LOGISTICAL MANAGEMENT OF RAMPING BACK UP FOR RETURN TO BUSINESS
April 23, 2020
GRATITUDE¡ AOC Celebrates its 15th year
¡ AOC Chairs & CAOs ...COVID 19 Pulse Surveys...especially from the eye of the storm Departments
¡ Membership has grown by 20+% in the last 10 days with Residents and Fellows signing up for their free memberships https://www.aoc-ortho.com/registration/
¡ 700+ Members across 128 University Based Orthopaedic programs
¡ AAOS Leadership Drs. Kristy Weber and Joe Bosco
GRATITUDEAOC = free memberships, free analysis, free webinars, free mentorship network, free best practice
presentations, free special interest groups (i.e. Epic, Cerner, Women’s Leadership Forum)...
This is not possible without generous support from our sponsors.... and I am delighted to announce that Brad Lee, President of Breg has signed a 5 year extension of its support to the AOC.
AOC FOCAL POINTS¡ Immediate Connections, Content, and Context during COVID 19
¡ AOC Women’s Leadership Forum (Happy Birthday to our leader Bobette Patterson!)
¡ AOC Business & Leadership Modules for Program Directors, Residents, and Fellows to prepare for the “business of orthopaedics” and ”navigating the job market”
¡ AOC Opioid Minimization Committee...identifying best practices across the AOC
¡ Due diligence around establishing high-value, cost effective: Recruitment Services; Leadership Development Programs
©BREG, INC. ALL RIGHTS RESERVED. CONFIDENTIAL. NOT FOR DISTRIBUTION. 5
©BREG, INC. ALL RIGHTS RESERVED. CONFIDENTIAL. NOT FOR DISTRIBUTION. 6
Solution for facilities using telehealth who would like to continue to prescribe DMEPOS products for their patients.
Benefits of Telehealth:
Clinical support: develop workflows for your staff to provide DMEPOS items after a physician or APP telehealth visit, maintains continuity of patient care remotely
Business support: help DME departments maintain operations through logistical support (i.e. drop shipping at flat rate) and up to date communications around compliance.
Patient experience: enable and provide support of patients in the convenience of their own homes with measuring, fitting and delivering bracing and cold therapy products.
Breg Telehealth Support Offering
123
©BREG, INC. ALL RIGHTS RESERVED. CONFIDENTIAL. NOT FOR DISTRIBUTION. 7
Breg Telehealth Support
Telehealth appointment with
physician
Remote brace evaluation with
specialist
Product drop-shipped to patient’s home
Remote fitting appointment with
patient and specialist
• Telehealth program options:• In-house bracing program (facility does own billing)• Outsourced inventory program (3rd party does the billing)• Direct to Patient
©BREG, INC. ALL RIGHTS RESERVED. CONFIDENTIAL. NOT FOR DISTRIBUTION. 8
Products for Patient’s with Delayed SurgeriesTotal Knee Arthroplasty, Meniscal Repairs• Patient’s experiencing painful symptoms from OA and meniscus tears • Brace helps manage patient symptoms with unloader braces
©BREG, INC. ALL RIGHTS RESERVED. CONFIDENTIAL. NOT FOR DISTRIBUTION. 9
Products for Patient’s with Delayed SurgeriesLigament Procedures• Patient’s experiencing some acute symptoms and instability • Brace helps with stability, proprioception, overall compression and support• Able to use post-operatively if recommended
©BREG, INC. ALL RIGHTS RESERVED. CONFIDENTIAL. NOT FOR DISTRIBUTION. 10
Products for Patient’s with Delayed SurgeriesAll Elective Surgeries: Cold Therapy• In clinical studies cold therapy is shown to reduce pain, inflammation, edema and
narcotic use.¹²³⁴ • May help manage symptoms until they are able to reschedule their surgery• Continue to benefit from post-operative use of the system after their procedure.
