The Green Mountain Care Board and VMS Education and Research Foundation

1. The Green Mountain Care Boardand VMS Education and Research Foundation Optimizing rural care  Better quality, Better health, Lower costs

2. Better care, better health, lower costs How can leaders accelerate innovation? “You have to have the willto improve; You have to have ideasabout alternatives to the status quo; and then you have to make it real through execution. All three have to be arranged by leaders – they are not automatic.” • Actualize 3 planned levels of care • Make VT a magnet for the workforce • Become the national benchmark for measurement • Reduce the gap between practice and policy

3. Vermont Rural Physician Leaders Community Phil Brown MD, Berlin CVMC - Chief Medical Officer Internal medicine, Emergency medicine Kevin Buchanan MD, Randolph Clara Martin Center - Medical director Psychiatry Ovleto Ciccarelli MD, Randolph Gifford Health Care - Surgical Chairperson General Surgery David Coddaire MD, Morrisville Community Health Services of Lamoille Valley Medical director, Family practice Mark Crane MD, Berlin CVMC - General Surgery Lou DiNicola MD, Randolph Gifford Health Care - Pediatrics Jeremiah Eckhaus MD, Montpelier CVMC - Family practice Sharon Fine MD, Danville Northern Counties Health Care - Medic al director Family practice Steve Genereaux MD, Wells River Little Rivers Health Center - Medical director Family practice Nikki Gewirz PA-C, Randolph Gifford Health Care - General Surgery Mark Heitzman MD, Berlin CVMC - Cardiology Sarah Kemble MD MPH, Springfield Springfield Medical Care Services - Medical director Internal medicine, Preventive medicine, Public health Mike Kilcullen MD, Woodstock Ottauquechee Health Center – Pediatrics Dina Levin MD, Randolph Gifford Health Care - Obstetrics and Gynecology John Matthew MD, Plainfield The Health Center – Executive and Medical director Internal medicine, Family practice Josh Plavin MD MPH, Randolph Gifford Health Care - Medical Director Internal medicine, Pediatrics, Pubic health Deborah Richter MD, Montpelier Family practice, Addiction medicine Joel Silverstein MD, Morrisville Copley Hospital – Chief Medical Officer Internal medicine, Gastroenterology Peter Thomashow MD, Berlin CVMC – Psychiatry Chairperson Psychiatry Sean Uiterwyk MD, White River Junction White River Family Practice – Independent practice Family practice Mark Yorra MD, Barre CVMC - Internal Medicine

4. Qualitative research - Key informant interviews What? • Health resource allocation planning • Measurement of health care processes and outcomes • Payment policy and payment reform • Communication with Board • Retention and recruitment of physicians Who? • People who know what’s going on in their community • Insight on the nature of problems and recommend solutions Advantages • Candid/in-depth • Detailed rich data • Nuanced and actionable • Trust/sensitive topics • Motivation and beliefs • Raise interest/enthusiasm • Build/strengthen relationships • Stay connected/clarify issues Disadvantages • Difficult to selection the “right” informants • Diversity? Bias? • Difficult to schedule • Difficult to generalize unless many involved

5. Actualize 3 planned levels of care3 levels of care by design “Our current clinical capabilities are such that we never lose a life because we are missing capacity when a life threatening situation presents itself; but we are all really stressed ” • FQHC medical director • Core community based services • readily available • Regionalized specialty services • reasonably available • Tertiary and quaternary care • emergently available Regionalized/shared general surgery Ovleto Ciccarelli MD, Randolph Gifford Health Care - Surgical Chair General Surgery

6. Thoughts on Future Delivery of Surgical CarePresentation to The Green Mountain Care Board Presented by Ovleto Ciccarelli, MD Disclaimer: This presentation represents the personal opinions of the presenter and does not represent an official opinion or position of Gifford Medical Center of Gifford Medical Center

7. Gifford Medical Center Ovleto Ciccarelli, MD TIERS OF SURGICAL CARE • CARE TO BE PERFORMED IN A TERTIARY CENTER • Technically complex surgery (i.e. cardiac, neuro) • Complex infrequently performed surgery (i.e. pancreatic, esophageal and non-cardiac open thoracotomy) • SURGERY THAT SHOULD REMAIN IN A COMMUNITY SETTING • Commonly performed surgeries (i.e. breast, hernia, intra-abdominal surgery) • SURGERY THAT MAY OR MAY NOT BE DONE IN A COMMUNITY SETTING DEPENDING ON SURGICAL SKILLS AND PERIOPERATIVE SUPPORT • Advanced laparoscopic and/or thorascopic surgery with short postoperative stays and the patient with comorbid conditions that are amenable to local advanced perioperative care Thoughts on Future Delivery of Surgical Care

8. Gifford Medical Center Ovleto Ciccarelli, MD STATEWIDE INITIATIVES TO SUPPORT A REGIONAL NETWORK OF CARE • Common information/technology system • Quality improvement system (NSQIP) to allow for comparison of surgical outcomes among all participating surgeons • Statewide licensing and credentialing process • A central repository/inventory of available surgical skills and services • Centralized recruitment to meet needs of all hospitals • Regional surgical providers who work at more than one facility • Rotation of providers with advanced skills to community facilities • Rotation of emergency room availability • Centers of Excellence (i.e. metabolic and bariatric surgery) Thoughts on Future Delivery of Surgical Care

