Enhancing patient care through better data
 

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Enhancing patient care through better data Presentation Transcript

  • 1. Enhancing Patient Care Through Better Data Wayne Pan, MD, MBA, Chief Medical Officer The Individual Practice Association Medical Group of Santa Clara County Inc. (SCCIPA)IHA’s Tenth Annual P4P Stakeholders Meeting • September 22, 2011 • Los Angeles
  • 2. What I Did During MySummer Vacation
  • 3. ourperspective
  • 4. retrospectoscope
  • 5. whoweare
  • 6. Santa Clara County 1,304.01 sq. miles 1,781,642 (2010) $74,335
  • 7. 5 PCP 80 Specialists 173 PCP 343 Specialists 57 PCP 104 Specialists 11 PCP 30 SpecialistsSCCIPA founded in 1986 physician-owned, physician-governed 800+ physicians - 240+ PCPs, 550+ specialists all 9 hospitals - including a tertiary care center 9 health plans (Commercial and Medicare Advantage)
  • 8. ourjourney
  • 9. theneed
  • 10. it’snottechnology
  • 11. signalvsnoise
  • 12. it’saboutthepatient
  • 13. peopleprocessesplatform
  • 14. 3P’speopleprocessesplatform
  • 15. big Cpeopleprocessesplatform
  • 16. culturepeopleprocessesplatform
  • 17. culture?
  • 18. patientcentered
  • 19. efficient
  • 20. evidencebased
  • 21. promotequality
  • 22. makeiteasy
  • 23. 4processes
  • 24. communication
  • 25. collaboration
  • 26. Case ManagersPatients PCPs Specialists coordination
  • 27. anticipation
  • 28. it’snottechnology
  • 29. technology 1st
  • 30. designphilosophy
  • 31. put hot triggers in the path ofmotivated people BJ Fogg, PhD Director, Persuasive Technology Lab Stanford University
  • 32. work withhumannature BJ Fogg, PhD Director, Persuasive Technology Lab Stanford University
  • 33. lazysocialhabits BJ Fogg, PhD Director, Persuasive Technology Lab Stanford University
  • 34. ourplatform
  • 35. platformcommon web-based communication platformfacilitates administrative functionsrules-based management of processesintuitive user-interfaceembed quality reminders into office/provider workflowprovider feedbackprovide actionable clinical data at point of care
  • 36. platformcommon web-based communication platformfacilitates administrative functionsrules-based management of processesintuitive user-interfaceembed quality reminders into office/provider workflowprovider feedbackprovide actionable clinical data at point of careallow patients to access their own dataallow patients to provide feedback and enter their own data
  • 37. anticipation
  • 38. 4dimensionaldata
  • 39. financial
  • 40. administrative
  • 41. clinical
  • 42. retrospective
  • 43. reactivecare
  • 44. + behavioral
  • 45. predictive
  • 46. proactivecare
  • 47. provideactionabledata
  • 48. @pointofcare
  • 49. @home
  • 50. thecareteam
  • 51. thecarecontinuum
  • 52. ourplatforms
  • 53. ACCESSEXPRESS
  • 54. peopleprocessesplatform
  • 55. peoplehospitalistsSNFistsonsite case managerscomplex case managersutilization review staff
  • 56. peopleprocesseshospitalistsavailable 24/7evaluation of patients for possible redirection to SNFaggressive use of observation statusannual coding/documentation training for risk adjustmentnotification of PCP of admission/dischargedischarge summary faxed to PCP
  • 57. peopleprocessesSNFistsongoing evaluation of patients to reduce rehospitalizationnotification of PCP of admission/dischargedischarge summary faxed to PCP
  • 58. peopleprocessesonsite case managersdaily review of patients based on Milliman guidelinesactively involved with discharge planningall discharge needs authorized/arranged prior to dischargepost-discharge follow-up on all patients with DME/HHC needs
  • 59. peopleprocessescomplex case managerswarm hand-off between onsite and ccmuse of clinical and non-clinical staff to assist patient and family caregivers with care coordinationinsure follow-up with PCP/specialist within 2 weeks
  • 60. peopleprocessesutilization review staffall authorizations/referrals reviewed using Milliman guidelinesworking closely with PCPs/specialists/ccm to facilitate care coordinationcompliance with regulatory guidelinesgenerate member/provider letters regarding medical necessity decisionsphysician performance and quality reportingidentification of potential quality issuescontinuous process improvement
  • 61. thepatientjourney
  • 62. IPAhosspital onsitedischarge case planner manager hospitalistpatient family discharge planning thepatientjourney
  • 63. IPA hospitalisthosspital onsitedischarge case planner manager hospitalist Rxpatient family patient discharge medication planning reconciliation thepatientjourney
  • 64. IPA hospitalist hospitalisthosspital onsitedischarge case planner manager hospitalist Rx discharge instructionspatient family patient patient outpatient discharge medication physician planning reconciliation follow-up thepatientjourney
  • 65. IPA hospitalist hospitalisthosspital onsitedischarge case planner manager hospitalist Rx discharge instructions Rx discharge instructionspatient family patient patient patient family outpatient discharge medication physician discharge planning reconciliation follow-up thepatientjourney
  • 66. IPA hospitalist hospitalisthosspital onsitedischarge case planner manager hospitalist Rx discharge instructions Rx discharge instructionspatient family patient patient patient family outpatient discharge medication physician discharge planning reconciliation follow-up thepatientjourney
  • 67. discharge IPA hospitalist onsite case manager AE discharge instructions patientoutpatient physician follow-up
  • 68. 48hr call IPA onsite case manager AE discharge instructions PCP patientoutpatient physician follow-up
  • 69. post pcp visit call AE internal non-clinical staff discharge instructions PCP patientoutpatient physician follow-up
  • 70. IPA hospitalist hospitalisthosspital onsitedischarge case planner manager hospitalist Rx discharge instructions Rx discharge instructionspatient family patient patient patient family outpatient discharge medication physician discharge planning reconciliation follow-up thepatientjourney
  • 71. admissionhospitalistadmission orders patientmedication reconciliation
  • 72. discharge hospitalistadmission new Rx orders patientmedication reconciliation
  • 73. pcp visit pcpadmission review orders new Rx med list patientmedication reconciliation
  • 74. discharge retail pharmacy pcp new Rx patient“new” medication reconciliation
  • 75. thepatientjourney
  • 76. endo hosp meds er exercise diabetic patientself-testing pcp preventive care diet education snf
  • 77. endo hosp meds er exercise pself-testing pcp preventive care diet education snf
  • 78. endo p AE hosp meds er exerciseself-testing pcp preventive care diet education snf
  • 79. endo p hosp meds er exerciseself-testing pcp preventive care diet education snf
  • 80. AE endo p hosp meds er exerciseself-testing pcp preventive care diet education snf
  • 81. endo hosp meds er exerciseself-testing pcp preventive care p diet education snf
  • 82. endo hosp meds er exercise pself-testing pcp preventive care diet education snf
  • 83. endo hosp meds er exercise p AEself-testing pcp preventive care diet education snf
  • 84. endo hosp meds er exercise AEself-testing pcp p preventive care diet education snf
  • 85. endo hosp meds er exercise diabetic patientself-testing pcp preventive care diet education snf
  • 86. peopleprocessesplatform
  • 87. culturepeopleprocessesplatform
  • 88. it’saboutthepatient
  • 89. thankyouwpan@ppmsi.com