the reality of becoming a high performing health … reality of becoming a high performing health...

The Reality of Becoming a High Performing Health System

Parag Agnihotri, MD Medical Director, Continuum of Care

Vicki DeBaca DNS, RN VP, Health & Provider Services

Mrs. Ruiz, 82 and her daughter Maria. Unfortunately Mrs. Ruiz became ill.

Maria called Sharp; the phone was answered quickly. and Maria gave her email address for access to the Sharp Web Portal

Maria gave her email address for access to the Sharp Web Portal

Arriving at the clinic…. They used the LED directory and the patient check in kiosk.

A friendly employee called Mrs. Ruiz back quickly.

Dr. Yang arrived quickly with her complete medical history in hand. He was friendly and reassuring. He also arranged an e-consult with a cardiologist.

After the cardiologist appointment she quickly had a full treatment regime include home monitoring.

The next day her diagnostic tests were available on the web portal.

Time passes and Mrs. Ruiz starts forgetting to take her medications

Unfortunately her health declined and she was re-admitted to the cardiac unit.

After her hospital stay a Skilled Nursing Facility was recommended. The Case Manager coordinated a care plan.

Email reminders of appointments were sent to her daughter Maria.

The team at the hospital took good care of Mrs. Ruiz.

The Chronic Care Nurse reviewed her progress. The APC Nurse did home visits. The entire team was kept in the loop.

After six months Mrs. Ruiz’s condition stabilized and she is now home.

Another success story from a High-Performing Health System

How?

How do you address this in a large multispecialty medical group with … 1.2 million visits

200,000 assigned patients

445 Physicians

60 NP/PA

2000 Clinic staff

21 Clinic locations

Leading a Case for Change

Our Journey to culture change

The best place to receive care… The best place to work…

The best place to practice medicine…

Since 2010 … Our desire to become…

Relentless pursuit to build the culture and be consistent • The Sharp Experience • Leadership • Communication • Staff and Team meetings • Education • Collaboration • Compensation

2009-10

We led a Case for Change

2010 Create Change

Model & Define Goals

2011

Allocate Resources

2011

Physician Engagement

2012

Measure Patient

Engagement

2013

Demonstrate Effectiveness

with

Balanced Scorecard

2014

Add Technology

to supplement

care

Significant breakthrough

Implementation Timeline

Engage Patients

Align Stakeholders

Create Workflows

Build Teams

Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

What We Did: Making an HPHS Happen

Accountability

Care Coordination

Technology Use

Compensation Practices

Quality Measurement

Efficient Provision of Services

Organized System of Care

Our Steps to Becoming a HPHS

Align Stakeholders

Create Workflows

Build Teams

Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Sharp

Align Stakeholders

Qu

alit

y

Serv

ice

Pe

op

le

Fin

ance

Gro

wth

Co

mm

un

ity

Sharp’s Pillars of Excellence

Align Stakeholders

Create Workflows

Build Teams

Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Pillar High Performing Health System

Align Stakeholders

Create Workflows

Build Teams

Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Quality Use clinical quality measures to measure process and outcomes of care

Service Use industry survey instrument to assess patient experience and engagement

Finance Address appropriate resource utilization rates and total cost of care

Growth Increase membership and net revenue

Community Enhance community outreach

People Improve provider satisfaction and wellness

Pillars of Excellence

Pe

rfo

rman

ce M

eas

ure

me

nt

Syst

em

R

ep

ort C

ards b

y Pillar

System Strategic Plan, Five-Year Plan

System Goals/Target

Entity Strategic Plans, Five-Year Plans, Goals/Targets, Dashboard

Dept./Unit Goals/Targets, Business Plans Supplier/Partner Goals/Targets, Business Plans

Individual Goals/Target

Individual Accountability Grid, Action Plans

Individual Merit, Bonus

Align Stakeholders

Create Workflows

Build Teams

Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Align Stakeholders

Create Workflows

Build Teams

Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Our Report Care: Balanced Score Card Sample

10%

Perfect Care Diabetes Measures Achieve top decile performance on diabetes perfect care measures

4 Rating : => 51% 3 Rating : =>49% but < 51% 2 Rating : =>47% but < 49% 1 Rating : =>45% but < 47% 0 Rating: <45%

5%

Patient Satisfaction Measures

Achieve overall medical group patient satisfaction equal to or greater than 90th percentile. 4 Rating : => 90th percentile 3 Rating : =>80th but < 90th 2 Rating : =>70th but < 80th 1 Rating : =>60th but < 70th 0 Rating: < 60th percentile

