2013 Annual Conference

Care Process Improvement

Friday, 2:00 p.m. - 3:15 p.m.

Patient-Centered Medical Home: The Journey towards Recognition and Sustainability
Robert Pesce, MD, FAAP, Medical Director, HealthPoint Medical Group; and Cami Leech Florio, MHA, MABMH, Manager, Clinical Operations, HealthPoint Management Services
This presentation will summarize HealthPoint Medical Group's journey towards Patient-Centered Medical Home recognition under the 2011 NCQA Standards. The speakers will reflect on the planning, implementation, and recognition processes, the team approach to disease management, and unique considerations of a PCMH model in both adult medicine and pediatric settings.
Upon completion of this activity, participants should be able to describe the NCQA 2011 Standards and Process for Patient-Centered Medical Home recognition; detail the relationship and similarities between EMR Meaningful Use, PQRS, payer incentives, and Patient-Centered Medical Home; describe a planning and implementation process for Patient-Centered Medical Home in an adult or pediatric primary care setting; identify the supporting functions of Patient-Centered Medical Home implementation, including optimizing use of the EMR, developing care management teams, and analyzing/reporting clinical data; and apply the team building and change management principles that facilitate implementation of a large scale change.

Leveraging Days Wait to Appointment and Outpatient Patient Satisfaction Scores to Improve Retention Rates, Reimbursement, and Reporting Metrics
Brian Harte, MD, SFHM, President, South Pointe Hosptial, and Eric D. Hixson PhD, MBA, Director, Outcomes and Analytics, Business Intelligence/Medical Operations, Cleveland Clinic
With increasing responsibility for containment of healthcare costs and intense competition between systems for healthcare dollars, patients are more selective in their search for care. This case study demonstrates how to create a competitive advantage through greater understanding of patient demographics and disease states and their impact on patient satisfaction.
Upon completion of this activity, participants should be able to describe the prior work examining effect of days wait time to appointment on patient-reported satisfaction; demonstrate variation in satisfaction with wait time based on a number of variables including subspecialty, disease complexity/severity, visit type, gender, age, and distance from clinic; demonstrate how business reviews and monthly balanced scorecards powered by automated business intelligence solutions have been used as transparent tools that drive transformational change and improvement throughout the system; and review processes by which institutions can create similar databases to understand regional clinical population and tailor scheduling processes to best accommodate patients.

Improving Medication Adherence: Understanding the Patient's Perspectives
Colleen A. McHorney, MD, Senior Director, U.S. Outcomes Research, Merck Sharp & Dohme Corp.; and Frederick J. Bloom Jr., MD, MMM, Associate Chief Quality Officer, Geisinger Health System
This session will provide an overview of the collaboration between the Community Practice Service Line of Geisinger Health System and Merck, with the primary objective to heighten clinicians' awareness of and ability to address medication non-adherence during routine interactions with patients.
Upon completion of this activity, participants should be able to understand the clinical and socioeconomic costs of medication adherence and its effect on patient health outcomes; recognize the difference between a clinician's point of view of medication adherence compared to that of adult patients with chronic disease, such as diabetes; review and understand the 10 Tenets of Medication Adherence; and understand the collaboration, including a description of the program, objectives, timelines, measurement and structure including the roles of each organization.

Using Clinical Analytics to Optimize Care Coordination across Multiple Sites of Care
John Cuddeback, MD, PhD, Chief Medical Informatics Officer, Anceta; Mary Lantin, MPH, Vice President, Client Services, Humedica; Jonathan Hines, MD, Chief Medical Officer, and Kelly Schaudt, Senior Director of Lean Operations, Wilmington Health
As provider groups begin to assume financial risk for population health, they need to determine priorities for care by viewing patients in the context of comparative data. Groups are also taking advantage of predictive models built using large databases that stratify patients by risk of some outcome, e.g., estimating the risk of hospital admission over the next six months for a patient with heart failure. As interactive analytical applications are deployed to multiple regions or sites across a large heath system, the ability to tailor queries to a site's specific interests enhances the use of data to optimize care coordination. Medical groups using Humedica MinedShare® for clinical analytics will share their experiences in balancing the value of flexibility against the need for consistency.
Upon completion, participants will be able to cite the advantages and disadvantages of different models of governance for data and analytics to support care coordination across health systems.

Friday, March 15, 2013
3:45 p.m. - 5:00 p.m.