9. Gifford Medical Center Ovleto Ciccarelli, MD EDUCATIONAL NEEDS TO FOSTER AN INTEGRATED SURGICAL COMMUNITY • Multi-institutional morbidity and mortality conference • Additional training for Physician Assistants to improve operative skills • Mini fellowships for community surgeons with respect to critical care and acute care surgery • Telemedicine support to allow for provision of care in local settings Thoughts on Future Delivery of Surgical Care

10. Magnetize VT for the workforce Team based care – Rethink the workforce Planned expansion of mid–level care “The role of mid-level practitioners must be recognized; as physicians practicing in rural communities we are extremely dependent on having a close working relationship with mid- level practitioners. The only model that works is a team approach” “From the view point of a mid-level it’s very difficult to be effective if we aren’t included in professional, management and planning discussions. We are expected to know everything; we are expected to do everything, but we don’t necessarily have access to all the support that physicians have like CME, newsletters and other professional opportunities supporting lifelong learning. Sometimes we can feel like the red-headed step child.” New team members Community health workers “We’ve taken many steps toward becoming a patient centered medical home, but there is a need for more community health workers, health coaches and panel management. People used to know how to help each other; there were layers of support in the community; we need trained trusted members of the community to teach us all how to be more self reliant” Practice based quality improvement staff “We need to scale up training a workforce for the future of primary care which will include more medical assistance level personnel to help manage the data entry involved in monitoring quality and controlling costs.  The work keeps increasing and the workforce stays the same!” Nikki Gewirz PA-C, Randolph • Gifford Health Care - General Surgery • Jeremiah Eckhaus MD, Montpelier • CVMC - Family practice

11. Become the national benchmark for measurementChecking little boxes versus meaningful measurement Design valid trusted metrics “As an organization we can produce significantly different rates based on the methodology we use to collect the data. If we use a manual chart review process on a random sample of 70 patients to determine if we documented tobacco use status we score 100%; the same rate calculated through the Meaningful Use methodology using our EMR is 85%. Similarly, manual method results in 45% of our patients being counseled about stopping tobacco use, where the Meaningful Use method shows a 15% counseling rate and for some practitioners the rate is as low as 4%” Reduce the administrative burden “I’ve practiced primary care in other parts of the country; Vermont is the best place for primary care that I’ve been; But, if the administrative burden continues to increase, the good intentions underlying the documentation requirements and other administrative burdens will ruin the appeal of VT for primary care” • Sarah Kemble MD MPH, Springfield • Springfield Medical Care Services - Medical director • Internal medicine, Preventive medicine, Public health

12. Reduce the gap between practice and policyBetter care, better health, lower costs • Actualize 3 planned levels of care • Make VT a magnet for the workforce “If you don’t know where you’re going, any road’ll take you there” • Become the national benchmark for measurement “Our shared goal should be improvement of value as defined by the outcomes that matter to patients and costs over meaningful episodes of care” Tom Lee MD, Sept 2012 • Reduce the gap between practice and policy • “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it's the only thing that ever does” • Margaret Meade • Josh Plavin MD MPH, Randolph • Gifford Health Care - Medical Director • Internal medicine, Pediatrics, Pubic health

13. Vermont Rural Physician Leaders Community Phil Brown MD, Berlin CVMC - Chief Medical Officer Internal medicine, Emergency medicine Kevin Buchanan MD, Randolph Clara Martin Center - Medical director Psychiatry Ovleto Ciccarelli MD, Randolph Gifford Health Care - Surgical Chairperson General Surgery David Coddaire MD, Morrisville Community Health Services of Lamoille Valley Medical director, Family practice Mark Crane MD, Berlin CVMC - General Surgery Lou DiNicola MD, Randolph Gifford Health Care - Pediatrics Jeremiah Eckhaus MD, Montpelier CVMC - Family practice Sharon Fine MD, Danville Northern Counties Health Care - Medic al director Family practice Steve Genereaux MD, Wells River Little Rivers Health Center - Medical director Family practice Nikki Gewirz PA-C, Randolph Gifford Health Care - General Surgery Mark Heitzman MD, Berlin CVMC - Cardiology Sarah Kemble MD MPH, Springfield Springfield Medical Care Services - Medical director Internal medicine, Preventive medicine, Public health Mike Kilcullen MD, Woodstock Ottauquechee Health Center – Pediatrics Dina Levin MD, Randolph Gifford Health Care - Obstetrics and Gynecology John Matthew MD, Plainfield The Health Center – Executive and Medical director Internal medicine, Family practice Josh Plavin MD MPH, Randolph Gifford Health Care - Medical Director Internal medicine, Pediatrics, Pubic health Deborah Richter MD, Montpelier Family practice, Addiction medicine Joel Silverstein MD, Morrisville Copley Hospital – Chief Medical Officer Internal medicine, Gastroenterology Peter Thomashow MD, Berlin CVMC – Psychiatry Chairperson Psychiatry Sean Uiterwyk MD, White River Junction White River Family Practice – Independent practice Family practice Mark Yorra MD, Barre CVMC - Internal Medicine