2012 AMGA Annual Conference

Care Process Improvement

Care Process Improvement
This track is dedicated to sharing innovations developed by healthcare organizations for improving health outcomes, lowering the cost of care, and increasing patient and provider satisfaction. Healthcare leaders and directors involved with quality management should attend these sessions, hear about the solutions, and build upon these innovations by continuing the quality improvement cycle at their organizations.

Friday, 2:00 p.m. - 3:15 p.m.
Lessons Learned: A Commercial ACO One Year Later

Lee Sacks, MD, Executive Vice President, Chief Medical Officer, Advocate Health Care and Chief Executive Officer, Advocate Physician Partners; and Mark Shields, MD, Senior Medical Director, Advocate Health Care
This presentation focuses on how the integrated model of care developed by Advocate Physician Partners to align physicians, patients, and payers was successfully transitioned to an accountable care-type model, a shared savings model designed to drive enhanced collaboration among physicians, hospitals, payers, and employers. It will explore how governance, technology, financial models, evidence-based medicine, and other measures improve quality and efficiency.
Upon completion of this program, participants will be able to describe a governance structure and physician alignment model supporting cultural change for thousands of independent and employed physicians; describe a model of care that integrates all stakeholders, physicians, patients, and payers with a common goal to improve quality and value of care; design an infrastructure with proven outcomes that impacts clinical care, efficiency, medical & technological infrastructure, patient safety, and patient experience; establish a financial funding model which includes a pay-for-performance incentive, aligning physicians and improving clinical outcomes; describe the use of information technology to support all stakeholders in the delivery of care; identify how to take an existing infrastructure to the next level by incorporating Medical Home and Accountable Care guidelines; and develop a shared savings model that reduces waste and improves care coordination throughout the continuum, resulting in lower costs and more appropriate and effective care for the patient.

Friday, 2:00 p.m. - 3:15 p.m.
The Quality and Cost Impact of Health Engagement Programs

Kathleen Yaremchuk, MD, Chair of Otolaryngology-Head and Neck Surgery and Vice President, Office of Clinical Practice Performance, and Michelle Nelson, BS, Director of Clinical Performance Measurement, Henry Ford Medical Group
Many payers are implementing Health Engagement Programs to ensure all subscribers and spouses are seen by their primary care physician at least once per year.  Henry Ford Medical Group has piloted one such program in conjunction with Henry Ford Health System-owned Health Alliance Plan.  This presentation will review the health expenditures and quality improvement of this population before and after implementation of the program.
Upon completion of this session, participant group practices should be able to initiate a patient outreach program that will enable them to improve their ambulatory quality scores and increase patient satisfaction.

Friday, 2:00 p.m. - 3:15 p.m.
Mitigating the Dark Side of an Integrated Practice: Park Nicollet's Enhancements to the Consult Process

David Homans, MD, Chief of Specialty Services, and Laura Frazier, Vice President of Surgical Services, Kasi Alen-Freese, Lead Quality Improvement Specialist and Project Manager for Consult Integration, Park Nicollet Health Services
Park Nicollet Health Services benefits from being a comprehensive highly integrated group practice. With increasing size and geographic dispersion, however, interpersonal networks began to weaken. Some specialty physicians who considered themselves "entitled" to referrals began to demonstrate less service-oriented behaviors. Thus, the benefits of size, geographic dispersion, and integration were not translated into improved experience, timely access, or flow for patients who required specialty consultations. This presentation will explore both the technical and cultural challenges Park Nicollet is addressing to radically improve the consultation process and implement seamless patient communication and information flow.
Upon completion of this activity, participants will be able to be able to identify the challenges group practices face when leveraging their integration; identify how to use the benefits of integration to bridge the change gap; and describe the techniques Park Nicollet has used to mitigate these challenges.

Friday, 3:45 p.m. - 5:00 p.m.
Creating a Medical Home: Using Population Health Software for Patient Outreach (and Profit!)

John J. Walker, MD, CPE, Chief Medical Officer, Cornerstone Health Care
Development of the Patient-Centered Medical Home (PCMH) may provide optimal, patient centered care while simultaneously controlling rising healthcare costs. This presentation will discuss the creation of a service line called Patient Care Advocates, an outreach program using the population management software to mine data and educate patients on the importance of receiving appropriate treatment. The presenter will focus on results, both clinical and financial, and how the program can be the first step in the development of PCMH in a fee-for-value system.
Upon completion of this activity, participants should be able to discuss how population management software can be utilized for patient outreach and its impact on patient care and outcomes; and delineate how a component of the Patient Centered Medical Home can be funded in a fee-for-service setting.

