Team members from Mercy Clinics, Inc. (from left to right): Del Konopka, Clinic Education Coordinator, David Swieskowski, M.D., M.B.A., Vice-President for Quality, and Sharon Phillips, Chief Operating Officer.

Mercy Clinics, Inc., a large multispecialty medical group base in Des Moines, Iowa, employs 138 physicians in 12 specialties, practicing in 35 locations and responsible for 793,000 patient visits in 2006. More than half of the physicians are in family practice, general internal medicine, and pediatric specialties, and belong to a larger health system. Other specialty services include geriatric medicine, neurology, otolaryngology, plastic and reconstructive services, rheumatology, and surgery. In addition to the specialties, quick care clinics, urgent care clinics, and physical therapy clinics are offered.

Since 2002, Mercy Clinics has been using Wagner’s Care Model to improve preventive and chronic care. In 2006, group introduced the newly created position of Health Coaches to propel change in office sites and to provide a “medical home” for the patients served. A medical home is a team approach to providing comprehensive healthcare services in a high-quality and cost-effective manner. In a medical home, the patient, his or her family, primary care physician, and other health professionals develop a trusting partnership based on mutual responsibility and respect for each other's expertise. Partners share information with each other to ensure the health of the patient.

Global action steps were required to achieve these goals and old workflow processes were re-tooled. Plan-Do-Study-Act (PDSA) cycles for small changes were instrumental in leveraging successful system change, and lessons learned were applied along the way. Use of disease registries gave the redesign credibility and quantified the impact of the change on patient outcomes. Data has provided the clinic group a voice at the table with insurers and in collaboratives. This was a large transformation for the clinic system, but the organizational vision and IOM Aims provided focus. Leadership buy-in, commitment, and involvement in the initiative also occurred since the goals and objectives of the system redesign fit into the strategic plan.

Mercy Clinics decided that the best way to achieve the IOM Aims is to focus on “Patient Centeredness” because it uniquely embraces the other five Aims. For example, one cannot have patient centeredness without safety, and likewise for all the other Aims. To achieve this, all six areas of Wagner’s Care Model were adapted to improve preventive and chronic care for all the patients served. The Quality Committee’s vision was to create a patient-centered medical home that coordinates care across providers and sites and embraces the Care Model and the IOM Aims. The goals were to provide:

1. Systems to ensure patients receive all the recommended evidence-based care they can benefit from and wish to receive.
2. Registries to track all patients’ chronic care and preventive healthcare goals.
3. Team-based care coordinated by Health Coaches and overseen by physicians.
4. Self-Management Support and ongoing relationships with Coaches to help patients meet their goals.
5. Safety ensured by processes built into the system.

The current healthcare delivery system presented many barriers. Among them were:

• Lack of time. It would take 24.8 hours a day to provide all the evidence-based services recommended. No matter how motivated a physician is, there is not enough time in the day.
• Information explosion. Growth in the number of published clinical trials has expanded exponentially. Primary care doctors cannot possibly keep up with all they are expected to know.
• Humans are naturally prone to error. We rely on physician’s memory and individual effort to avoid errors. The expectation that this will work is not realistic.
• Lack of measurement. Traditionally they did nothing to measure clinical and service quality, which diminished their significance.
• Reimbursement system. The current fee-for-service payments reward quantity and not quality. In fact, bad quality is consistently rewarded more than good quality because it usually takes less time and leads to reimbursable rework. For example, insurers pay more for an infected surgical wound than one that heals properly.
• Physician culture. Mercy Clinics believes that this is the most significant barrier to improved quality. Traditionally, physicians are trained to be reactive rather than to proactively plan for the future. Autonomy is ingrained in them which unfortunately prevents standardization and makes it more difficult for them to relinquish control of tasks even when others can do them more efficiently. Physicians are not taught to collaborate, so they tend to communicate poorly with each other, tend to think in terms of personal accountability rather than systems, and tend to lack a sense of urgency for change.

