the cleveland clinic’s journey from volume to value in the era of healthcare reform david l....
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The Cleveland Clinic’s Journey The Cleveland Clinic’s Journey from Volume to Value in the from Volume to Value in the
Era of Healthcare ReformEra of Healthcare Reform
The Cleveland Clinic’s Journey The Cleveland Clinic’s Journey from Volume to Value in the from Volume to Value in the
Era of Healthcare ReformEra of Healthcare Reform
David L. Longworth, M.D.David L. Longworth, M.D.
Chair, Medicine InstituteChair, Medicine Institute
Associate Chief of Staff, Clinical Integration DevelopmentAssociate Chief of Staff, Clinical Integration Development
Cleveland ClinicCleveland Clinic
About Me…About Me…About Me…About Me…
• Practicing internist and ID Practicing internist and ID physician for 32 yearsphysician for 32 years
• Cleveland Clinic 1986-Cleveland Clinic 1986-2002, 2011- present2002, 2011- present
• Massachusetts 2002-2011Massachusetts 2002-2011
• Doctoring and medical Doctoring and medical education my core skillseducation my core skills
• No disclosuresNo disclosures2
AgendaAgendaAgendaAgenda
• Our imperativeOur imperative
• Our strategyOur strategy
• Transforming the care delivery Transforming the care delivery modelmodel
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• Cost
• Price
• Outcomes
• Transparency
• Growth strategy
Our Burning PlatformOur Burning Platform
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The Value ImperativeThe Value ImperativeThe Value ImperativeThe Value Imperative
Volume Value
The shift to value is the centerpiece of our strategy
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Value DefinedValue DefinedValue DefinedValue Defined
Value = Outcomes Cost
Outcomes QualityHealth StatusProcess Experience
CostEvent Episode Per Capita
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Reducing Unnecessary Reducing Unnecessary VariationVariation
Reducing Unnecessary Reducing Unnecessary VariationVariation
• Improves quality
• Decreases cost
• Demonstrates value
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Value-Based Care: Central to StrategyValue-Based Care: Central to Strategy
Care System
Retail Venues Home
CC ClinicCommunity- Based
Organizations
Ambulatory D&TIndependent Physician
Offices
Hospitals
Rehab
Skilled Nursing Facilities
MyChart
EmergencyPost-Acute(other)
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Care System
Cleveland Clinic Integrated Care ModelCleveland Clinic Integrated Care Model
Retail Venues Home
CC ClinicCommunity- Based
Organizations
Ambulatory D&TIndependent Physician
Offices
Hospitals
Rehab
Skilled Nursing Facilities
MyChart
EmergencyPost-Acute(other)
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Transforming CareTransforming CareTransforming CareTransforming Care
• Evidence/Experience
• Standardization
• Hand-offs
• Continuum
System of Care
• Pt Experience
• Quality
• Safety
• High Reliability
• Efficiency
VALUE 10
Tool: Care PathsTool: Care PathsTool: Care PathsTool: Care Paths
• Standardization vehicle
• Integration mechanism
• Led by Clinical Institutes
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Care Path DefinedCare Path DefinedCare Path DefinedCare Path Defined
• Multidisciplinary
• Optimizes value
• Reduces unnecessary variation
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Care Path DefinedCare Path DefinedCare Path DefinedCare Path Defined
• Evidence or experience-based
• Not always a single approach
• Expected practice yet allows judgment
• Some clinical activities will not apply13
Care Path Development Care Path Development Care Path Development Care Path Development
1. Disease Identification
2. Care Path Guide
5. Programming/Build
3. Technical Specs & Workflow
4. Mapping
6. Production14
Care Path ApproachCare Path ApproachCare Path ApproachCare Path Approach
1.Disease Identification
• Enterprise Criteria• Scope/Episode
2.GuideClinical Narrative
• Purpose• Background and Significance• Clinical evaluation and Documentation• Workflow Narrative and Tools• Outcome measures• Citations
3.ContentKnowledge Base
• Visit/Venue Matrix• Workflow Diagrams• Documentation• Orders• Metrics• Snapshots• Reports
4.MappingData Definition
• Map to ontologies• Data sources• Data storage• Rules• Mock Ups
5.ProgrammingBuild
• Epic configuration• Orders/Order Sets• Factors• Forms
Move to ProductionNear-term work
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Fully Mature Care Path Guide Fully Mature Care Path Guide Will Address:Will Address:
Fully Mature Care Path Guide Fully Mature Care Path Guide Will Address:Will Address:
• Quality metrics
• Appropriateness criteria
• Screening & prevention guidelines
• Health status measures
• Cost
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Care Path GuideCare Path GuideDevelopment ApproachDevelopment Approach
Care Path GuideCare Path GuideDevelopment ApproachDevelopment Approach
• Driven by Clinical Institutes
- > 750 caregivers
• Collaboration - Cross-Institute, Cross-Venue & Quality Alliance
• Wave 1: 50 Care Path Guides by 12/31/13
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We are building Vespas and We are building Vespas and Maseratis…Maseratis…
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Hip and Knee “Vespa” Development
“Vespa” WorkgroupDevelopment and Implementation
