARTMENT: PILOTS AND PROJECTS TRACKING AND WORKFLOWCQ

CCL

INICS

QPID

          

Fill out Pilot Initiation Form & submit to QPID

Review Pilot Initiation for Redundancy

Catalog the Pilot’s 

ParametersNO

Review Redundancy 

with Originator

YES

Variant Pilot Required?

Closeout PilotNO

Assess QPI Measurement 

Support Required?

YES

Queue Support Request & Fulfill

YES

Assign Resources, Establish Task 

Team,Create Project Plan, Embark on Work 

Measure Improvements and Report to CQC. Complete Closeout form for 

QPID

Review for Permanent 

ImplementationOperationalizeYES

NO

Iden

tifies prob

lem in

 clinic(s)

Refers to CQICRefers to task force (work group)

Creates Pilot

Iden

tifies prob

lem

Drafts pilotRefers pilot to 

PEC for approval

Creates Pilot

 Fill out Pilot Progress Forms and submit to QPID at agreed upon intervals

No

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Cycle Time Project

AltaMed Overall Medical Cycle TimeMay 2010 - May 2011

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11

May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11

LA County (CHLA Excluded) OC County LA and OC Goal

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Establishing an ACN• Leadership and collaboration

– Establish a clear leader who is able to be inclusive– Establish a process but must be decisive– This is possible with aligned mission and values

• Must adequately capitalize• Physician leadership and engagement

41August 2011 Confidential - Not for Distribution

ACN Committee Structure

42August 2011 Confidential - Not for Distribution

PODS

Regional POD Board:

3-7 additional influential providers

Regional POD Board:

3-7 additional influential providers

Regional POD Board:

3-7 additional influential providers

Regional POD Board:

3-7 additional influential providers

Clinical Leadership Council – Regional Structure

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Sample CLC Projects• Medical management

– Standard Intake (HRA) workflow for high-risk patients– Standard Transitions workflow

• Disease Management– Advanced directives (POLST) standardization and

accessibility– Diabetes mellitus standardization inpatient and outpatient

• Credentialing– Quality standards– Hospital privileges for non-admitting providers

• HIT– EHR recommendations and rollout– ACN-wide HIE

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Q & A

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Quick Wins

Improved patient access

Reduced ED visits

Reduced LOS

Reduced re-admissions

Improved Provider satisfaction

Physician Engagement

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Role of HIT in Transformation

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We are here

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Project Unity@AltaMed

CLINICALINTEGRATION

ENGINE

ConnectApproveManageIntervenePredict

Care Team Workflow &ViewsClinical Applications & PathwaysUtilization & Case MgtChronic Disease MgtDisease Registry and PortalElectronic Health Record

Interface ManagementSemantic Data MapperMaster Patient IndexCommunity Patient RecordPatient consent & privacy 

Security

Record SharingPatient & Family EngagementPrevention & Wellness SupportProvider / Patient CommunicationIVR communicationBehavioral Data

Clinical Decision Support Alerts & NotificationsCost & Quality AnalyticsPopulation Health Reporting

CARE MANAGEMENT

HEALTH INFORMATION

EXCHANGE

PATIENT HEALTH

RECORDS

ANALYTICS

PATIENT- CENTERED

CARE

PATIENT PORTAL

PRIMARY CARE

PORTAL

SPECIALIST PORTAL

HOSPITAL PORTAL

HOME HEALTH PORTAL

MEDICAL MANAGEMENT

CALL CENTER /

IVR

MOBILE DEVICES

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“Triple Aim”“Triple Aim”

“Transform

into a clinically integrated healthcare delivery system within 3 years 

prepared for reimbursement based upon value and quality, not volume”

Communication Collaboration

Anticipation

Coordination

“Quadruple Quiver”“Quadruple Quiver”

-Donald Berwick-Donald Berwick- Martin Serota- Martin Serota

Improving the experience of careImproving the experience of care

Improving the health of populationsImproving the health of populations

Reducing per capita cost of healthcare

Reducing per capita cost of healthcare

Vision Realized

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Summary

• AltaMed is transforming while rapidly growing• It’s no longer business as usual• We have new models of leadership, management and care• This requires new partners and new tools• It also requires robust IT systems

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