A Leaders' Guide to Creating the
Business Case for Planned Care
A Toolkit
Authored by:
The faculty of HRSA's Finance and Redesign Pilot Collaborative
Ann Lewis and Christine St. Andre, co-chairs
Sharon Buttress
Roger Chaufournier
Cindy Hupke
Jerry Langley
Cory Sevin
Ron Yee
May 2006


Acknowledgement
This leader's guide and toolkit is one of the work products resultant from
two
years of field work involving Federally Qualified Health Centers actively
implementing the Planned Care Model as part of their work in the Health
Disparities Collaboratives initiative sponsored by the Health Resources
Services
Administration (HRSA). The authors wish to thank HRSA for its vision in
recognizing the need for tools and resources to assist health centers with
this
challenge of supporting organizational transformation. Specific
recognition should
be given to Fred Butler, HRSA Project Officer for the Finance and Redesign
Pilot
Collaborative where the evidence base for this toolkit was established.
The
authors also wish to thank those health centers that participated in the
Finance
and Redesign Pilot, including:
• Denver Community Health Services; Denver, CO
• Community Health Center, Inc.; Middletown, CT
• Rural Health, Inc.; Anna, IL
• Holyoke Health Center; Holyoke, MA
• White River Rural Health Centers, Inc.; Augusta, AR
• Community Health Center of Lubbock; Lubbock, TX
• Aaron E. Henry Community Health Services Center; Clarksdale, MS
• Family Health Centers, Inc.; Orangeburg, SC
• One World Community Health Center; Omaha, NE
2


TABLE OF CONTENTS
I.
II.
III.
IV.
V.
Introduction to the Business Case
The Change Package and a Model for Transformation
Getting Started
Toolkit Index
Business Case Bibliography
3


(back to Table of Contents)
I. Introduction to Understanding the Business Case
Background
In 1999, the Health Resources Services Administration (HRSA) launched
an ambitious initiative to change the predominant care delivery model in
the
Federally Qualified Health Centers (FQHC's). The HRSA initiative, known as
the
Health Disparities Collaboratives (HDC), adopted the Wagner Care Model
presented in Figure 1 as its new model for care delivery. Through
implementation of this model, FQHC's across the US have begun a journey
toward organizational transformation and improved population health
outcomes.
Health System
Organization of Health Care
Community
Resources and Policies
Self-Mgt
Support
Delivery
System
Design
Clinical
Information
Systems
Decision
support
Informed,
Activated
Patient
Productive
Interactions:
Prepared,
Proactive
Practice Team
Evidence-based clinical management
Collaborative treatment plan
Effective therapies
Self-management support
Sustained follow-up
Functional and Clinical Outcomes
Figure 1. The Wagner Care Model
The Health Disparities Collaboratives initiative has done a lot to improve
the
historical perception about care delivered in the FQHC's. The data that
has been
collected through this initiative has demonstrated improved clinical
outcomes for
patients with chronic conditions and in some cases shown that the care
provided
in the FQHC's is superior to that provided in the private sector. An
evaluation of
the Collaboratives conducted by the Agency for Healthcare Research and
Quality
(AHRQ) reflected that, on balance, the health centers participating in the
HDC
process felt that it had a positive impact on their organization and their
patient
populations.
One of the major issues associated with a movement toward the Planned Care
Model is the reality that there are costs associated with implementing and
4


sustaining the required practice changes. Throughout the history of the
Health
Disparities Collaboratives health center leaders have questioned how to
subsidize the new work of Planned Care. The fundamental business case of
any
organization comes down to the simple equation of margin equals revenue
minus
expenses. To explore the business case for planned care, attention must be
paid to both components of this equation.
The Cost of Implementing the Care Model
The implementation of the Planned Care Model does require a front end
investment by the health center. The costs include such examples as the
time
and lost productivity of staff who participate in training activities,
time to test
changes and implement the change package; the costs associated with
supporting clinical registries and data entry; time to provide patient
education and
other services such as group visits which might not be reimbursed by third
party
payers; max packing services that might not add to reimbursement.
A recent study funded by AHRQ focused on evaluating the impact of the
Health
Disparities Collaboratives from a variety of different perspectives. 1
As part of that
study conducted by Elbert Huang, M.D. and Marshall Chin, M.D., they
quantified
the aggregate costs for a health center to implement the Planned Care
model.
The cost was calculated on a per patient basis and ranged between $6.41
and
$23.93 per patient for the first year. This amount translates to between
1.98%
and 8.2% of the total health center budget. The wide range is attributable
to both
the size of the organization as well as its efficiency with its internal
quality
improvement and change management processes. Over time, the costs of
planned care likewise vary, with 80% of the health centers reporting that
after the
first year, costs declined as a percentage of budget.
The Business Case for Planned Care
It is clear that a front end investment is needed in order to implement
the
Planned Care Model. This leads to the obvious question of whether there is
a
longer term return on investment for this initial investment. The nature
of the
HDC is such that clinical outcomes as well as process measures are tracked
and
reported by each participating health center. This data has reflected
improvements across the board of both outcomes and process measures in
most
major disease categories. Unfortunately, these measures are not easily
linked
to financial measures of performance. Further, the nature of payment
systems
1
. The Agency for Healthcare Research and Quality conducted a study of
Health Centers who participated
in the Health Disparities Collaboratives from the Midwest Cluster. Drs.
Marshall Chin and Elbert Huang
were the principal investigators from the University of Chicago. The
results of the study have not been
released publicly as of the end of 2005. However, the information
referenced was presented by Drs. Huang
and Chin at the September, 2005 Community Health Institute in Miami
sponsored by the National
Association of Community Health Centers.
5