The goals were selected because inconsistent delivery of services was frustrating and it was discovered the problem was not with the providers but rather with the system in which they worked. Mercy Clinics has come to believe that clinical quality in a large physician group is determined more by the systems in place than by the actions of the individual physicians. Given the barriers and the Quality Committee’s frustration, a need was identified for a complete redesign of the current care delivery system. It had become evident that the current system was originally designed for acute episodic care and not the chronic and preventive care that has become so important in primary care medicine. Wagner’s Chronic Care Model became the framework to overcome healthcare system barriers and served as the catalyst for reaching the six IOM Aims. Mercy Clinics found that physicians need and respond well to guidance in learning ways to proactively make changes to improve quality.

Safe: Safety as a system priority
Patients with diabetes were surveyed to determine which of the 10 IOM rules they felt were most important and to assess how they felt their clinic performed on that rule. The 638 responses to the survey revealed that “providing the safest care” tied with “being treated as a whole person” was the most important to them. Processes were standardized for safety:

• Returning lab results to patients on the first day they become available;
• An algorithm put into place for managing coumadin therapy that improves outcomes compared to physician-managed care;
• Physicians using standing orders and guidelines for chronic diseases that make the right thing to do the default;
• Patient education materials being standardized and processes are in place to improve medication adherence;
• Process documentation audits done regularly and lab results audited to make sure they are handled appropriately; and
• Any malpractice cases reviewed every six months to identify trends needing attention from a system or individual standpoint.

Effective: Evidenced-based decision making, shared knowledge and the free flow of information.
Outcome data is measured and reported for diabetes, hypertension, and coumadin therapy and reports are generated at the practice and provider levels that are distributed un-blinded monthly. The Quality Committee creates evidence-based guidelines for chronic and acute diseases and preventive health care. Disease-specific documentation templates ensure delivery of all recommended care. Standing orders for immunizations, diabetes, hypertension, and coumadin therapy are used. Quality Committee meets monthly to review protocols and guidelines, and communication is via newsletters, Medical Directors, office managers, and all practices’ meetings. Algorithms are in place to combat clinical inertia. Health Coaches meet for two hours twice a month for training and to share best practices.

Patient-Centered: Customization based on patient needs and values. Care based on continuous healing relationships. The patient is the source of control.
Practices have implemented and expanded the position of Health Coach to help patients develop individual plans to reach their goals. The first 4 Coaches were a BSN, an LPN, a CMA, and a psychologist. There are now 14 full-time Health Coaches with a move to hiring all registered nurses for the role, with clerical support for the data entry. The Health Coaches are taught to use the concepts of Rollnick (1999) and Lorig, to assist patients with health behavior change. Mutual discovery and respect of patient values are the basis of these concepts and parallel the organization’s value of compassion. Self-Management Support focuses on goals patients identify as important to them. A form, called the “5As” form, serves as a tool which guides the Coaches when delivering this service. The Health Coach assists patients in meeting their goals, interacts with patients between office visits, and is readily available when needed by patients. They are also instrumental in the recruitment of, preparation for, and assistance with shared medical appointments (SMAs).

The SMAs are currently lead by mid-level providers at four clinics, and are overwhelmingly successful in terms of access efficiency as well as staff and patient satisfaction. Specific care protocols are used based on chronic illness and preventive health needs and on evidence based-practice. Patient satisfaction surveys are conducted annually to evaluate the clinics’ performance on patient-centered topics. A Patient Advisory Workgroup on Quality (PAW-Q) was created and meets every two months, with the result of many of their suggestions being incorporated into services. A customer service statement and behavioral standards have been developed and training of the staff to respond more effectively to patient needs has begun. As the system worked diligently on meeting disease outcomes, a need was identified to address mental health issues, so funding was sought and a grant awarded to provide depression screening and first level treatment in the primary care offices. The importance of this project has been supported by the PAW-Q response and the diagnosis of twice the anticipated cases of depression among the diabetic population.

