Today Join Us to a New Future

2. Today Join Us to a New Future John Bachman-Primary Care Online Steve Adamson-Retail Clinics Kurt Angstman-Diamond Project Tom Harman-Video/In house Communication For High Risk Patients

3. Let us Begin With an Expedition on the Planet Kruos

4. Online Consultations-Platform

5. The Story 1995 Patients could do histories on computers 2003 Wrote a Review for Mayo Proceedings Negotiations with GE 150,000 dollar contract 2006 Medfusion for Department of Family Medicine (AAFP/Mysis) 450 000 dollars Practice Committee of Mayo Negotiations 6 months

6. Ready to Launch July 2007 started with our own department employees It had lots of bugs Online Consultations were done with IMH Medfusion had issues Prescription module was terrible Diagnostic codes were primitive Functional but not very sophisticated Not many people were doing consultations The set up was for a small group Eliminated prescription refill, simple messaging

7. Cultural Change Fear everyone would use it immediately We are already busy enough This does not work so well we can wait. Developed the term �Soft Start� July until November met with Medfusion weekly to go over issues November felt good enough to enroll patients March felt good enough to begin charging

8. So What Happened?

10. First Year�s Financials

12. Demographics (first year) Average age was 39 and 2/3 are on women

13. 20-60 have done most

14. We have made an impact on protocols Communicating directly with doctors instead of nursing We decrease phone tag, We make money We save time tracking down doctors, We provide standardized education We provide prevention services.

15. Protocols 201 in a year

17. Talking with the Appointment Desk

18. Nurse phone protocol

19. Still not done . . .

20. Look how much time was used by us

21. Look how much time Mary had to spend on this

22. The digital way . . .

24. The doctor gets an e-mail notification �You have a virtual Office Visit�

25.

27. Doctor�s Actions

28. 30 minutes later Mary reads doctor�s note & UTI treatment plan

29. c

30. Which would you want? Call Nursing time for protocol Clinician time to say ok Appointment desk Nurse faxes prescription Verbal instructions Time in hours Clinic loses money Go Online Clinician uses set protocol Clinician checks prevention Instructions that are written Prescription faxed automatically Time in minutes MMSI $35 charge - margin better then an exam

31. We have had impact on allowing people to contact us without coming in

32. In one year 368 Mayo employees and Mayo dependents did not have to come in for a visit This was 40% of the consultations done by our employees or dependents! 70 non-employees did not have to come in for a visit A study showed that patients did not return any higher then people seen in the office

33. Prescription Refills

34. Case Heartburn/Depression

39. Most VOVs have GDMS sent to the Clinician So what?

40. So in October we saved a life Dr Furst ordered a colonoscopy based on GDMS from a prescription refill Detected a localized adenocarcinoma

41. Many Online Consultations allow us to be Thoughtful Standardization of care plans Time to think about issues

42. What has not worked out well? The past two months we have experienced slow downs-People do consultations and get error messages It happens 8% of visits It is a MEDFUSION issue as it affects their whole system and occurs at peak times (5PM is a killer) They are working on improving this Our administration is talking with them about reducing our payments because of this poor service

43. How to be successful Sustaining technologies Listen to customer Give people what they want Seek higher margins Target larger markets Culture of control, oversight, and planning Disruptive Technologies Separate from the organization Creativity is destructive Find markets not served well and ignored Revise as you move Uncertainty Show rising profit/value

44. This is disruptive technology Status Quo People gather data Patients do medicine on the phone or office Patients are left to initiate help Disruption Computer gathers data People do medicine online MessagingStandardized Medicine Retail Clinics House Calls Online Chronic Disease Management

45. We have made major changes in past year Confusion of going to wrong site has been virtually eliminated People quitting too early in their online consult has improved Ease of questioning Patients and staff have grown and learned We do not have to tell people basics of how to do consults as much Methods of recording, informing patients, and developing faster methods

46. So what is our biggest hurdle? Ourselves Tyranny of the urgent. We are so busy with today that we do not anticipate tomorrow How do we get people today to solve problems in the future?

