Read the TWC Continuity of Care Case Study - HIMSS

HIMSS Ambulatory Davies Award: Independent Ambulatory Practice

The mission of The Wright Center is to continuously improve education and patient care in a collaborative spirit to enhance outcomes, access and affordability. Executive Leadership Linda Thomas-Hemak, MD Jignesh Sheth, MD Brian Ebersole Teresa Lacey, RN Clinical Innovation Tiffany Jaskulski Courtney Dempsey Health Information Technology and Innovation John Janosky Edward Wargo Communications/Development Maria Montoro-Edwards, PhD Jennifer Hetro Kerri Price

The Wright Center (TWC)

5 South Washington Avenue, Jermyn, PA 18433

Case Study One

The Clinical Value of Continuous and Consistent Healing Relationships with Patients and Colleagues Fragmentation within complex care delivery and medical education systems pose significant challenges to longitudinal continuous healing relationships, which are essential for high-quality patient care and educational outcomes. To improve patient-centered care continuity in all out-patient settings, TWC utilized Qualis Health’s Empanelment Guide to illuminate EMR-driven workflow of team-based care delivery for defined populations. All providers and staff were assigned to color-coded teams based on FTE availability, and patients were empaneled based on preference and historical attachments to providers. Health IT was used to establish empanelment teams, create visual cues through automated scheduling alerts and promote team-based accountability for population-based care delivery and health outcomes utilizing registry and exception reports. Compliance was measured at all staff levels; metrics for TWC’s scheduling team is referenced in this case study. We encourage any practice in its current state to introduce the replicable and scalable models outlined in this TWC case study.

Local Problem Identified and Intended Outcome Our mission mandates attention to patient and resident satisfaction with the care experience. Longitudinal continuity is a primary determinant of satisfaction and historical global dissatisfaction with care continuity called for action. TWC’s physician leadership recognized enhanced relationships between providers, residents and patients in the outpatient clinics as a top, mission-related priority. The following barriers were hindering continuous longitudinal healing relationships: • The resident rotation schedule was not always consistent or integrated into the clinic’s schedule, making it very difficult to know when to reschedule a patient to follow up with the same resident. • Resident outpatient schedules would change last minute to accommodate the hospitals needing additional coverage. • The majority of our patients identified with only one primary physician, Dr. Linda Thomas-Hemak; she was their physician for many years before she collaborated with TWC and began training residents and collaborating with faculty partners as well as non-physician providers. • TWC could not schedule under resident physicians’ numbers in the EHRs chart; it was not possible to bill under resident physicians’ NPI numbers. These issues made it difficult to conceptualize the necessary steps to ensure resident/patient continuity. After research and assessment, TWC determined the need for an empanelment project and utilized the Qualis Health Empanelment Guide. Determining the number of patients who can be empaneled per team according to provider/extender FTE presence in the clinic was a priority. Once team capacities were determined, TWC reviewed all patient charts and identified a trackable method to assign patients to their provider teams. The ultimate goal was to ensure patients consistently see familiar primary care providers, inclusive of residents, at every visit.

Design and Implementation 1. Provider Teams were Created; Number of Patients Decided per Team; Continuity Honored by Strategic Team Availability TWC assessed the size of the population and the capacity of primary care providers and residents’ FTE presence in the clinic and determined three teams would be adequate to optimize panel size and access. The teams were assigned colors - green, blue and purple - and were structured to flex with staff transitions or increases in providers or patients within the clinic. Next, TWC assigned the appropriate number of patients to each team using the following formula: take the provider FTE presence for the team and multiply by 210, then by the number of patients seen per day (three patients per hour), to come to the Panel Capacity = (210*FTE Presence*Patients per day)/3.7 (the average amount of visits per patient per year). As indicated in the figure (right), the blue team’s capacity is 3,244 patients. Knowledge of the capacity of each panel was imperative to maximize the respective team capacity, efficacy and satisfaction of residents and patients. 2. Identify the Provider Team to which the Residents Belong For successful empanelment, the process included efforts by the chief residents to ensure there was at least one resident present in the outpatient clinic per color-coded team at all times. The number of attending physicians present in the clinic was the deciding factor on the number of residents needed to be placed in the clinic per team and the number who could be placed to comply with accreditation and supervision standards. Maintaining the provider-to-resident ratio was a significant task as the residents were pulled to cover shortages in the hospitals as needed. After this was identified, physician leadership acknowledged that residents’ outpatient rotation blocks should never be affected due to shortages in the hospital settings. In the current year, the chief resident and an associate program director created a schedule that would be more conducive to the outpatient continuity blocks. The final empanelment list was published and shared with all staff in the outpatient clinics, eliminating confusion regarding team members and resolving the lack of continuity amongst the panels. © 2015 | The Wright Center | HIMSS Ambulatory Davies Award The Clinical Value of Continuous and Consistent Healing Relationships with Patients and Colleagues

