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Quality Update - Health care quality issues for Minnesota's health care leaders

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Transforming to Achieve Patient-Centered Outcomes

Solutions focused across the care continuum

Eye flowchartValue-based payment models are pushing organizations toward the disruptive innovation of patient-centered care across the continuum.

Minnesota shows a relatively high level of adoption of value-based payment models. According to the Minnesota Business Partnership, the state is tenth in the nation in the share of Medicare beneficiaries covered by Medicare ACOs, and 43 percent of the state’s primary care practices are certified as medical homes.

Early experimentation in these models has helped organizations understand the transformation needed. A full commitment to value-based care requires the business to align care delivery, financial management, and technology resources across settings of care. Those committed to value-based care are restructuring and changing culture.

New business structure

Organizations committed to value-based care have a strong central governance structure with physician leadership and engagement across the care network.

Over the last couple of years, HealthEast has moved from vertical silos to a holistic approach across the entire organization. “We went from individual responsibility for success in our business units to having a single strategic business unit across the whole continuum,” said Cathy Barr, senior vice president and chief operating officer at HealthEast. It extends from primary care to specialty clinics, hospitals, home health, hospice, and the EMS division.

Similarly, Lakewood Health System, a rural health system, restructured three years ago to eliminate silos and focus on improving value to patient. "The hospital, clinics, and care center all had their own worlds,” shared Tim Rice, Lakewood Health System, president and CEO. “Even though they worked well together, we restructured them all under one division and one leadership team, to drive value-based care.”

Measure alignment

This level of integration requires investment in data analytics and reporting capabilities. Internal and external sources of clinical and financial data need to be married and used for longitudinal management of risk.

Quality is under one leader no matter where you are in the Lakewood Health System. Six care coordination workgroups— care coordination, IT governance, quality, patient experience, payer relationships, and community health—report into a single value council. A consolidated scorecard brings together the measures of its six workgroups and serves as an overall driving mechanism.

HealthEast uses a balanced scorecard with true north metrics of clinical quality, employee/physician satisfaction, patient experience, and financial performance. “We are aligning our quality improvement initiatives with our payer incentives, from MSSP (Medicare Shared Savings Program) and various commercial products,” Kevin Garrett, MD, HealthEast senior vice president and chief medical officer, added. “This alignment is across the entire continuum.”

Its clinical quality pillar is driven by a “flawless care” metric—a set of about 70 individual process and outcome measures, which cross care settings. “We needed to broaden our focus to a market basket of measures for flawless care that truly engages people across the continuum,” Barr noted.

Every week, the health system completes a prescriptive, three-phase review process using frontline huddles, a business unit roll up, followed by executive leadership team review of the entire organization.

Just ending the first year of its flawless care philosophy, HealthEast saw a 10.4 percent year-over-year improvement in its quality measures, exceeding its goal of two percent improvement. Next year’s goal is four percent.

Care delivery redesign

Health care organizations are reimagining and redesigning care delivery. HealthEast and Lakewood are using multidisciplinary teams in primary care to serve as care coordination hubs for patients across care settings.

Teams consist of physicians, physician assistants, psychologists, social workers, diabetes educators, and others who are needed to support patients. These multidisciplinary teams increase value for the patient and reduce the workload on providers by distributing responsibilities to all the members of the team. They allow physicians to focus their time and skills, while the rest of the team supports the other aspects of care.

Both health systems have started to remodel physical spaces to enhance communication and connection for their multidisciplinary teams.

Lakewood Health System, one of the first to adopt the Medical Home model, is extending the approach to all of its patients. It is bringing care coordination to the entire system from clinics, the care center, to home-based services. Rice said, “Results showed the Medical Home approach improved quality, patient and provider relationships, reduced admissions and ER visits, and helped address medication use. Why not do that for all of our patients?”

The system is growing its technical capabilities for care management across the continuum. Participating in the MSSP ACO of Essentia Health provided Lakewood access to a robust electronic health record system that gives Lakewood the ability to integrate data to gain further insight into its quality of care, and links care coordinators to patients to manage their overall health and wellness. The system is now testing and validating data consolidated through its population health software to support care coordination. “It’s been a three-year journey. I think we are just now getting to the point where we are comfortable with the data and we can do more with it,” said Rice.

Culture of innovation

Comparative performance data offers benchmarks for achievable levels of care and drives compensation in value-based payment programs. Reaching or staying ahead of the curve requires innovation.

HealthEast is using a Lean-based approach to continuous improvement. Physician leaders are paired with an administrative partner to align and cascade the system's Lean methodology, goals, and objectives to all providers and non-providers. The system recently celebrated a milestone of 100,000 ideas submitted overall by frontline staff, providers, and non-providers, on how to improve, enhance or be more efficient in the work that they do.

Lean improvement activities, such as Kaizen workshops take place across the system. During a Kaizen event, multidisciplinary teams come together for a week to work intensively on making significant improvements to a process or set of standards. Customers are always invited to participate. Non-owned organizations in the value chain have participated as well, such as a senior care organization for wound care and medical device companies related to the cardiac catheterization lab.

“We try to scale up very quickly if ideas are proving to make sense,” said Garrett. “We try to generalize care management approaches to the entire population and scale them up as rapidly as we can. We want to have one standard of care.”

HealthEast is rapidly identifying and testing new ideas using clinics as incubators. It has started a process of periodically designating one of its 14 locations as a “model clinic.” The location serves as a learning lab for continuous improvement activities. The model clinic chooses different areas to work on and holds Kaizen learning cycles every couple of weeks. Kaizen teams take about 15 percent of the clinic’s staff offline for a week.

Ideas that test successful move through two waves of spread and adaptation across all of the other clinics. This phased scaling allows for additional learning and adaptations.

Uncertainty

Health care strategists acknowledge there’s uncertainty as reimbursement models evolve. But, they advise organizations to continue moving along the path to valuebased care. The structural and cultural shifts needed are extensive. Delays in building toward transformation may leave organizations playing catch up.

“You have to start early if you are going to be ready for payments based on value,” said Rice. “It takes a lot of time to really transform into a whole new model of how you view, deliver, and effectively execute on value.”