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Travel Connections Performance Improvement Leadership Development Program Lynn E. Keplinger, MD, FACP Deborah Kaplan, RN Keith Hampton, MSN, APRN, ACNS-BC February 19, 2010

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Sponsor Les Hall, MD - Chief Medical Officer

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Advisors Robert Lancey, MD Anne Fitzsimmons, MD

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Mascot

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Aim Statement One year after transferring Travel Connections to Fairview clinic we will have: Developed at least a budget neutral business within General Internal Medicine Increased MU pharmacy usage rate for Travel prescriptions from 12% to 50% Increased 0% MU identified patients to 5% MU identified while gaining 25% of the patient base into General Internal Medicine

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What is Travel Connections? A full service approach to the international traveler providing education, vaccines, prescriptions and individualized attention to particular health needs.

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Why Move Travel Connections? Timing was right Academic involvement Research potential New product line for General Internal Medicine Resident and fellow opportunities in both Infectious Diseases and Internal Medicine

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SERVICE COMMUNITY

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INFLUENCING FACTORS

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Budget Neutral Business Fixed costs Salaries Taxation Variable sources Visits Immunizations (no revenue sharing) Prescriptions Downstream referrals

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Increased Pharmacy Usage Establish relationships Memorandum of understanding drawing on Shoreland protocols Print prescriptions to Fairview pharmacy without signature Adequate medication supplies Codes developed for Fairview prescription tracking Develop reporting capability for tracking Vaccine pricing for competition

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Documentation Move from handwritten notes to electronic record Create PowerNote Encounter form creation Secondary provider noted Validate vaccinations in EMR Travel history form placed on website Receipt book

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Travel Connections Patient Encounter Form VisitCPTCharge ___Travel education general99499$60.00 ___Vaccine administration90471$12.00 _X_Facility fee754000000$0.00 Adult Vaccinations Vaccine DoseCharge Code Charge ___Immune Globulin **Travel < 3 months 0.02ml/kg IM x 165124952 $ 43.00 **Travel > 3 months 0.06ml/kg IM x 165124952 $ 43.00 ___Hepatitis A(Vaqta) 1ml IM, day 065115433 $ 75.00 1ml IM 6-18 mo.65115433 $ 75.00 ___Hepatitis B(Recombivax) 1ml IM, day 065190746 $ 31.00 1ml IM, 1 mo.65190746 $ 31.00 1 ml IM, 6 mo.65190746 $ 31.00 ___Influenza 0.5ml IM65048329 $ 13.00 ___Meningovax(Menomune) 0.5ml SC65801213 $ 147.00 ___Meningovax(Menactra) 0.5ml IM65121000 $ 144.00 ___Japanese Encephalitis 0.5ml IM day 065124967 $ 319.00 (Ixiaro) 0.5ml IM day 2865124967 $ 319.00 ___MMR 0.5ml SC65804468 $ 83.00 ___Polio(IPOL) 0.5ml SC65802597 $ 41.00 (Give dose 1&2 4-8weeks apart, dose 3 6-12 mo after dose 2) ___Td 0.5ml IM65803496 $ 34.00 ___Tdap 0.5ml IM65124509 $ 49.00 ___PPD 5TU 0.1 ml ID65363526 $ 10.00 ___Rabies(Imovax) 1ml IM day 065804506 $ 259.00 1ml IM day 765804506 $ 259.00 1ml IM day 21/2865804506 $ 259.00 Other ___Typhoid(Typhim Vi) 0.5ml IM q 2 yrs65124898 $ 69.00 ___Typhoid oral(Vivotif) 1 cap q48hrs x 4 $ 65.00 Boost q 5 yrs $ 65.00 ___Yellow Fever 0.5ml SC q 10 yrs65802571 $ 113.00 Pediatric Vaccinations VaccineAgesDoseCharge Code Charge ___Immune Globulin **Travel < 3 months 0.02ml/kg IM x 165124952 $ 43.00 **Travel > 3 months 0.06ml/kg IM x 165124952 $ 43.00 ___Hepatitis A(Vaqta)1-18 yrs0.5ml IM, day 065115441 $ 38.00 1-18 yrs0.5ml IM 6-18 mo65115441 $ 38.00 ___Hepatitis B(Recombivax)Birth-19 yrs0.5ml IM, day 065190746 $ 16.00 Birth-19 yrs0.5ml IM, 1 mo.65190746 $ 16.00 Birth-19 yrs0.5ml IM, 6 mo.65190746 $ 16.00 Laboratory Studies ___Influenza, injection 65124471 $ 13.00 (1=today/2=prior to return/3=fasting) ___Meningovax(Menactra)> 2 yrs0.5ml IM65121000 $ 144.00 ____BMP ___Polio(IPOL) primary series2 mo0.5ml SC65802597 $ 41.00 ____CMP 4 mo0.5ml SC65802597 $ 41.00 ____CBC 6-18 mo0.5ml SC65802597 $ 41.00 ____CBC with diff 4-6 yrs0.5ml SC65802597 $ 41.00 ____G6 PD ___Tdap11yrs and >0.5ml IM65124509 $ 49.00 ____Rabies IGG ___PPD 5TU 0.1 ml ID65363526 $ 10.00 Dx___________________________ ___Rabies (Imovax)Birth1ml IM day 065804506 $ 259.00 1ml IM day 765804506 $ 259.00 1ml IM day 21/2865804506 $ 259.00 Return to Clinic:______________ ___Typhoid(Typhim Vi)> 2 yrs0.5ml IM q 2 yrs65124898 $ 69.00 Immunization only ___Typhoid(Vifotif)> 6 yrs1 cap q48hrs x 4 $ 65.00 Boost q 5 yrs $ 65.00 ___Yellow Fever> 9 mo0.5ml SC q 10 yrs65802571 $ 113.00 Signature:___________________ __ Grand Total $____________