1. The efficacy of continuous cryotherapy on the postoperative shoulder: A prospective, randomized investigation Singh H, et al. Journal of Shoulder Elbow Surgery 2001; 10:522-5
2. A randomized prospective study to assess the efficacy of two cold-therapy treatments following carpal tunnel release. Hochberg J. Journal of Hand Therapy 2001; 14:208-215
3. Continuous local cooling for pain relief following total hip arthroplasty. Saito N, et al. The Journal of Arthroplasty; Vol 19; No. 3, 20044. Continuous-flow cold therapy after total knee arthroplasty. Morsi E. The Journal of Arthroplasty; Vol 17; No. 6, 2002
©BREG, INC. ALL RIGHTS RESERVED. CONFIDENTIAL. NOT FOR DISTRIBUTION. 11
Special thanks to the AOC and all
of its members!
For more information, please contact Jay Subbert [email protected]
TODAY’S ROCKSTAR PRESENTERS
Neil Ravitz, MBAChief Administrative Officer & COODepartment of Orthopaedics, UPENN
Yvette TehanChief Administrative OfficerDepartment of Orthopaedics, U. Rochester
TODAY’S AGENDA
Where to begin?
Quantifying the pipeline and forecasting new business in gradual return
Associating resource requirements (clinic, peri-operative, and associated staffing)
Partnering with institution, faculty, and staff to address
Q&A
Understanding the Impact of COVID-19 Elective Procedure Cancellations on Orthopaedics Surgical Volumes and Ramp Up Implications
M u s c u l o s k e l e t a l a n d R h e u m a t o l o g y S e r v i c e L i n e
April 2020
15Strategic Decision Support
Background‣ During this time nearly all elective Orthopaedic procedures have been postponed‣ Medically urgent cases continue‣ Clinic volumes have been substantially reduced and telehealth visits have been offered
Goals• Determine Impact of Cancelled Cases on the Department of Orthopaedic Surgical Volumes• Determine how long it might take to make up “lost” cases once surgeries are permitted• Understand the impact of various tactics that can be implemented• Use these estimates to start the discussion and develop plans to implement when surgeries and in-
person clinics are re-opened.
16Strategic Decision Support
Understanding the Impact
Identify the Case Shortfall
�Develop
Scenarios for addressing the Case Shortfall
�
17Strategic Decision Support
Considerations/Limitations‣ Various levels of retention of exiting scheduled cases are modeled but impact is unknown
• Various factors including loss of sick time, insurance, or financial hardship may prevent a patient from proceeding with surgery
‣ Assumes telehealth visits will generate surgeries at the same rate as an in person visit• Potential exists to identify and schedule patients for surgery during this time that could create additional
demand when surgery is permitted, but true rate is still unknown
‣ Assumes volume of medically urgent patients will remain constant
‣ Scenarios do not take into account the operational considerations such as:• Inpatient bed availability• Supply Availability• Ability to fill clinics if capacity is increased• Availability of clinicians to see patients
18Strategic Decision Support
Approach – Part 1
Gather Calculate Apply Estimate Identify Project
Background Data
• Historical and current volumes and operational
metrics
Visit ratios
•Ratio of Non Urgent Surgeries
Scheduled to Visits•% Medically Urgent
Ratios
To current visits (in person and
telehealth) volumes
“Lost” Volume
Incorporate estimate of Medically Urgent
volumes into projections
Currently Scheduled Cases
Develop sensitivity analysis to account
for levels of retention of existing
scheduled cases
Generated Cases
From:• ongoing clinic
visits• ongoing
telemedicine visits
Case Shortfall
19Strategic Decision Support
Avg Cases Per Week % Inpatient
% Outpatient
Medically Urgent% Medically Urgent
Median New Cases Generated Per WeekMedian Non Urgent Cases Generated Per Week
Scheduling Time To Surgery (Median - Days)Scheduling Time to Surgery (Median-Weeks)
Max Cases Per Week (Existing Capacity Proxy)
Gather Background Data
6
max
20Strategic Decision Support
Background Data, Ratios, and Calculation
Median Visits Per Week (inc POVs)
Ratio of Non Urgent Surgeries Scheduled to Visits
Clinic Visits Per Week during Slowdown
Surgeries Scheduled Via Clinic Per Week during Shutdown
Telehealth Visits Per Week (Proj) during Slowdown
Surgeries Scheduled Via Telehealth Per Week during Shutdown
21Strategic Decision Support
Background Data (FY20) – Template for UseFoot & Ankle
General Ortho Hand Joints Neuro Onc
Shoulder & Elbow Spine Sports Trauma
Ortho Total
Avg Cases Per Week 330% Inpatient% Outpatient
Medically Urgent 50% Medically Urgent 15%Median New Cases Generated Per Week 308Median Non Urgent Cases Generated Per Week
258
Scheduling Time To Surgery (Median - Days) 22
Scheduling Time to Surgery (Median-Weeks) 3.1
Max Cases Per Week (Existing Capacity Proxy) 419
DefinitionsMedically Urgent - based on allowed cases remaining on schedule from March 16- March 27 (as of 3/24)Scheduling Time to Surgery - based on the time between when a patient schedule surgery and the date of surgeryMax Cases per week - based on the maximum number of cases done in any week in 2020. Trauma and Joints adjusted since the max weeks for these specialties was substantially higher than other weeks.
