Enhancing patient care through better data

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Enhancing patient care through better data

  1. 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. 2. What I Did During MySummer Vacation
  3. 3. ourperspective
  4. 4. retrospectoscope
  5. 5. whoweare
  6. 6. Santa Clara County 1,304.01 sq. miles 1,781,642 (2010) $74,335
  7. 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. 8. ourjourney
  9. 9. theneed
  10. 10. it’snottechnology
  11. 11. signalvsnoise
  12. 12. it’saboutthepatient
  13. 13. peopleprocessesplatform
  14. 14. 3P’speopleprocessesplatform
  15. 15. big Cpeopleprocessesplatform
  16. 16. culturepeopleprocessesplatform
  17. 17. culture?
  18. 18. patientcentered
  19. 19. efficient
  20. 20. evidencebased
  21. 21. promotequality
  22. 22. makeiteasy
  23. 23. 4processes
  24. 24. communication
  25. 25. collaboration
  26. 26. Case ManagersPatients PCPs Specialists coordination
  27. 27. anticipation
  28. 28. it’snottechnology
  29. 29. technology 1st
  30. 30. designphilosophy
  31. 31. put hot triggers in the path ofmotivated people BJ Fogg, PhD Director, Persuasive Technology Lab Stanford University
  32. 32. work withhumannature BJ Fogg, PhD Director, Persuasive Technology Lab Stanford University
  33. 33. lazysocialhabits BJ Fogg, PhD Director, Persuasive Technology Lab Stanford University
  34. 34. ourplatform
  35. 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. 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. 37. anticipation
  38. 38. 4dimensionaldata
  39. 39. financial
  40. 40. administrative
  41. 41. clinical
  42. 42. retrospective
  43. 43. reactivecare
  44. 44. + behavioral
  45. 45. predictive
  46. 46. proactivecare
  47. 47. provideactionabledata
  48. 48. @pointofcare
  49. 49. @home
  50. 50. thecareteam
  51. 51. thecarecontinuum
  52. 52. ourplatforms
  53. 53. ACCESSEXPRESS
  54. 54. peopleprocessesplatform
  55. 55. peoplehospitalistsSNFistsonsite case managerscomplex case managersutilization review staff
  56. 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. 57. peopleprocessesSNFistsongoing evaluation of patients to reduce rehospitalizationnotification of PCP of admission/dischargedischarge summary faxed to PCP
  58. 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. 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. 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. 61. thepatientjourney
  62. 62. IPAhosspital onsitedischarge case planner manager hospitalistpatient family discharge planning thepatientjourney
  63. 63. IPA hospitalisthosspital onsitedischarge case planner manager hospitalist Rxpatient family patient discharge medication planning reconciliation thepatientjourney
  64. 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. 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. 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. 67. discharge IPA hospitalist onsite case manager AE discharge instructions patientoutpatient physician follow-up
  68. 68. 48hr call IPA onsite case manager AE discharge instructions PCP patientoutpatient physician follow-up
  69. 69. post pcp visit call AE internal non-clinical staff discharge instructions PCP patientoutpatient physician follow-up
  70. 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. 71. admissionhospitalistadmission orders patientmedication reconciliation
  72. 72. discharge hospitalistadmission new Rx orders patientmedication reconciliation
  73. 73. pcp visit pcpadmission review orders new Rx med list patientmedication reconciliation
  74. 74. discharge retail pharmacy pcp new Rx patient“new” medication reconciliation
  75. 75. thepatientjourney
  76. 76. endo hosp meds er exercise diabetic patientself-testing pcp preventive care diet education snf
  77. 77. endo hosp meds er exercise pself-testing pcp preventive care diet education snf
  78. 78. endo p AE hosp meds er exerciseself-testing pcp preventive care diet education snf
  79. 79. endo p hosp meds er exerciseself-testing pcp preventive care diet education snf
  80. 80. AE endo p hosp meds er exerciseself-testing pcp preventive care diet education snf
  81. 81. endo hosp meds er exerciseself-testing pcp preventive care p diet education snf
  82. 82. endo hosp meds er exercise pself-testing pcp preventive care diet education snf
  83. 83. endo hosp meds er exercise p AEself-testing pcp preventive care diet education snf
  84. 84. endo hosp meds er exercise AEself-testing pcp p preventive care diet education snf
  85. 85. endo hosp meds er exercise diabetic patientself-testing pcp preventive care diet education snf
  86. 86. peopleprocessesplatform
  87. 87. culturepeopleprocessesplatform
  88. 88. it’saboutthepatient
  89. 89. thankyouwpan@ppmsi.com

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