enhancing patient care through better data

Enhancing Patient Care Through Better Data

Wayne Pan, MD, MBA, Chief Medical OfficerThe Individual Practice Association Medical Group of Santa Clara County Inc. (SCCIPA)

IHA’s Tenth Annual P4P Stakeholders Meeting • September 22, 2011 • Los Angeles

What I Did During My Summer Vacation

ourperspective

retrospectoscope

whoweare

Santa Clara County1,304.01 sq. miles

1,781,642 (2010)$74,335

5 PCP80 Specialists

57 PCP104 Specialists

173 PCP343 Specialists

11 PCP30 Specialists

SCCIPAfounded in 1986physician-owned, physician-governed800+ physicians - 240+ PCPs, 550+ specialistsall 9 hospitals - including a tertiary care center9 health plans (Commercial and Medicare Advantage)

ourjourney

theneed

it’snottechnology

signalvsnoise

it’saboutthepatient

peopleprocessesplatform

peopleprocessesplatform3P’s

peopleprocessesplatformCbig

culturepeopleprocessesplatform

culture?

patientcentered

efficient

evidencebased

promotequality

makeiteasy

4processes

communication

collaboration

coordination

PCPs

Specialists

Patients

CaseManagers

anticipation

it’snottechnology

technology 1st

designphilosophy

put hot triggers in the path of

motivated peopleBJ Fogg, PhD

Director, Persuasive Technology LabStanford University

work with humannature

BJ Fogg, PhDDirector, Persuasive Technology Lab

Stanford University

lazysocialhabitsBJ Fogg, PhD

Director, Persuasive Technology LabStanford University

ourplatform

common web-based communication platformfacilitates administrative functionsrules-based management of processesintuitive user-interfaceembed quality reminders into office/provider workflowprovider feedbackprovide actionable clinical data at point of care

platform

common web-based communication platformfacilitates administrative functionsrules-based management of processesintuitive user-interfaceembed quality reminders into office/provider workflowprovider feedbackprovide actionable clinical data at point of careallow patients to access their own dataallow patients to provide feedback and enter their own data

platform

anticipation

4dimensionaldata

financial

administrative

clinical

retrospective

reactivecare

behavioral+

predictive

proactivecare

provideactionabledata

@pointofcare

@home

thecareteam

thecarecontinuum

ourplatforms

ACCESSEXPRESS

peopleprocessesplatform

hospitalistsSNFistsonsite case managerscomplex case managersutilization review staff

people

hospitalistsavailable 24/7evaluation of patients for possible redirection to SNFaggressive use of observation statusannual coding/documentation training for risk adjustmentnotification of PCP of admission/dischargedischarge summary faxed to PCP

peopleprocesses

SNFistsongoing evaluation of patients to reduce rehospitalizationnotification of PCP of admission/dischargedischarge summary faxed to PCP

peopleprocesses

onsite case managersdaily review of patients based on Milliman guidelinesactively involved with discharge planningall discharge needs authorized/arranged prior to dischargepost-discharge follow-up on all patients with DME/HHC needs

peopleprocesses

complex case managerswarm hand-off between onsite and ccmuse of clinical and non-clinical staff to assist patient and family caregivers with care coordinationinsure follow-up with PCP/specialist within 2 weeks

peopleprocesses

utilization review staffall authorizations/referrals reviewed using Milliman guidelinesworking closely with PCPs/specialists/ccm to facilitate care coordinationcompliance with regulatory guidelinesgenerate member/provider letters regarding medical necessity decisionsphysician performance and quality reportingidentification of potential quality issuescontinuous process improvement

peopleprocesses

thepatientjourney

thepatientjourney

dischargeplanning

hosspitaldischargeplanner

IPA onsitecase

manager

hospitalist

patient family

thepatientjourney

dischargeplanning

hosspitaldischargeplanner

IPA onsitecase

manager

hospitalist

patient family

Rx

patient

medicationreconciliation

hospitalist

thepatientjourney

dischargeplanning

hosspitaldischargeplanner

IPA onsitecase

manager

hospitalist

patient family

Rx

patient

medicationreconciliation

hospitalist

dischargeinstructions

patient

outpatientphysicianfollow-up

hospitalist

thepatientjourney

dischargeplanning

hosspitaldischargeplanner

IPA onsitecase

manager

hospitalist

patient family

Rx

patient

medicationreconciliation

hospitalist

dischargeinstructions

patient

outpatientphysicianfollow-up

hospitalist

Rx

discharge

dischargeinstructions

patient family

thepatientjourney

dischargeplanning

hosspitaldischargeplanner

IPA onsitecase

manager

hospitalist

patient family

Rx

patient

medicationreconciliation

hospitalist

dischargeinstructions

patient

outpatientphysicianfollow-up

hospitalist

Rx

discharge

dischargeinstructions

patient family

outpatient physician follow-up

dischargeinstructions

patient

discharge

hospitalistIPA

onsitecase

manager AE

outpatient physician follow-up

dischargeinstructions

patient

PCP

IPA onsitecase

manager

48hr call

AE

outpatient physician follow-up

dischargeinstructions

patient

PCP

internalnon-clinical

staff

post pcpvisit call

AE

thepatientjourney

dischargeplanning

hosspitaldischargeplanner

IPA onsitecase

manager

hospitalist

patient family

Rx

patient

medicationreconciliation

hospitalist

dischargeinstructions

patient

outpatientphysicianfollow-up

hospitalist

Rx

discharge

dischargeinstructions

patient family

medication reconciliation

admissionorders

patient

admission

hospitalist

medication reconciliation

new Rx

patient

discharge

hospitalist

admissionorders

medication reconciliation

reviewmedlist

patient

pcp visit

pcp

new Rxadmissionorders

“new” medication reconciliation

new Rx

patient

discharge

retailpharmacy pcp

thepatientjourney

preventivecare

diabeticpatient

meds

self-testing

dieteducation

exercise

pcp

er

hosp

snf

endo

preventivecare

meds

self-testing

dieteducation

exercise

pcp

er

hosp

snf

endo

p

preventivecare

meds

self-testing

dieteducation

exercise

pcp

er

hosp

snf

endo p AE

preventivecare

meds

self-testing

dieteducation

exercise

pcp

er

hosp

snf

endo

p

preventivecare

meds

self-testing

dieteducation

exercise

pcp

er

hosp

snf

endop

AE

preventivecare

meds

self-testing

dieteducation

exercise

pcp

er

hosp

snf

endo

p

preventivecare

meds

self-testing

dieteducation

exercise

pcp

er

hosp

snf

endo

p

preventivecare

meds

self-testing

dieteducation

exercise

pcp

er

hosp

snf

endo

p AE

preventivecare

meds

self-testing

dieteducation

exercise

pcp

er

hosp

snf

endo

pAE

preventivecare

diabeticpatient

meds

self-testing

dieteducation

exercise

pcp

er

hosp

snf

endo

peopleprocessesplatform

culturepeopleprocessesplatform

it’saboutthepatient

thankyouwpan@ppmsi.com