Coastal Medical’s CMO, Ed McGookin Discusses ACO Transformation Process
Edward McGookin, M.D. is the Chief Medical Officer at Coastal Medical and is responsible for the oversight of all clinical activities at Coastal Medical as well as practice transformation towards Patient Centered Medical Home. Ed sat down with HITC’s Rob Waters to discuss the key components of Coastal Medical’s transformation process, the role of technology and some of the lessons learned from the HMO movement to wards delivering more accountable patient centered care.
Rob Waters: Why is patient satisfaction such an important part of the triple aim of accountable care organizations?
Ed McGookin:The reason for the primacy of patient satisfaction in the Triple Aim is that a focus on patient satisfaction addresses what has been lost in our fee-for-service model of health care. Our current health care delivery system does not provide consistent, high-quality medical care (National Research Council, 2001). The Centers for Medicare & Medicaid Services (CMS) has linked reimbursement to patient satisfaction. But the reason that patient satisfaction is such an important part of the Triple Aim is not that it is incentivized or mandated. The experience of institutions such as the Cleveland Clinic and the Mayo Clinic have shown that improving the patient experience of care can lead to substantial improvements in patient safety and quality of care (Merlino, 2013). Our health care delivery system must provide what patients need, not simply what science and technology can provide.
RW: With ACO’s stressing the need to move away from being data rich, but knowledge poor, how does Coastal Medical prioritize and meet more than 70 quality metrics?
EM: We quickly learned that until data is analyzed and represented in actionable formats, we simply have information rather than knowledge. All data sets include signals as well as noise and as an organization, we run the risk of interpreting noise as if it were a signal or failing to detect a signal amid the noise (Wheeler, 2000). Every organization works with finite resources and none can afford to use those resources inefficiently. Responding to data takes energy. We cannot afford the time or expense of implementing programs or process changes based on faulty interpretations of our data. It is imperative that we undertake change with a clear sense of why and how we will make those changes and what our intended outcomes will be.
Every organization that has tried to meet performance targets feels the sense of being made to “jump through hoops”. We constantly question whether the process changes we make really improve care or quality rather than simply fulfill a requirement that has no positive impact on outcomes. As an organization that has successfully performed on more than 70 quality metrics, we can honestly say that tracking performance and conscientiously responding to the data does in fact improve outcomes. As a pediatrician, I was mortified to see data that indicated my sexually transmitted infection (STI) screening rate in sexually active adolescents was less than 20%. I made all kinds of excuses and looked for all the possible flaws in the methodology for collecting the data. When we looked at the workflow processes in our office around STI screening we realized that the data was full of signals, but we had never looked or listened to them in the past. We changed our workflows and office standards around STI screening and within 6 months we improved our STI screening rates by more than 75%.
Electronic Health Records (EHR) provide health care organizations with an unprecedented ability to collect data. We have leveraged our EHR to collect data in structured data fields to facilitate reporting and responding to the opportunities to improve patient care or office processes. We have also realized that our EHR, like most EHR’s, was designed to receive and organize data, but that it was poor at producing actionable reports from the data we had entered. Coastal Medical employs four full-time data analysts who work to collect and report the data we use to inform the clinical program changes that we undertake. Despite the resources this team brings to our organization, we needed data analysis tools that could consume and aggregate our own EHR data, data from payers, and data from sources outside Coastal. We became a development partner with our EHR vendor to develop an analytics platform to meet our growing data analysis needs and are now beginning to use that data to inform our clinical programs.
RW: In your efforts to increase total cost transparency, what are some key strategies to effectively manage high-risk patient populations for the “sickest 5 percent”?
EM: Coastal has found that just has been stated by many other organizations, 5% of patients spend almost 50% of the healthcare dollars (Stanton, 2006). In our case, 6.2% of our patients account for 50% of our total cost of care. We began by referring to these patients as “high-opportunity” rather than “high-risk”. We realized that the patients in this demographic could benefit the most from care coordination. We developed interdisciplinary rounds or “care conferences” for this group of patients and have learned a great deal directly and indirectly from them.
Care conferences generally involve patients with poorly controlled chronic diseases or polychronic conditions. They are conducted in each office at least once weekly and involve the office manager, nurse care manager, clinical pharmacist and primary care physician (PCP). Often a representative from a home nursing agency that provides palliative and hospice care for our patients attends these conferences as well. Each member of the team reviews the chart records for the information relevant to their role in the care of the 15-20 patients who will be discussed in the one hour conference. Issues such as appointment no-show rates, last exam, emergency department utilization, hospitalizations, sub-specialty engagement, laboratory screening, polypharmacy, medication adherence, narcotic utilization, fall risk, advance directive status, and gaps in care are presented to the PCP who synthesizes the information and develops an action plan with the team.
