Radical Rosewood A Roadmap to APM Transformation we are family we - - PowerPoint PPT Presentation

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Radical Rosewood A Roadmap to APM Transformation we are family we - - PowerPoint PPT Presentation

Oct 19, 2022 215 likes •637 views

Radical Rosewood A Roadmap to APM Transformation we are family we are family The Framework Setting the stage Transformation at Rosewood Investment Measures of Success Informatics & Reporting Next steps we are

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we are family we are family

Radical Rosewood

A Roadmap to APM Transformation

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The Framework

  • Setting the stage
  • Transformation at Rosewood
  • Investment
  • Measures of Success
  • Informatics & Reporting
  • Next steps
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Current State of Health Care

High cost of total care in the healthcare system Suboptimal quality Dissatisfied patients Dissatisfied providers & staff

Increased demand for care with dwindling number of PCPs Failure to address what truly impacts the health of our patients

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Encounters! Encounters! Encounters!

  • Basis for payment: Face-to-face visit with a medical

provider

  • Churning encounters in the same old model just yields

the same old results

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Oregon Alternate Payment Methodology & Value Based Care

An opportunity to challenge our assumptions & transform how we provide care.

Do patients need to come to the clinic to have their needs met? Is a physical exam always necessary? Is the focus on physical health improving our patients’ overall well being? Can we design

  • ur system to

address the factors that truly influence

  • utcomes?

Is the medical provider the best professional to meet their needs?

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Core Components

Building multi-disciplinary, co-located care teams Transforming the day-to-day model of care

  • PCPs engaged in population health, panel management & complex care management
  • Redefined roles for RNs, MAs & Clinical Support Staff
  • Improved coordination with integrated providers (RD, BHC, SW, CHW, PMHNP)

Increasing staff to support the new model

  • Integrated Providers: PMHNP, MSW, BHC, RD
  • RNs for new patient enrollment, triage, and nursing visits
  • Community Health Workers for patient outreach, social work support, and case management
  • MAs to support primary care teams and population management

Expanding access to care & developing new ways to connect with patients

  • Nursing visits for acute & chronic controlled issues
  • Telephone & video visits with providers
  • Electronic communication (email via MyChart)
  • E-consults with specialists

Screening for and address social determinants of health Developing robust analytics & reporting

Leverage existing technology for more convenient care! True team-based care. Protected time for PCPs! Address the real barriers to health. Demonstrate value!

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Teams

Patient & Family

CARE TEAM EXPANDED TEAM SUPPORT TEAM

SUPPORT TEAM RD, BHC, MSW, CHWs, PMHNP + MA CARE TEAM 2 PCPs, 3 MAs, RN, Clinical Support Staff EXPANDED TEAM Intake RN + MA, Triage RN + Call Center Patient Benefit Coordinators, Receptionists

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“Team Time”

Population Health Management

Chronic disease registry management Cancer screening registry management Panel Management

Care Coordination

Review and manage complex patient care Consult specialty providers Manage care transitions from hospital admissions e-Consult (2017)

Alternative Patient Visits

Telephone visits Secure patient email Telemedicine Psychiatry Group Visits & Video Visits (2017-2018)

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Protocol-based RN Visits

Acute Issues (e.g. Pharyngitis, Dysuria, Conjunctivitis) Controlled Chronic Issues (e.g. DM, HTN) New Patient Intake Visits

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New Patient Intake Workflow

MA

  • Best Practice Advisories (e.g. SBIRT, OneKeyQuestion)
  • Reason for visit
  • Recent visits with other care providers (ER, urgent care, previous PCP)
  • Vital signs
  • Reconciliation with Care Everywhere (outside records, verify pharmacy)
  • Social history

RN

  • Reconciliation with Care Everywhere (medications & problem list)
  • History (medical, surgical, family)
  • Notes (use Smart Phrase)
  • Plan (Problem List)
  • Agenda-setting & shared decision making
  • Labs
  • Referrals (internal & to community agencies)
  • Warm handoffs

