Accountable Care

Primary Care: Are You Busy Or Effective (or Both)?

May of 2018 we turned on dashboards on the Value of Care for a group of 400 providers. On the dashboard the scale of 0 – 100, a 70 was considered “good value,” below this there were significant opportunity for higher value care. The average score for our providers was 35.

Within hours the phones began to ring – “my care is better than this,” “my dashboard is wrong,” “your data is incomplete” – the general sentiment was “I am making a bigger difference that you are saying I am.”

Let’s look at the facts – they were busy – usually filling their schedule to 80+%, moving through the day giving 100% to each person sitting before them. At the end of the day going home feeling tired but sure of their contribution to their patients. They must be high quality, effective, and their patients are benefiting based on days, months, and years of committed work.

So why the relatively low scores? We set up teams to investigate. The ability to click down to a member level allowed the providers to see what was going on with their patients. Were the patient really theirs or not? An examination revealed YES! Then why weren’t their blood pressure, cholesterol, asthma, blood sugars, immunizations, and screenings not at goal?

Barbara was supposed to come back in but never did, Bob travels all the time, Suzie stopped taking her meds, but never communicated it, John’s son got ill and he missed his appointment and never came back in…. The list of reasons went on and on. But the reality did not change – we were confusing being busy with meeting the needs of our patients. Often, we were not seeing the patients that needed us the most.

This lead to new systems, new ways of proactive (and automated) outreach. Soon the right patients were in the right practice at the right time. Quality took a jump up. Providers knew they were doing the best thing for all of their patients, not just the ones in front of them.

Busy was now productive and we were adding years to the lives and life to the years of those we served!

Is your practice busy, effective, or both?

Avoiding the #3 Cause of Death in the USA: US Hospitals & What You Need To Know About It – Part 2

The gauntlet had been laid.  Don Berwick and the Institute for Healthcare Improvement (IHI) had challenged hospitals in America to save 100,000 lives.  Time was ticking away, educational programs, mentoring, training had begun but would they achieve the goal?

Eighteen months later on June 14th 2006 at 9 a.m. – Dr. Berwick took the stage to announce the results: “Hospitals enrolled in the 100,000 Lives Campaign have collectively prevented an estimated 122,300 avoidable deaths and, as importantly, have begun to institutionalize the new standards of care that will continue to save lives and improve health outcomes into the future.”

But that was only the beginning.  Remember, if there are 5,723 registered hospitals in the US, this initiative got 2,300 of them to commit in the first few months.  By the end of the campaign 3,100 hospitals had enlisted.  But thousands of Americans were still dying in US hospitals from preventable causes each month.  So the IHI moved the goal – in December 2006, IHI launched a second, expanded effort, the Five Million Lives campaign.   At its formal close in December 2008, the Campaign celebrated the enrollment of 4,050 hospitals, with more than 2,000 facilities pursuing each of the Campaign’s 12 interventions to reduce infection, surgical complication, medication errors, and other forms of unreliable care in facilities. Eight states enrolled 100% of their hospitals in the Campaign, and 18 states enrolled over 90% of their hospitals in the Campaign.

In 2011 the Secretary of the Department of Health and Human Services Kathleen Sebelius and Dr. Berwick launched the Partnership for Patients, which brings together hospitals, employers, physicians, nurses, and patient advocates along with state and federal governments in an effort to make hospital care safer, more reliable, and less costly.  The Partnership for Patients aimed to decrease preventable hospital-acquired conditions by 40 percent by the end of 2013, resulting in approximately 1.8 million fewer injuries to patients and more than 60,000 lives saved over the next three years. It also sought to reduce hospital readmissions by 20 percent by decreasing the rate of preventable complications during transitions from one care setting to another. The Partnership was to be funded by up to $1 billion in federal money made available under the Patient Protection and Affordable Care Act, including $500 million through the Community-Based Care Transitions Program and up to $500 million through the Centers for Medicare and Medicaid Innovation.    At the core of this initiative are 26 Hospital Engagement Networks, with 3,700 hospitals, working with health care providers and institutions to identify best practices and solutions to reduce hospital acquired conditions and readmissions.  Early results are showing strong progress in 8 of the 10 patient safety priority areas of the Partnership for Patients, more findings are scheduled to be released soon.

