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Using A Nursing Coordination of Care Model

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  • 1. Using  A  Nursing  Coordination  Of  Care  Model   To  Create  A  “Temporary  Medical  Home”     Gelb Consulting, An Endeavor Management Company 2700 Post Oak Blvd Suite 1400 Houston, Texas 770567     P + 281.759.3600 F + 281.759.3607 www.endeavormgmt.com/healthcare
  • 2. Using  A  Nursing  Coordination  Of  Care  Model   To  Create  A  “Temporary  Medical  Home”     Introduction and Overview   Academic  Medical  Centers  have  unique  and  specific  issues  to  address  in  regard  to  the   coordination  of  care  for  patients  traveling  from  out  of  state  and  out  of  the  country.    Many   coordination  of  care  models  have  been  tested  with  varying  results.    This  specific  care   coordination  model  addresses  the  needs  and  concerns  of  those  patients  who  travel  from  afar.         The  original  charge  of  the  Destination  Program  at  the  University  of  Michigan  was  to  create  a   Destination  Program  (DP)  strategy  to  address  coordination  of  care  for  those  patients  coming   from  a  distance.    Patients  who  travel  from  over  90  to  100  miles  or  over  one  hour  have  different   needs  than  those  patients  who  live  near  their  care  institutions.         Our  charge  was  to  determine  what  specific  issues  needed  to  be  addressed  that  were  different   and  unique  to  this  population.    A  culture  change  to  create  a  new  way  of  thinking  was  a  primary   goal.    The  desired  outcome  was  to  move  the  Healthcare  System  into  being  a  “Destination   Hospital.”         A  second  goal  was  to  increase  the  number  of  patients  with  complex  diseases  requiring  acute   care  to  travel  from  farther  distances  to  receive  this  care  at  the  University  of  Michigan.     Marketing  alone  may  increase  the  number  of  patients  but  added  volume  could  cause  capacity   issues.           Our  task  was  to  determine  what  those  issues  were  and  to  create  a  plan  to  address  the  issues.     In  turn,  to  create  an  “Ideal  Patient  Care  Experience”,  for  those  patients  coming  to  the   Institution  for  care.    If  the  patient  and  referring  physicians’  experience  was  not  excellent,  the   plan  would  fail.    A  prerequisite  for  this  goal  was  to  provide  travel-­‐sensitive,  coordinated  care   for  this  population.    By  creating  a  “Temporary  Medical  Home,”  during  the  intake  period  we   would  able  to  ensure  accountability  at  intake.         It  was  also  anticipated  that  improvements  in  the  system,  and  processes  to  care  for  such   patients,  coupled  with  enhanced  marketing  efforts  (that  highlight  the  expertise  and  clinical   research)  would  increase  patient  activity  and  provide  a  “halo”  effect  for  enhancing  brand   recognition.        The  ultimate  outcome  would  be:   1. Increased  patient  volumes  for  groups  of  patients  with  favorable  payer  mix,     2. Improved  revenue  to  support  the  healthcare  missions,  and     3. A  greater  potential  number  of  patients  to  enter  innovative  clinical  trials.           ©  2013  Endeavor  Management.  All  Rights  Reserved.       Page  2  
  • 3. Using  A  Nursing  Coordination  Of  Care  Model   To  Create  A  “Temporary  Medical  Home”     In  addition,  it  was  expected  that  the  improved  systems  and  processes  developed  would  diffuse   throughout  the  health  system  to  enhance  the  care  provided  to  all  patients.    The  Destination   Program  Office  also  had  a  vision  of  serving  as  the  ‘clinical  laboratory’  for  better  processes  of   care.       With  this  effort,  metrics  of  success  were  determined  by:         • Increased  patient  volumes  from  out  of  state  and  internationally       • Digital  campaign  metrics  showing  dollars  spent  versus  returns  on  patient  activity   with  positive  ROI       • Long  term  metrics  showing  favorable  ROI,  calculated  by  tracking  patients  through   episodes  of  care  and  dollars  associated  with  that  patient  activity  over  months,  years,   and   • An  increase  in  clinical  research  activity     Using  Lean  techniques  with  the  Gelb  Patient  Experience  Mapping,  the  University  of  Michigan   DP’s  were  able  to  identify  “best  practices”  among  the  clinics  and  create  a  new  standard  of  care   for  the  institution.    The  next  step  in  the  new  standard  of  care  involved  identifying  a   “Temporary  Medical  Home”  for  each  patient  to  create  coordination  along  the  entire  episode  of   care.             