the green mountain care board and vms education and research foundation optimizing rural care better...
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The Green Mountain Care Boardand
VMS Education and Research Foundation
Optimizing rural care
Better quality, Better health, Lower costs
Better care, better health, lower costs
1. Actualize 3 planned levels of care2. Make VT a magnet for the workforce3. Become the national benchmark for
measurement4. Reduce the gap between practice and policy
“You have to have the will to improve; You have to have ideas about alternatives to the status quo; and then you have to make it real through execution. All three have to be arranged by leaders – they are not automatic.”
How can leaders accelerate innovation?
Vermont Rural Physician Leaders CommunityPhil Brown MD, Berlin
CVMC - Chief Medical OfficerInternal medicine, Emergency medicine
Kevin Buchanan MD, RandolphClara Martin Center - Medical directorPsychiatry
Ovleto Ciccarelli MD, RandolphGifford Health Care - Surgical ChairpersonGeneral Surgery
David Coddaire MD, MorrisvilleCommunity Health Services of Lamoille ValleyMedical director, Family practice
Mark Crane MD, BerlinCVMC - General Surgery
Lou DiNicola MD, RandolphGifford Health Care - Pediatrics
Jeremiah Eckhaus MD, MontpelierCVMC - Family practiceSharon Fine MD, Danville
Northern Counties Health Care - Medic al directorFamily practice
Steve Genereaux MD, Wells RiverLittle Rivers Health Center - Medical director Family practice
Nikki Gewirz PA-C, RandolphGifford Health Care - General Surgery
Mark Heitzman MD, BerlinCVMC - Cardiology
Sarah Kemble MD MPH, SpringfieldSpringfield Medical Care Services - Medical directorInternal medicine, Preventive medicine, Public health
Mike Kilcullen MD, WoodstockOttauquechee Health Center – Pediatrics
Dina Levin MD, RandolphGifford Health Care - Obstetrics and Gynecology
John Matthew MD, PlainfieldThe Health Center – Executive and Medical directorInternal medicine, Family practice
Josh Plavin MD MPH, RandolphGifford Health Care - Medical Director Internal medicine, Pediatrics, Pubic health
Deborah Richter MD, MontpelierFamily practice, Addiction medicine
Joel Silverstein MD, MorrisvilleCopley Hospital – Chief Medical OfficerInternal medicine, GastroenterologyPeter Thomashow MD, Berlin
CVMC – Psychiatry Chairperson Psychiatry
Sean Uiterwyk MD, White River JunctionWhite River Family Practice – Independent practiceFamily practice
Mark Yorra MD, BarreCVMC - Internal Medicine
Qualitative research - Key informant interviews
What?1. Health resource allocation planning2. Measurement of health care processes
and outcomes3. Payment policy and payment reform4. Communication with Board5. Retention and recruitment of physicians
Who?• People who know what’s going on in
their community• Insight on the nature of problems and
recommend solutions
Advantages• Candid/in-depth• Detailed rich data• Nuanced and actionable• Trust/sensitive topics• Motivation and beliefs• Raise interest/enthusiasm• Build/strengthen relationships• Stay connected/clarify issues
Disadvantages• Difficult to selection the “right”
informants• Diversity? Bias?• Difficult to schedule• Difficult to generalize unless many
involved
Actualize 3 planned levels of care3 levels of care by design
“Our current clinical capabilities are such that we never lose a life because we are missing capacity when a life threatening situation presents itself; but we are all really stressed ”- FQHC medical director
1. Core community based services• readily available
2. Regionalized specialty services• reasonably available
3. Tertiary and quaternary care• emergently available
Regionalized/shared general surgery
Ovleto Ciccarelli MD, RandolphGifford Health Care - Surgical ChairGeneral Surgery
of Gifford Medical Center
Ovleto Ciccarelli, MD
Disclaimer: This presentation represents the personal opinions of the presenter and does not represent an official opinion or
position of Gifford Medical Center
Thoughts on Future Delivery of Surgical
Care
Presentation to The Green Mountain Care Board Presented by
Gifford Medical CenterOvleto Ciccarelli, MD
Thoughts on Future Delivery of Surgical Care
TIERS OF SURGICAL CARE
CARE TO BE PERFORMED IN A TERTIARY CENTER
•Technically complex surgery (i.e. cardiac, neuro)
•Complex infrequently performed surgery (i.e. pancreatic, esophageal and non-cardiac open thoracotomy)
SURGERY THAT SHOULD REMAIN IN A COMMUNITY SETTING
•Commonly performed surgeries (i.e. breast, hernia, intra-abdominal surgery)
SURGERY THAT MAY OR MAY NOT BE DONE IN A COMMUNITY SETTING DEPENDING ON SURGICAL SKILLS AND PERIOPERATIVE SUPPORT
•Advanced laparoscopic and/or thorascopic surgery with short postoperative stays and the patient with comorbid conditions that are amenable to local advanced perioperative care
Gifford Medical CenterOvleto Ciccarelli, MD
STATEWIDE INITIATIVES TO SUPPORT A REGIONAL NETWORK OF CARE
• Common information/technology system
• Quality improvement system (NSQIP) to allow for comparison of surgical outcomes among all participating surgeons
• Statewide licensing and credentialing process
• A central repository/inventory of available surgical skills and services
• Centralized recruitment to meet needs of all hospitals
• Regional surgical providers who work at more than one facility
• Rotation of providers with advanced skills to community facilities
• Rotation of emergency room availability
• Centers of Excellence (i.e. metabolic and bariatric surgery)
Thoughts on Future Delivery of Surgical Care
Gifford Medical CenterOvleto Ciccarelli, MD
EDUCATIONAL NEEDS TO FOSTER AN INTEGRATED SURGICAL COMMUNITY
• Multi-institutional morbidity and mortality conference
• Additional training for Physician Assistants to improve operative skills
• Mini fellowships for community surgeons with respect to critical care and acute care surgery
• Telemedicine support to allow for provision of care in local settings
Thoughts on Future Delivery of Surgical Care
Magnetize VT for the workforce Team based care – Rethink the workforce
Planned expansion of mid–level care“The role of mid-level practitioners must be
recognized; as physicians practicing in rural communities we are extremely dependent on having a close working relationship with mid- level practitioners. The only model that works is a team approach”
“From the view point of a mid-level it’s very difficult to be effective if we aren’t included in professional, management and planning discussions. We are expected to know everything; we are expected to do everything, but we don’t necessarily have access to all the support that physicians have like CME, newsletters and other professional opportunities supporting lifelong learning. Sometimes we can feel like the red-headed step child.”