Maximizing Limited Care Management Resources to Improve Clinical Quality and Ensure Safe Transitions
Scott Flinn, MD, Medical Director, Deborah Schutz, Director of Health Services Management, and Fritz Steen, RN, MBA, Ambulatory Care Manager, Arch Health Partners
This presentation will demonstrate how patient registries, incentives, and a Lean care management team (care management RN, CDE, case managers, SNF NP, and pharmacist) can help your practice exceed HEDIS benchmarks for chronic disease management, enhance patient self-management, and facilitate safe transitions of care.
Upon completion of this activity, participants should be able to describe how patient registry data and properly structured incentives can be used to improve clinical quality metrics and care; integrate professional care team staff into practice operations to improve patient activation and chronic disease self-management (RN, CDE, pharmacist); and integrate professional care team staff into practice operations to facilitate safe transitions of care (RN inpatient case manager, RN complex case manager, SNF NP, etc.).

Scribes in Clinical Practice: A Means of Improving Provider Efficiency and Satisfaction
Marcia Sparling, MD, Assistant Medical Director, and Tom Sanchez, Director of Operations, The Vancouver Clinic
The Vancouver Clinic piloted the use of scribes in five different departments, using a contracted service with prior experience in Emergency Department settings. The organization developed an efficient, flexible model that increased the capacity to see patients, but nevertheless shortened the provider work day. Clinical documentation, and provider and patient satisfaction improved; financial performance was variable.
Upon completion of this activity, participants should be able to describe the challenges of scribes; evaluate different models of documentation support and their relative strengths; and create a model of a scribe program for consideration in their ambulatory setting.

Practical Practice: Patients and Providers Partnering to Build Communication Skills Essential for Patient- and Family-Centric Care
Samer Assaf, MD, Sharp Rees- Stealy Medical Group; and Ross Adams, MS, CCC-SL, Patient Advisor
In developing communication skill-building trainings, Sharp Rees-Stealy Medical Group discovered that partnering with patients to provide practical practice proved most beneficial. The presenters will outline the pitfalls of excluding patients, segregating providers by job role, and the success in training all healthcare team members together with patients playing a significant and central role.
Upon completion of this activity, participants should be able to describe the importance of effective open communication in collaborative patient-centered care and in team building; recognize and increase their use of three important communication skills (open-ended query, empathy, and reflective listening) in their practices; explore new ways to partner with patients at the practice level; and develop strategies for communication workshop development.

Developing a Department of Practice Transformation
Robert W. Brenner, MD, MMM, Chief Medical Officer, and Jamie Reedy, MD, MPH, Medical Director of Practice Transformation, Assistant Medical Director of Quality, Department of Care Coordination/Utilization Management, Summit Medical Group
It is clear that in order to remain financially solvent, medical groups must ready their organizations for success under value-based payment models. Summit Medical Group has approached this challenge by creating a Department of Practice Transformation. This presentation will overview this journey, describe the challenges and successes, and offer specific examples.
Upon completion of this activity, participants should be able to describe the reasons for developing a Department of Practice Transformation; delineate the roles and responsibilities of a Department of Practice Transformation and those of the individuals that staff this department; list the key success factors for transforming care; describe the stages of transformation and change management experienced by SMG; and cite specific examples of how the Department of Practice Transformation at SMG has managed to ensure continuous improvement in care for individuals and the health of populations at an appropriate cost.

Establishing a Palliative Medicine Service in a Large Ambulatory Medical Group
Barney Newman, MD, Medical Director, and Maura Del Bene, NP, Associate Director, Palliative Medicine, Palliative Medicine Service, WESTMED Medical Group
The new frontier of palliative care is the outpatient setting when serious illness is present.  The involvement of palliative care, from the time of diagnoses, has the highest impact potential for patient-centered, quality, and cost-effective care. This presentation will describe the principles, strategies, and tools employed to implement the program at WESTMED Medical Group.
Upon completion of this activity, participants should be able to define Palliative Care (from time of diagnoses through death, medical specialty for serious illness); differentiate between primary and secondary palliative care; differentiate between ambulatory versus hospital based palliative medicine services; understand the role/value of primary palliative care in a large outpatient medical system to potentially improve pain and symptom control, patient/family satisfaction, and cost savings for individuals diagnose with serious illness; describe three core components to a palliative medicine consultation; discuss effective strategies for the delivery of palliative care in diverse settings of integrated outpatient practice, long term care setting and hospitalist program; describe the capacity of the EMR to identify, clarify, and incorporate palliative principles/practices/screenings; and identify three-to-five tools specific to palliative care assessments, triggers, decisional aids, prognostication and generalist resources.