Friday, 3:45 p.m. - 5:00 p.m.
Achieving Breakthrough Chronic Disease Outcomes

Robert E. Matthews, Vice President for Quality, PriMed Physicians and President and Chief Executive Officer, MediSync; and Douglas Romer, MD, Family Practice Physician and Chairman of the Board, PriMed Physicians
Many medical groups that are actively working to improve chronic disease outcomes achieve moderate success, typically with improvements of 20-30% over their baseline when attempting to achieve the evidence-based outcome standards of care.  This often translates to about a 60% success rate on a single variable like blood pressure, A1c, LDL, etc. This presentation will discuss the characteristics of an approach to quality improvement that has resulted in breakthrough performance improvement defined as a success rate of 75-95% in a single variable as achieved in a community-based physician group with more than 100,000 patients including 30,000 hypertension patients and 10,000 diabetics.
Upon completion of this presentation participants will be able to define characteristics of medical group efforts that achieve modest performance improvement versus those efforts that achieve breakthrough performance improvements; identify the cultural challenges that occur when medical groups attempt to achieve breakthrough performance as compared to moderate performance improvements; and identify the major challenges posed when attempting to "spread" breakthrough performance to additional medical quality projects (i.e., additional disease states).

Friday, 3:45 p.m. - 5:00 p.m.
Enhancing Primary Care Capacity in Managing Chronic Conditions at Lower Costs to the Community

Wayne Hales Cannon, MD, Primary Care Clinical Program  Leader, and Brenda Reiss-Brennan, MS, APRN, CS, Mental Health Integration Leader, Primary Care Clinical Program, Intermountain Healthcare
This presentation will review the specific Mental Health Integration (MHI) delivery strategies that have improved the efficient management and outcomes of chronic diseases and complex comorbid conditions. This includes promoting "whole health" and well being in the management of chronic disease in the primary care setting.  Results will describe the cost benefit of collaborative primary and mental health care that leads to improved functional status in patients and improved satisfaction and confidence among physicians in managing mental health problems as part of routine medical care at a neutral cost with specific reduction in ER utilization.  Presenters will share current results of descriptive (qualitative) and comparative analyses related to factors that promote or deter improved outcomes across medical group clinics in various stages of MHI implementation.
Upon completion of this activity, participants should be able to identify key universal medical group operational MHI measures that would promote sustained delivery of team based coordinated quality care required to prepare practices to meet the standards for integrated health homes and ACOs; explain how Intermountain's full clinical integration model can be adapted to help local primary care redesign advance beyond speciality collocation challenges in managing the social process and cost of multiple complex chronic diseases (depression, diabetes, asthma, substance abuse, bipolar, heart disease, ADHD, CHF, obesity, chronic pain); identify key social factors among primary care providers and staff and patients that account for improved quality outcomes; describe key social factors that impede patients and their families from experiencing positive outcomes in managing their health conditions beyond the medical encounter; and define institutional norms and rules of exchange required to sustain improved quality at lower cost to our communities.

Saturday, 11:00 a.m. - 12:15 p.m.
Team Up for Health

Jerry Penso, MD, MBA, Medical Director, Continuum of Care, and Samer Assaf, MD, Physician Leader, Team Up for Health Program, Sharp Rees-Steely Medical Group; and Stephen Beeson, MD, Author, Practicing Excellence: A Physician's Manual to Exceptional Health Care
Changing patient behaviors is challenging, yet will be required if physician organizations want to achieve better health outcomes. Sharp Rees-Stealy has improved critical communications skills, recruited patient advisors onto the care team, and strengthened connections with community resources-resulting in measurable improvements in patient self management support and clinical care. This presentation will highlight the group's Team Up for Health project to improve patient self-management support.
Upon completion of this activity, participants should be able to define patient self-management and barriers to its achievement; identify the reasons why improving patient self-management is critical to achieving better clinical, patient experience, and cost of care outcomes; identify what strategies can be successfully incorporated into office practice to improve patient self-management; and create successful tactics at their organizations to engage and motivate the entire care team (including patient advisors) in improving patient self-management.

Saturday, 11:00 a.m. - 12:15 p.m.
The Road to Care Coordination: Detours, Speed Bumps, and Expressways

Vicki L. Hunt, MD, Consultant, Primary Care Internal Medicine, Employee and Community Health, Stephanie G. Witwer, MS, RN, Nurse Administrator, Division of Primary Care, and Linda M. Meyer, RN, BSN, MBA, Ambulatory Nurse Supervisor for the Adult Care Coordinators, Division of Primary Care, Mayo Clinic
This presentation will provide a case study of the experience, resources needed, pitfalls and lessons learned, and ideas about the optimal preparation of staff for a comprehensive care coordination program in the primary care practices at Mayo Clinic in Rochester, Minnesota. It will also explore the impact of the introduction of RN Care Coordinators in a primary care practice, technology that supports care management processes, and moving from a disease-centric to a patient-centric model of care.
Upon completion of this activity, participants should be able to identify resources needed to implement successful care coordination models; describe some of the pitfalls and lessons learned from implementation of care coordination; and describe the optimal preparation of a Care Coordinator.

Saturday, 11:00 a.m. - 12:15 p.m.
NCQA Patient-Centered Medical Home Recognition: Conquering the Application, Is It Worth It?