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3. Label Patients According to Their Team While the chief residents were working on the schedules, the outpatient clinics began labeling patients within the EHR according to the providers they preferred or saw most frequently. For example, if a patient saw a physician from the green team four times in the last two years and a physician from the blue team once, they would be assigned to the green team in an effort to honor the relationships that patients already formed with their providers. At any time, if a patient decided that he or she wanted to follow a different physician at TWC, their team could be switched to accommodate the request. In order to begin this process, the Electronic Health Record (EHR) Specialist generated a report of all patients seen in the clinic over the past 3 years and their respective providers, which was further broken down by the frequency that the patients saw each provider. From this report, a team of residents and the EHR Specialist entered the patient’s team in a trackable form called the “Preferred Provider Form.” Once the patient was assigned to a particular team, chart alerts were created (left) to inform the scheduling staff of patients’ team designations. Disease Management/Health Maintenance continuity alerts were included on sidebars to clearly state the patient’s team assignment. 4. Train Staff on How to Schedule According to Empanelment By 2012, empanelment was fully implemented and a step-by-step empanelment training guide was created for the scheduling and front office staff. After the empanelment process was rolled out for the entire practice and staff was trained, the EHR Specialist worked with IT to generate performance reports showing compliance with proper color-coded scheduling by individual and team performance. Following the implementation of scheduling according to empanelment, TWC established the goal of 90% scheduling compliance. To date, we average 85.95% scheduling compliance. TWC uploads scheduling compliance reports on a monthly basis and the outcome graphs are circulated to staff and routinely monitored by the office managers and physicians. From the beginning of the project, we have seen a 14.31% increase in empanelment-based scheduling compliance.

The figures (right) show the individual measures run charts for each person who scheduled patients. Each scheduler is held accountable for the measures with ongoing coaching and inclusion of the metrics in their semi-annual reviews. These objective measures of performance determine annual performance-based bonus eligibility.

© 2015 | The Wright Center | HIMSS Ambulatory Davies Award The Clinical Value of Continuous and Consistent Healing Relationships with Patients and Colleagues

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How Was Health IT Utilized?

Once the empanelment project was implemented, physician leadership wanted to begin identifying quality Healthcare Effectiveness Data and Information Set (HEDIS) measures for the empanelment teams. TWC had participated in the Pennsylvania Chronic Care Initiative for several years and was familiar with reporting these quality measures. Minor revisions to the report were needed to clarify which member of the team saw each individual patient, such as the addition of columns to detail the provider/resident who created the progress note and the team color listed on the patient’s Preferred Provider Form. The data is run monthly for the practice and uploaded by the IT Department. Programming pulls data into individual and empanelment team metrics for care process delivery and health outcomes.

In order to assess resident satisfaction, TWC administered a survey both pre- and post-empanelment implementation, and found a measurable improvement of overall resident satisfaction with empanelment. Residents expressed an enhanced, genuine sense of continuity of care with their patients post-implementation. The results are displayed below.

© 2015 | The Wright Center | HIMSS Ambulatory Davies Award The Clinical Value of Continuous and Consistent Healing Relationships with Patients and Colleagues

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Assessment of patient satisfaction with the continuity of their care was also a top organizational priority. CAHPS patient satisfaction surveys were conducted in the clinic in 2013 and 2014 for NCQA certification, before and after the implementation of empanelment. Many of the survey results show a positive upswing in patient satisfaction. Green boxes in the second figure surround all areas of improvement in survey metrics in 2014 from baseline with several improving components reflective of enhanced care continuity. Before Empanelment

After Empanelment

Lessons Learned • • •

Leadership needs to prioritize the necessity of care coordination and continuity of care for resident education and patient satisfaction in the outpatient clinic setting. Patients need to be scheduled under the attending physicians to eliminate confusion of clinic staff and residents with strict adherence to color-coded empanelment. Initial scheduling of patients under the resident NPI numbers to ensure continuity interfered with capturing CPT billing for the visits and created significant confusion as well as potential for lost revenue. The interface between the single vendor practice management system and the EHR required the billing office to reconcile the EHR scheduled provider with the supervising physician status in the E-Superbill. This re-work drove reversion in the scheduling process to the level of the supervising faculty. Alternative tracking methodology attaching residents to the visit experience needed to be developed as a result to track resident continuity. Potential revenue loss without this accommodation could have been significant for complex visits and also well visits, especially in light of the overhead costs of routine vaccinations. It is imperative to educate all staff who schedule patients at the initial stages of empanelment to gain their buy-in regarding its importance. In order for empanelment to be successful, there must be leadership, management, physician, resident, staff and patient buy-in. For TWC, the EHR made the process easier to mark the exceptions to empanelment compliance in a “To Do” as opposed to a “Triage.” The date component in a Triage template was not a trackable field in the EHR for the reports needed. After discovering the issue, TWC retrained staff to document all exceptions in a “To Do” trackable notation.

Financial Considerations The cost of developing and implementing EHR-driven empanelment was nominal in comparison to the value empanelment created. The total cost of EHR functionality development and the portion of an EHR Application Specialist’s salary for the project was approximately $10,000. Empanelment is now a part of the practice workflow with minimal additional financial or resource investment.

© 2015 | The Wright Center | HIMSS Ambulatory Davies Award The Clinical Value of Continuous and Consistent Healing Relationships with Patients and Colleagues

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Read the TWC Continuity of Care Case Study - HIMSS

HIMSS Ambulatory Davies Award: Independent Ambulatory Practice The mission of The Wright Center is to continuously improve education and patient care...

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