Saturday, March 16, 2013
11:00 a.m. - 12:15 p.m.

Applying Lessons from Two Years of a Commercial ACO to a Medicare Shared Savings Program
Lee Sacks, MD, Executive Vice President, Chief Medical Officer, Advocate Health Care and CEO, Advocate Physician Partners; and Mark Shields, MD, Senior Medical Director, Advocate Health Care
This presentation will outline the lessons learned over two years from one of the largest commercial ACOs that resulted in a Medicare Shared Savings Program. Presenters will describe how Advocate Physician Partners' integrated model of care successfully transitioned to an accountable care-type model, explore how specific measures improve goals of accountable care, and outline how to modify it for Medicare beneficiaries.
Upon completion of this activity, participants should be able to describe a governance structure and physician alignment model supporting cultural change for thousands of independent and employed physicians that is successful for care of both commercial and Medicare patients; 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 impact clinical care, efficiency, medical and 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; describe how to take an existing infrastructure to the next level by incorporating Medical Home and Accountable Care guidelines; and develop a shared savings model for commercial and Medicare patients that reduces waste and improves care coordination throughout the continuum, resulting in lower costs and more appropriate and effective care for the patient.

Saturday, March 16, 2013
2:00 p.m. - 3:15 p.m.

Medicare Shared Savings ACOs: One Organization's Initial Lessons Learned
Gregory A. Spencer, MD, FACP, Chief Medical Officer, Crystal Run Healthcare
Crystal Run Healthcare's CMO discusses how it became one of the nation's first Medicare Shared Savings Program ACOs-and examines the lessons learned in its first year of the program. Dr. Spencer will discuss how to assess an organization's strengths and weaknesses, and how to build a leadership team to oversee the transition to value-based care. He will offer guidance on how to establish the clinical infrastructure needed to effectively use embedded care managers to help build medical neighborhoods and how an EHR can be the backbone for an enhanced data warehouse to create more effective clinical dashboards and identify patient care gaps.
Upon completion of this activity, participants should be able to identify organizational strengths and weaknesses in preparing for the ACO model; assemble a leadership team to help patients and providers make the transition to a value-based system; and describe the lessons Crystal Run has learned during its first year of ACO operation.

Population Health (Medical Home 2.0)
Beth Averbeck, MD, Associate Medical Director, Primary Care, and Joan Flaaten, Regional Clinic Director, NEST Region, HealthPartners
HealthPartners has taken team-based care to the next level through a framework of population health.  Based on HealthPartners' care design principles of reliability, customization, access, and coordination, the organization has redesigned care team roles to maximize productivity, connected with partners to improve coordination, and developed innovative ways to access care.
Upon the completion of this activity participants should be able to describe using resources effectively and efficiently to serve high-cost or high- utilization populations; and how HealthPartners has worked across its system and community to meet the mission of better health, better experience, and lower cost for the patient.

Transforming Care Delivery by Moving from Episodic to Coordinated Payment
Kenneth E. Berkovitz, MD, System Medical Director, Summa Cardiovascular Institute, and Chair, Department of Cardiovascular Disease, Summa Akron City and St. Thomas Hospitals, Summa Physicians Inc.; Robert A. Gerberry, JD, Associate General Counsel, and Robert  Hunter, MBA, MA, System Administrative Director, Summa Cardiovascular Institute, Summa Health System
This session will explore the collaboration between Summa Physicians and the Summa Cardiovascular Institute to innovate care delivery, drive higher quality, and lower costs. To achieve these goals, Summa implemented a multifaceted strategy including participation in an accountable care organization, a clinically integrated network, and in the CMMI Bundled Payment Care Improvement Initiative (BPCII).  The presentation will highlight the care redesign process necessary to deliver the highest quality care at the lowest cost for patients seeking cardiovascular care.
Upon completion of this activity, participants should be able to define criteria to evaluate organizational readiness to participate in initiatives such as bundled payment programs, accountable care organizations or other value-based purchasing programs with governmental and commercial payers and employers; design and implement evidenced-based clinical guidelines to reduce care variations and lower costs for cardiovascular services across multiple system hospitals, including high-cost conditions focused on by ACOs and participants in bundled payment programs; build upon prior Physician-Hospital partnerships to engage physicians in collaborative efforts to reduce fragmented care and delivering a more coordinated product through aligned financial incentives; and identify the legal and regulatory issues applicable to health systems and their physicians related to gainsharing, shared savings distributions, and other mechanisms to reward physicians for both clinical production and achievement of quality and cost outcomes.

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