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Luncheon Panel. Health Care Transformation. The journey toward a medical home in Harlan, Iowa Don Klitgaard, MD, FAAFP MMC Medical Director With Duane Magee, patient. Goals of our discussion. Process of transformation – what have we been doing in past 2+ years to become a PCMH

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health care transformation

Luncheon Panel

Health Care Transformation

The journey toward a medical home

in Harlan, Iowa

Don Klitgaard, MD, FAAFP

MMC Medical Director

With Duane Magee, patient

goals of our discussion
Goals of our discussion
  • Process of transformation – what have we been doing in past 2+ years to become a PCMH
  • Physician experiences with changes
  • How has this affected the patient experience?
  • What have we learned so far through the process?
who are we myrtue medical center harlan ia
Who Are We?Myrtue Medical Center – Harlan, IA
  • Critical access hospital/rural health clinic system, integrated since 1991
  • Medical staff – 7 Family Physicians, 1 Med/Peds, 1 general surgeon, 3 PAs, 2ARNPs
  • Nursing staff – 35, Office staff - 22
  • Main clinic in Harlan, community of 5200 in rural Iowa, and 3 satellite clinics in Avoca, Shelby and Elk Horn
  • Full scope of practice – Inpatient, ER, NH, OB, procedures, clinic coverage
practice demographics
Practice Demographics
  • 20,787 active patient e-records
  • Newborns to 107 year olds
  • Wellness to acute illness to chronic disease care
  • 38,000+ clinic visits in last year
  • $6.5 million gross clinic revenue
  • $159,000 net clinic income
  • Payors – 39% Medicare, 30% Wellmark BC/BS, 20% other commercial insurers, 7% Medicaid, 4% self-pay
where we started in 2005 06 ripe for practice level change
Where we started in 2005-06 – ripe for practice-level change
  • Interim, then new CEO
  • No clinic manager
  • Nurses union turmoil – large nurse turnover
  • Many failed practice improvement projects
  • Failed EHR implementation/lost IT staff
  • Stressed Medical, office, and nursing staff
  • We want to improve and change but we know that we need help to do it!
the imperative to change
The Imperative to Change

According to the Future of Family Medicine Report:

“unless there are changes in the broader healthcare system and within the specialty, the position of family medicine in the United States may be untenable in a 10-20 year time-frame, which would be detrimental to the health of the American public.”

do we really have to change
Do we really have to change?
  • “You don’t have to change, survival is optional”, C. Edwards Deming
enter the transformed ndp
Enter the TransforMed NDP…
  • What is it about? (vision)
  • What changes are we making through it? (process)
  • What are we learning through the process? (outcomes)
transformed mission
TransforMED Mission

The mission of TransforMED is to lead and empower family physicians in implementing the new model of care

the transformed project
The TransforMed Project
  • AAFP-funded National Demonstration Project - $8 million initial investment
  • Applied January 2006
  • Selected April 2006
  • 24 month project began June 2006 and ended May 31, 2008
  • Evaluation period will end December 2008
national demonstration project
National Demonstration Project

36 sites from around the country were selected to study the new model.

