REINVENTING HEALTHCARE: The Evolution of the CHC Model of Care

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REINVENTING HEALTHCAREThe Evolution of the CHC
Model of Care

• Mark Murray, MD, MPA
• Mark Murray Associates
• Sacramento, CA
• 916-441-3070
• fax [phone]

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History and Development

• History
• Unique mission
• Defined structure/governance/set of regulations

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Goal

• BPHCfunded Health Centers will be recognized as
  the model for quality primary health care in the
  United States for 16 million patients.

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How can this be accomplished?

• Recognize the product and the business
• Identify the customer
• Respond to the customer
• Build from that platform
• Align all stakeholder incentives in order to
  accomplish goals

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Current Status

• Disparate programs
• Indistinct boundaries
• Confusion
• Semi-successful attempts at redesign/chronic
  care model
• Loose federation of structures/ideas/operations

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Critical Commonalities

• Serve the underserved
• Product is healthcare in the context of
  relationship
• Everything else is architecture, infrastructure
• Match and balance demand for service to the
  supply or resource for that service

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Building Blocks
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Building Blocks plus Infrastructure
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Current Healthcare Realities

• Introverted/introspective
• Delay
• Metrics demand, supply, activity, gap, variation

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Terms

• Demand what the customer wants/what we should be
  doing
• Activity what we are doing
• Supply what we could be doing
• Backlog what we should be doing but havent
• Wait list/queue/work in progress/inventory/warehou
  sebacklog
• Constraint/bottleneck the rate limiting step

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Why are Delays Important?

• Patient satisfaction
• Staff satisfaction
• Provider satisfaction
• Increase cost
• Reduce revenue
• Adverse clinical outcomes
• Perception that delay means lack of resource

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Why do queues form?

• Demand gt Supply
• Variation
• Paradigm
• Buffer for revenue, for predictability and for
  assurance of 100 utilization (false
  productivity)

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Demand gt capacity
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Sources of demand variation

• Randomness of presenting patients
• Randomness of clinical condition/acuity/time
• Randomness of internally generated demand
• System factors (includes discontinuity, future
  open schedule, etc.)

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Sources of supply variation

• Lack of time in/out policies
• Number of providers
• Pattern of providers
• Carve outs that restrict flexibility
• Other system constraints (rooms, staff,
  equipment, etc.)

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Moment of truth

• Even if the average demand average supply
• The variation of demand, plus the variation of
  supply
• Will result in a queue

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Demand capacity for breast clinic
Number
60
40
20
0
Week
3 January 2000
22nd January 2001
Total number of patients referred
Number of clinic slots available
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Computer model demonstration
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Access to Care Platform
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Access Issues

• Access problem is a delay problem
• Delay is systems problem

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• Every system is designed perfectly to get the
  results it gets

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Critical Design Elements

• Continuity
• Capacity

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Access Models

• Traditional
• Carve Out
• TWT (Todays Work Today)

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Paradigm Shift

• Old
• In order to protect today, we push work to
  tomorrow.
• New
• In order to protect tomorrow, we pull work into
  today.

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Results

• Patient satisfaction improved
• Staff satisfaction improved
• Provider satisfaction improved
• Delays reduced
• Continuity improved
• Quality improved
• Unnecessary visits reduced
• Financial improvement

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Physical Exams
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Number of Days for 3rd Available Routine
Appointment
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Alaska Native American Health Care Pediatrics
1
2
5
6
3
7
4
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Match with PCP2-Year Comparison
Avg. 72
of Match
Avg. 59
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Improved Clinical Outcomes
2000 1Q
1999 Q4
1998 Q4
Interventions ? Health prompt ? Continuity ?
Advanced Access
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Change in Visit UtilizationApril 1995 - March
1997Sacramento
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Over and Under Appointments
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Improved Finances Average per month over 1 year
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Improved FinancesAverage per month over 1 year
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Process and Principles

• Team
• Aim
• Change
• Measure

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High Leverage Changes for Access Improvement

• Balance demand and supply daily
• Reduce backlog
• Decrease appointment types
• Develop contingency plans
• Reduce demand for visits
• Increase the supply

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High Leverage Changes for Office Efficiency

• Balance the demand and capacity for non
  appointment work
• Synchronize patients, providers and information
• Predict and anticipate needs
• Optimize rooms, equipment and staff
• Manage the constraints

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Operational Level
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Fundamentals

• Product
• Customer desire
• Continuity
• Capacity
• Incentive
• Patients cant wait
• I see my patients

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Stakeholders and Alignmentof Incentive

• Patients
• No waits
• Continuity with Provider
• Organization
• Maximize throughput
• Optimize revenues
• Grow the panel
• Providers
• See own patients
• Payers
• Value for payment
• Maximize panel

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Alignment of Incentive / Shift in Thought

• Delay is critical
• Leadership
• Move away from visits as value to panel as value
• Output equity to input equity

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Fixed Points
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Unfixed Points
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Challenges in Shiftto Panel from Visits

• Practice variation
• Financial implications
• Visits for current patients will be reduced
• Leadership inspires the mission

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Panel Size
Well open Poor Over full
Poor
Well
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Effect of Reduced Visits
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Replacement with New Patients
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4200 Visits

• Goal
• Outcome

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Equation

• Panel x visits per year
• equals
• provider visits per day x provider days per year

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Equation
P Panel Pt. V. Patient Visit Pr. V.
Provider Visit D Days
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Panel SizePanel X visits/year Appointments/day
X days

• Continuity
• Return rates
• Non visit care
• Telephone
• Max packing
• Group Visits
• Care Team
• Number of part-time providers

• Distribution of appointments
• FTKA
• Support
• Clinical FTE expectation
• Bookable hours
• Appointment Length
• Documentation templates

• Clinical FTE expectation
• Other activities

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Benefits

• Respond to customer
• Respond to mission
• Expand Access (16 million)
• Break away from marginalization
• Optimization of clinical care

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Clinical Care

• Only optimized when delay reduced
• Preventive
• Chronic care
• Early detection
• Mental health

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Chronic Care Model
Health System
Community
Health Care Organization
Resources and Policies
ClinicalInformationSystems
DeliverySystem Design
Self-Management Support
Decision Support
Prepared, Proactive Practice Team
Informed, Activated Patient
Productive Interactions
Improved Outcomes
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RESULTS

• Improved compliance with preventive guidelines
• Improved care for patients with chronic illness
• Improved early detection

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Diabetes Registry
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Lipid Profile Each YearPercent of participants
with a lipid profile.
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LDL Levels Percent of participants with a most
recent LDL level lt130mg/dl.
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Partial Success

• Redesign
• Chronic Care Model

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More Complete Success

• Start with product, business and customer
• Consider no delays ( access to care ) as a system
  property
• Panel management, not visit management in order
  to align incentives
• Adjust panels if needed promote growth
• Salary plus variable pay based on a compass