the virginia mason medical center’s “medical home” virginia mason medical center’s...

The Virginia Mason Medical The Virginia Mason Medical CenterCenter’’s s ““Medical HomeMedical Home””A team approach to safe and reliable A team approach to safe and reliable

patient carepatient care

Ingrid Gerbino, MD, FACPWashington Patient Safety Coalition

May 4, 2010Seattle, WA

2

Virginia Mason Medical CenterStrategic Plan

© 2010 Virginia Mason Medical Center

TodayToday’’s Topicss Topics• Developing a robust culture of safety intertwined

with a quality-focused management method in primary care

• Using reliable systems to deliver safe and timely preventive care to decrease costly non-value added imaging

• Leveraging a team to care for patients with chronic /complex conditions

• Sharing the successes of partnering with a large employer and payer to implement an “ambulatory ICU”



Our Vision for Primary Care at Our Vision for Primary Care at Virginia Mason Medical CenterVirginia Mason Medical Center

BETTER• Patients have

preventive needs completed on time

• Evidence-based care as standard

• Robust technology and registries

• Quality leader in patient satisfaction

FASTER• Advanced open

access• Immediate test

result reporting• No unnecessary

waiting (patient and care team)

• All work done in flow

MORE AFFORDABLE

• Hidden, wasteful costs eliminated

• Less expensive/alternative ways to obtain care

• Everyone can afford our services

• VM is preferred provider

Transform the primary relationship in healthcare: between patients and their primary care team

© 2009, Virginia Mason Medical Center

5

Just Culture

•Console the Error•Coach the At-Risk•Punish the Reckless

Adopting Change Adopting Change

“Practice improvements often fail because they rely on the willingness of physicians, who are already too busy, to take on additional work.”

Bodenheimer, T., “Coordinating Care – A Perilous Journey through the Health care system”, NEJM; 358:10, p1064, 2008


The Virginia Mason Production System• There is an obsession with

safety• The patient is always first• There is engagement of all

employees to produce the highest quality

• We strive for the highest staff satisfaction

We adopted the key philosophies of the We adopted the key philosophies of the Toyota Production System and applied Toyota Production System and applied

them to healthcare:them to healthcare:


The Patient is Always FirstThe Patient is Always First

• The patient is at the top of our strategic plan

• Value is defined by the patient

• VM’s Patient Safety Alert System (PSA) encourages transparent reporting and rapid response


Patient Safety Alert ResultsPatient Safety Alert Resultsas of December 31, 2009as of December 31, 2009

14,604 Patient Safety Alerts Diagnosis/Treatment 25% Medication Errors 21% Systems 36% Equipment/Facilities 4% Safety/Security/Conduct 14%

Average # of PSAs/month 2002- 3/month 2003- 10+/month 2004- 17/month 2005- 251/month 2006- 276/month 2007 -238/month 2008 - 226/month 2009 - 244/month


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““If you are dreaming about itIf you are dreaming about it……you can do it.you can do it.””

Sensei Chihiro Nakao


Reliable SystemsReliable Systems““Attention to PreventionAttention to Prevention””



Urgency: Urgency: ““adults receive 54.9 percent of adults receive 54.9 percent of recommended care.recommended care.””

“The deficits we have identified in adherence

to recommended processes for basic

care pose serious threats to the health of

the American public. Strategies to reduce

these deficitsin care are warranted.”

The Quality of Health Care Delivered to Adultsin the United States

Elizabeth A. McGlynn, Ph.D., Steven M. Asch, M.D., M.P.H., John Adams, Ph.D.,Joan Keesey, B.A., Jennifer Hicks, M.P.H., Ph.D., Alison DeCristofaro, M.P.H., and Eve A.