New team membersCommunity health workers“We’ve taken many steps toward becoming a
patient centered medical home, but there is a need for more community health workers, health coaches and panel management. People used to know how to help each other; there were layers of support in the community; we need trained trusted members of the community to teach us all how to be more self reliant”
Practice based quality improvement staff“We need to scale up training a workforce for the
future of primary care which will include more medical assistance level personnel to help manage the data entry involved in monitoring quality and controlling costs. The work keeps increasing and the workforce stays the same!”
Nikki Gewirz PA-C, RandolphGifford Health Care - General Surgery
Jeremiah Eckhaus MD, MontpelierCVMC - Family practice
Become the national benchmark for measurement
Checking little boxes versus meaningful measurement
Design valid trusted metrics“As an organization we can produce significantly
different rates based on the methodology we use to collect the data.
If we use a manual chart review process on a random sample of 70 patients to determine if we documented tobacco use status we score 100%; the same rate calculated through the Meaningful Use methodology using our EMR is 85%.
Similarly, manual method results in 45% of our patients being counseled about stopping tobacco use, where the Meaningful Use method shows a 15% counseling rate and for some practitioners the rate is as low as 4%”
Reduce the administrative burden“I’ve practiced primary care in other parts of
the country; Vermont is the best place for primary care
that I’ve been;But, if the administrative burden continues to
increase, the good intentions underlying the
documentation requirements and other administrative burdens will ruin the appeal of VT for primary care”
Sarah Kemble MD MPH, SpringfieldSpringfield Medical Care Services - Medical directorInternal medicine, Preventive medicine, Public health
Reduce the gap between practice and policyBetter care, better health, lower costs
1. Actualize 3 planned levels of care2. Make VT a magnet for the
workforce“If you don’t know where you’re going, any
road’ll take you there”
3. Become the national benchmark for measurement
“Our shared goal should be improvement of value as defined by the outcomes that matter to patients and costs over meaningful episodes of care”
Tom Lee MD, Sept 2012
4. Reduce the gap between practice and policy
“Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it's the only thing that ever does”
Margaret Meade
Josh Plavin MD MPH, RandolphGifford Health Care - Medical Director Internal medicine, Pediatrics, Pubic health
Vermont Rural Physician Leaders CommunityPhil Brown MD, Berlin
CVMC - Chief Medical OfficerInternal medicine, Emergency medicine
Kevin Buchanan MD, RandolphClara Martin Center - Medical directorPsychiatryOvleto Ciccarelli MD, RandolphGifford Health Care - Surgical ChairpersonGeneral SurgeryDavid Coddaire MD, MorrisvilleCommunity Health Services of Lamoille ValleyMedical director, Family practiceMark Crane MD, BerlinCVMC - General SurgeryLou DiNicola MD, RandolphGifford Health Care - PediatricsJeremiah Eckhaus MD, MontpelierCVMC - Family practiceSharon Fine MD, DanvilleNorthern Counties Health Care - Medic al directorFamily practiceSteve Genereaux MD, Wells RiverLittle Rivers Health Center - Medical director Family practiceNikki Gewirz PA-C, Randolph
Gifford Health Care - General SurgeryMark Heitzman MD, BerlinCVMC - Cardiology
Sarah Kemble MD MPH, SpringfieldSpringfield Medical Care Services - Medical directorInternal medicine, Preventive medicine, Public health
Mike Kilcullen MD, WoodstockOttauquechee Health Center – Pediatrics
Dina Levin MD, RandolphGifford Health Care - Obstetrics and Gynecology
John Matthew MD, PlainfieldThe Health Center – Executive and Medical directorInternal medicine, Family practice
Josh Plavin MD MPH, RandolphGifford Health Care - Medical Director Internal medicine, Pediatrics, Pubic health
Deborah Richter MD, MontpelierFamily practice, Addiction medicine
Joel Silverstein MD, MorrisvilleCopley Hospital – Chief Medical OfficerInternal medicine, GastroenterologyPeter Thomashow MD, Berlin
CVMC – Psychiatry Chairperson Psychiatry
Sean Uiterwyk MD, White River JunctionWhite River Family Practice – Independent practiceFamily practice
Mark Yorra MD, Barre
CVMC - Internal Medicine
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