Leads: Morris, Spalding, Partin,Fogleman, Piar, Weber, ORI Clinical Expert(s), Coordinated Care, CI
StructuredDocumentation
Order Sets
Decision Support(ex: “Bundle Busters”)
CareCoordination
ProcessMeasures
OutcomesMeasures
Patient-EnteredData
Hip / Knee“Vespa”
Technology-ReadyComponents
Hip / KneeArthroplasties
Care Guide
Purpose of this Guide:
The Cleveland Clinic Orthopaedic and Rheumatologic Institute performs more than 1200 primary Total Hip Arthroplasties (THA) per year, making it one of the higher volume surgeries in the Cleveland Clinic. THA is also one of the most variable surgeries performed in the United States, with cost1 procedure, implant selection, length of stay (LOS), infections and re-admission rates, and post-operative management2 varying greatly between and within most systems. 19
Comprehensive Care CoordinationComprehensive Care CoordinationThe Second Key CompetencyThe Second Key Competency
Comprehensive Care CoordinationComprehensive Care CoordinationThe Second Key CompetencyThe Second Key Competency
• Aligned across the continuumAligned across the continuum
• Focus on high risk patientsFocus on high risk patients
• Primary and specialty carePrimary and specialty care
• Leverage technologyLeverage technology
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ContractingContractingContractingContracting
• We are aligning contracting with the We are aligning contracting with the clinical enterpriseclinical enterprise
• Multidisciplinary contracting team with Multidisciplinary contracting team with Physician and Finance Co-ChairsPhysician and Finance Co-Chairs
• Subject matter content experts for Subject matter content experts for specialty carespecialty care
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The Cleveland Quality AllianceThe Cleveland Quality AllianceThe Cleveland Quality AllianceThe Cleveland Quality Alliance
Independent Physicians CC Institutes
Quality Alliance
Jointly-established quality standardsJointly-established quality standardsReward for quality and efficiency Reward for quality and efficiency
Drive to better outcomesDrive to better outcomesDrive to improve value for patients, providers and payersDrive to improve value for patients, providers and payers
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The Quality AllianceThe Quality AllianceFour Strategic ObjectivesFour Strategic Objectives
The Quality AllianceThe Quality AllianceFour Strategic ObjectivesFour Strategic Objectives
• Superior practice quality and efficiency
• Document high-quality care
• Recognize superior performance
• Distribution vehicle for CCICM 24
Over 5,000 Provider MembersOver 5,000 Provider MembersOver 5,000 Provider MembersOver 5,000 Provider Members
As of 1.11.13
Total Membership = MD/DO/DPM/Team-Health ED (3,545) + AHP (1,535)25
We are moving to population We are moving to population management in all primary care practices management in all primary care practices
We are moving to population We are moving to population management in all primary care practices management in all primary care practices
• 260,000 lives260,000 lives• 240 providers240 providers• 39 practices at 29 sites39 practices at 29 sites• Team based careTeam based care
- Testing different models of PCMHTesting different models of PCMH- Embedded care coordinators, pharmacistsEmbedded care coordinators, pharmacists- Enhanced accessEnhanced access
• Epic registry functionEpic registry function• Advanced IT population management and Advanced IT population management and
analytic capabilities in developmentanalytic capabilities in development
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Other care transformation tacticsOther care transformation tacticsOther care transformation tacticsOther care transformation tactics
• Wellness widgetWellness widget
• E-visits E-visits
• Shared medical appointmentsShared medical appointments
• Distance healthDistance health
• Other lower cost sites of serviceOther lower cost sites of service
• Rationalizing sites of service Rationalizing sites of service distributiondistribution
• Preferred post-acute partnershipsPreferred post-acute partnerships
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… And we are teaching the young people these new skills
… And we are teaching the young people these new skills
• 126 IM residents moved to block rotations in population management in July 2012
• CCLCM curriculum implemented years 1, 2
• OU and South Pointe partnership
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The Cleveland Clinic’sThe Cleveland Clinic’sSecret SauceSecret Sauce
The Cleveland Clinic’sThe Cleveland Clinic’sSecret SauceSecret Sauce
• ModelModel
• LeadershipLeadership
• CultureCulture
• InnovationInnovation
• EngagementEngagement
• PridePride
Patients First30
““The strength of the pack is the The strength of the pack is the wolf, and the strength of the wolf wolf, and the strength of the wolf
is the pack…”is the pack…”
““The strength of the pack is the The strength of the pack is the wolf, and the strength of the wolf wolf, and the strength of the wolf
is the pack…”is the pack…”
Rudyard KiplingRudyard Kipling
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“The future belongs to those who believe in the beauty of their dreams…”
“The future belongs to those who believe in the beauty of their dreams…”
Eleanor Roosevelt
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