Making Value-Based Care Happen Accelerating Change over 15 Years at a Multisite Primary Care Clinic

Disclosures Principal of Leibig-Shepherd, LLC No conflicts of interest

Learning Objectives Identify four foundational components of primary care practice transformation (the lessons learned at Clinica Family Health Services). Describe the performance improvement process Clinica uses to assure change moves the primary care practice towards its transformation goals. List examples of practice changes which accomplish planned care and population management to increase value-based care.

Clinica Family Health 2015 Clinical Staff 2015 Demographics: 51 Physical Health Clinician FTE 14 Behavioral Health Clinician FTE 6 Dentists FTE / 9 DH FTE Clinics in the Homeless Shelter, Mental Health Center 2 Full Pharmacies, 2 Pharmacy Outlets, School of Pharmacy Total Staff of ~500 Admit to 2 community hospitals Community-wide EHR 2015 Demographics: 47,423 patients, 200,000+ visits Women of child bearing age and children under 18: 64.9% Deliveries: 1,229 Patients over age 65: 4.5% Hispanic or minority: 73% Patients non-English speaking: 39% Patients living at/below FPL: 61% Patients living at/below 200% FPL: 92%

Transformation Journey 1998: Joined the IHI Chronic Care Collaborative Beginning population management with diabetes Continuity always a critical function 2000: Delivery system redesign (The Big 3) Access Office efficiency through transition to teams Alternative visits 2001: Expanded redesign focus (The Big 6) Information management Patient engagement

Transformation Journey 2001-2004: Planned care approach to PI Asthma, depression, chronic pain Preventative health care Redesign architectural layout to support team care 2004-2013: Spread & sustain innovation Alternative visit model Behavioral Health Integration Other chronic illnesses-ADHD, Bipolar Patients… Implemented EHR 2005 Safety-anticoagulation program CU School of Pharmacy NCQA Level 3 PCMH, Diabetes

Transformation Journey 2013-2016: Expand core team members and roles, and community outreach Home visit program Dental Hygienist on Pod Portal enrollment >50% Nursing Co-visits Clinical pharmacists on Pods Pods 2.0-nurse co-visits Community partnerships with public housing and CORHIO

Lesson #1: Transformation is SLOW

Foundational Changes: The Big 6 #1 Continuity #2 Access #3 Team based care #4 Expanding the care delivery model #5 Improved IS design #6 Patient engagement

Continuity Action Steps Empanel patients to a PCP and team Routinely measure continuity by PCP/team Measure and balance panel size Manage un-assigned and new patients monthly Educate staff and patients on continuity Use scripts and “team talk”

Lesson #2: It all depends on continuity ↑Continuity Decreases ↑ Continuity Increases Hospitalizations Length of Stay Referrals to specialists Number of RX’s ER visits Tests, studies Demand for visits Costs for everyone Patient satisfaction Staff satisfaction Provider satisfaction Clinical outcomes Access to PCP

#2 Access 1998 next available appointment- well woman appointment 6 weeks newborn visit 2 weeks follow-up for a sick patient 3 weeks no-shows 36% new patient 6-8 weeks .

Managing Access Today

Lesson #3: All models are wrong, some models are useful #1 Continuity #3 Team based care #5 Improved IS #4 Expanding the model #2 Access #6 Patient engagement

Improving Access 1. Optimize the Care Team 5a. Decrease appt. types 5b. Reduce backlog 5c. Supply & Demand 5d. Panel Mgmt. 5. Change the scheduling paradigm 3. Reduce demand for in clinic visits 4. Develop contingency plans for high demand times 2. Measure & report access outcomes 1. Optimize the Care Team

Improving Access and Outcomes

From the RWJF LEAP Program improvingprimarycare.org #3 Team Based Care Leadership to build team culture Develop a core team structure Create clear roles & responsibilities Enable staff to work independently Patients are a member of the team Leadership provides team time Leadership provides training Leadership facilitates career ladders From the RWJF LEAP Program improvingprimarycare.org 17 17

Create and Test a Core Team Model 3.4 FTEs of Provider 4.2 FTEs of Medical Asst. 1 Nurse Team Manager 1 Clinical RN 1.5 Case Manager 1 Behavioral Health Prof. 2 Front Desk 1 Medical Records ½ Referral Case Manager Dental Hygienist Clinical pharmacist 18

Architecture to Support Teams Courtesy Boulder Associates

Teams Use Standing Orders

Outreach-Explicit Team Roles

Improving Outcomes Through Team Based Care

Lesson #4: Create a quality habit Formal process for improvement Review prior PDSAs Expect completion Leadership decides on spread Have a change process plan for both spreading and sustaining change

#4 Alternative Visits: Expanding the Care Model Non-compliant or not-yet-engaged? Phone care EHR portal Home visits Integrated behavioral health on team Hygienist on the team Some patients do better in group setting

Why Groups? Improve health outcomes Increase access to care The Group Visit Model Why Groups? Improve health outcomes Increase access to care Promote patient and staff satisfaction Engage patients and families Clinica Family Health Services

Clinica Group Visit Offerings Continuity Groups Asthma ADHD Patients on Warfarin Prenatal care Newborn to 2 years Diabetes Parenting/Girls Depression Anxiety Heart Healthy Pain Management Groups

Education vs. Facilitation Leader is teacher Provider directed Educational topics Provider offers answers and support Expert opinion Educated advice Care based on provider assessment Leader is conductor Patient directed Use content threads Patients offer answers and support Peer opinion Personal experience Care based on patient self assessment

Expanding the Care Model Lesson #5: Relationship opens the door to better care models Expanding the Care Model

#5 Improved Information Systems EHR Data entry Business Intelligence Analytics Accountability data Performance improvement (PI) data PI patient care tools

PI Outcomes by Team

Lesson #6: Need granular data for Performance Improvement

PI Patient Care Outreach Tool

PI Patient Care In-reach Tool

#6 Patient Engagement

Getting the Patient and Family on the Team Governance Board Patient voice committee Direct improvement design Participate in evaluating PDSAs Patients on PI committees Facilitated group visits Survey comments Video testimonials, story corps

Moving Forward from the Big 6 Expanding the core team Primary Dental Provider, empanelment Clinical pharmacists Nurse co-visits Community partnerships iPN-community wide shared medical record Asthma home visits with the county housing inspectors CU and Regis Schools of Pharmacology CORHIO ADT reports

Clinica Family Health Services NCQA Diabetes 2011/2014 NCQA PCMH Level 3 2010/2013 Joint Commission Accredited since 2002 2015 HRSA Audit Perfect Score

Nominated by Staff Only non-management staff interviewed Top Work Place Awarded by the Denver Post 2012, 2013, 2014, 2015, 2016

Transformational visits Transformational Relationships “Interaction is the heart of planned care” Levels of patient and team engagement Brief Transactional visits Acknowledgement of psychosocial context Reflection, goal setting and coaching Transformational visits (relationship of mutual influence)

Lesson #7 Always keep the patient at the center of decision-making

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