Align Stakeholders

Create Workflows

Build Teams

Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

2020 Care Model

Vicki DeBaca, RN VP Health & Provider Services

Care Management Programs • Population Health • Disease Management • Chronic Care Nurses • Complex Case Management Pharmacy Refill Clinic Mental Health Integration Leveraging Technology Office Standardization

• Health Coaching • Health Education Classes • Community Resources • Healthier Living Classes • Patient Representatives

on Committees

• Peer to peer reviews

Align Stakeholders

Create Workflows

Build Teams

Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Keep Patients Healthy, Happy and at Home

Population Health Risk Stratification Interventions

Programs for Chronic Diseases Implementation of evidence based guidelines

Tier 2: Moderate Severity 20%

Walking well; need periodic screening tests Preventive Care Reminder Program

Annual wellness exam and targeted outreach

Tier 1: Low Severity 60%

Chronic Diseases with two hospitalizations; needs co-ordination of care

Reduce avoidable hospitalization

Tier 3: High Severity

15%

5%

Tier 4: Complex

Align Stakeholders

Create Workflows

Build Teams

Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Continuum of Care

SNF ALF/B+C Hospital

Hospital CM Hospitalist COC post discharge calls

Home Home Health Case Manager Extended Care Team

Outpatient

Team Based Care Disease m/m programs Healthier Living Chronic Care Nursing w/PCP Complex Case m/m Pharmacy Programs

Emergency

Room & Urgent

Care

Urgent Care Collaboration Education

Transitions - Palliative care

Align Stakeholders

Create Workflows

Build Teams

Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Align Stakeholders

Create Workflows

Build Teams

Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

30-Day All Cause Readmission Rate: Senior HMO Population

Align Stakeholders

Create Workflows

Build Teams

Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

30-Day CHF Readmission Rate: Senior HMO Population

Teamwork Who is on your team?

Align Stakeholders

Create Workflows

Build Teams Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Safe Care Requires a Team and a System

8-hour day 8-hour day

0

2

4

6

8

10

12

14

16

18

20

22

PCP Physician day(Based on a panel size of 2000 patients)

Prevention 10 hours/day

Patient Education: 2 hrs/day

Care Coordination: 2 hrs/day

Direct Patient Care 7 hours/day

Hours

Care Coordination: 2 hrs/day

Align Stakeholders

Create Workflows

Build Teams Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Roles of Continuum of Care Teams

• Hospital and SNF discharge planning

• Coordination of care to reduce readmissions

Hospital and SNF Case Management

• Catastrophic or high risk cases e.g. Organ Transplant, MVA , Multiple Comorbidities, UM, Discharge Plan

Complex Case Management

• Team work with PCP, embedded model

• Post hospital and coordinate care of high risk multiple chronic condition patients -- short term

Chronic Care Nursing

• Long term engagement and management

• CHF, COPD,CAD, Asthma, Diabetes Disease Management

• Medication therapy management

• High cost, Refill, Adherence, High risk, Reconciliation Pharmacy Program

• Group classes and peer support group

• Example Chronic Diseases, Obesity Health Coaching

Align Stakeholders

Create Workflows

Build Teams Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Have a Common EHR Platform How to find us in Touchwork

Align Stakeholders

Create Workflows

Build Teams Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Create Workflows with Automation

Align Stakeholders

Create Workflows

Build Teams Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Create Workflows with Standardization

Align Stakeholders

Create Workflows

Build Teams Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Care Team Staff Ratios

R u ervisor - are Managers R riage Referrals Month R ase Manager evel - Mem ers R ase Manager evel - Mem ers o ulation ealth ase Manager - Mem ers R ase Manager ele- ealth - Mem ers M - Mem ers MA Mem ers ommunit ealth or er Mem ers A ministrative u ort R M - Mem ers

Align Stakeholders

Create Workflows

Build Teams Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Level III

Level II

Level I

Optimize Care Team Roles

Align Stakeholders

Create Workflows

Build Teams Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Teamwork

Case Managers Social Worker

Disease Managers Care Specialists

Clinic Staff Pharmacist/Pharmacy Tech

Health Coach

OK, now you have a team, but how effective are they? Are the patients engaged?

Align Stakeholders

Create Workflows

Build Teams Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Engage the Patient: Partner with me

Form personal connection

Face-to-face interaction

Step-by-step wellness plan

Coordination of care across the system

Patient specific education material

Shared care plans

Medication adherence reporting

Use HIT to engage all patients not just present

Align Stakeholders

Create Workflows

Build Teams Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Measure the Engagement Rate

Align Stakeholders

Create Workflows

Build Teams Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Patient Engagement

• Patient engagement for Population Health Programs as high as 60% patient experience

• Top two in the state as ranked by Consumer Reports

Patient Engagement and Well Being

AMGA HPHS: Care Coordination & Efficient Provision of Services

Align Stakeholders

Create Workflows

Build Teams Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Devices that Drive Healthier Behavior

…the booming mHealth market will grow to $26 billion by 2017, with a worldwide market of 1.7 billion users looking to use their smartphones and tablets to take care of their health. Currently, there are about 97,000 mobile health applications…

---Research 2guidance 2013

88% of physicians want patients to track or monitor their health at home.