22Strategic Decision Support
Background (FY20) and Projections – Template for UseFoot & Ankle
General Ortho Hand Joints Neuro Onc
Shoulder & Elbow Spine Sports Trauma
Ortho Total
Median Visits Per Week (inc POVs) 2,460
Ratio of Non Urgent Surgeries Scheduled to Visits
10%
Clinic Visits Per Week during Slowdown 478
Surgeries Scheduled Via Clinic Per Week during Shutdown
48
Telehealth Visits Per Week (Proj) during Slowdown
123
Surgeries Scheduled Via Telehealth Per Week during Shutdown
13
DefinitionsClinic Visit Per Week During Shutdown based on Completed and Scheduled Visits for 3/16/2020-4/03/2020Telehealth Visits based on 5% of Median Visits per Week
Italics represent calculated metric
23Strategic Decision Support
Scheduled Cases
Currently ScheduledFoot & Ankle Hand Sports
1 16-Mar 3 132 23-Mar 4 10 303 30-Mar 18 44 534 6-Apr 15 52 235 13-Apr 17 29 206 20-Apr 5 19 157 27-Apr 5 19 98 4-May 5 14 179 11-May 7 17 310 18-May 3 3 411 25-May 3 412 1-Jun 10 913 8-Jun 2 014 15-Jun 3 3 415 22-Jun 2
24Strategic Decision Support
Ortho Total100% Retention
Retention Scenarios90% Retention 80% Retention 70% Retention 60% Retention 50% Retention
1 16-Mar2 23-Mar3 30-Mar 234 211 187 164 140 1174 6-Apr 440 396 352 308 264 2205 13-Apr 612 551 490 428 367 3066 20-Apr 714 643 571 500 428 3577 27-Apr 825 743 660 578 495 4138 4-May 900 810 720 630 540 4509 11-May 967 870 774 677 580 48410 18-May 996 896 797 697 598 49811 25-May 1020 918 816 714 612 51012 1-Jun 1052 947 842 736 631 52613 8-Jun 1059 953 847 741 635 53014 15-Jun 1083 975 866 758 650 54215 22-Jun 1090 981 872 763 654 54516 29-Jun 1094 985 875 766 656 547
Cumulative Demand ScenariosThe current situation will likely impact the ability of patients to proceed with surgery. To date only 70% of surgeries have been rescheduled which may be a starting point for the impact.