Timely: Anticipation of needs.
Software is used for scheduling and registration and facilitates measurement of access by third next-available appointment for family practice, internal medicine, and pediatrics. (Third available appointment data is used to reduce the chances of underreporting of data due to last-minute cancellations by physicians or patients). Industry benchmarks are eleven days to third available appointment in the best performers for all practice types. These benchmarks differ by specialty, and are: Family Practice at twenty-four hours in best performers (25th percentile), Internal Medicine at three days in best performers, Pediatric Primary Care at one day in best performers. Based on benchmarks for better performers obtained from Navigant Consulting, the data shows that the system overall contains best practice performers, but is slightly below the better performers by specialty group. Office visit cycle time is also measured. The data suggests that the two clinics currently measuring cycle time have room for improvement.

Preplanned visits and the registry ensure services are done when due, offering patients care beyond their expectations. Patients are called with lab results before they can call the office, since the goal is to return all test results to patients on the day they become available. Health Coaches plan office visits by reviewing charts and identifying needs before the visit. They proactively contact patients who are overdue for care or not meeting goals as appears on the registry. Training and support for Health Coaches occurs during bimonthly meetings.

Efficient: Continuous decrease in waste. Cooperation among clinicians. The need for transparency.
Care processes are being redesigned to relieve physicians of nursing and clerical duties. Wagner’s Care Model improvements are consistently increasing revenues and reducing costs. Physicians are now giving up some of their autonomy to create standard work, and now agree to use the same guidelines, processes, and standing orders. Examples of this are: The use registries for diabetes, hypertension, preventive health care, and immunizations to prevent duplication between offices and to ensure all tests are done, which eliminates uncertainty about who is delivering what care when. Full-time Health Coaches have been hired for all primary care clinics creating new standard work processes. Standing orders for chronic diseases make the right choice the default. A single process is now in place for reporting lab results to patients, reducing the chance they will be lost and decreasing incoming phone calls for lab results. The number of patients at their INR goal has increased as the algorithm has been refined. The state Quality Improvement Organization (QIO) and state health department furnished registries. Since the original registry filled to capacity, the QIO partnered with Mercy Clinics to design a new registry that will be the template for one offered nationwide. The new registry, which works for all chronic diseases and preventive care, went live with a successful data conversion in early May 2007. Diabetes educators from the hospital teamed with the Coaches and they share access to the disease registry. Many of the practices are participating in three separate learning collaboratives. Physician performance reports are shared un-blinded, and performance data is shared with the community through the largest insurer and presentations with local organizations. This sharing generates dialogue that is mutually beneficial, and the system’s tools are shared with any organization that asks. In recognition for containing costs, generic prescribing is tracked per physician.

Equitable: Embraces each of the IOM rules.
Outcomes were measured based on age and no difference was found between Medicare and non-Medicare populations, despite the state’s CMS reimbursement being among the lowest in the nation. In comparing P4P against the total diabetes population, there were no differences in outcomes. Patient education handouts are offered in languages other than English, at a sixth-ninth grade reading level, since appropriate health literacy is important. Interpretive services are accessible in all group practices. Care is provided free or at reduced cost for all who demonstrate need and no restrictions are placed on access for Medicaid patients or any other payer types.

The improved patient outcomes make a strong case for the care delivery redesign, but financial success is critical for the program to sustain itself and spread. Initially Mercy Clinics proposed that the program would become self sustaining from:

1. Pre-work done by the staff would allow billing of a higher level of service.
2. Increased internal referrals such as labs, diagnostic testing, and office visits.
3. Billing for self-management support.

To confirm this, they performed a financial analysis of diabetes care at the North Clinic, which introduced health coaches (1.6 FTE) in January of 2006. Compared to the previous year , they found a 51% increase in visits for diabetes, a 178% increase in microalbumin tests, and a 46% increase in HgA1c testing. This increase in diabetes care netted an extra $76,879 in revenue.

In addition, the coaches off-loaded physician and nurse work valued at $15,183, they billed for level 1 visits (which netted $45,025), and they were the key reason the clinic achieved its P4P goals, netting $114,000. The total increase in net revenue of $251,087 does not include gains made for work with hypertension or pre-visit review which led to increase internal referrals for such things as complete physicals, immunizations, DXA, mammograms, and occult blood testing. The total direct cost for coach salaries and increased lab testing was $87,856, which subtracted from the net revenue leaves a contribution to overhead of $163,231. This overhead contribution makes a convincing financial case for the care process changes even without the P4P income.