But recall that only 3,700 of the 5,723 hospitals in the US are engaged, meaning that over 2,000 hospitals are not on board and thousands of Americans are still suffering unnecessarily.  And recognize that this is looking at the prevention of adverse events, not at which institutions are the best at different procedures.  The best spine hospital may not be (and often isn’t) the best heart surgery facility in your community.

So how do you find the right hospital?  It takes research and time. It also takes a willingness to sift through a lot of different data to tease out what information would be important to you. Let’s think through a visit to the hospital – the quality of the health care a patient receives depends on many things besides the skill of the surgeon. Many health care providers at a hospital will be directly involved in care before, during, and after surgery. The metrics a patient will want to know span a broad spectrum of considerations, from scientific data on mortality and complications associated with previous treatment of patients with the same condition to the more subjective data on how patients respond to the physician and staff managing their care.

A result of this complexity in defining a good hospital is the proliferation of information sites that exist. In addition to the payers websites (carriers who are often dependent on contracting agreements with the hospitals), patients can go to anything from yelp.com and Angie’s List (which also provide reviews on low complexity services like dry cleaning), to state report card sites or national sites such as Hospital Compare which may or may not have information on metrics associated with your condition. For heavier science aficionados, there are reporting agencies like CareChecks and The Dartmouth Atlas which may look at patient outcomes on a larger system level. Reports are also often put out by institutions such as the Kaiser Foundation or Commonwealth Fund that speak to hospital quality.  Somewhere in the middle of this very complex gamut are sites like Vitals or Health Grades. More traditional outlets such as Consumer Reports or the US News & World Report create hospital listings as well.

But it is not just the hospital.  The doctor and the care team he or she works with make a significant difference.  In the next blog we will consider how to find and use these “best in class” doctors.

Avoiding the #3 Cause of Death in the USA: US Hospitals & What You Need To Know About It – Part 1

By DrScott – Posted on March 18, 2014 on www.compassphs.com

Preventable Adverse Events (PAE’s) are the #3 cause of death in the US, leading to between 210,000 and 440,000 American deaths annually.  This must stop.  But how?  The answer involves one of the best stories in US healthcare history.

It started when Dr. Donald Berwick, the co-founder, president and CEO of the Cambridge-based Institute for Healthcare Improvement (IHI), was driving with his son, Dan to the airport.  Dan, a political campaign strategist, explained that he was bringing 350 volunteers to Florida for a weekend to knock on 50,000 doors for his candidate.

Awed by the numbers, Berwick, 57 at the time and a clinical Professor of Pediatrics and Health Care Policy at Harvard, shared IHI’s frustration about the slow pace of change in medicine when it came to adopting practices known to improve care and reduce errors.  As the former head of quality-of-care measurement for a large HMO, Berwick knew the numbers: As many as 98,000 American hospital patients die annually from poor care or medical errors. IHI researchers estimate that approximately 15 million incidents of medical harm occur in U.S. hospitals annually, roughly 40,000 every single day.

So, Berwick asked his son the critical question: “What makes your work so effective?” Dan explained what it takes to run a successful political campaign – coming up with concrete numbers (i.e. how many people you want to reach), establishing field offices to reach more people locally, inviting the widest possible participation, giving specific instructions to workers, and setting a deadline.

The IHI  only had 75 people on staff at the time and no way to mount the national campaign needed to create any significant change, or did they?  On December 14th 2004, Dr. Berwick gave a speech to a room full of hospital administrators.  He said, “Here is what I think we should do.  I think we should save 100,000 lives.  And I think we should do that by June 14, 2006 – 18 months from today.  Some is not a number; soon is not a time.  Here’s the number: 100,000.  Here’s the time: June 14, 2006.”

To accomplish this the IHI proposed six specific interventions for hospitals to adopt that had been proven to reduce unnecessary deaths.  If you have been reading the blogs on the book Switch by Dan and Chip Heath, you will appreciate that the “rider” now has a clearly defined goal to achieve.

