GE Healthcare Camden Group Insights Blog

Top 10 Critical Success Factors for Care Model Redesign

Posted by Matthew Smith on Jun 24, 2015 12:33:27 PM

As the healthcare landscape shifts from volume-based fee-for-service reimbursement toward value-based risk sharing payments and penalties, organizations must develop new and innovative strategies across all care delivery channels. In order to move to true value-based care, financial models must be aligned, and the quality and overall patient health and outcomes must be addressed. Care model redesign is a necessary solution to achieve success and long-term sustainability.

The process of care redesign entails a systemic shift in the way care is delivered across the continuum with input from leadership, acute and post-acute clinical and administrative staff, and community partners and stakeholders. To ensure effective and efficient integration and strategic alignment, a governing steering committee should be established, and their vision and recommendations implemented by working groups that focus on distinct components. The following represents the top 10 considerations needed to implement transformative care.

1. Use an interdisciplinary care team approach supported by plans of care. Focusing on the accountability and improvement of the care delivered across settings for all dimensions of health and associated costs is a collaborative approach. It includes different disciplines working together to share knowledge and skills to guide and impact patient care. A physician drives the clinical care but collaborates with the entire team, with the ambulatory care manager as the consistent thread who follows the patient throughout the continuum of care. The patient and his/her family or caregiver is an integral part of the care plan development. The developed goals are patient-centric and focused on the patient’s preferences and wishes, taking into account specific cultural and linguistic needs. Each provider and/or discipline contributes to and aligns care with the patient’s plan and goals.

2. Target care from both a medical condition(s) and social determinant perspective. In order to move to true value-based care, the overall health, safety, and well-being of a patient must be addressed. The delivery of coordinated, quality care needs to expand from the acute setting across the continuum, with a focus not only on the clinical aspects of care, but of equal importance, and at times more important, the social determinants of health. This includes access to care, caregiver support, behavioral health, social economic status, health literacy, adequate food and shelter, addiction, etc. Key components of a “whol-istic” approach include: patient/family engagement, tools for effective self-management of chronic conditions, an individualized comprehensive treatment and continuum-based care plan, health education for disease and medication management, primary care, and care management follow up – all supported with appropriate community-based resources.

3. Facilitate new patient identification, and identify high-risk population(s) to address barriers to care (e.g., poverty, behavioral health, health literacy, social support, etc.). The use of risk stratification is necessary to manage patient populations and identify high risk and risk rising patients who need proactive and careful management. The development of interventions to address individual clinical and social needs is recommended to improve the success rate of transitioning the delivery of care across settings. Risk stratification methods enable the prioritization of clinical workflows by cohorting patients for population health and disease and chronic care management programs. Additionally, they help ensure patients receive an assessment and inclusion into the appropriate case management programs. Homegrown and proprietary platforms exist, but all stratification models should include the critical components of comorbidities as well as (but not limited to) age, poor pain control, and low functional status or cognitive deficits to calculate a risk score.

4. Expand utilization management (“UM”) focus from episodic to complex chronic care, post-acute care or community-based care delivery needs. UM is increasingly important to manage healthcare costs and services across the continuum. Traditional UM is episodic and driven by point-of-care medical necessity and appropriateness of ongoing provision of care. As alternative payment and service delivery models are developed and tested by The Centers for Medicare and Medicaid Services and adopted by private payers, the care delivered will need to be considered across the continuum. The delivery of the right care at the right time in the right setting is evolving the role of UM. It requires considering a longitudinal approach to care provided outside of the four walls of the hospital, moving away from acute episodes to proactive delivery of complex, chronic care that maintains a patient’s health in a community-based setting.

5. Align primary care physicians (“PCPs”) incentive compensation to encourage coordination and access to all care team members. As the care delivery model for PCPs continues to move toward patient-centered models by organizing as a medical home or medical neighborhood, compensation models need to promote health outcomes and the coordination of care team members across the continuum. PCPs are tasked with driving care through a proactive, collaborative approach with patients and specialists with a focus on chronic disease management. New models of care delivered by PCPs will improve the health of populations and value for patients and compensation plans need to support the evolution of care delivery.

6. Develop new provider contracting models to address care across the continuum and engage new physicians and provider networks. As alternative payment models reward and penalize organizations for the quality of care provided, there is a corresponding need to evolve physician compensation models from a production/Relative Value Unit focus to one of value. Contracts need to clearly define the organizational strategy and goals as well as the expectations and accountabilities of the contracted providers. When designing compensation models, key factors to consider include aligning organizational and system goals with physician goals, identifying the appropriate quality benchmarks, and determining the proportions of compensation tied to risk, productivity goals, and quality.

