1. Organizational and Operational Efficiencies in Michigans Health Care Safety Net Peter D. Jacobson, JD, MPH Valerie Myers, PhD Judith Calhoun, PhD Presented to the CHRT Safety Net Symposium 29 October 2010

2. Overview Study of Michigans health care safety net organizations Focus on efficiencies Context of health care reform

3. Methods Qualitative interviews Components of an efficient clinic Strengths/challenges Strategies for improving efficiencies How organized Data collection

4. Sample – Clinic types **Interviewed at each site N=29 Sites FQHC -14 Free Clinic -12 Hybrid - 3 N= 96 Interviews Interviews by Clinic Type CEO/Executive** Medical Director/Clinic Director** Nurses/Direct Worker Clerical/Reception Various Volunteers

5. Sample (N=96) - Position Types 5

6. Components of an Efficient Clinic Staff Leadership Transparency Open communication Clear expectations Requisite education and training Reliability and dedication

7. Components of an Efficient Clinic Aligned vision Clinic mission is consistent throughout staff Partnerships With local hospitals, physicians for referrals Processes Appointment scheduling Patient flow Established policies/procedures Quality of care

8. Administrative Efficiency Domains People HR/ Staff/ Volunteers (Free Clinics) Management Training Processes Patient flow Appointment Scheduling Technology Health IT EHR ENVIRONMENTAL MODIFIERS - Physical space, insurance coverage, $$, health care system

9. Clinical Efficiency Domains Quality of patient care Medical and non- medical staff Availability of services (in-house or by referrals) Case management Continuity of care Coordination of services Referral networks ENVIRONMENTAL MODIFIERS - Physical space, insurance coverage, $$, health care system

10. Enabling Services Efficiency Domains Ability to leverage resources Non-medical care services Transportation Translation services Administrative support Community outreach ENVIRONMENTAL MODIFIERS - Physical space, insurance coverage, $$, health care system

11. Key Context for our Findings Measurement is limitednumbers not robust Variation Lots of variation across clinics, but not a lot across clinic type Efficiency and inefficiency share vocabulary

12. Efficiency or Inefficiency? Common terms or examples used for efficiency/ inefficiency EfficiencyInefficiency Appointment scheduling Patient flow Coordination/ Continuity of care Referrals Patient wait time Information systems Case management Patient education

13. How are Efficiencies Measured? MeasureDo not measure Formal QI methods Mostly FQHCs or other clinics with measurement tied to funding Six Sigma Balanced scorecards Benchmarks # patient visits, length of visit, no show rates, volunteer hours N/A Informal QI methodsMonthly meetingsMany clinics do not formally measure efficiency Mental comparison to other clinics

14. How are Efficiencies Measured? As specific as Volume/productivity Time-related (patient wait time, appointment length) Clinical quality (Joint Commission/HRSA requirements) Patient satisfaction As vague as The basicsimmunizations, patient wait times As honest as I really dont know

15. A Closer Look at Administrative Efficiencies People Leadership Processes Patient flow Technology Health IT/EHR

16. What Contributes to Efficiencies? Clinicians Committed Staff Staff Knowledge Staff Training Leadership Teamwork Volunteers

17. Leadership Contributes to Efficiency Leader Fundraising Building referral networks Teamwork Supporting and promoting mission Institutional memory Communic ation Transpare ncy Clear expectations More efficient clinics had more than one person in this role Change brings short- term inefficiency

18. Efficient Patient Flow Systems Flexible Everyone has a different style so we try to balance [staff] out so they get a breather from a really demanding doctor (FQHC talking about patient flow) Adaptive Creativity (e.g., color-coded pods) to fit the needs of the clinic Measured Well staffed Well implemented Not crowded – manageable patient loads

19. Examples of Patient Flow Strategies Color-coded pods for patient flow Team assigned to color-coded pod Functions like a mini-doctors office Express Careacute walk-ins for colds, sore throats, sprained ankles. Patients stay in roomstaff come to them Patients rotate in a circle to see all professionals Sign-in and complete simple form Huddling (pre-visit planning)

20. Specific Challenges Staffing Volunteers HR Communication Plant/Structural Inadequate space Organizational capacity Funding Continuity/coordination of care/referrals

21. Technology No ITNew ITEstablished IT Both efficient and inefficientInefficientMostly efficient/Unknown Known systems that people know how to use efficiency Inefficiencies of paper-based systems (retrieval times, data reports) Change brings inefficiency in the short term Interoperability issues Many reported increase in efficiency with IT after adjustment period Hope that IT will bring efficiency Unknown resolution of interoperability issues Unknown long-term sustainability of new systems

22. Computer System Inefficiencies Insufficient data collected/provided Interoperability lacking Slows processes Decreases patient flow 22

23. Computer System Inefficiencies Accessing patient information difficult Within the clinic Across multiple clinic sites With clinic partners Support for patient referral Follow-up especially problematic Efficient manual follow-up when staff value/take ownership of referral process 23

24. Computer System Efficiencies Tracking and monitoring of patient data across care episode, affiliated sites, referrals Overall practice management processes Reporting/tracking financial data For few Free Clinics with computer access, positive benefits in quality of patient care and related processes Quite a change for us in every aspect of process management Short-term inefficiencies, significant long-term benefits 24

25. Areas for Improving Computer System Overcome staff resistance/adjustment - Complete transition processes to newer systems - Restructure/reorganize for staffing alignment - Provide adequate staff training Integrate systems/interoperability Improve software Free/Hybrid clinics lack adequate funding FQHCs report adequate funding, split on use 25

26. Study Conclusions More challenges mentioned than efficiencies Structural/HR challenges predominant FQHCs more adept with HIT and HR than Free Clinics Substantial variation in efficiencies (i.e., patient scheduling works well for some, but nightmare for others) Lack of sharing best practices

27. Study Conclusions No clear organizational model as best practice – models evolve Consider hybrid as a strong model Concept of medical home in safety net organizations is tenuous

28. Study Implications Measurement needs to be improved and integrated into funding mechanisms Highly committed leaders drive change Leadership development Leadership team

29. Study Implications Unknown impact of health reform on safety net organizations Affordable Care Act invests heavily in FQHCs Free Clinics could become irrelevantpatients further marginalized Invest in Free Clinics/Hybrids?

30. Study Implications Need to invest in knowledge transfer (i.e., guidelines, best practices) Difficult to meet HITECH/meaningful use rules Environment a driver of variation, not clinic type Money matters, but not the biggest problem

31. Policy Recommendations Include measurement as contingency for funding Federal/state funding essential for Investment in HIT/data Free Clinics to survive Access/continuity of care jeopardized Disparities continue for uninsured populations

32. Policy Recommendations Expand public health nursing to staff clinics Expand telemedicine capabilities Explore regional strategies Encourage alternative delivery models and workforce requirements

33. Practice Recommendations Invest in information systems/data analysis Develop administrative/clinical best practices Process improvements Appointment scheduling Patient flow Transportation

34. Practice Recommendations Human resources Recruit providers Access to specialists Provide adequate Staff training Educate patients (health literacy) Improve staff communications

35. Future Research Understand characteristics of those clinics measuring efficiency Measure quality of clinical care Specify/measure return on investment (ROI) Comparative ROI analyses across clinic types