---PricewaterhouseCoopers– HRI Physician Survey, 2010

Align Stakeholders

Create Workflows

Build Teams Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Sometimes, people like talking to computers

Align Stakeholders

Create Workflows

Build Teams Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Outreach in Multiple Ways Outreach using MySharp web portal

and Nuance telephonic outreach messages

Goal: Minimize the number of lists to the Physicians and Clinic sites

Align Stakeholders

Create Workflows

Build Teams Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Medication Therapy Management

AMGA HPHS: Use of Information Technology & Evidence-Based Medicine

Align Stakeholders

Create Workflows

Build Teams Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Medication Therapy Management Program aids prescription refills

• 60,000 Rx refills completed in 2013

• 140,000 medication related

tasks addressed • Projected volume of 120,000

refills

Physician Involvement and Engagement

Parag Agnihotri, MD Medical Director, Continuum of Care

Physician Engagement Strategy

1. What do you want your Physicians to do?

2. Do they know how to do the work?

3. Do they have the resources to do the work?

4. Are physicians motivated to do the work?

Ralph Jacobson, Leading for a Change: How to Master the Five Challenges Faced by Every Leader. he ea er’s ool ox

Align Stakeholders

Create Workflows

Build Teams Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Physician Satisfaction with Leadership

Align Stakeholders

Create Workflows

Build Teams

Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Compensation Practices

AMGA HPHS: Compensation Practices

• Reduction in the complications of heart disease by 22%

• Stroke reduced by 11%

Compensation practices that reward management of chronic diseases

$

Align Stakeholders

Create Workflows

Build Teams Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Leadership of the Culture

• Commitment to Standards of Care

• Transparency

• Peer reviews

• Mandatory quarterly training

• Sharing best practices

Align Stakeholders

Create Workflows

Build Teams

Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Two-Year Physician Leadership Academy

• Develops emerging Physician leaders

• Continuous learning, innovation, teamwork, sharing and personal growth

• Accountability

Align Stakeholders

Create Workflows

Build Teams

Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Group Specific Clinical Guidelines

Align Stakeholders

Create Workflows

Build Teams Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Address Practice Variation: Peer Review

Dr. A Dr. B Dr. C Dr. D Dr. E Dr. F Dr. G Dr. H Dr. I Dr. J Dr. K Dr. L

Align Stakeholders

Create Workflows

Build Teams Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Continuous Improvement Process ‘All or none’ Diabetes bundled care

30.0%

34.0%

38.0%

42.0%

46.0%

50.0%

Centralized process

52% have advanced perfect care

Change in BP criteria

48% Goal

Align Stakeholders

Create Workflows

Build Teams Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Measure Effectiveness

Quality Results: Diabetic Eye Exam

Diabetic Eye Exam Rate: Senior HMO Population

Align Stakeholders

Create Workflows

Build Teams Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Quality Results: Glaucoma

Glaucoma Screening Rate: Senior HMO Population

Align Stakeholders

Create Workflows

Build Teams Engage Patients

Use Technology

Engage Physicians

Quality Results: Chlamydia Screening

Chlamydia Screening Rate in Women 16-24 Years: Commercial HMO Population

Align Stakeholders

Create Workflows

Build Teams Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Quality Results Overall

Align Stakeholders

Create Workflows

Build Teams Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

AMGA: Quality Measurement and Improvement Activities

Clinical Quality Top performing Medical Group status in California for 10 years in a row

Awards and Recognition

Acclaim Award Honoree Top 10% Nationally for Patient Satisfaction 2014 Doyle Award : CHF program; recognition by mcg guidelines with its highest honor Number two medical group state score in 2013 by Consumer Reports based on patient experience among 170 medical groups Top Medical Group 2014; 2013 and 2012 ranked #2 by local newspaper based on local resident votes Baldridge Quality Award Winner

CAPG Elite Status for seven years in row IHA state Top Performing Medical Group status for 10 years in row State’s Office of Patient Advocate 2013 4/4 stars rating: 207 groups In top 90% of scores for all the medical groups across the specific quality measure Our program has received 2013 C.O.R.E. award recognition by organization under the People Pillar AAAHC accredited for 32 years.

