Leadership Symposium

1. Leadership Symposium Setting the Course for Change Patient centered Medical Home 4.17.2012

2. 2 Objectives • Recognize how creating the Medical Home through Care Model Redesign supports the IHS strategic vision • Identify the guiding principles of a team-based care model • Understand the components of the care model and implementation strategies • Describe how care packages based on evidence-based medicine improve the quality of patient care

3. Medical Home Redesign care to create the ideal Iowa Health System experience that focuses on the “Best Outcome for Every Patient Every Time”

4. Iowa Health System “The road to the future is constantly under construction.” ~ A Wise Man

5. Changes to the Future of Healthcare Payment Model Innovative Quality Systems Population Management Clinical Integration Electronic Heath Record / CPOE Meaningful Use Measures Structure of the Health Care Delivery System

6. Iowa Health SystemCommitment to the Future Physician Alignment (NewGroup) Clinical Integration PCMH (Patient Centered Medical Home) Integrated Health Management Advanced Medical Team Hospice / Palliative Care ACO/ICO Development Physician Leadership Academy

7. Iowa Health System “For tomorrow belongs to the people who prepare for it today.” ~ African Proverb

8. 4 Value-Based Strategy Physician Alignment Delivering Value Demonstrating Value Value-Based Contracting

9. Prototype Clinics Grimes Family Physicians • Dr. Dennis Bussey • CarinBejarno, ARNP • Janell Schlosser, MHA Clinic Administrator • Cora Duncan, RN • Donna Starck, CDE • Kate LaFollette, RN Project Coordinator

10. Prototype Clinics Lakeview Internal Medicine • Dr Heather Roberts • Dr Tyler Casey • Dr Dan Allen • Dr Ailey Brehmer • Dr Katie Burns • Heath Hill, MHA Clinic Administrator • ReneaSeagren RN • Carrie Leiran RD, LD • Carrie Koenigsfeld, PharmD • Kate LaFollette, RN Project Coordinator

11. Care Model Redesign / Care Packaging • Redesign care and align incentives to produce quality care with a reduction in total cost of care based on defined metrics • Improve clinical quality outcomes aligned with evidence based guidelines • Improve employee, physician, and patient / family satisfaction with care provided through the new model • Implement a team based care model • Identify, prioritize and sequence five Care Packages that provide enhanced quality with effective cost efficiencies at the identified prototype clinics

12. 8 • Care Model Redesign & Care Packaging Team Based Care Models The fundamental structure or the “track” in which quality care will run Care Packages Quality Care will be designed through the use of Care Packages or “cars” that will run on the track

13. 10 Team Based Care ModelGuiding Principles Multidisciplinary teams working at the top of their licenses Daily team communication for effective team work Complete planning prior to day of visit Effective communication to patients and families Creating health literate educational handouts Create and implement a standard rooming process Create and implement a standard room set-up Institute standard medication reconciliation process Create and implement standardized BP Protocol Practice effective EMR task management processes PDSA (Plan, Do, Study/Check, Act)

14. 11 Implementing the Care Model

15. Team Based Care • A Multi-Disciplinary Team – Top of Licensure • Physicians • Mid-Level Providers • RNs • RDs • CDEs • Pharm D • CMAs • Schedulers

16. 12 Team Model • Goal: Multidisciplinary team working at top of license • Nursing staff, providers, scheduler, RN, pharmacist

17. Care Model Basics • Co-location • Huddles • Task management • Phone tree • First call resolution • Standardization • Standardized Room Set Up • Standardized Rooming Process / Family Team Care • BP protocol • Medication conciliation • Change management • PDSA • Health literacy • Made materials health literate • Teach back

18. Co-Location

19. Co-Location

20. 15 Team Huddles Daily communication among entire clinic Includes entire team PDSA Office Flow Review Quality Measures and Difficult Patients

21. Phone Tree Goal: 1st Call Resolution Reduced call abandonment rate: -11% Overall task reduction: -31% Reduction in tasks assigned to providers: -15%

22. 16 Room Standardization Room Set Up Standardized Rooming Process BP Protocol Medication Reconciliation

