My Nurse Call Center:

1. My Nurse Call Center: Providing Care For Patients Outside Of The Four Walls Raedean VanDenover Director, Care Management | UnityPoint Health Dr. Stephanie Reyburn Physician | Quincy Medical Group

2. My Nurse Call Center My Nurse Overview My Nurse is a free health information service for the public Sponsored by Iowa Health System and it’s affiliate hospitals Located in Sioux City, Iowa My Nurse is staffed by registered nurses 24/7/365 24/7 Staffing began in 1999 Positioned to support the clinical initiatives of the system

3. My Nurse Call Center Our Services: Triage Triage callers to determine appropriate level of care Utilize RelayHealth Relay Care software Triage completed by RN’s only Medical director oversight and approval of triage guidelines and call priority

4. My Nurse Call Center Our Results: My Nurse Call Center Overall

5. My Nurse Call Center Our Results: Physician After Hours Only

6. My Nurse Call Center Note:Data range is March 5, 2012 thru March 31, 2013

7. My Nurse Call Center My Nurse Staffing 17.0 FTE Registered Nurses 5.9 FTE Licensed Practical Nurses 4.9 FTE Non-Clinical Support Staff 0.5 FTE Report Analyst 1 RN Manager 1 Director 1 Medical Director

8. My Nurse Call Center Our Services: Physician After-Hours Calls Provide coverage for physician clinics after hours 2012: 48% of all calls are PAH calls Currently serving 90 clinics and 405 providers Coverage is 5pm to 8am Triage calls and page the physician only when necessary

9. My Nurse Call Center Our Services: Triage Top Adult Guidelines: Abdominal pain or discomfort Post op problems Chest pain/chest discomfort Headache Pregnancy and Pre-term labor (20-37 weeks) Top Pediatric Guidelines: Fever Cough Vomiting Cold symptoms Trauma to the head

10. My Nurse Call Center Physician After-Hours Triage Description Over 80% of Triage calls fall into one of six dispositions:

11. My Nurse Call Center Our Services: Post-Discharge Call Follow up to evaluate understanding of their discharge instructions, pain management, medication management and their need for further health information Diagnosis specific questions to assess and reinforce compliance with Evidence Based Practice Presented in a “Teachback format”

12. My Nurse Call Center Our Services: Post-Discharge Follow up Calls Post discharge call is made within 24 hours of discharge If patient is not able to teach back, My Nurse will teach back key components from discharge summary Second call is made post discharge day 2 to assess understanding of discharge instructions If unable to teach back a follow up referral is made

13. My Nurse Call Center Post-Discharge Calls 2012 Results

14. My Nurse Call Center Quality 90% benchmark Quarterly Audits are completed for all staff 1% of all calls reviewed Weekly review of all new employees as needed QA/QI results for 2012 is 93%

15. My Nurse Call Center 2012 Progress Completed Integrated Chronic Care Disease Management Training for all call center staff Trained all staff on use of EHR Waterloo Triage transitioned to My Nurse Increased additional clinics to Physician After Hours by 25% Focused on staffing and training to prepare for 2013 projects focused on continued clinical integration of the call center

16. My Nurse Call Center 2013 Progress Transitioned 1 additional clinic to Physician After Hour Service Access to EHR for New Group patients Training on use of EHR and GPMS Launched Pilot with Central Iowa to schedule next day appointments Implemented Physician After Hours Services for Quincy Medical Group (26 physicians) Training and support for Iowa Health Home Care Triage process Installed new phone system to allow for call recording Began ED Post Discharge call for Fort Dodge Region

17. My Nurse Call Center Looking Ahead Continue to support clinical initiatives of the system Improve call center metrics to industry standards Capitalize on updated phone system technology and reporting to drive process improvement and performance Continue to expand post discharge calls beyond inpatient discharge

18. My Nurse Call Center Looking Ahead Move additional clinics to after hours call service Continue implementation of scheduling next day appointments Increase volume and focus of QA/QI program. Continue to consider additional expansion opportunities

19. My Nurse Call Center New Brand, New Name My Nurse becomes My UnityPoint Nurse

20. My Nurse Call Center New Website myunitypointnurse.org Physician-finder resource Articles about more than 1,000 health-related topics Customer satisfaction survey

21. My Nurse Call Center Project Innovation Team 3: Value Based HealthcareReducing ER Visits and Admissions Project Champion: Dan Evans, M.D. Project Leader: Stephanie Reyburn, M.D. Project Team: Dan Evans, M.D. Hrishikesh Ghanekar, M.D. Stephanie Reyburn, M.D. Raymond Smith, M.D. Musab Saeed, M.D. Aric Sharp, CEO Patty Williamson, CFO Project Coach: Mo Kasti

22. My Nurse Call Center Quincy Medical Group Quincy Population, 40,630 Service Area 112,000 Founded in 1937 135 providers 100/35 (Phys/Midlevel) 28 Specialties 50% Primary Care, 50% Specialty Care All primary care under CRHC Broad Ancillary Scope McKesson EHR

23. My Nurse Call Center Quincy Medical Group Location Outreach

24. My Nurse Call Center Quincy Medical Group Leadership Institute Focused on Developing Change Agents Innovation Projects Aligned with the Triple Aim Value – Cost of Care Service – Patient Experience Quality – Measurement & Improvement

25. My Nurse Call Center Value Scoping Our Project Reducing Cost Quality Imaging Admissions Generic Rx Readmissions Emergency Room Nursing Home Direct Various Strategies HP3 Project Current 9.6% NP Care Project