47. Messaging

48. Wouldn�t it be nice to do things smarter and not work harder? We can with Online Messaging!

49. Messaging Oversight committee has approved Batch results and send them online with template messaging resulting in no phone tag or letters Potential to have all employees receive normal results this way Super fast, permanent record, easy to see if read NO TOM notes by patient care providers!

50. In summary our first year We are moving to the right side of history and our patients are the beneficiaries It is making a difference every day

52. Save Time - Go Online

54. Convenience Clinics Potential for Mayo Clinic Rochester Steven C. Adamson, M.D.

55. Today�s Meeting Convenience Clinics What they are Why they are Who are their partners How they may affect our care How they may affect our ability to shape population-based care What we plan to do What we are asking

56. Definition A retail health care clinic that provides a limited menu of common, low intensity primary care services outside of the standard medical facilities Low cost, open access Often partner with other retail entities Multiple insurance/payment options available

57. Consumer Driven No appointments Short visits Only the limited problem addressed Convenient hours Convenient locations Fixed price

58. MCR Convenience Clinic Goals Primary Goals Increase primary care access to employees and community members Maintain continuity of care Decrease cost of care through more efficient use of facilities and staff

59. MCR Convenience Clinic Goals Secondary Goals Provide needed services to our patients at a time and place that is convenient to their needs Decrease ED volumes and low acuity patients Increase potential access for community patients into the Mayo Clinic practice

60. Why This is Different From Urgent Care? Defined package of services for the patient Not care for all health concerns Defined work for the practitioner Specified through protocols and templates Supplements rather than diverts the practice Limited waiting time for patients

61. The Plan 2 locations (High traffic, Convenient, Pharmacy) North & South (500-800 sq. feet) ~500 sq. feet required for an exam room, bathroom, waiting area Single NP provider

62. Key Operational Considerations Registration of patients performed by the NP Confirm identification for existing patients Confirm identification for new patients (no existing Mayo Clinic #).

63. Key Operational Considerations (Cont.) Registration of patients performed by the NP Registration, S&P and other stakeholders are working on processes in order to ensure due diligence Reviewing expedited processes in other areas (ED, Blood donor) New registration is minimal Approximately 1-3 new patients per day in Urgent Care experience

64. Key Operational Considerations (Cont.) Patient Access Currently provide follow-up in primary care services (or others as needed) to ED patients Patients registered through the convenience clinic would not be guaranteed paneling within primary care services 4-7% open appointment access in primary care settings projected

65. Providers Staffing and Oversight 2.9 NP FTE per location Oversight by Family Medicine physicians and Director Hiring by Family Medicine NP Manager and HR Staffing Specialist Protocols reviewed and revised by ALMC and MCR NPs and physicians Appropriate care for focused problems

66. List of Services Allergies (ages 6+) Bladder Infections (Females ages 12-64) Bronchitis (ages 10-65) Cold/Flu Ear Infections Pink Eye Styes Sinus Infections (ages 5+) Strep Throat Swimmer�s Ear Vaccines (Flu, Pneumonia) Pregnancy Testing (ages 18+)

67. List of Services (Cont.) Skin Conditions (athlete�s foot, cold sores � ages 12+, insect/tick bites � ages 12+, impetigo, minor skin infections & rashes, minor sunburn, poison ivy � ages 3+, ringworm, swimmer�s itch) Ear wash Wart removal Sports and/or college physicals (Future opportunity) Blood Glucose (Future opportunity)

68. Target Market Data The Rochester market including NW, SW, SE, NE quadrants; Byron; Eyota; Kasson; Mantorville; Oronoco; Pine Island; and Stewartville was used to estimate potential market demand. The Rochester market including NW, SW, SE, NE quadrants; Byron; Eyota; Kasson; Mantorville; Oronoco; Pine Island; and Stewartville was used to estimate potential market demand.