MA

  • Return to provide vaccines, mammogram orders, FIT test, AVS and schedule

necessary follow up appointments

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RN Intake Lessons

  • Paradigm shift with role of nurses
  • RN working at top of licensure
  • Agenda setting for successful first visit with PCP
  • Higher show rate for first appointment with PCP
  • Complete picture of the patient’s needs, including

social determinants

  • Time to really listen to patients, to get a detailed

history, come up with a plan that is a collaboration between the patient and the RN, so that the intervention does not need to be determined in a quick visit with a provider

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Screening for Social Determinants of Health

  • Review of national models (including

PRAPARE)

  • 13 questions that address employment,

housing, food insecurity, stress, trauma & social isolation

  • Focus on questions that are actionable and

relevant to our community

  • Version 3.0 in production (revisions based on

data analysis & feedback)

  • Development in EMR pending information

from Epic and further study of our tool

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Rosewood’s Social Determinants Screening Tool

  • 10. Stress is when someone feels tense, nervous, anxious, or can’t

sleep at night because their mind is troubled. How stressed do you feel now? (Circle one: 1 being the least stressed and 10 being the most stressed) 12 3 4 5 6 7 8 9 10

  • 11. Emotional trauma occurs when there is extreme stress that was

unexpected, unavoidable and overwhelmed your ability to cope. Have you experienced an event in your life that has led to emotional trauma?

  • a. Yes
  • b. No
  • c. Unsure
  • 12. How often do you see or talk to people that you care about and feel

close to? (For example: talking to friends on the phone, visiting friends or family, going to church or club meetings)

  • a. Less than once per week
  • b. 1 or 2 times per week
  • c. 3 to 5 times per week
  • d. More than 5 times per week
  • 13. Today or in the past year, have you or someone in your household

had to go without any of the following?

  • Food
  • Clothing
  • Utilities (electricity/heat)
  • Rent/Mortgage Payment
  • Transportation
  • Child care
  • Medicine/Prescriptions
  • Medical, Dental, Mental Health or Substance Abuse Care
  • Phone
  • Legal help
  • Other: __________________
  • 1. What is your current work situation?
  • a. Unemployed and seeking work
  • b. Part time work
  • c. Full time work
  • d. Otherwise not employed & not seeking work (select from the following list):

□Student □Retired □Disabled □Unpaid primary care giver □Not listed

  • 2. Is your current work situation affecting your ability to take care of your

health or your family’s health?

  • a. Yes
  • b. No
  • 5. What is your housing situation today?
  • a. I have housing of my own and am NOT worried about losing it
  • b. I have housing of my own, but I am worried about losing it
  • c. I do not have housing of my own (staying with others, in a hotel, on the street, in

a shelter)

  • 6. Within the past 12 months we worried whether our food would run out

before we got money.

  • a. Often true
  • b. Sometimes true
  • c. Never true
  • d. Don’t know
  • 7. Within the past 12 months the food we bought just didn’t last and we

didn’t have money to get more.

  • a. Often true
  • b. Sometimes true
  • c. Never true
  • d. Don’t know
  • 8. In your daily life, do you feel physically and emotionally safe?
  • a. Yes
  • b. No
  • c. Unsure
  • 9. In the past year, have you been afraid of your partner or ex-partner?
  • a. Yes
  • b. No
  • c. Unsure
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Social Determinants of Health Snapshot of Findings*

*n = 125 (New Patients in August)

36% were worried about whether food would run

  • ut before they got

money 33% lack housing of their own or worried about losing it 18% unemployed & seeking work

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Social Determinants of Health Snapshot of Findings*

*n = 125 (New Patients in August)

0% 5% 10% 15% 20% 25% 30% % Yes

Today or in the past year, have you or someone in your household had to go without any

  • f the following?