Standards  created  for  Phase  I  of  the  pilot  program:     Temporary  Specialty  Medical  Home  Pilot  Program   • Each  patient  is  assigned  a  “Home  Center”  based  on  his  or  her  primary   medical/surgical/cancer  site.   • The  home  center  is  responsible  for  coordination,  financial  clearance,  and  all   appointments  for  that  patient  during  the  “episode  of  care.”   • The  Central  Access,  Call  Center,  collaborates  on  patients  that  cross  home  centers.         The  current  flow  of  the  patients  through  the  pilot  system  was  characterized  by  multiple   handoffs  and  specialized  functions  by  many  teams,  an  example  of  which  are,  call  centers,   registration,  insurance  verification,  scheduling,  physician  triage,  evaluation  by  physician   extenders,  treatment  or  procedure  scheduling,  inpatient  teams,  discharge  planning,  and  post   acute  transition  care.    Care  coordination  in  Destination  Programs  was  focused  only  on  new   patient  entry  into  the  institution  up  initiation  of  care  for  Phase  I.    A  Journey  Coordinator   position  was  proposed,  as  an  enhancement  to  the  pilot  but  will  be  discussed  in  a  companion   White  Paper.   ©  2013  Endeavor  Management.  All  Rights  Reserved.       Page  3  
  • 4. Using  A  Nursing  Coordination  Of  Care  Model   To  Create  A  “Temporary  Medical  Home”     Review of Care Coordination   Many  institutions  use  specially  trained  nurses  combined  with  clerical  staff  to  service  new   patients  seeking  care.    However  none  of  the  institutions  reviewed  use  the  same  resources  for   treatment  navigation.    Similarly,  teams  responsible  for  coordination  or  care  during  a   hospitalization  or  transition  care  are  distinct  from  those  interacting  with  the  patient  on  entry   into  the  system.    A  model  which  takes  advantage  of  the  relationships  with  the  patient  and   family  from  the  first  contact  throughout  the  treatment  and  transition  had  not  to  our   knowledge,  had  not  been  piloted.         Rationale for Action   Health  care  reform  will  require  better  coordination  of   Coordination  of  care  has  been   care.    The  spectrum  of  coordination  of  care  can  range   defined  by  AHRQ  as:   widely  from  health  maintenance  to  diagnosis  to     treatment  to  follow  up  care  of  a  disease.           Care  coordination  is  the     deliberate  organization  of   The  numerous  touch  points  within  the  system  make   patient  care  activities  between   the  very  effort  of  care  coordination  complex.    A  review   two  or  more  participants   of  the  “episode  of  care”  was  plotted  out  in  a  Value   (including  the  patient)  involved   Stream  using  Lean  techniques.    Due  to  the  varying   in  a  patient’s  care  to  facilitate  the   levels  of  experience  with  Lean  work,  we  decided  to   appropriate  delivery  of  health   make  the  Value  Stream  very  basic  so  that  all  levels  of   care  service.    Organizing  care   the  health  care  staff  could  easily  see  and  understand   involves  the  marshaling  of   the  work.       personnel  and  other  resources     needed  to  carry  out  all  required   We  started  the  Value  Stream  with  the  intake  phone  call   patient  care  activities,  and  is   to  the  “Central  Destination  Call  Center.”    The  patient   often  managed  by  the  exchange   was  then  triaged  to  the  Patient  Financial  Counselors   of  information  among   for  clearance  and  simultaneously  to  the  clinic  for   participants  responsible  for   medical  acceptance.    Once  accepted,  and  if  financially   different  aspects  of  care.       cleared,  the  patient  was  given  a  tentative  appointment   two  weeks  out.    This  timing  was  decided  based  on   administrative  needs  for  insurance  verification,  clinical  needs  for  medical  records  and  patient   needs  for  scheduling  flights,  travel  and  getting  their  affairs  in  order.             ©  2013  Endeavor  Management.  All  Rights  Reserved.       Page  4  