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Travel Clinic PowerNote

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Facility Renovation at Fairview Transfer vaccine refrigerator Transfer Travel Connections telephone number to Fairview Purchase a safe Set up computers to allow prescription printing Signage

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Stephens College Patient Flow

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Travel Clinic Patient Flow

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Road Blocks Negotiate with Dean of School of Health Professions regarding timing of position transfer to General Internal Medicine Construction in Fairview clinic Nurse position posting issues Obtain and purchase protocols Pharmacy printer functional Completed PowerNote

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And then the Bomb.

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A New Stakeholder Emerges Matt Levsen, Associate Chief Financial Officer

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Vaccine Costs/Charges Vaccinemark-up from costCPTCharge Code FY08 Units FY09 Units FYTD10 (Oct) Units Yellow fever single dose 150% 9071765802571000 Hep A (Vaqta) 175% 9063265115433224325163 Hep A peds (Vaqta) 175% 90633651154414,0283,4801,138 Typhim Vi 150% 9069165124898000 Adacel 175% 90715651245091,7973,2431,609 Td (Decavac)175%90714658034962,0661,608175 IPOL150%90713658025972,2561,164126

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Initial Projections Travel Connections 2008 Business Plan Projections Updated Projections Number of visits17282,200 Office visit revenue$31,773 $89,000$154,440 Vaccine revenue$68,202$86,831More than $0 Number of prescriptions1,7002,1642,600 Projected downstream revenue-$497,200

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Next Steps Monthly Monitoring Marketing Patient Recruitment into GIM Evaluate Patient Acquisition into MUHC Community Activities

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Patient Tracking Increased 0% MU identified patients to 5% MU identified while gaining 25% of the patient base into General Internal Medicine Medical Home development NCQA Guidelines for Physician Recognition Programs 9 standards 7 th standard referral tracking

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More Collaborators! Scott Barger Debi Bell Diane Bernard Beth Bernt Joe Cameron Gordon Christensen Janet Collins Adam Cullina Kevin Dellsperger David Fleming Nancy Forrest Kim Grissum Paula Heaviland Robert Hodge Tammy Kemp Matt Levson Liz Lukehart

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Even More Collaborators ! Stephanie Lumley- Hemme Bill Martin Del McMillan David Mountjoy Richard Oliver Penny Paisley David Parker Sharon Rafferty Dick Schaefer Don Scharlott Neil Schmidt John Schoemehl Mari Beth Schultz William Sparks Herb Stanley William Steinmann Abby Tuttle Tim Waller Amy Watring

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Special thanks to Stephanie Lumley- Hemme