7. Include value-based incentives and key performance metrics to provide appropriate and accountable care. Reporting quality measures is a familiar practice for providers who have participated in pay-for-performance programs such as Physician Quality Reporting System or the Hospital Inpatient and Outpatient Quality Reporting Systems. To promote appropriate and accountable care, existing and new value-based model metrics are now tied to incentives and penalties for providers to prove they are not only decreasing the overall cost of care delivered but are meeting quality standards. As payers continue to expand patient populations required for reporting financial and quality metrics, effective management and alignment of contract incentives is needed to ensure that care is delivered efficiently to lower costs but also improve the quality of the care delivered.

8. Create clinical data analytic functions and integrate relevant data sources (e.g., practice management, claims, financial, pharmacy, etc.) to support clinically data-driven efforts with real-time data. A robust data analytics infrastructure is necessary to integrate varying tools and data sources and to manage the vast amount of data to support real time, point of care decision-making. Health information exchanges or data warehouses are platforms to provide a solution to improve data integration functionality, aggregating data so staff spends its time analyzing data (not integrating data) and meeting organizational performance goals. The capabilities of the system should include all data sources related to clinical and patient experience, financial and cost performance, and quality data.

9. Develop robust communication, feedback, and reporting systems. The development of the most sophisticated data analytics infrastructure and the clinical information derived from the care of the patients is of little use if that knowledge is not communicated in a timely, meaningful way to the appropriate providers or systems across the continuum. If these gaps in communication of healthcare information are not addressed with the same effort as the development of information systems, the gap will continue to grow as networks expand and population panels increase. Greater consideration needs to be placed on communication enhancements to improve the quality and safety of clinical services. It is critical to view the communication needs from multiple directions – within and outside of the organization, with PCPs and community-based organizations, and between providers and their patients.

10. Develop system-wide tracking, reporting and accountability plan(s) to drive to population health-based outcomes and to compare internal and external peer group benchmarks and trends. Long-term success and intervention sustainability cannot be achieved without the continuous performance improvement and continuum based key performance indicators. Data reported in real time dashboards fosters close monitoring and analyzing both the financial and clinical data. Tracking, review, and actionability of the results will target the successes, areas of needed improvement, and the gaps in care for continued care delivery improvements.

Topics: Care Model, Care Team, Care Redesign, Transfomative Care

Three Keys to Improved Medical Practice Workflow Redesign

Posted by Matthew Smith on Apr 28, 2015 3:25:00 PM

New consumer-oriented service delivery sites such as retail clinics and virtual visits are popping up to fill voids in access to care. In order to successfully compete in the future, medical groups must evaluate the way they currently operate with a critical focus on managing patient access through the promotion of consumer-oriented services and efficient workflows. One way of competing in this new market is to increase access without adding locations or providers by improving the efficiency of existing locations and providers. Redesigned workflows place the patient at the center of the care model, with the goal of improving patient engagement and access to care. This results in a better patient experience and improved clinical outcomes at reduced cost.

1. Identify Care Model and Care Team

One of the key attributes in workflow redesign is to identify the care model and care team needed to ensure that providers and staff are practicing at the top of their license or skill set. This might mean transferring work from providers to clinical staff or from clinical staff to front office staff. It also entails identifying the most valuable use of all staff time. This may be achieved through effective use of technology while engaging patients through the use of patient portals, email, text messaging, and home monitoring.

2. Utilize Process Flow Mapping

Another attribute is to utilize process flow mapping to create a picture of the current-state workflows and identify areas of potential waste or bottlenecks. Once current-state workflows are mapped, utilize a team of providers and staff to create a vision for the future (or ideal state). Work as a team to eliminate as much waste as possible to move towards the future state. Establish performance targets for the ideal state and measure baseline performance to gauge progress. Conduct cycle time studies as part of the redesign effort as an effective measure of wait time (value-added vs. non-value added time). Test the redesign efforts and compare results to established targets and continue to modify until goals are achieved.

3. Optimize Technology to Meet Clinical Care Needs

Finally, ensure providers and staff are effectively trained on the practice management (“PM”) and electronic health record (“EHR”) systems and that the technology is fully optimized to meet clinical care needs. Spend time shadowing providers to evaluate how the system is used in practice and what changes can be easily made to better accommodate workflows. Make sure a local resource may be contacted with questions or advice as well as dedicated site-specific subject matter experts (“SMEs”) for immediate troubleshooting. Create a continuous learning environment, through the use of webinars, on-site educational sessions, and shadowing to increase provider/staff adoption of the technology, and reduce rework or general frustration due to a lack of training or appropriate optimization of the system.

Workflow redesign efforts, if successfully implemented, can significantly decrease non-value added time by allowing for increased time with patients and increased access to care. Improving operational efficiencies and optimizing electronic systems also increases provider and staff satisfaction thereby supporting a patient-centered environment.

Medical Practice Workflow Redesign, The Camden Group,

Topics: EHR, Care Model, Workflow Redesign, Medical Practice Workflow Redesign, Care Team

Subscribe to Email Updates

Value Model, Health Analytics

Recent Posts

Posts by Topic

Follow Me