These practices were randomly assigned to

one of two groups

  • 18 facilitated practices will engage in a transformative process to fully implement a new model of care
  • 18 self directed practices will be provided the information to implement the model of care in a self directed manner.
goals of the ndp evaluation
Goals of the NDP Evaluation
  • To generate and disseminate new knowledge about the process of practice transformation.
  • To evaluate and compare the effects of two transformation approaches (i.e., facilitated vs. self-directed) on practice and patient outcomes.
goals of the ndp evaluation1
Goals of the NDP Evaluation
  • To determine the effect of the New Model (PCMH) implementation on the following:
    • Patient outcomes
    • Patient-centered care
    • Staff/physician working relationships
    • Financials of the practice
what we agreed to
What we agreed to:
  • Implementation - all aspects of the New Model during the 24 months
  • Evaluation – staff/patient satisfaction surveys, clinical/chart reviews, financial reviews, etc.
  • Dissemination – lessons learned during the NDP will be shared in many venues
  • Staff commitment – lead physician and staff member for learning collaboratives in KC, monthly phone conferences, ongoing e-mails, on-site visits with TransforMed staff
what we received in return
What we received in return:
  • A worthy vision – gets to the heart of medicine, especially FM/primary care
  • Practice Enhancement Facilitator – 1 for each 6 practices
  • Exposure to best practice ideas in all areas of practice redesign
  • Ongoing consultant support
  • Some specific IT product assistance
patient experience pcmh concept
Patient experience – PCMH concept
  • Concept make sense?
  • Importance to patients, families, employers, community
myrtue medical center clinics projects
Myrtue Medical Center Clinics Projects
  • Where to start?
  • How do you eat an elephant….?
  • Prioritized by :
    • Easy wins/low-hanging fruit – needed practice at team design and needed confidence-builders
    • Largest obstacles to improved care earlier
    • What made sense in the big picture – some projects built on others
our transformation process where and how to start
Our transformation process – where and how to start
  • Team building/Vision sharing – soft, but critical
    • Main focus in the first 2-3 months
  • Honest Self-Assessment – brutal reality check
    • First month
  • Goal development/Timeline setting
    • Started thinking about and discussing right away, details gradually took shape over the first 3-4 months
our transformation process overview of the projects
Our transformation process - Overview of the projects
  • Projects – the work starts in earnest
    • Staff empowerment/redesign
    • Advanced Access Scheduling
    • EHR Implementation – Oh, the pain……….
    • Clinic process review
    • Chronic Disease Management
    • Clinical decision support/Point of care reports
    • Wellness integration
myrtue medical center clinics current projects
Myrtue Medical Center ClinicsCurrent Projects
  • Staff redesign/empowerment –
    • Daily nursing huddles – easy/effective
    • Lead nurse selection and development
    • Clinic manager – critical missing element
    • Immunization nurse – improved efficiency
    • Health coaches/Chronic Disease Management nurses – manage registries, proactive care;
myrtue medical center clinics current projects1
Myrtue Medical Center ClinicsCurrent Projects
  • Open Access/Advanced Access Scheduling
    • Accurately matching supply with demand
    • Started with a 2 week internal study of
      • Supply – hours available by provider by day
      • Demand – appointments requested by provider and as a whole
    • Gave us an accurate picture of problem times – supply/demand mismatches
    • Made changes in scheduling to help – opened more open slots on busiest days/times, added evening hours
    • Continual reassessment and revision process
    • This can now drive good decisions on need for more staff as well as how to handle holidays, vacations, crunch times better
patient experience access
Patient experience - access
  • Open/Advanced access
  • Extended hours
  • Saturday hours
  • Impressions of access changes?
myrtue medical center clinics current projects2
Myrtue Medical Center ClinicsCurrent Projects
  • EHR implementation/use – go live was 2/07
    • HUGE change for all, especially Med Staff
    • Planning, planning, more planning crucial – 2 yrs
    • Many benefits
      • Intraoffice e-messaging
      • E-prescribing
      • Real-time documentation with templates
      • Expanded access to information
    • Allows for a new level of population-based care, point of care improvements, etc
    • An extremely useful tool, but not an end
patient experience technology
Patient experience – Technology
  • EHR
  • E-prescribing
  • Change in patient experience – laptops, information access, rxs
myrtue medical center clinics current projects3
Myrtue Medical Center ClinicsCurrent Projects
  • Clinic process review - started asking many hard questions
    • How does information flow around our office? How should it flow in an efficient, effective medical home? Who does what process, and should they?
      • rx refills, NH questions, phone messages, lab results
    • How can we as a Medical staff make group decisions to make our staff’s days (and patient’s care) better?
      • Standardized care - templates, flow sheets, standing orders
      • Moving towards true team care of patients – especially those with chronic diseases
    • Not easy, but big returns in efficiency!
myrtue medical center clinics current projects4
Myrtue Medical Center ClinicsCurrent Projects
  • Chronic Disease Management /Population Management/Health Coaches
    • Diabetes, asthma, hypertension, CHF……who?
    • First had to develop disease registries – not easy
    • Foster a true team approach to care – OUR team of physician, nurse, scheduler, health coach (as opposed to calls from insurer’s nurse, CMS reviewer, etc.)
    • Allows flexibility – simple reminder calls to lengthy face-to-face interventions, either planned or opportunistic
    • Health Coaches to monitor populations of patients – get them in for needed care, provide proactive interventions, help give patients more empowerment and control
    • HUGE potential for improved care
patient experience chronic disease management
Patient experience – Chronic disease management
  • See value with family, as employer?
myrtue medical center clinics current projects5
Myrtue Medical Center ClinicsCurrent Projects
  • Clinical decision support/Point of care (POC) reports – 2008?
    • Offers enhanced disease registry functions not available in EHR
    • POC reports based on EHR data run through a protocol engine
      • Single page report
      • Makes visits much more productive
      • Easily identifies needed care
      • Can delegate which things nursing can do by standing order and which a physician should discuss with the patient
    • When paired with CDM, much potential for large improvements in patient/population care quickly
    • However, another level of technology – cost/interface barriers
patient experience point of care reminders
Patient experience – Point of care reminders
  • Would you like this?
  • See benefits as patient?
myrtue medical center clinics current projects6
Myrtue Medical Center ClinicsCurrent Projects
  • Financial review
    • Individual physician and group finances evaluated
      • Offer insights into possible areas of improvement
    • Highlights the need for ongoing dialogue and education of the medical staff about business, billing and coding issues
      • Emphasizes the underlying inherent conflict in many physicians between the business of medical practice and the practice of medicine – “just let me take good care of my patients”
myrtue medical center clinics current projects7
Myrtue Medical Center ClinicsCurrent Projects
  • Office Redesign – in process
    • Satellite clinic remodels
    • Plans for major clinic overhaul to optimize care under the PCMH model
  • Wellness integration – in process
    • MMC funding/leading community Wellness Center project – open late 2009
    • Will offer many opportunities to encourage wellness and integrate into our practice
patient experience wellness
Patient experience – Wellness
  • Impressions from a parent, school administrator, individual
continuing toward a pcmh future projects
Continuing toward a PCMHFuture Projects
  • Website enhancement/Patient portal
    • Scheduling and refill requests
    • Electronic bill pay
    • E-visits/e-mail communication
    • Secure lab results
    • Collect PMH on-line
  • Referral tracking – “Trudy”
  • Enhanced communication with hospitals/specialists
  • Kiosks in office – check-in, update demographics, enter symptoms, instant claims adjudication……
  • The list keeps growing!
patient experience website etc
Patient experience – Website, etc
  • Would you use and anticipate other to also?
our transformation process
Our transformation process