  • 5. Using  A  Nursing  Coordination  Of  Care  Model   To  Create  A  “Temporary  Medical  Home”     Once  the  “Home  Center”  was  selected,  which  occurred  by  service  line  or  multidisciplinary   specialty  clinic,  that  “Home  Center”  became  the  “Temporary  Specialty  Home”  for  that   Destination  patient.    This  effort  created  accountability  for  the  Destination  Patient  and  assisted   in  smoother  hand  offs  to  other  departments.           See  Diagram  1.       Diagram  1     Designate   Temporary   Specialty   Medical  Home         Diagram  1  shows  the  number  of  steps  from  intake  to  clinic  scheduling  and  beyond.    The  “C”  recognizes  tasks  that  can   be  done  by  clerical  staff,  and  “N”  by  nursing  staff.    The  red  clinical  decision  tree  boxes  note  that  major  clinical   decision  in  care  is  necessary  before  moving  on  to  the  next  step.    Physician  review  is  needed  at  these  touch  points.    The   Patient  Financial  Counselors  verify  insurance  and  in  many  cases  have  a  separate  appointment  with  the  patient  prior   to  the  clinical  appointment.    Metrics  were  measured  on  the  episode  of  care  during  this  pilot,  evaluating  the  timing   standards  for  scheduling  the  clinic  appointment  and  for  scheduling  surgery  once  the  patient  was  assessed.    Discharge   home  was  classified  as  to  the  patients  home  state  or  county  because  many  patients  stayed  in  the  Ann  Arbor  area  for  a   period  of  time  after  discharge  from  the  hospital  for  follow  up  and  further  evaluation  needed  before  returning  home.     It  was  from  this  value  stream  exercise  that  accountability  was  needed  to  improve  the  patient  care  experience.    This   was  also  verified  by  the  Gelb  Experience  Mapping  results.     ©  2013  Endeavor  Management.  All  Rights  Reserved.       Page  5  
  • 6. Using  A  Nursing  Coordination  Of  Care  Model   To  Create  A  “Temporary  Medical  Home”       In  summary,  improved  coordination  of  care  for  Destination  Patients  from  the  first  patient   contact  though  the  evaluation,  treatment  planning,  treatment,  and  transition  care  addressed   many  of  the  deficiencies  in  current  care  process,  and  improved  performance.    This  unique   coordination  of  care  model  was  piloted  for  four  years.    It  also  transitioned  with  a  new  EMR.     The  capabilities  and  synergism  of  which  were  not  yet  discovered.         The  “lessons  learned”  from  this  model  included  a  need  for  a  person  to  step  in  during  hand  offs   to  ensure  that  patients  flowed  smoothly  through  their  experience,  at  least  in  the  transition   period.    The  Destination  Program  Office  performed  this  function  during  the  pilot.       The  next  step,  Phase  II,  was  to  explore  the  “Temporary  Specialty  Medical  Home”  concept  using   of  a  team  of  clerical  and  advanced  nursing  personnel  to  coordinate  care  for  patients  with   complex  diseases  requiring  acute  care  and  using  a  Journey  Coordinator  to  oversee  the  care   during  the  hand  off  touch  points.    Please  see  White  Paper  “Using  Journey  Coordination  for  an   Ideal  Patient  Care  Experience.”       ©  2013  Endeavor  Management.  All  Rights  Reserved.       Page  6  
  • 7. Using  A  Nursing  Coordination  Of  Care  Model   To  Create  A  “Temporary  Medical  Home”     About Endeavor   Endeavor  Management,  is  an  international  management  consulting  firm  that  collaboratively   works  with  their  clients  to  achieve  greater  value  from  their  transformational  business   initiatives.  Endeavor  serves  as  a  catalyst  by  providing  pragmatic  methodologies  and  industry   expertise  in  Transformational  Strategies,  Operational  Excellence,  Organizational  Effectiveness,   and  Transformational  Leadership.     Our  clients  include  those  responsible  for:     • Business  Strategy   • Marketing  and  Brand  Strategy   • Operations   • Technology  Deployment   • Strategic  Human  Capital   • Corporate  Finance     The  firm’s  40  year  heritage  has  produced  a  substantial  portfolio  of  proven  methodologies,   deep  operational  insight  and  broad  industry  experience.  This  experience  enables  our  team  to   quickly  understand  the  dynamics  of  client  companies  and  markets.  Endeavor’s  clients  span  the   globe  and  are  typically  leaders  in  their  industry.       Gelb  Consulting,  a  wholly  owned  subsidiary,  monitors  organizational  performance  and  designs   winning  marketing  strategies.  Gelb  helps  organizations  focus  their  marketing  initiatives  by   fully  understanding  customer  needs  through  proven  strategic  frameworks  to  guide  marketing   strategies,  build  trusted  brands,  deliver  exceptional  experiences  and  launch  new  products.     Our  websites:   www.endeavormgmt.com   www.gulfresearch.com   ©  2013  Endeavor  Management.  All  Rights  Reserved.       Page  7  

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