23. 17 Care Model Basics • Pre Visit Calls • Goal: Complete planning prior to day of visit • My Nurse / RN • Part of multidisciplinary team • Extension of the clinic • Pre visit calls and proactive outreach • Chart Updates (Medical / Surgical / Family/ Social History) • Screenings Updated or Scheduled • Breast / Colon / Prostate / Cervical Screening • Immunizations • Vision / Hearing Screenings

24. Previsit Call Text Template

25. Care Package Goals • Functional and Risk Status • Improve functional status and sense of well being • Reduce and manage co-morbidities • Satisfaction and Perceived Health Benefits • Improve overall service satisfaction – staff / patients • Cost • Reduce overall cost • Reduce office visits / Increase phone calls and RN visits • Reduce Pharmacy / Indirect cost • Reduce redundant lab costs

26. 9 • Care Packaging It is when care is redesigned and incentives are aligned to produce quality care with a reduction in total cost of care Adult Preventive Hyperlipidemia Well Child Hypertension Diabetes

27. Adult Preventive

28. 21 Adult Preventive 20-25 Components addressed for All Adult Physicals Age and Gender Specific Pre-Visit Planning – RN / My Nurse Review / Update Past Medical, Social, Family, Surgical History Lipid / DM Screening Cancer Screening Breast / Cervical / Colon / Prostate Depression Screening PHQ-2 / PHQ-9 Immunizations Flu / Tetanus / Pneumonia / Zoster Counseling Tobacco / Alcohol / ASA / Folic Acid

29. Hypertension Hypertension Goals RN Care Package BP protocol/competencies Patient education and teach back Standing orders

30. Hypertension Goals

31. Hypertension • Accurate BP Measurements at all visits • Staff / Provider Competencies Completed • Net Learning / Skill competencies • Educate HTN Patients at every office visit • Teach Back Education Methodology • Health Literate Education Materials • EHR order set / Web Based tools • HTN Patients reach / maintain goal • 130/80 – DM / CKD • 140/90 – All other patients • Reduce Cost • RN HTN Care Program

32. RN Hypertension Care Program • Provider Referral for entry into the Program • RN Schedules / EHR Note Types • Verification of EKG / Labs being UTD • Education • Diagnosis / Management • Lifestyle Modifications • Standing Orders • Medication titration / Lab monitoring • Office / Phone follow ups

33. Hyperlipidemia Hyperlipidemia EHR changes/flow sheet

34. Hyperlipidemia Goals • Evaluate/Classify New Patients with Hyperlipidemia • Framingham Score (CoQ Measure) • Assess Lifestyle Risk / Other Risk Factors • Lab Evaluation to R/O Secondary Hyperlipidemia • FBS / TSH / Cr / LFTs / UA • Initiate Lifestyle Modifications • RN Care Program • Diet / Weight Management / Exercise / Smoking / EtOH • Initiate Lipid Lowering Rx per guidelines • ATP III Classification / Treatment Goals • Monitoring of Lipids / LFTs while on Therapy

35. Hyperlipidemia Flow Sheet

36. 24 Diabetes Care Package • Changed/added to EHR templates • Documentation of all elements in one place • Changed text templates • Interdisciplinary team approach • See RN, dietician/DE, or pharmacists in addition to physician • Supporting diabetic patients • Bringing diabetic education to the clinic • Personalized care, tailored to their needs

37. Well Child • Multiple screenings needed in first five years • Lead, TB screening • Social and developmental screenings • Autism screening • Using Ages and Stages Questionnaire on-line • Parents complete questions on line before Well Child appointment • Returned and scored electronically • Results available at visit, referrals made as needed • Software can run reports, reminders, provide education

38. Data CoQ – year end for LVIM and Grimes Quality Metrics for beginning 2012 Employee satisfaction survey Patient satisfaction

39. Year End CoQ Data - LVIM

43. Employee Satisfaction Survey

44. Patient Satisfaction

45. Next Steps • Improving care coordination • Communication across settings • Coordinating care across settings • Interdisciplinary Team • Adding mental health counselor (Grimes) • Increased coordinator role for RN (LVIM) • Deployment plan

46. Stories Patients Staff perspective Physician perspective

47. Contact Information Kate LaFollette lafollcs@ihs.org 515-471-9292