Some of the insights from these care conferences have included the importance of patient engagement and ensuring that care plans are genuinely patient-centered. We have been reminded of the importance of taking the time and effort to understand what the enabling and motivating factors are in a patient’s care as well as the barriers to care are for an individual patient. Operationally, the value of effective pre-visit planning for office visits has been demonstrated repeatedly through these conferences. The impacts of behavioral determinants of health have prompted us to develop an integrated behavioral health program. We have seen a significant increase in the quality of care when patients are involved in our disease management programs. Our utilization of hospice care increased from 114 admissions in 2012 to more than 500 admissions in 2013. This is another example in which measuring and responding to performance data improves performance and quality of care. Finally, these care conferences have illustrated the importance of having a prospective means of identifying patients for care coordination and our data analytics now incorporates predictive modeling capabilities.
Post-acute care is an area where there is a great deal of variation in practice standards that result in unnecessary expenditure, duplication or delays in services, poor communication and risk for readmission. We have developed a Transition of Care clinical pathway and implement this for every patient leaving the hospital or a skilled nursing facility. Ensuring a safe and effective transition of care is one of the primary roles of our Nurse Care Managers.
RW:By distributing the workload of closing gaps in care for patients that have proven to be difficult to engage with, what are some of the best practices you’ve taken note of? What works? What doesn’t?
Patients who are difficult to engage with are often patients whose wishes are not in alignment with those of their caregivers. This is where the challenge of truly patient-centered care is contrasted to physician-centered care. Patient-centered care is a dimension of quality and transparency and individualization of care is imperative in a patient’s experience of care (Berwick, 2009).
“Every system is uniquely and perfectly designed to produce the results it is currently producing” (Senge, 1990). Our work in closing gaps in care has given us much clearer insight into the work flow and clinical processes that enable those gaps. The best practices we have observed include previsit planning, preappointment lab testing, expanding the roles of office staff and medical assistants in rooming patients and facilitating medication reconciliation and improving team functioning through lean process workflow redesign.
What doesn’t work? Asking physicians to do “one more thing”. There is already too much going on in the one-to-one encounter with the patient to add anything else. Physicians are spending too much time after a patient encounter or at the end of a day of seeing patients. EHR’s in their physician-centric designs have excelled at redistributing work to physicians. Very often this is work that can and should be done by other office and clinical professionals. We are looking toward innovative ideas such as scribing and assistant order entry as new ideas to consider (Sinsky et al., 2013).
RW: Given the speed at which the culture of healthcare is being asked to change, what are some of the lessons that can be applied from the HMO movement of previous years?
EM:Physicians who practiced in an HMO model before joining Coastal remark that we look more like a HMO as our ACO evolves. We have visited Kaiser-Permanente and have met with leaders in other clinically integrated organizations to learn from their experience in population health management. These interactions have reinforced the importance of providing care when patients need it and we have responded by ensuring access to care on weekends, holiday and evenings.
In order to take responsibility for the care of a population of patients we must engage the patients who need care or care coordination whether they engage with us or not. We use our data capabilities to identify the patients who need to come in for care or need a reminder for screening laboratory or imaging studies. We have learned the value of telephonic care particularly when the healthcare provider on the phone is introduced by a patient’s physician as a colleague and a valued member of the patient’s healthcare team. The emphasis on a team of healthcare providers made up of office staff, physicians, nurses, nurse care managers, and pharmacists has differentiated the experience of care for Coastal patients. It is inspiring when individuals proudly relate their experiences as Coastal patients in public discussions about the changing healthcare system.
Ed recently presented at the 2013 Accountable Care & Health IT Strategies Summit, San Francisco.
View the HD Video presentation and download the PPT Here
Utilizing Technology to Meet the Needs of a Changing Healthcare System
Utilizing eCW since 2006, Coastal Medial was an early adopter of technology specifically designed to improve patient care and reduce medical errors. The record has done all of this and much more. Currently, Coastal is using technology to reinvent the payment model for their ACO by utilizing the new CCMR functions. This new tool will enable the group to review data in real time and modify patient management strategy to reach even more of their goals which center around improving the patient experience and quality of care they provide, as well as reducing the cost of care across their entire population of patients.
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