25Strategic Decision Support
Estimate Ungenerated (“Lost”) VolumeAverage Number of SurgeriesMedically Urgent .Missed Cases Per Week
Cumulative Demand (based on the schedule)Surgeries Generated from In person visits during ShutdownSurgeries Generated from Telehealth visits during ShutdownQueue
Case Shortfall=
++
-
26Strategic Decision Support
Understanding the Impact
Identify the Case Shortfall
�Develop
Scenarios for addressing the Case Shortfall
�
27Strategic Decision Support
Approach – Part 2
� � �Identify Operational Changes that can be
made
• Clinic Capacity• OR Capacity
Develop Scenarios based on levels of operational change
1. Increase Clinic Capacity by 20%
2. Achieve Max OR volume (may require in crease in Clinic Capacity)
3. Increase OR capacity by 15% (requires increase in Clinic Capacity)
Factor in Patient Retention
• 100%• 90%• 80%• 70%• 60%• 50%
Sensitivity AnalysisScenariosLevers
28Strategic Decision Support
Scenario 1
Scenario 2
Scenario 3
Make Up VolumesAvg Cases Per Week 330 330 330Max Cases Per Week (Capacity) 419 419 419Clinic Capacity Needed Per Week 1.20 1.36 1.57Cases Generated Per Week 396 419 482
IP Cases Generated 196 207 238OP Cases Generated 200 212 244
Incremental Cases Per Week 66 89 152IP Incremental Cases 33 44 75OP Incremental Cases 33 45 77
Make Up Cases
Scenario 1: Increase Clinic Capacity 20%Scenario 2: Reach Max OR Volume every weekScenario 3: Increase OR Capacity 15% above Max OR Volume
Scenario 1: Increase Clinic Capacity 20%Scenario 2: Requires Clinic time to increase 36%Scenario 3: Requires Clinic time to increase 57%
29Strategic Decision Support
Clinic Starts:
Missed Cases
In Person Visits
Tele-medicine
CumulativeSchedQueue
Case Shortfall
Weeks to Make Up Volume
CumulativeSchedQueue
Case Shortfall
Weeks to Make Up Volume
Sc 1 Sc 2 Sc 3 Sc 1 Sc 2 Sc 330-Mar 840 95 26 234 485 7.3 97.0 8.8 164 555 8.4 111.0 10.0
6-Apr 1120 143 39 440 498 7.6 99.7 9.0 308 630 9.6 126.1 11.413-Apr 1400 191 52 612 546 8.3 109.2 9.9 428 729 11.1 145.9 13.220-Apr 1680 238 64 714 663 10.0 132.6 12.0 500 877 13.3 175.5 15.927-Apr 1960 286 77 825 772 11.7 154.3 14.0 578 1019 15.4 203.8 18.44-May 2240 334 90 900 916 13.9 183.2 16.6 630 1186 18.0 237.2 21.5
11-May 2520 381 103 967 1069 16.2 213.7 19.3 677 1359 20.6 271.7 24.618-May 2800 429 116 996 1259 19.1 251.8 22.8 697 1558 23.6 311.6 28.225-May 3080 477 129 1020 1454 22.0 290.9 26.3 714 1760 26.7 352.1 31.9
1-Jun 3360 524 142 1052 1642 24.9 328.4 29.7 736 1958 29.7 391.5 35.48-Jun 3640 572 155 1059 1854 28.1 370.9 33.6 741 2172 32.9 434.4 39.3
15-Jun 3920 620 168 1083 2050 31.1 410.0 37.1 758 2375 36.0 474.9 43.022-Jun 4200 667 180 1090 2262 34.3 452.4 40.9 763 2589 39.2 517.8 46.929-Jun 4480 715 193 1094 2478 37.5 495.5 44.8 766 2806 42.5 561.2 50.8
Ortho Total
Scenario 1: Increase Clinic Capacity 20%Scenario 2: Reach Max OR Volume every weekScenario 3: Increase OR Capacity 15% above Max OR Volume
Scenario 1: Increase Clinic Capacity 20%Scenario 2: Requires Clinic time to increase 36%Scenario 3: Requires Clinic time to increase 57%
Cumulative:Queue
Generated By 100% Retention: 70% Retention:
COVID-19 ResponseYvette Tehan, Chief Administrative Officer
Christopher Blankenberg, Director of Operations
University of Rochester Medical Center
Greater Rochester Area COVID-19 Tracker
Greater Rochester Area COVID-19 Tracker
URMC Ortho Outpatient Clinic Locations weekly volume then and now
LocationsTypical Weekly
VolumeCurrent Weekly
Average Total
Current Weekly Average In-
Person
Current Weekly Average
TelemedicineBuilding D 2,679 1,015 519 496Penfield 354 67 22 44Victor 334 117 77 40Highland Hospital 237 92 12 80Strong West 236 56 24 32Webster 226 18 0 18Greece Ortho 149 42 34 8Brighton Podiatry 134 62 56 6Greece Podiatry 124 29 28 1