Ongoing assessments – metrics

  • Metrics, common in business, are largely unused in most smaller practices
  • Wait times, staff satisfaction, patient satisfaction, billing/coding reviews and improvements, individual physician and practice level financial assessments
  • Very helpful internally to identify opportunities, gauge process change effectiveness
  • If not understood completely and used punitively, will derail progress – measuring complex process





March, 2008

June, 2007

so what have we learned at mmc and in the ndp
So………what have we learned?(at MMC and in the NDP)
  • Change is hard and slow
    • Transformation on many levels
      • of practices – culture change
      • of physicians – personal change
      • of patient expectations
    • Practices not used to system-level changes
    • Personally, I think this will be a 3-5 year process, even with a motivated, unified practice with adequate resources
what have we learned
What have we learned?
  • Relationships matter
    • Practice’s capacity for change and ability to follow through is heavily dependent on strong relationships within the practice
    • Need to build and foster strong relationships on all levels to be successful with changes
    • Especially important at times when practice under much stress – i.e. EHR implementation
what have we learned1
What have we learned?
  • Medical practices are extraordinarily complex
    • Small changes often have large impacts
    • Large, difficult changes may be necessary but have small impacts overall
  • Change management is an essential skill that practices need to be successful
    • Eidus’ theorum of change difficulty
what have we learned2
What have we learned?
  • Leadership is Key
    • Need strong leaders in all areas
      • Physician/mid-level
      • Clinic manager/nursing
      • Administration/financial
      • IT systems
    • If not all on the same page, ability to make changes hampered or halted
what have we learned3
What have we learned?
  • Transformation has to happen on the personal level also
    • Is a gradual change from physician-centered thinking and office practices to team-based, patient-centered care
    • This is just as hard as (or harder than ) the practice-level process changes
what have we learned4
What have we learned?
  • Technology has great potential, but several problems limit it’s current usefulness and widespread implementation.
    • lack of interoperability
    • Expense
    • amount of resources and energy needed to make things work together
what have we learned5
What have we learned?
  • PCMH is more than the sum of its individual parts
  • Measurements (NCQA, etc) are important and get at many parts of the PCMH, but not the full essence
  • Medicine is art in addition to science
  • Patients want healing, not just diagnosing or curing
the old model of care doesn t make sense in the pcmh context
The old model of care doesn’t make sense in the PCMH context
  • Coordinated, not just episodic care
  • Proactive, not just reactive care
  • Emphasis on achieving and maintaining wellness, not just treating illness
  • Team-based care
  • Comprehensive care
  • We need high tech and high touch
many current national trends align well with the pcmh model
Many current national trends align well with the PCMH model
  • Emphasis on quality and transparency
    • Patients, employers, CMS, payors, health systems
  • Emphasis on patient-centered care
    • Convenient, timely, patient-friendly
  • Emphasis on technology – not just in our practices but in individual patient’s lives
    • Google Health,, WellMark/UHC, etc. will change health care perceptions and expectations
  • Emphasis on practice redesign/innovation
    • PCPCC, TransforMed/AAFP, IHI
  • Emphasis on wellness promotion/disease prevention
where does that leave us
Where does that leave us?
  • Buyers of care should find what they have been buying unacceptable
  • Providers of care should find it unethical and even immoral to continue to provide episodic, uncoordinated care
  • Patients should be at the center of a redesigned system that needs both:
    • Transformation of medical practice
    • Reformation of payment for care to support it
how do the participating practices feel about the transformed ndp
How do the participating practices feel about the TransforMed NDP?
  • Extremely excited and encouraged
  • Much harder than we thought initially
  • Absolutely worth it and imperative!
  • Privileged to be part of the process
how can stakeholders help
How can stakeholders help?
  • Support/fund pilot projects
    • Need to include PCPCC blended payment model
      • Continued fee-for-service
      • CDM fee
      • Additional P4P incentives
  • Support those working to affect change
    • Funding educational efforts, learning collaboratives
    • Tap into national/state primary care academies
  • Support innovators/early adopters
    • Technology improvements
    • Support for PCMH concept in your sphere of influence
  • Support Primary Care education
    • In medical schools, primary care residencies
website resources
Website Resources
  • Patient-Centered Primary Care Collaborative –
  • TransforMed –
  • AAFP –
  • Center for HIT –
  • Institute for Healthcare Improvement –
  • Iowa Healthcare Collaborative –
  • Myrtue Medical Center –
contact information
Contact information
  • Don Klitgaard, MD
  • 1220 Chatburn Avenue
  • Harlan, IA 51537
  • 712-755-5130 (PCMH)
  • 712-579-1911 (cell)