26. My Nurse Call Center Selected Project Goals: Reduce Avoidable Admissions and Avoidable ER Visits
 Increase outpatient services Increase access to care after clinic hours Improve coordination of care post-hospital discharge and for chronic condition patients 

27. My Nurse Call Center Our Project Plan Approach Narrow Scope Collect Data Educate ourselves and benchmark Pick early wins Develop plans Engage and secure stakeholder buy-in Implement early wins Evaluate what we have learned

28. My Nurse Call Center National Data on Admits and ER Visits Potentially Preventable Admissions & Visits PPAs: 25% of all initial hospital admissions National annual rate -94 per 1,000 beneficiaries Heart failure most frequent clinical reason PPVs: 59% of all ambulatory ED visits (treat and release) National annual rate -158 per 1,000 beneficiaries Infections of upper respiratory tract most frequent clinical reason MEdpAC October 5, 2012

29. My Nurse Call Center Other Causes of ED Admissions Lack of after hours nurse triage Poor coordination with Home Health Care Limited Ambulatory Care Clinic and/or primary care hours on weekends Culture of taking all admissions from Emergency Room Poor transitions in care between inpatient & outpatient Lack of community education about preferred access points

30. My Nurse Call Center Benchmarking Research What Others are Doing to Reduce Cost Everett Clinic – Set goal to reduce total healthcare cost by 25% by 2016 through reducing admissions and moving to generic prescribing, etc. Geisinger Health Plan – decreased hospital admissions by approximately 15% by implementing a Medical Home model utilizing nurse case managers targeting specific patient risk panels. Mt. Kisco Medical Group – an on-call physician from the group sees patients presenting to the ER to determine if the patient needs to be admitted. CIGNA Medical Group – is increasing urgent care capacity, implementing a nurse triage line, and educating patients in order to reduce preventable ER visits.

31. My Nurse Call Center 10 Proposed Initiatives After Hours Nurse Triage Phone Service via Iowa Health System Home Health Care via QMG-Iowa Health System Home Health Care, Home Medical Equipment, Palliative Care, In-Home Hospice Expand ACC and/or primary care hours Expand infusion center hours Hospitalist assessing patient in Emergency Room Use Nurse Care Coordinator Model – BCBS Int. Medical Home Discharge Nurse to assure good transition to outpatient Nursing Home NP model of care Patient education about preferred access points Educate physicians on preferred ER referral process

32. My Nurse Call Center Approach to Securing Buy-in Small Family Practice Call group meeting Large group meeting with Family Practice, Internal Medicine, and Rural Clinic providers Presentation at Shareholder meeting One on One meetings with Physicians throughout Primary Care

33. My Nurse Call Center Nurse Triage Nurse Triage call line launched March 4, 2013 for 26 providers Provides Better customer Service and access to a health professional Reduces avoidable ER visits Reduces physician after hours call intensity

34. My Nurse Call Center Home Health Care Partnering with Iowa Health System Implementation underway - in process of hiring director Goals: Reduce readmissions Decrease the overall cost of care Capture a revenue opportunity for Iowa Health & QMG Medicare MSSP data average 406 visits/1000 lives across Iowa Health System. Quincy at 127 visits/1000 lives Opportunity for increased community based services for our patients

35. My Nurse Call Center Home Health MSSP Data

36. My Nurse Call Center Expanded Hours ACC Hours (Walk In Clinic) New Physician hired – extending Saturday hours to all day starting Summer 2013 Primary Care Offices Exploring Sunday Hours via Rotation

37. My Nurse Call Center Hospitalist in ER Dr. Vardaros signed with a start date of October 2013. Hospital Call Group to explore engaging with the ER on a routine basis. Will reduce avoidable ER admissions.

38. My Nurse Call Center BCBS Medical Home Care Model Launched January 2013 37 super visits have been completed with another 10 scheduled Goal is 200 enrolled patients by August 2013 Potential next step… Use MSSP data to identify similar high-risk Medicare patients for care coordination Apply Iowa Health Advanced Medical Team Model

39. My Nurse Call Center Admission/Discharge Planner Launched October 2012 Better transition of care from hospital to outpatient including scheduled follow-up visits, ancillary capture, med reconciliation and improved communication with provider offices Next step – additional staff member has been hired to meet face to face with every patient when admitted and discharged

40. My Nurse Call Center Nursing Home Care Model Launched April 2012 NP Onsite at all Nursing Homes in Quincy Has led to more satisfied patients, reduced ER visits, and reduced avoidable admissions All primary care providers currently utilizing the service

41. My Nurse Call Center Consistent Patient Education Reviewed Iowa Health System “Red, Yellow, Green” care action plans for utilization with patients Implementation Fall ‘13 Action plans available for wound care, care, stroke, pneumonia, high blood pressure, heart failure, diabetes, depression, and COPD

42. My Nurse Call Center Transition Plan - Sustainability

43. My Nurse Call Center Leadership Lessons Learned Teamwork Care Value is Big Work, Narrow the Scope, don’t boil the ocean Assign clear roles Leverage resources Holding each other accountable Innovation = Idea + Execution

44. My Nurse Call Center Next Steps with My Nurse Allow My Nurse Access to EHR Begin scheduling next day appointments Expand Physician After Hours Service to additional specialties

45. My Nurse Call Center “My UnityPoint Nurse, how may I help you?” Questions?