SMARTCARE-Innovation in Care Delivery

1. SMARTCARE-Innovation in Care Delivery AMIA Primary Care Work Group Symposium Deepti Pandita MD Consultant , Internal Medicine Chair, Physician Informatics Park Nicollet-Health Partners Health system. Minneapolis , MN

2. 25,000 employees 1,800 physicians 60+ dentists 6 hospitals 50 primary care locations 22 locations 1 transitional care unit 1,800,000 members 1,200,000 patients 55+ specialties

3. What would Primary Care look like if you could design care without payment in mind? SmartCaremodel How far can we push the model, while continuing to focus on the quadruple aim?

4. Why Change ? • Patient experience  shifting expectations • Access to care • Convenience • Variable informed consumer (the good and the bad of the internet) • Health Care Cost • Fragmented care • Inefficiencies, service duplication • Impact of EMR on care delivery • Paradigm shift in thinking • Workforce development • Sustainability Because we have to.

5. Established January 4, 2016

6. What is Smart Care? • A new primary care clinic that uses an innovative model to deliver care while focusing on: • Quality • Affordability and Price transparency • Convenience and patient experience • Sustainability • Innovation

7. Smart Care Clinic Features • Full-service primary care clinic • Preventive care • Chronic disease management • Acute health care needs • Ages 12 and up • Take all insurances that cover Park Nicollet

8. SmartCare • Full-service primary care clinic staffed by: • Physicians • NP/PAs • RN Clinicians • Offer in-person visits, plus: • Phone visits • Video visits • E-visits

9. Smart Care Team & Roles RN Clinician: NP/PA: MD: Independently treat simple, acute conditions using standing orders with MD oversight Less expensive than other retail offerings Care navigation function Preventive health exams (Physicals) Stable chronic condition management Care planning Less expensive visit when compared to MD Reserved for high acuity patients or those with complex conditions Resource supporting RNs and NP/PAs

10. What is different about Smart Care? • Maximize use of care delivery options other than traditional in-person visits • Scheduled telephone visits • Secure video visits and e-visits • Care team expansion • You don’t have “a doctor,” you have a care team • Shared panel • Shift care whenever possible to most appropriate level clinician • Consistent offering of extended hours • 7-7 Monday through Friday, 8-12 on Saturday • Price transparency • EMR is a part of our team. We embrace it.

11. Smart Care Business Model • All clinicians salaried • It changes what you think about • Immediate escalation of care when needed • Patient receives one bill at highest necessary level • Significant differentiator from retail care • Only 8 exam rooms • Small footprint • Shared “team space” to facilitate collaboration • Shared Visits • Even “Switched” visits

12. Affordability • Pre-visit planning for all visits • Placing the patient into the right level of care • Offering different visit types that may be a fraction of the cost • Less specialty referrals and UC/EC visits = Affordability to patient and decreased TCOC

13. Addressing Quality • Clinical quality: • Park Nicollet is a state leader in many Minnesota Community Measures • Consistent Pre-visit planning • Consistency in documentation • Everyone knows where to look for the required information • Consistency in treatment plans • Clinician agreement – required for a shared panel • Making it easier for patients to follow through with treatment plans • Improved access • Better communication, follow-up

14. What we expect to see.. • We expect to see a loss in fee-for-service revenue • Supporting new role of RN Clinician • Lower reimbursement for video and telephone visits • We anticipate a lowered risk adjusted Total Cost of Care. • Long term goal may consider benefit design; employers may offer this as a benefits option, or perhaps a product on an exchange( UHC and BCBS considering this)

15. Innovation Always thinking of new and better ways to deliver care • Texting for phone visits • Direct patient scheduling for phone visits • Less specialty referrals • Medicare annual wellness visits done by RNs • Fall ATP focusing on role of the RN clinician

16. What patients notice • “In SmartCare the patient’s situation dictates the deployment of staff vs. a traditional clinic that decides how the staff are deployed and forces the patient through that system” • More efficient staff utilization • Patients treated as they need, not as the clinic needs • Staff roles are flexible • Square pegs not forced into a round hole • The patient experience is much more personalized. Not a pass off from role to role (handoffs)

17. “They worked to make time for me and got me right in. I was not expecting that. Answered all my questions and calmed my concerns.” “I'm really impressed with Smartcare. Everything from scheduling, to checking in, to conversations with the nurse and doctor was excellent. Thank you!!!!!!” SmartCare Patients

18. “I NEVER in a million years would expect to hear, stop by tomorrow and the next day if you can so we can check on progress. Just walk in...we will wedge you in with someone and if the Dr. needs to be alerted we will do it. If you're capable, meet the problem where you find it and solve it on the spot. DON'T pass it to the next overburdened person”

19. Sustainability • SmartCare team approach allows for: • Increased flexibility in hours/scheduling • Ability to leave work at work • Team members feeling they have the resources they need to be effective and satisfied with work • No “pajama time” work-shared in basket and shared documentation ensures work gets done on time.

20. How they got care • ~60% of care provided by non MD • 17% of total visits “scheduled phone visits” • Expect this to grow as we build our panel • Also an underestimate- not capturing RN phone visits • 5% RN visits • 4% video visits, 8% e-visits

21. Comparison

22. Preliminary • Diagnosis codes in SmartCare similar to other PC clinics at Park Nicollet Health Services  ---- meaning we have not cherry picked only healthy patients • Reported TCI of .73 ,ACG index 1.29 • Sample size approx. 3000 patients

23. SmartCare stats (One year Stats)

24. Patient satisfaction-one year stats

25. Work RvU generation

26. Quality Metrics

27. Quality measures

28. What Did not Work • EMR does not support “team “ in PCP Field • How do you attribute Quality Measures and Pay for Performance? • Patient confusion regarding Self Scheduling with a Team • Patient Portal not friendly to support this model • Shared learning around patient behavior regarding “Care Teams”

29. Quick Wins • Provider Satisfaction –Home on Time!! • Patient Satisfaction-problem addressed same day, usually within 30 minutes • Consistency of care-Developed Templated Protocols that are easy to use for common conditions • Extended hours are a huge win • Reduced TCC-Insurances noticed us!!

30. Long term (1-2 years) • Scaling and adding clinics in north and south regions • Adding full spectrum pediatrics • Accepting self pay patients • Adding “mini smart care” models at other PC sites • Offering Smartcare as a standalone insurance product