33.5% 17.3% 16.2%
Initial Steps• Cancel elective surgeries (1,400+ from 3/13-5/4)• Cancel non-essential outpatient clinic visits (11,000+ from 3/16-4/17)
• Somewhat concurrent launch of phone then Zoom telemedicine visits• Inconsistent mix of in-person and telemedicine visits
• Not efficient, but not a problem while the volume is low
• Initiatives • Re-launched Orthopaedic Injury Clinic in conjunction with Emergency Medicine
• Initial planning for the Building D Procedure Room to accommodate minor trauma cases• Staff Re-deployment cover critical needs
• APP’s to Access Center for phone triage• APP’s and Clinic Staff to cover COVID Screening at clinic entrances• Access Center and Physician Support Staff – WFH• Limited number of staff sent home with pay
• Developed Telephone/Video Workflow with Walk-in X-ray• Walk-in X-ray workflow vital for maintaining Telemedicine volume
• Developed reporting capabilities to track Department, Locations, and Providers
Orthopaedic Injury ClinicIn coordination with
• Med Center Sr. Leadership • Emergency Medicine
Objective• Keep MSK injuries out of the ED
Orthopaedic Injury Clinic • 3 locations
• Central – Building D• Westside – Greece Ortho• Eastside – Victor Ortho/FF Thompson
APP’s Redeployed to manage phone triage
• 600 calls per day – Ortho Access Center• 55 per day - Injury line
Telephone/Video Workflow with Walk-in X-rayTelephone and Video Workflow
Provider PSS In-person Visit Check-OutVideo/Telephone VisitWalk-in X-ray
Review Schedule
Mark each patient with either IP, C, T
V, or X
If X, then indicate what the next visit should be T,
or V
Submit schedule to APP, PSS, and AA
PSS contacts patients
PSS directs patient to CCO, Gre Ortho , Vic.
Walk-in Hours 8:00AM to 4:00PM
Then, schedule either a Video or Telephone visit for after the X-
ray is complete
Is x-ray requested?
Schedule Video or
Telephone visit
Is Video or Telephone requested?
Confirm in-person or
cancelation with patient
Yes
No
Yes
No
Patient Arrives in clinic
Check-in and Rooming actions
completed
Provider evaluates patient and completes
Disposition Notes
Video or Telephone Visit
Arrived
Chart and Zoom/Phone
meeting opened
Provider evaluates patient and completes
Disposition Notes
If in-person
Patient arrives at CCO, Gre Ortho, or
Vic for X-ray
COVID screening is
performed at front door
Rad Tech completes X-
ray
Patient exits clinic
Initially X-rays will be performed as Walk-In visits. The volume will be monitored and a
scheduling mechanism put in place if needed
OAS Reviews Disposition
Notes
Is an in-person or Telephone
follow up requested?
Schedule visit and perform
check out workflow
OAS sends PSS in basket
message
Is Video or X-ray requesed?
Yes
No
Yes
Place order if X-ray or specialty
imaging is needed
Place order if X-ray or specialty
imaging is needed
APP reviews schedule and places order
for any patients with
an X
Patient is directed to
Ortho Check-in Desk
Ortho Check-in performs
eRecord Registration and notifies X-ray that patient has
arrived
Enterprise-Level Reporting
Home-grown Reporting
Recovery Steps• Surgical Case Stratification/Scheduling Algorithm
• Relating 3 types to 4 conditions• Emergent, Urgent, Elective case types• Community prevalence of COVID19, Hospital COVID19 burden, supply chain, staff availability• Red, yellow, green scheduling pattern
• Estimated timeframe for backlog given all unknowns ranges 12-18 months• OR and Staffing Capacity, Pipeline Capacity, Shift in Socioeconomic Status
