Bridge 2 Excellence: Patient Centered Medical Home Implementation A joint venture with GIM and RISE

Patient Perspective Wait! 2

Patient Acute Service Utilization 3

No Show Impact 4  61% of patients arrive for scheduled appointments  ~20% are materially late  Impact not planned for and used effectively  Results in average of 20 minute gap in schedules in nearly 1 of 4 appointments

BMC GIM Physician Productivity 5  Productivity higher than expected at 8 visits / session  Significant process barriers prevent higher productivity  Patient no-show and reschedule rates are material  Low average sessions per provider per week result in limited access for patients  All identified barriers are addressable, and expect 12 visits per session is attainable

Future State of Primary Care Key Drivers  Payor Consolidation  Continued downward pressure on costs  Payment Reform  Move from transaction based payment to payment based on outcomes  Global payment demonstrations, ACOs  Penalties for readmissions, admissions for ambulatory sensitive conditions  Accountability for health of population  Fewer publicly insured patients in FFS arrangements  Once insured, patients have choices and vote with their feet  Clout matters – volume brings scale and negotiating leverage Future Requirements  Primary care should be “front door” to system; must be welcoming and responsive to patient needs  Practices should be patient-centric  Need capacity in practices to see new patients and existing patients with urgent needs  Patients need continuity when their physician is not available; care teams become critical  Teams can be accountable for a panel of patients; they have to be a size that people know one another and patients know who to call  Need short cycle information and metrics  Need system of leadership and accountability that is supported by training, tools and measurement 6

Transforming Primary Care A Comprehensive Approach What Is Needed  Create Capacity  Measure and improve clinical quality and enhance patient experience  Design and organize care to improve outcomes and lower costs How Is It Achieved Extend the physician through allied professionals and “virtual visits” Move tasks to the most appropriate member of the care team Use technology to eliminate work Continuous data analysis leading to proactive patient outreach Consolidated data leads to more effective and focused visit Focus on patient experience at every point of contact Create and manage to a customer- specific Medical Cost Action Plan Build evidence-based protocols into the process Inform patients so they are active participants in care decisions

What does all this mean?  First emphasis should be on unleashing capacity  Improvements in quality and cost will follow  Improvements occur primarily as a result of focusing on process and accountability  Unwarranted variability must be eliminated to support effective flow  Will require a fundamentally different process  Incremental change will not yield the transformation needed  Leadership development is key to transformation and sustainability  May need to evaluate reward and incentive structures  In this unique environment, patient panels must be owned by care teams, not individual physicians  Possible to substantially increase visit and patient volume  Double capacity of visits and 50% increase in patients not inconceivable  Of value today and in ACO environment 8

Two initial areas of focus Create a dedicated care team with clear accountability and goals  Team means more than group of people sharing rooms  Team is accountable for a panel of patients  Each team a has part-time medical director, full-time practice manager, practice assistants, check in-check out, and nursing resources available  Team held accountable for clearly identified metrics Create technology-enabled team designed to contribute to the care experience and support the practice  Emphasis on completing as much as possible in advance of visit  Optimized scheduling  Pre-visit prep including eligibility and insurance verification, history of present illness, and med rec  Most of the follow through and care planning activities completed by this team 9

Proposed Scorecard Stop Light Version

Operationalize Decision Order Entry Prescriptions Pt education Letters Calls Refill Rx Results Management 15 min 5 min Presenting issue Review History Physical Exam Plan Discuss Options Decide Educate Complete Note Daily Huddle Arrive Patient Collect Copay Manage Patient Wait Vital Signs Room according to Protocol Optimized Schedule Verify Eligibility Verify Insurance Med Reconciliation History of Present Illness Select Family and Social History Care Gaps (TBD) Wellness Gaps (TBD) Virtual Visits (TBD) Operationalize Decision Prior Authorization Referrals EMR Optimization Clinical Protocols (Initial) Existing support role Existing support role New extender role New extender role Physician Operationalize Decision Order Entry Prescriptions Prior Authorization Referrals Pt education Documentation Complete Note Coding Letters Calls Check Labs Refill Rx Patient Visit 20 min4 min (Est)9 min (Est) Presenting issue Med Reconciliation History Physical Exam Plan Decide Update EMR Begin Referrals Verify Eligibility Verify Insurance Collect Copay Arrive Patient Vital Signs Care Planning Follow- Through Registration & Room Pre-visit Prep Schedule Transfer to Practice 15 min4 min9 min Patient Visit Care Planning Follow- Through Check-in & Room Pre-visit Prep Care Planning AFTER Hands on and dedicated care team focused on efficient patient flow New Patient Coordinator role takes work off rest of care team Predictable provider process more readily accommodates patient fluctuations Provider able to complete “today’s work today” BEFORE  Support team not focused on effective patient flow  Provider process unpredictable  Provider schedules not flexible to daily patient fluctuations  Provider has significant work carryover beyond scheduled session A Day in the Life of the Practice (Phase 1) 7 min4 min 15 min 11 The Extended Care Team

Project Timeline

The Case for Transformational Change B2EBMC Mission Patient Centered Medical Home Financial Sustainability

TRAINING KICK-OFF 28 New Rise Employees Trained