But this was a challenge for hospitals to embrace and get behind.  If they did embrace it, it implied that unnecessary deaths were occurring in their hospitals.  So, Dr. Berwick made it personal.  At his speech he asked the mother of a girl who had been killed by a medical error to join him.  She said, “I’m a little speechless, and I’m a little sad, because I know that if this campaign had been in place four or five years ago, that Josie would be fine….  But, I’m happy, and thrilled to be a part of this, because I know you can do it, because you have to do it.”  Another guest on the stage, the North Carolina State Hospital Association Chair, then spoke up: “An awful lot of people for a long time have had their heads in the sand on this issue, and it’s time to do the right thing.  It’s as simple as that.”  (Switch: the elephant was motivated).

The IHI made joining the campaign easy; hospital CEO’s only had to sign a one page form.  Once a hospital enrolled, the IHI team helped them embrace the new interventions.  Research, step by step instructions guide and training were provided, and regular teleconferences with the hospital leaders to share their victories and struggles were arranged.  Hospitals with early successes were encouraged to become mentors of hospitals who joined the campaign later. (Switch: the path had been made easy).

But would they achieve the goal? Eliminating errors and documenting the results had never been done this way in the US Healthcare system. As a patient, the challenge of finding an excellent facility and doctor to use can be daunting.

The Next Generation of Value Based Medicine: Corporate Population Health Management™ – Part 1

Working with corporations and providers to create Value Based Care. Read more at the Open Health Market Blog: The Next Generation of Value Based Medicine: Corporate Population Health Management™ – Part 1.

Special Medical Provider(s) Wanted

GOH Medical is growing.  Over the next several months we will need to add a new medical provider: a doctor, nurse practitioner, or a physician’s assistant.  Do you know the right person for this job?  Here are some thoughts to consider;

  1. “Not on our watch”  The Institute of Medicine has boldly declared that we “know what to do, but are not doing what we know” and this must stop.  What would a clinic look like if the commitment was to proactive, preventive health care first; illness management and reactive care second?  We are looking for a provider that wants to review each patient for possible future issues to address them before they develop symptoms.
  2. “Committed to curing the ‘I Feel Fine’ Syndrome”  There is a big difference between “I feel fine” and “I am healthy.”  Patient engagement before symptoms occur is vital to preventing diabetes and heart disease, and diagnosing cancer in stage 1.  Using The Seven Numbers as a teaching tool and foundation we empower each patient to learn and live the Seven Numbers that Can Save their Life,
  3. “Only the best” When problems do appear what does it take to find the best solution? A large part of GOH Clinic is making sure that each person gets what they need when they need it at the right place for the right price – whatever it takes.  Coordination of care, transitions of care, communicating and getting records sent out, and following up are vital commitments,
  4. “Technology leverage” Text, email, blogs, electronic health and medical records, the latest equipment.  We are looking for a technology geek/nerd with a personality,
  5. “Part of a team”  Each teammate at GOH Medical is a link on a chain that includes everyone from the maintenance crew to the super-specialist at the hospital.  All important for a successful healthcare, over-communication and a commitment to six sigma/lean processes ensure success,
  6. “A teacher committed to delegation and empowerment”  Medical knowledge doubles every 18 months.  The best we can do for patients is to understand their challenge, educate them, suggest a course, and encourage them to learn as much as they can to play an active, vital role in their health; GOH Medical understands that there is more that we know that we do not know, than there is that we know, about any particular topic.  Even if we read 24/7/365 we will fall hopelessly behind.  There is no place for arrogance, coercion or convincing; only sharing what we know, sharing what we expect to occur, and then closely communicating if this does not occur over time.  We are a member of a team, we empower, encourage and give 110% effort.
  7. “Focusing first on lifestyle” Food is the strongest drug we put in our bodies every day, exercise the best medicine; but that is not all, there are The Seven Healers we need to pull into our lives each day.  It is from this foundation that we encourage our patients to win the Game of Health.
  8. “An open minded healer” Allopathic medicine has changed the worldEvidence based, informed, outcomes oriented… and it is incomplete and often fails to provide complete healing.  Weak in mind:body medicine, lifestyle intervention, natural healing, myofascial manipulation, meridian management/acupuncture, supplements and other disciplines that may be less rigorous or researched in their body of knowledge, these other disciplines  must be recruited for whole person, successful healing.  Focusing on the patient, not the dogma of one discipline, is required,
  9. “Courageous” we do not believe in codependency or enabling – this means supporting patients to support themselves through The Empowerment Dynamic – TED, not rushing in to “save” or “cure” our patients.  Our patients are not powerless victims of situations; they are powerful creators of a great life and we are a vital member of their team.  Healthcare workers want to help, but this can digress into a one up: one down dependency – one we are committed to avoid.  Sometimes it takes more time and effort to promote, but ultimately it is the road to health,
  10. “Serving all”  With our innovative GOH4Health, GOH4Wellness, and GOH4Breakthroughs we serve people with and without insurance, insured patients and corporations.  Our population based, proactive approach minimizes the waste and redundancy creating very high Value {= (quality + safety)/cost} care.
  11. “Loving” we are followers of Jesus Christ.  This is not to say we discriminate, convince, coerce or force our beliefs on others – quite the opposite.  We see each patient as a gift, tremendous potential, and our commitment is to make sure they know we are Christians by our actions; the loving, non-judgemental care they receive from us.  At GOH Medical, all are welcome, all are served.