69. Marketing Strategy Articulated as one of the many options available to access Mayo Clinic care Guidance as to the best choice for sample medical problems will be provided

70. Financial ConsiderationsCost Difference Opportunities Generated by Design Cost of Delivery Convenience Clinic Model savings - an average range of approximately $71-240 per visit When considering revenue earned per visit, convenience clinics are at a loss of $22 per visit (max.), while the lowest DSS cost is still at an approximate negative $53. Opportunities Generated by Design Cost of Delivery Convenience Clinic Model savings - an average range of approximately $71-240 per visit When considering revenue earned per visit, convenience clinics are at a loss of $22 per visit (max.), while the lowest DSS cost is still at an approximate negative $53.

71. Financial ConsiderationsRevenue Difference

72. Cost Avoidance Primary Care Services & ED Potential annual cost avoidance of $ 1.1 million Based on calculation: 3.6 visits per hour 46% employee population, 10% Government, 44% Commercial DSS Cost � CC Cost % based on Albert Lea Demographic split% based on Albert Lea Demographic split

73. Cost Avoidance (Cont.) Primary Care Services & ED Potential annual cost avoidance of $ 1.1 million Based on Potential Population 600 ED visits &10,400 Primary Services Anticipated patient populations 60% FM, 30% CPAM, 10% PCIM % based on Albert Lea Demographic split% based on Albert Lea Demographic split

74. Potential Positive Effects to ED and Primary Care Practice ~600-800 low acuity visits pulled from the ED Opens 4-7% of the Primary Care Practice Ability to panel new employee and community populations Market data shows that Geisinger pulls from the ED � 20-30% of the patients would have sought emergency services, but cannot see large differences in ED volumes Market data shows that Geisinger pulls from the ED � 20-30% of the patients would have sought emergency services, but cannot see large differences in ED volumes

75. What has happened??!! Exceeded capacity the day we opened Initial site was intentionally equipped with 2 exam rooms This site has been double staffed for 75% of the hours to date

76. Second site Second site just opened and is within a grocery store in Rochester Also busy from the opening bell.

77. Effects Decrease in ER volume for the primary care practices No increase in subsequent utilization of services Has helped decrease per member per month costs

78. Future scope? At this point not sure likely will have a third site in Rochester at some point Also have discussed partnering with local large employers to provide services on a contract basis.

79. Questions??

81. Innovations from Mayo ClinicSTFM December 2008 Kurt Angstman, MD Consultant, Department of Family Medicine Assistant Professor of Family Medicine Medical Director, Mayo Family Clinics Mayo Clinic Rochester

82. I have no relevant financial relationships to disclose.

83. OBJECTIVES To identify the challenges of managing depression in the primary care setting To describe the DIAMOND initiative � a model for depression management in primary care To discuss the roles of a PCP, care manager and psychiatrist in the DIAMOND model. To present preliminary results of DIAMOND

84. The Burden of Depression The leading cause of disability and premature death among people aged 18-44 worldwide Expected to be the second leading cause of disability in people of all ages by the year 2020 Remains an undiagnosed and under-treated condition. only 46-57% of the 12 million cases in the United States are receiving treatment for major depression only 18-25% is adequately treated.

85. Depression Treatment in Primary Care Primary care physicians are likely to see depression in their clinics compared to any other disorder except hypertension. Diagnosis and management of depression poses a challenge to a busy primary care practice. About 50% are treated; 20-40% with substantial improvement in 12 months High drop-out rate Barriers present Access to mental health resources Competing demands for PCP�s time Tracking/follow-up

87. DIAMOND Depression Initiative Across Minnesota Offering New Direction Led by Minnesota non-profit organization Institute for Clinical Systems Improvement (ICSI) Introduces the collaborative model into primary care practices across the state Reimbursement offered only if practice changes and implements key components of collaborative care.

88. Interventions to Improve Depression Management in Primary Care Enhanced role of nurse/allied health worker (care management) Increased integration between primary and secondary care (consultation � liaison) Telephone management Use of tracking system-Registry Monitor patients with PHQ-9 Guideline implementation/educational strategies generally ineffective

89. DIAMOND Care Fully integrated into PCP practice Care managers are PCP employees- not specialty or psychiatry employees Weekly review by psychiatrist Management recommendations are referred BACK to PCP Key component is communication between CM and PCP

90. Depression Careby PCP Incorporation of PHQ-9 as �vital sign� for depression Rooming personnel key in documentation Provider can also add if needed based on clinical scenario Diagnose depression confirms diagnosis via PHQ-9 Initial vs. recurrent (prior therapies???)

