1. Team Care at The Cleveland Clinic Kevin D. Hopkins, MD Section Head-Family Medicine Strongsville Family Health Center Cleveland Clinic

2. Agenda Planning for Change Program Overview & Structure Outcomes Taking it to “the next level”

3. It’s All About Increasing Value The Right Thing to Do in Any Payment Methodology Focus on maximizing value delivered to patients Explore strategies that increase value Enter into contracts that share in value created Value = Quality Cost

4. Introduction to Value-Based Operations: The Industry is Changing Volume- Driven Healthcare VALUE- Driven Healthcare Cost Quality Fragmented Fee-for-service Connected Bundled Accountable

5. Managing Population Health Today: The FFS model Tomorrow: The Value-Based model Care of the individual Payment for each service we provide Predictability! Care of a population Payment based on the quality and efficiency of our care Uncertainty and risk!

6. 6 “Care Transformation” is Critical Transform clinical operations Assemble the right care team Reward added value with sustainable payment models Support with the correct Analytics 17

7. Patient-Centered Medical Home The Key to Success “Patient-centered medical home (PCMH) is a model of care where patients have a direct relationship with a provider who coordinates a cooperative team of healthcare professionals, takes collective responsibility for the care provided to the patient and arranges for appropriate care with other qualified providers as needed.” NCQA

8. There’s No Place Like a “Medical Home” Physician Directed Practice Comprehensive and Coordinated Care Payment for Added Value Enhanced Access Patient Engagement Safety and Quality Treatment of Patient as a “Whole”

9. Transform Clinical Operations Standardized Care Paths Proactive, targeted outreach Patient follow-up & engagement Enhanced access Engage other providers Pre-visit planning Chronic disease management

10. The Time Problem Time needed for chronic illness care for 2,500 patients 1 Time needed for preventive care for 2,500 patients 2 Time needed for acute care 1 10.6 hours/d 7.4 hours/d 4.6 hours/d 1. Østbye TH, et al. Ann Fam Med. 2005;(3)209–214. 2. Yarnall KS, et al. Am J Pub Health. 2003;93(4)635–641. Based on various analyses:

11. Assemble the Right Team MD Medical Assistant Care Coordinator Pharmacist Patient

12. Strongsville FHC

13. Background There are many factors exerting considerable pressure on our healthcare system: - -Reimbursement for care is static and uncompensated care is increasing - -Increased level of acuity of outpatient office visits - -Primary Care Physician utilization rates are 90-95% - -Healthcare Reform-ACA provisions

14. Background Press Ganey data for appointment convenience - -50% “very good” (median: 51%, 90th percentile: 59%) Leakage - -This is lost-opportunity for higher-quality care for the patient, and revenue for the organization.

15. Team Care “Team Care” is a higher-efficiency practice style designed to: Increase accessibility Improve quality of clinical care Increase patient throughput Improve satisfaction at all levels (physician, employee, and patient)

16. Team Care A “Team Care” model utilizes a team- approach in caring for patients Responsibilities are delegated and shared Each individual in the chain of patient care functions to the highest level of their qualifications.

17. Team Care Outpatient Visit: Stage 1: Gathering data Stage 2: Physical exam and synthesis of data Stage 3: Medical decision-making Stage 4: Patient education and plan-of-care implementation

18. Team Care Workflow With a “Team Care” model, the clinical assistant gathers and documents the data. The clinical assistant: - -Takes a competent history - -Presents to the physician - -Remains in the room with the physician and patient - -Completes all documentation of the visit - -Implements the treatment plan - -Gives patient instructions (AVS), ensures understanding, and completes the visit

19. Medical History Medication Review Medication refill requests discussed Allergies Health Maintenance Smoking/Substance abuse Changes to medical/surgical history

20. Medical History Reason for visit Note template is loaded in the progress note Collect and document the History of Present Illness and ROS

21. Team Care Workflow With a “Team Care” model, the clinical assistant gathers and documents the data. The clinical assistant: - -Takes a competent history - -Presents to physician - -Remains in the room with the physician and patient - -Completes all documentation of the visit - -Implements the treatment plan - -Gives patient instructions (AVS), ensures understanding, and completes the visit

22. Team Care Workflow The physician (with the assistant still in the room): Confirms the history Performs the physical exam Makes medical management decisions Articulates diagnostic/treatment plan

23. Team Care Workflow The physician leaves the exam room of the completed patient. Orders pended by the clinical staff are filed by the physician. The physician signs any prescriptions that are not electronically transmitted. Physician starts the process with the next patient prepped by the other medical assistant

24. Team Care Workflow The medical assistant reviews the After Visit Summary with the patient along with any prescriptions or ordered tests. Patient education is given and reviewed. The patient is escorted to the appointment desk by the clinical staff.

26. Care Coordination RN Care Coordinator embedded Hospital Discharges - -DM-2 - -CHF - -COPD - -Pneumonia - -MI - -CKD

27. Clinical Pharmacist Referrals for: - -Polypharmacy - -Medication compliance - -Medical literacy

28. Key Metrics Increase volume of patients seen Increase efficiency/decrease scheduling wait time Increase accessibility to quality physician care Increase patient satisfaction Improve quality of patient care Increase clinical employee satisfaction Increase physician satisfaction

29. Access – Patients Added May 2011 – August 2013 Ramp Up Team Care Missing MA

30. Patient Satisfaction 2011- 2013 (Q1)

31. Total Visits Normalized per Clinical FTE 2010-2013 (2013 Projection)

32. WRVU’s normalized for Clinical FTE 2010-2013 (2013 Estimation)

33. *Days not worked not considered

34. Outcomes Quality Indicators Chosen for Improvement Team Care started 2Q 2011 Q1 2011 Q2 2011 Q3 2011 Q4 2011 Q1 2012 Q2 2012 Q3 2012 Blood Pressure Control 74%76%81%79% 78% A1c Diabetics 96% 98%96%98%97%99% Diabetes Screening 89%90% 91% 93% Hyperlipid- emia Screening 79%80% 74%77%79%81% Mammogra m Completed 77%78% 75%78%79%78%

35. Sensitivity Analysis Potential Financial Impact Per Day6810 Annual Add1,3381,7842,230 Revenue$156,546$219,024$273,780 Expenses$61,992 EBIDA$94,554$157,032$211,788

36. BIO Cards Bio Cards so Patients can put a face with a name and to promote our Team!

37. Taking It to the Next Level Expand Team Care at Strongsville to include 6 Family Medicine Physicians - -6 MA/MA/MD Teams - -1 more in 2014 Transform 1 in 4 primary care practices to TeamCare to increase volume; fund care coordination and PreVisit MAsTransform 1 in 4 primary care practices to TeamCare to increase volume; fund care coordination and PreVisit MAs Care coordinators and PreVisit MAs (pre-visit planning, health maintenance and wellness) support all providersCare coordinators and PreVisit MAs (pre-visit planning, health maintenance and wellness) support all providers