1. Making Value-Based Care Happen
Accelerating Change over 15 Years at a Multisite Primary Care Clinic

2. Disclosures
Principal of Leibig-Shepherd, LLC
No conflicts of interest

3. Learning Objectives
Identify four foundational components of primary care practice transformation (the lessons learned at Clinica Family Health Services).
Describe the performance improvement process Clinica uses to assure change moves the primary care practice towards its transformation goals.
List examples of practice changes which accomplish planned care and population management to increase value-based care.

4. Clinica Family Health 2015 Clinical Staff 2015 Demographics:
51 Physical Health Clinician FTE
14 Behavioral Health Clinician FTE
6 Dentists FTE / 9 DH FTE
Clinics in the Homeless Shelter, Mental Health Center
2 Full Pharmacies, 2 Pharmacy Outlets, School of Pharmacy
Total Staff of ~500
Admit to 2 community hospitals
Community-wide EHR
2015 Demographics:
47,423 patients, 200,000+ visits
Women of child bearing age and children under 18: 64.9%
Deliveries: 1,229
Patients over age 65: 4.5%
Hispanic or minority: 73%
Patients non-English speaking: 39%
Patients living at/below FPL: 61%
Patients living at/below
200% FPL: 92%

5. Transformation Journey
1998: Joined the IHI Chronic Care Collaborative
Beginning population management with diabetes
Continuity always a critical function
2000: Delivery system redesign (The Big 3)
Access
Office efficiency through transition to teams
Alternative visits
2001: Expanded redesign focus (The Big 6)
Information management
Patient engagement

6. Transformation Journey
: Planned care approach to PI
Asthma, depression, chronic pain
Preventative health care
Redesign architectural layout to support team care
: Spread & sustain innovation
Alternative visit model
Behavioral Health Integration
Other chronic illnesses-ADHD, Bipolar Patients…
Implemented EHR 2005
Safety-anticoagulation program CU School of Pharmacy
NCQA Level 3 PCMH, Diabetes

7. Transformation Journey
: Expand core team members and roles, and community outreach
Home visit program
Dental Hygienist on Pod
Portal enrollment >50%
Nursing Co-visits
Clinical pharmacists on Pods
Pods 2.0-nurse co-visits
Community partnerships with public housing and CORHIO

8. Lesson #1: Transformation is SLOW

9. Foundational Changes: The Big 6
#1 Continuity
#2 Access
#3 Team based care
#4 Expanding the care delivery model
#5 Improved IS design
#6 Patient engagement

10. Continuity Action Steps
Empanel patients to a PCP and team
Routinely measure continuity by PCP/team
Measure and balance panel size
Manage un-assigned and new patients monthly
Educate staff and patients on continuity
Use scripts and “team talk”

11. Lesson #2: It all depends on continuity
↑Continuity Decreases
↑ Continuity Increases
Hospitalizations
Length of Stay
Referrals to specialists
Number of RX’s
ER visits
Tests, studies
Demand for visits
Costs for everyone
Patient satisfaction
Staff satisfaction
Provider satisfaction
Clinical outcomes
Access to PCP

12. #2 Access 1998 next available appointment-
well woman appointment 6 weeks
newborn visit 2 weeks
follow-up for a sick patient 3 weeks
no-shows 36%
new patient 6-8 weeks .

13. Managing Access Today

14. Lesson #3: All models are wrong, some models are useful
#1 Continuity
#3 Team based care
#5 Improved IS
#4 Expanding the model
#2 Access
#6 Patient engagement

15. Improving Access 1. Optimize the Care Team
5a. Decrease appt. types
5b. Reduce backlog
5c. Supply & Demand
5d. Panel Mgmt.
5. Change the scheduling paradigm
3. Reduce demand for in clinic visits
4. Develop contingency plans for high demand times
2. Measure & report access outcomes
1. Optimize the Care Team

16. Improving Access and Outcomes

17. From the RWJF LEAP Program improvingprimarycare.org
#3 Team Based Care
Leadership to build team culture
Develop a core team structure
Create clear roles & responsibilities
Enable staff to work independently
Patients are a member of the team
Leadership provides team time
Leadership provides training
Leadership facilitates career ladders
From the RWJF LEAP Program improvingprimarycare.org 17 17

18. Create and Test a Core Team Model
3.4 FTEs of Provider
4.2 FTEs of Medical Asst.
1 Nurse Team Manager
1 Clinical RN
1.5 Case Manager
1 Behavioral Health Prof.
2 Front Desk
1 Medical Records
½ Referral Case Manager
Dental Hygienist
Clinical pharmacist 18

19. Architecture to Support Teams
Courtesy Boulder Associates

20. Teams Use Standing Orders

21. Outreach-Explicit Team Roles

22. Improving Outcomes Through Team Based Care

23. Lesson #4: Create a quality habit
Formal process for improvement
Review prior PDSAs
Expect completion
Leadership decides on spread
Have a change process plan for both spreading and sustaining change

24. #4 Alternative Visits: Expanding the Care Model
Non-compliant or not-yet-engaged?
Phone care
EHR portal
Home visits
Integrated behavioral health on team
Hygienist on the team
Some patients do better in group setting

25. Why Groups? Improve health outcomes Increase access to care
The Group Visit Model
Why Groups?
Improve health outcomes
Increase access to care
Promote patient and staff satisfaction
Engage patients and families
Clinica Family Health Services

26. Clinica Group Visit Offerings
Continuity Groups
Asthma
ADHD
Patients on Warfarin
Prenatal care
Newborn to 2 years
Diabetes
Parenting/Girls
Depression
Anxiety
Heart Healthy
Pain Management Groups

27. Education vs. Facilitation
Leader is teacher
Provider directed
Educational topics
Provider offers answers and support
Expert opinion
Educated advice
Care based on provider assessment
Leader is conductor
Patient directed
Use content threads
Patients offer answers and support
Peer opinion
Personal experience
Care based on patient self assessment

28. Expanding the Care Model
Lesson #5: Relationship
opens the door to better care models
Expanding the Care Model

29. #5 Improved Information Systems
EHR
Data entry
Business Intelligence
Analytics
Accountability data
Performance improvement (PI) data
PI patient care tools

30. PI Outcomes by Team

31. Lesson #6: Need granular data for Performance Improvement

32. PI Patient Care Outreach Tool

33. PI Patient Care In-reach Tool

34. #6 Patient Engagement

35. Getting the Patient and Family on the Team
Governance Board
Patient voice committee
Direct improvement design
Participate in evaluating PDSAs
Patients on PI committees
Facilitated group visits
Survey comments
Video testimonials, story corps

37. Moving Forward from the Big 6
Expanding the core team
Primary Dental Provider, empanelment
Clinical pharmacists
Nurse co-visits
Community partnerships
iPN-community wide shared medical record
Asthma home visits with the county housing inspectors
CU and Regis Schools of Pharmacology
CORHIO ADT reports

38. Clinica Family Health Services
NCQA Diabetes 2011/2014
NCQA PCMH Level 3
2010/2013
Joint Commission
Accredited
since 2002
2015 HRSA Audit
Perfect Score

39. Nominated by Staff Only non-management staff interviewed Top Work Place Awarded by the Denver Post , 2013, 2014, , 2016

40. Transformational visits
Transformational Relationships “Interaction is the heart of planned care”
Levels of patient and team engagement
Brief Transactional visits
Acknowledgement of psychosocial context
Reflection, goal setting and coaching
Transformational visits
(relationship of mutual influence)

41. Lesson #7 Always keep the patient at the center of decision-making

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