Kerr, M.D., M.P.H.n engl j med 348;26 june 26, 2003

URGENCY: The Time FactorURGENCY: The Time Factor

• Estimates are that it would take a physician 7.4 hours per day to provide all recommended preventive services to a typical patient panel

• Plus, 10.6 hours per day to provide high-quality long-term care

Source: Yarnell et al, Primary care: is there enough time for prevention, Am J Public Health 2003; 93:635-41


Prevention in Primary CarePrevention in Primary Care

• VISION: To create the systematic delivery of on-time, effective and appropriate preventive health interventions for the patients we serve.

• AIM: Collaborate with patients for a lifetime of “attention to prevention”



Enhanced Health MaintenanceEnhanced Health Maintenance

Dear Dr. Dipboye,

I wanted to write and thank you for scheduling a routine colonoscopy for me this June. A cancerous tumor was discovered and I had surgery on July 9th removing this mass before it had the opportunity to spread. Without the screening, I would not have known about this tumor as I had no symptoms.

Thanks – I am a firm believer inroutine exams.

Sincerely,Tony …

The Impact of a SystemThe Impact of a System


VM Primary Care: VM Primary Care: We provide prevention interventions at every We provide prevention interventions at every

contactcontact


Reliable SystemsReliable SystemsMistakeMistake--Proofing Use of Costly ImagingProofing Use of Costly Imaging


Reliable SystemsReliable SystemsEnsuring Imaging is ValueEnsuring Imaging is Value--AddedAdded

Headache: -23%Low back pain: -23%Sinusitis: -27%

Mistake-proofing Implemented

Reduction in imaging


Without a team and a system, the burden of Without a team and a system, the burden of delivering safe care is virtually impossibledelivering safe care is virtually impossible

2

6

8

10

4

16

14

12

Physician(Based on a panel size of 2000 patients)

DirectPatient

Care

Prevention

PatientEducation

Care Coord.

“Practice improvements often fail because they rely on the willingness of physicians, who are already too busy,to take on additional work.”

-Tom Bodenheimer

8 HourDay

10 hours/day

2 hours/day

2 hours/day

7 hours/day

18

20

Hours/Day


Team Delivery SystemTeam Delivery System

A primary care delivery system that leverages the skills and training of MDs, medical assistants, RN care managers and pharmacists so can each do what they are best suited to do for the patients served.


Team RolesTeam RolesMedical Assistant:• Standard rooming sequences (vitals, review medication list and updating

as appropriate)• Review Health Maintenance Module for patient’s needed preventive care• Interventions, prompting/coordinating scheduling of these interventions• Shared documentation• Coordinating provider “flow” through the dayRN:• Patient assessment• Empowerment of patient for self care• Protocol driven-teaching and coaching for chronic conditions• Nursing proceduresPharmacist:• Medication management for chronic conditions • Advanced protocols for disease state managementProvider:• Diagnosis and treatment of new problems• Oversight of complicated problems• Minor surgical and diagnostic procedures• Mentor and coach for team based care



Linked VisitLinked Visit

MA

MD

RN

Patient

• RN sees patient post-MA standard rooming, sets agenda, reviews status

• “Warm Handoff” between RN and MD occurs midway or near conclusion of RN visit process.

• MD affirms/adds and prescribes as needed

• RN confirms Patient/MD decisions and documents

• MD documentation based on standard documentation template used by MA, RN and MD

RN

Patient

Patient

Planned Care: Planned Care: a promise to the patients we servea promise to the patients we serve

• We know you Your chronic/complex diseases and issues What will make you confident in managing your disease

• We establish continuous healing relationships Reaching out by telephone to ensure consistent care Shared medical appointments/group visits

• We have a team to support you MD, RN Care Manager, Medical Assistant/Flow Manager,

Pharmacist, etc.