Our systems are in place, our team is becoming more competent and proactive.  By this fall we will be running smoothly and ready to serve a larger group of patients with a population based, whole person orientation.  We are looking for a provider(s) who shares our beliefs and philosophy to add years to the life and life to the years by empowering breakthroughs in the lives of those we serve.

Please contact us if you are interested or if you know someone who is.

Free at Last, Free At Last, Thank God I am Free At Last. Time to head home (the Medical Home)

I am overjoyed (and greatly relieved) that I can now report that I am a “free agent.” I met with Dr Stoltz last Thursday and, at this point, I am no longer associated with Medical Edge or Texas Health Physician Group and will not be opening an office with them.

So it is time to get down to brass tacks and figure out what we are going to do.  As all of you who know me well appreciate I am absolutely committed to

“Adding years to the life and life to the years of individuals, corporations, systems and nations to empower intuitive wellness.”

There will be two aspects of this pursuit for me – clinical practice and creating an Accountable Care System that empowers the Accountable (or Activated) Patient.

In the clinical practice I am committed to finding and growing old with a group of patients who too are committed to living a great life – reaching 100 years of age with vitality and joy.

What does not work for me in the practice is running in and out of rooms 15 minutes at a time until I am exhausted.  This model does not work – the American Healthcare System has proven this without a doubt.  So here are some basic to consider;

  1. One on one, face to face visits will be necessary for part of the time.  But guiding, directing, supporting, and coordinating the effort is as or more important to the process of attaining intuitive wellness.
  2. Creating a medical home with opportunities like group visits, on line visits, telephonic care, and having other members of the team like dietitians, exercise specialists, social workers, pharmacists available to us are also vital.
  3. Working with a great physicians assistant and/or nurse practitioner (and at some point additional doctors) as a part of the team will add tremendous value to the practice.
  4. Finally, the freedom to speak with the specialist or go to the visit when it could/would contribute greatly to your health cannot happen when I am running room to room but may be vital at times to your health.

So now we start building a new model.  The first thing is building the team to get the logistics of starting a practice accomplished.  Not glamorous but necessary.  let’s start with one foundational person; an organized, capable, motivated individual with some healthcare background (possibly an MA or nurse) who would like to run with the ball and create this enterprise.   Do you know this person?  If so, asap please send me their contact information to drscott@scottconard.com

Secondly, this individual will need some help.  Would anyone be willing to volunteer to help with basic tasks ranging from filling out forms to running errands?  It will take a village to create the ideal medical practice for our community, but and now we have the green light for go and we can proceed!

I miss you and look forward to seeing you soon in our new facility.

Dr Scott