91. Depression Care Initiate treatment No change from pre-Diamond options Medications Psychotherapy Combination

92. Integrate Care Managers into Depression Treatment Develop a patient-centric script that the primary care providers can use to describe the new program Encourage normalization of the new care model- �this is the way we treat depression.� Encourage face to face meeting of a care manager with the patient at the time of diagnosis- if possible. Present the care manager as an extension of the primary care provider.

93. Depression Care- DIAMOND PCP involved in depression care Questions from CM on care recommendations Recommendations for medication changes are through PCP More interaction between PCP and psychiatry Patient CAN be seen by PCP for follow up also

94. Care Managers Advantages for PCP TIME TIME TIME

95. Care Managers Advantages for PCP Evaluation and coordination of services. Intake to understand social network Social services, etc. Frequent follow up and screening Screening for: Chemical Dependency Mood disorders Anxiety and other co-morbidities

96. Care Managers Advantages for PCP Weekly review with psychiatrist New patients Patients who are not improving as expected Relapse prevention KEY component Review risk factors Review signs/ symptoms Medication discontinuation

97. DIAMOND Win:Win:Win Improved patient care Improved efficacy of treatment Improved specialty consultation Utilization of CM in the management of disease process Not dependent on PCP practice style, effectiveness Continued management by PCP

98. New role for psychiatry Traditional consult liaison means seeing patients identified by primary care providers. One patient at a time Patients wait 2-3 months to be seen New model Review patients with care manager & PCP Many more patients addressed in same time frame (20+) Patient problems are addressed within days of presenting Can focus on those needing attention

99. Patients Can have co-morbid mental health problems Can opt out at any time Can �graduate� if in remission for 2 months Response > 50% decrease in PHQ-9 Remission PHQ-9 < 5 for eight weeks If not better in 12 months, must graduate

100. DIAMONDPreliminary results

101. Goals and Current Status

103. Outcomes Response (PHQ reduced 50%) Remission (PHQ <5 for 2 months)

105. Questions ?? angstman.kurt@mayo.edu

107. Mayo Clinic Home Connection Thomas R Harman, M.D. Mayo Clinic, Rochester

108. I have no relevant financial relationships to disclose at this time

109. American TeleCare, ATI National Initiative to Provide Alternatives for Managing Complex Patients Initial Focused Program:Mayo Employees and Dependents

110. Outcome Results and Outcomes

111. Reduce ER/Hosp/SNF Utilization - Centura Home Health Initial Study Initial study of 17 patients with heart failure 3 years � net 73% reduction in costs for these patients

112. MCHC Goals Reduce Hospitalizations Reduce ER Utilization Improve quality of life Support established Primary Care provider Adjunct to current health care provider

113. Keys To Success Frequent contact Attention to patient�s interests Motivational change Patient example

114. Clinical DeliveryInteractive Video Augmented with Intelligent Monitoring

115. Clinical Delivery

116. Methods Technology enabled solutions: �Face to face� frequent, short video visits Monitor vital signs Monitor symptoms Education Mayo standards of care Midlevel provider and Physician team

117. Monitoring Patient Data Just like an office visit, data collected is reviewed by NP Action is using Mayo protocols

118. Monitoring Clinician is able to select monitoring questions Clinician determines frequency of monitoring Information is individualized to each patient Results reported on a �Dashboard�

119. Clinical Delivery Clinician Dashboard for Prioritizing Work Flow

120. Patient completes assessment questionnaire CNA obtains vital signs Clinician reviews results Clinician develops plan Patient completes monitoring questions Vital Signs obtained Clinician reviews results Clinician develops plan

121. Clinical Delivery Clinical Team Management - Telehealth Teams

122. Center of Excellence

123. Clinical Delivery COE � Interconnected National Network

124. Glimpse of some programs