Michael Rabovsky, MD, Vice Chairman, Medicine Institute and Vice Chairman for Clinic Affairs, Family Medicine, and Laurie Zahar, PMP, Project Manager, Medicine Institute, Cleveland Clinic
In 2009, the Cleveland Clinic formed a collaborative team to explore NCQA Medical Home Recognition. This presentation will discuss the application process and promote thought-provoking discussion on the value of Medical Home recognition for ambulatory practices and whether it is worth the effort. It will give the rationale for a medical home relative to improving quality, establishing quality improvement initiatives, improved patient safety, potential for reimbursement, and efficiency in the practices. Presenters will also share samples of work submitted that will help aid organizations contemplating this huge undertaking.
Upon completion of this session, participants will be able to assess their capacity to apply for PCMH recognition; analyze its benefit for their organization; and identify opportunities for practice redesign resulting from the application process.

Saturday, 11:00 a.m. - 12:15 p.m.
Leveraging Technology to Drive Patient Engagement and Improve Care Coordination

Pradeep Vangala, MD, President, Orlando Internal Medicine
As more organizations implement health IT and more data is produced, there is potential to transform this data into actionable information that engages patients, connects stakeholders and enhances care quality. This case study will describe how Orlando Internal Medicine's collaborative care model utilizes technology (mobile, online, and kiosk applications) to improve outcomes and quality reporting, as well as enable providers to enhance care coordination with a holistic view of a patient's history.
Upon completion of this activity, participants should be able to outline best practices for implementing a patient-centered care model and meeting accountable care organization objectives; identify strategies for enhancing patient engagement within an ambulatory care setting; explain how technology can be leveraged to streamline data collection for participation in pay-for-performance programs and quality-based incentives; and establish metrics to gauge the impact of technology on clinical outcomes.

Saturday, 2:00 p.m. - 3:15 p.m.
Using Clinical and Business Intelligence Tools Populated by HIE Data to Provide Efficient, Accountable Patient Care

Tom Deas, Jr., MD, Gastroenterologist and Board Member, North Texas Specialty Physicians
Learn the trends, results, and lessons experienced from a 600+ physician IPA organization that uses clinical and business intelligence quality reporting tools populated by HIE data to enhance care coordination and quality management and improve care delivery in a community of disparate EHRs across the continuum of patient care. This presentation will describe the governance and leadership structure of NTSP, as well as the benefits and results of NTSP's journey to implement a clinical and business intelligence tool that assists its physicians in their accountable care coordination and quality management activities. This presentation will also show clinical results and trends experienced by NTSP physicians after the deployment of the HIE-integrated quality measures and reporting application.
Upon completion of the presentation, the participant will be able to describe NTSP's advanced care model that includes strong physician governance and leadership, an integrated delivery system with HIE and quality reporting, and patient centeredness initiatives; describe the benefits realized by patients and physicians over a 36 month period from the use of an interoperable HIE platform; indentify clinical examples and results of physicians using the clinical decision support application supported by integrated HIE data at the point of care to track care quality measures, providing patients with more efficient and accountable care; discuss the benefits and trends realized by deploying quality reports (e.g., PQRS, Meaningful Use, HEDIS, Five-Star) produced by the HIE retrospectively, at the point of care, and prospectively; and explain the pivotal role of data analytics supported by HIE data in allowing physicians and patients to adhere to care guidelines and improve quality of care.

Saturday, 2:00 p.m. - 3:15 p.m.
An Integrated Approach to Heart Failure Care

Paul C. Freiman, MD, FACC, Cardiologist, and Donna A. Smith, RN, BSN, Director, Business Development, St. John's Health System
When St. John's Health System (SJHS) was selected as one of ten sites in the nation to participate in the Physician Group Practice (PGP) Demonstration Project, they accepted the goals of the project to promote efficiency and improve quality of health care provided to the patients they serve across the full continuum of care. SJHS identified heart failure patients as the population on which to focus strategies to improve coordination of care and reduce hospital readmissions. An integrated approach to collaboration and coordination of hospital and ambulatory heart failure services resulted in a reduction in heart failure admission and readmissions, and served as a model for managing patients with other chronic conditions.
Upon completion of this activity, participants should be able to identify issues which contribute to readmission of patients with heart failure; recognize interventions that improve quality of care of patients with heart failure; and identify interventions that reduce the likelihood of readmission for heart failure.

Saturday, 2:00 p.m. - 3:15 p.m.
Achieving Significant Outcomes Treating Weight Gain and Its Comorbid Conditions

James Roseto, MD, Medical Director of Internal Medicine Practices, Harvard Vanguard Medical Associates; Karen Handy, MPH, Manager, Nutrition Services, Palo Alto Medical Foundation; and Carol Lewis, Executive Director, Quincy Medical Group
 The epidemic rise in obesity presents clinical, operational, and financial challenges for healthcare institutions. The proposed changes under healthcare reform offer an increased impetus to implement effective treatments. This presentation reviews how AMGA member facilities are delivering evidence-based treatments with medically significant outcomes including reductions in comorbidities and medications.
Upon completion of this activity, participants should be able to list the evidence-based components of an effective obesity treatment program; discuss the typical medical changes that occur with an effective obesity treatment program; describe how to deliver a clinically and financially effective treatment for obesity; and identify operational and management support necessary for starting and maintaining a successful program.

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