Community Outreach

• Proactive patient outreach for preventive and chronic care

• Partner with organizations that address priority health needs such as cardiovascular and senior health organizations

• Inspire San Diego county residents to take action and responsibility for their health, safety and well-being

Align Stakeholders

Create Workflows

Build Teams Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Measure Effectiveness

Sharp ACO Collaborations

Commercial PPO Patients

SCMG and Sharp Rees-Stealy

Medical Group “SRSMG”

Pioneer ACO

Medicare Fee-for-Service

Beneficiaries

Sharp HealthCare, SCMG, SRSMG

Commercial PPO Patients

SCMG and Sharp Rees-Stealy

Medical Group “SRSMG”

Align Stakeholders

Create Workflows

Build Teams Engage Patients

Use Technology

Engage Physicians

Track Effectiveness: Population Health

14.55%

10.19%

6.52%

10.23%

7.05%

5.31%

7.61%

0%

2%

4%

6%

8%

10%

12%

14%

16%

Q1 2012 Q2 2012 Q3 2012 Q4 2012 Q1 2013 Q2 2013 Q3 2013

30 Day CHF Readmission Rate SRS Senior HMO Population

(Source: Claims)

9.09%

4.55%

11.76%

0.00%

4.76%

0.00%

0%

2%

4%

6%

8%

10%

12%

14%

Q1 2012 Q2 2012 Q3 2012 Q4 2012 Q1 2013 Q2 2013

30 Day COPD Readmission Rate SRS Senior HMO Population

(Source: Claims)

Align Stakeholders

Create Workflows

Build Teams Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Aligning Community Stakeholders: Sharp Extended SNF Care

• Contracted network of 60 SNFs

• Collaborators 10 SNF

• Reduced length of stay by 20%

• Improved 30 days readmission rate to be < 12%

Per Capita Cost of Care

Align Stakeholders

Create Workflows

Build Teams Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

AMGA HPHS: Accountability

Reduce per capita cost of healthcare

12% reduction in internal points used under the shared responsibility with hospital measuring post-acute care and ancillary funds

University of Best Practices Medical Group Collaboration to adopt best practices

The campaign to make San Diego a heart attack and stroke free zone

Continuous Improvement Process

58.7 58.1 57.3

52.2 49.8

45.5

30

35

40

45

50

55

60

65

2008 2009 2010 2011 2012 2013

Year

CAD Hospitalizations per 1,000 Senior HMO Members

per Year Data Source: Claims

2.9

3.3

3.1

2.9

2.7 2.7

1.5

1.7

1.9

2.1

2.3

2.5

2.7

2.9

3.1

3.3

3.5

2008 2009 2010 2011 2012 2013

Year

Stroke Hospitalizations per 1,000 SRS HMO Members

per Year Data Source: Claims

Align Stakeholders

Create Workflows

Build Teams Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

The Best Place to Work The Best Place to Practice Medicine

The Best Place to Receive Care

2009-10

We led a Case for Change

2010 Create Change

Model & Define Goals

2011

Allocate Resources

2011

Physician Engagement

2012

Measure Patient

Engagement

2013

Demonstrate Effectiveness

with

Balanced Scorecard

2014

Add Technology

to supplement

care

Implementation Timeline

Challenges and Opportunities

Align Stakeholders

Create Workflows

Build Teams Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Challenge: Moving from Individual to Team Based

Align Stakeholders

Create Workflows

Build Teams Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Challenge: Becoming an ACO

Align Stakeholders

Create Workflows

Build Teams Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Continuing Challenges and Opportunities

• Create transparent culture with good communication

• Increase accountability for better results

• Change management: The emotional and practical impact

• Engage everyone in the patient experience

• Create a better place to work • Integrate the EHR and technology • Continue to maintain visible,

passionate leadership to keep focus and energ on what’s im ortant

• Reward success

Align Stakeholders

Create Workflows

Build Teams Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Lessons Learned

Change is Hard: Share best practices

• Organization scorecard Align stakeholders

• Keep it simple and centralized Patient care workflows

• Highest scope of license Team based healthcare

• Measure Engage Patients

• Integrate and leverage it Use Technology

• Address practice variation Engage Physicians

• Demonstrate the ROI Measure Effectiveness &

Performance

What I Shall Do on Monday

We are lifelong learners too…

It is all about Teamwork!

In Summary: Process to Become a HPHS

Align Stakeholders

Create Workflows

Build Teams

Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Align Stakeholders

Create Workflows

Build Teams Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Sharp Experience video

We now welcome your questions…

Parag Agnihotri, MD Medical Director, Continuum of Care

Align Stakeholders

Create Workflows

Build Teams Engage Patients

Use Technology

Engage Physicians

Measure Effectiveness

Vicki Debaca, RN, VP Health Services