Food Clothing Utilities (electricity/heat) Rent/Mortgage Payment Transportation Child care Medicine/Prescriptions Medical, Dental, Mental Health, or Substance Abuse Care Phone Legal Help

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Measures of Success

Improved Health Outcomes Decreased Utilization Increased Satisfaction Increased Access

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Improved Health Outcomes

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Improved Health Outcomes

Children 2 months-18 years up to date with appropriate well child exam

Source: Epic Report: Clinic Panel Metrics: Well Child Check

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Improved Health Outcomes

Source: Epic Report: Clinic Panel Metrics: Adult Pneumonia Vaccination Status

Adult patients 65 years old+ up to date with pneumonia vaccination

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Improved Health Outcomes

Source: Epic Report: Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan

Screening for Clinical Depression & Follow Up Plan

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Source: Epic Report: Clinic Panel Metrics: Hemoglobin A1c Testing

Improved Health Outcomes

Adult patients with diabetes mellitus who are up to date with A1c testing based off of control status

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Improved Health Outcomes

Source: Epic Report: Clinic Panel Metrics: Foot Exam

Adult patients with diabetes mellitus up to date on neuropathy screening

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Improved Health Outcomes

Source: Epic Report: Clinic Panel Metrics: Diabetes: Urine Protein Screening

Adult patients with diabetes mellitus up to date on nephropathy screening

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Improved Health Outcomes

Source: Epic Report: Clinic Panel Metrics: Cervical Cancer Screening

Adult female patients up to date on cervical cancer screening

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Improved Health Outcomes

Source: Epic Report: Clinic Panel Metrics: Colorectal Cancer Screening

Adult patients up to date on colorectal cancer screening

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Improved Health Outcomes

A closer look at the last 9 months

8%

8

10 15 18 11 11 Epic Report: “YVFWC Colorectal Cancer Screening by Provider”

Before Radical Rosewood Transformation

1

9/2015-9/2016

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Continued Opportunities for Outcome Improvement

Source: Epic Report: Clinic Panel Metrics: Breast Cancer Screening

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Continued Opportunities for Outcome Improvement

Source: Epic Report: Clinic Panel Metrics: Hemoglobin A1c <9%

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Improved Health Outcomes

A closer look at the last 9 months

1%

4 8 4

30

9

DM panel decreased by 11 controlled patients DM panel increased by 3 patients DM panel decreased by 5 controlled patients

Epic Report: “YVFWC Hemoglobin A1c Control by Provider”

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DM Registry & Panel Management

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A1c improvement “above the line”

12.9 % 9.1% 11.9% 9.9% 11.9% 10.1 % 11.2% 10.6 % 10.8 % 9.4 %

3.8% 2.0% 1.4% 0.6% 1.8%

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A1c 7.9% 8/2015 Lost insurance coverage

Radical Rosewood implements team based care

1/27/16 A1c 12.9%

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5/28/16 A1c 9.8% Patient reports lifestyle

  • changes. Prefers to take 1

DM medication instead of 2 that have been recommended. RD follow up for self management 8/2016 A1c 9.1% RN visit for diabetes education 10/12/16 Office visit with PCP. Patient agreed to restart 2nd recommended medication. Will return November 2016 for follow up. 7/8/16 RD follow up 9/14/16 RD follow up Out of town visiting family March-April 2016 1/27/16 A1c 12.9% Office visit with PCP warm hand off to RD during visit 2/2016 Insurance renewed Office visit with PCP with warm hand off to team RN for diabetes education

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Patient Satisfaction Trends

= October 2015, when implementation begins.

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Patient Satisfaction

RW RW RW RW RW RW

Source: Report provided by independent Crossroads Survey Group

For 15 of 17 measures, Rosewood meets or exceeds national & state benchmarks.

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Patient Satisfaction

Source: Report provided by independent Crossroads Survey Group

RW RW RW RW RW RW

For 15 of 17 measures, Rosewood meets or exceeds national & state benchmarks.

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Patient Satisfaction

RW RW RW RW RW

For 15 of 17 measures, Rosewood meets or exceeds national & state benchmarks.

Source: Report provided by independent Crossroads Survey Group

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On the Horizon

  • Integrating social determinants of health

screening into the EHR

  • Measuring risk & complexity (inclusive of

social determinants of health )

  • Strategic balanced empanelment in a new

model of care

  • Video visits to improve patient access and

satisfaction

  • A new clinic built for comprehensive, team-

based care providing complete physical & mental health, dental health, and pharmacy

  • On-going innovation & improvement using

PDSAs and rapid cycle change

  • Formalize community partnerships with

agencies to help address social determinants

  • f health
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Investments

Transformation requires significant investment!

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we are family we are family

Thank you!