• Outpatient Clinic Scheduling• Redefine “normal” and “essential” visits• Non-COVID patients where continued delay in care may cause harm or worsening health• Reconfigure Patient Care Schedules
1. Stable scheduling methodology and clinical operations with scheduled blocks of in-person and telemedicine visits• Needed for efficient appointment scheduling by Access Center, Front Office, PSS• Promote consistent availability for in-person care 5 days/week by Division
2. Production leveling of clinical throughput – set at 2 patients/hour for in-person visits/provider• Minimize the patients’ total time in clinic• Provide appropriate social distancing
In-Person and Telemedicine Schedule Matrix
Phone/Video BlockIn-PersonName Division Designation Location AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PM AM PMBAUMHAUER, JUDITH F Foot and Ankle MD H&F 3 3 3 3BOWEN, CHRISTIE L Sports APP H&F 2 2 2 2 2 2 2BRADT, CARIE E Shoulder APP H&F 2 2 2 2 2BUCKLAEW, TIMOTHY Foot and Ankle APP H&F 2 2 2 2 2 2BYRNE, STACY L Foot and Ankle APP H&F 2 2 2 2 2 2 2 2COOPER, JAYNE L Adult Reconstruction APP H&F 2 2DIGIOVANNI, BENEDICT Foot and Ankle MD H&F 3 3 3 3 3 3FLEMISTER, ADOLPH S Foot and Ankle MD H&F 3 3 3 3 3OH, IRVIN C - FOOT FELLOWFoot and Ankle MD H&F 3 3GARDNER, LISA ANN Non-op Sports APP H&F 2 2GEORGE, CHRISTOPHER Sports APP H&F 2 2 2 2GOON, STEPHEN C Non-op Sports APP H&F 2 2 2HERBERT, MEGHAN Sports APP H&F 2 2JANNELLI, KIMBERLY ANN Adult Reconstruction APP H&F 2KETONIS, CONSTANTINOSHand and Wrist MD H&F 3 3 3 3KETZ, JOHN P Foot and Ankle MD H&F 4 3 3 4 3 3 3 3KINGSLEY, G SCOTT General APP H&F 2 2 2 2 2KLEEHAMMER, DANIEL G Sports APP H&F 2 2 2 2MCDONALD, STEPHANIE Non-op Sports DO H&F 2 2MAHMOOD, BILAL Hand and Wrist MD H&F 3 3 3 3 3 3 3 3MCHENRY, LINDA L Hand and Wrist APP H&F 2 2 2 2 2 2MILLER, RICHARD J Hand and Wrist MD H&F 3 3 3 3 3 3 3 3OH, IRVIN C Foot and Ankle MD H&F 2 2 2 2 2 2 2 2 2REAVEY, PATRICK Surgery - Plastics MD H&F 3 3RIZZONE, KATHERINE H Non-op Sports MD H&F 2SNIDER, JANET M Foot and Ankle APP H&F 2 2 2 2 2 2 2 2 2WASSERBAUER, DIANE Hand and Wrist APP H&F 2 2 2 2
Thur FriWeek 1 Week 2
Mon Tues Wed Thur Fri Mon Tues Wed
Recovery Steps - continuedStaffing/Operations• Update base staffing models per location by functional workgroup
• Priority – adequate staffing expedite workflow (no waiting)• Volume driven metrics for how to ramp number of staff by functional area
• Investigate a call system for patient arrival• Patients to wait in cars until they can enter the workflow process
• Investigate alternative staffing models and technology to minimize 1:1 in-person transactions (MyChart and Welcome)
Recovery Steps - continuedCost Containment• Suspension of annual merit raise program• Hiring freeze and furloughs• Hold on
• Capital spending• Business expenses• Electronic purchases
Essential Question• How can we do business differently to gain
efficiencies?
Thank you
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Now What? How To Get Patients Flowing Again
❖ A marketing recovery plan you can follow
❖ Marketing tools available to all
❖ What we see others doing
Google Listings
❖ Setup new Google Link❖ Own and optimize your listings
Google Posts
❖ Use Posts
❖ Be found (website, listings, email/text)
Proactive Messages
❖ Send open announcement & options❖ Collect patient feedback
Public GMB ViewLeverage Google’s Free Google My Business Pages
Proactive Messages To Patients
Ø Message previous patients
Ø Text Messages Best
Ø Email is also effective
Ø Stay in contact
Here To Help
Ø Let software & SocialClimb help
Ø AOC special free offer
Ø Recovery plan https://socialclimb.com/three-phase-covid-19-recovery-plan-for-medical-practices/
Ø Ty Allen - [email protected]