• We create an individualized plan of care with and for you


We are building a model which allows us to We are building a model which allows us to provide safe, effective and appropriate careprovide safe, effective and appropriate care

2

6

8

10

4

16

14

12

Flow Manager

RN Care Manager

Patient Physician PharmacistNP/PA IT

Hours/Day


Results of a team approach for Results of a team approach for patients with diabetes patients with diabetes


Patients with LDL to goal improved 12%

Results of a team approach for Results of a team approach for patients with diabetes patients with diabetes


Patients with HbA1C to goal improved 11%

2007 2007 –– 2009: Boeing 2009: Boeing ““ambulatory ICUambulatory ICU””programprogram

• Aim: reduce Boeing’s healthcare cost for employees with the most expensive health conditions by 15% while improving their health status

Focus on the top 20% of Boeing employees and dependents who generate most cost

Demonstrate quality, efficiency, and affordability Participate in analysis of the 2-year trial findings

• Patient experience: access to care, communication• Clinical outcomes• Utilization


The program included the following design The program included the following design specifications:specifications:

• Provide proactive services 24/7 access by phone Detailed patient education Personalized care plan Email access EMR Care coordination between PCP/Hospital/

Specialist/


Our Primary Care/Planned Care team approach Our Primary Care/Planned Care team approach provided the infrastructure for success.provided the infrastructure for success.

• We provide prevention interventions at every contact

• We create enhanced access to care• We provide planned care for patients with

chronic/complex conditions• We develop informed and activated patients• We coordinate information and services for our

patients


Profile of Boeing IOCP enrolleesProfile of Boeing IOCP enrollees


TOTALHypertension 52.2%

Depression 46.0%

Chronic Pain 40.4%

Obesity (BMI>30) 34.3%

Chronic GI disease 34.4%

Diabetes 32.2%

Asthma 13.5%

Other psychiatric conditions 15.3%

Cancer 13.0%

Coronary artery disease 11.7%

Chronic neurologic conditions 13.1%

Smoker 9.0%

Chronic kidney disease 7.7%

COPD 4.1%

Chronic liver disease 3.4%

Substance abuse 3.8%

CHF 1.6%

Chronic DiseaseN = 725

Actual reduction in annual per capita Actual reduction in annual per capita allowable claims experience:allowable claims experience:

--20%20%• Measured during 1st 12 months following enrollment for

276 IOCP patients vs a case-matched concurrent control group

• Comparison includes supplemental fees Boeing paid to PCPs for enhanced primary care

• Analysis standardized unit prices to neutralize the impact of price changes unrelated to the IOCP test

• Savings calculation achieved at 89% level of statistical certainty, despite small sample size


VMMC Cost/utilization metrics were outstanding! VMMC Cost/utilization metrics were outstanding!

Prescriptions (day supply)Prescriptions

Home Health VisitsDental

Office Visits

-100% -80% -60% -40% -20% 0% 20%

ER Visits

Outpatient Visits

Lab

Admits (acute)

Hospital Days (acute)

Radiology

Costs (standardized)

Out-patient (other)

PatientsPatients’’ functional health status and functional health status and experience of care improved, and experience of care improved, and

absenteeism was reducedabsenteeism was reduced

% Change% change in physical functioning score for IOCP patients compared to baseline

+ 14.8%

% change in mental functioning score for IOCP patients compared to baseline

+ 16.1%

% change in patient-rated care “received as soon as needed” compared to baseline

+ 17.6%

% change in average of patient-reported work days missed in last 6 months compared to baseline

– 56.5%

Successful Economic PerformanceSuccessful Economic Performance

Shared Success Program

Threshold

$ (M

illio

ns)


Continuous learning through the yearsContinuous learning through the years• While creating a culture that embraces change,

some individuals will ‘deselect’ out of the organization.

• Fully leverage the skills of all of your team members – all have invaluable contributions to safe and excellent care.

• Develop reliable tools that “fool-proof” the delivery of care - this will require continuous tests of change.

• Use simple interventions that can have a powerful impact (e.g., prevention at every interaction, impact of follow up phone calls by a caring team member).


““In times of change, In times of change, learners inherit the learners inherit the earth, while the learned earth, while the learned find themselves find themselves beautifully equipped to beautifully equipped to deal with a world that deal with a world that no longer exists.no longer exists.””

Eric HofferEric Hoffer


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