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”

- 6 -©2017 MGMA. All rights reserved.

PAM

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- 7 -

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)


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


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


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

http://www.digitaldutch.com/arles/tutorials/thumbnail_tags/galleries/thumbnail_tags_with_size/imagepages/image6.html

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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

http://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

42

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

[email protected]

Case Study: Teams That Work: Developing Models of Care Coordination

mailto:[email protected]

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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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Problem solving approach


• 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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PathWays model overview


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


Overcoming the challenges

• Standardization (forms,

terminology, data

gathering)

• Communication,

coordination w/care

partners

• Evidence based

• Skill development

(facilitation, teaching

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Success measures – cost/utilization


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!


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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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

[email protected]

503-601-3611

Women’s Healthcare Associates LLC

7650 SW Beveland St.

Ste 200

Portland, OR 97223

mailto:[email protected]

teams that work: developing models of care coordination

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