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The Harvard Vanguard Medical Associates LEAD Story

The Harvard Vanguard Medical Associates LEAD Story. Continuously Building Upon Innovation…. Since HCHP opened the doors in 1969, we have a strong history and culture of innovation…with an emphasis on the delivery of high quality care. Hypothesis for Health Care Transformation.

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The Harvard Vanguard Medical Associates LEAD Story

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  1. The Harvard Vanguard Medical Associates LEAD Story

  2. Continuously Building Upon Innovation…. Since HCHP opened the doors in 1969, we have a strong history and culture of innovation…with an emphasis on the delivery of high quality care

  3. Hypothesis for Health Care Transformation Payment & Coverage Reform (Finances/Economics) Redesign Clinical Care Delivery (Care Model Paradigm) + + Engagement of Multiple Stakeholders = Transformational Change in Health Care

  4. Clinical Outcomes Goals Measurably improve outcomes of our patients with: (1) Obesity (2) Cardiovascular Risk Hypertension / Diabetes / Dyslipidemia /Tobacco Use (3) Depression

  5. The Case for Redesigning Ambulatory Care Schroeder S. N Engl J Med 2007;357:1221-1228

  6. Patients’ behaviors are most critical determinant of health. • Patients’ behaviors are most costly determinant of health care. The Case for Redesigning Ambulatory Care Engage patients in healthful behaviors

  7. The ‘3rd Paradigm’ of Care & Between Visit Care HospitalClinicHome/Work/Play (1st Paradigm) (2nd Paradigm) (3rd Paradigm) LEAD Late Stage & Acute Care High Complexity High Cost Less patient participation Early & Mid Stage of Care Less Complexity Less Cost Moderate patient participation

  8. Changes in Pre-Visit, Visit & Post-Visit Pre-Visit Labs Demographic & PCP Verification Medication Reconciliation & Health Maintenance Update Streamlined & Service-oriented Check-in Process Included improvements to the “late patient” process, printed receipts, insurance card scanning, welcome packets for new patients, kiosks… Visit Medical Assistant Medication Reconciliation & Allergy Verification Use of “walkie talkies” for clinician-MA handoffs Post-Visit After Visit Summary (also available on MyHealth) Care Coordinator Role Cross-booking into specialty appointments & radiology

  9. Health Risk Assessment Tool Administer behavioral risk assessment at all physicals Physical Activity 58% sedentary Depression 33% dysthymic or depressed Nutrition 74% risky nutritional behavior Provide EPIC supports to document plan of care Deliver personalized, written instructions after patient visit Match patient to appropriate treatment option Monitor progress between visits

  10. Clinical Outcomes Interventions Prescriptions for Healthy Living Health Coach Virtual Nutritionist

  11. Use of the After Visit Summary: 2008

  12. MyHealth Enrollment

  13. LEAD Clinical Outcomes P Value = 0.091 0.17 0.5 0.042 0.42

  14. LEAD principles, approaches to change, operational processes and clinical tools have become integrated and infused into Harvard Vanguard Medical Associates . . . Transformation & Sustainability

  15. LEAD and HVMA 2009 Strategic Goal Development

  16. Reflections . . . The future we predict today is not inevitable. We can influence it, if we know what we want it to be… We can and should be in charge of our own destinies in a time of change. Charles Handy The Age of Unreason

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