makes systematic data collection of the financial impact of care delivery
changes
a challenge. Data can be presented showing systematic decreases in average
HbA1c levels for patients in the diabetes registries, and there is a
strong
evidence base available for the impact even small decreases in HbA1c level
on
co-morbidities and overall mortality. However, it is not easy to make the
further
correlation to the financial impact resulting from this work.2
Nonetheless, an evidence base is starting to evolve as a result of the
overall
industry's increased emphasis on disease management and chronic illness
care.
In November 2005, a meta-analysis of the disease management literature
conducted by David Krause was published in Disease Management. This
analysis sought to determine if there is an evidence base for a positive
return on
investment for disease management services which now represent a billion
dollar
market in the private sector. According to Krause's analysis, an economic
impact
has been demonstrated in the literature, and disease management programs
are
more economically effective with severely ill individuals and are more
economically effective when coordinated with disease severity.
In the health center arena, the most pertinent study was conducted in
South
Carolina by the Budget and Control Board. 3
The study reviewed a comparison of
health centers that have participated in the HDC compared to those who
have
not and to all primary care practices in the state. Figure 2 presents a
summary of
their findings for a large population of Medicaid patients.4
. The United Kingdom Prospective Diabetes Study (UKPDS) was a 10 year
study of a large population of
people with diabetes published in the British Annals of Internal
Medicine.. The study showed that a 1%
decrease in HbA1c level had a corresponding 35% decrease in cardiovascular
endpoints; an 18% reduction
in myocardial infarctions; a 15% decrease in strokes, an 18% reduction in
cataract extractions and a 17%
reduction in mortality.
3
. The study was conducted by Pete Bailey of the Office of Budget and
Control. The study has
subsequently undergone a validation by Mercer Benefits Consulting.
4
Adapted from Pete Bailey, South Carolina Budget and Control Board. 2005
2
6


Figure 2
Payment Profile for Patients with Diabetes from the Medicaid
Billing System
South Carolina, 2000 - 2002
Indicator
Selected
FQHC
All Family
Practice
Physicians
(Median)
$1,778
$576
$168
$634
$22
Avg. total annual payment per patient
Avg. annual drug payment per patient*
Avg. office visit payment per patient*
Avg. inpatient hospitalization payment*
Average emergency room payment*
For patients receiving the service
Source: South Carolina Office of Budget and Control 2004
$1, 340
$502
$441
$172
$15
The data from South Carolina are impressive as they show a dramatic
difference
in overall annual cost per patient. These reductions are due to decreased
hospitalizations, emergency room visits and subspecialty referrals
resulting from
increased emphasis on evidence-based guidelines and preventive care.
In the December 2005 issue of Family Practice Management Dr. Philip Mohler
reported that annual costs to support planned care in his private practice
total
$1,800 per physician, or $114 per diabetes patient per year.5
Using this cost
figure, combined with the medical cost savings from the South Carolina
data,
yields a theoretical return on investment of 3.84 to 1. Although the
practice
settings and patient population characteristics in these two examples do
not
match, it is logical to assume that there is a positive ROI of some
magnitude that
can be derived from the work of planned care.
Another example of cost savings to the system comes from the state of
Maine.
The Maine Primary Care Association testified before the State
Appropriations
and Financial Affairs Committee and reported that the health centers who
had
participated in a collaborative and therefore implemented planned care
experienced a 48% drop in hospitalizations associated with diabetes as
compared to a 14% drop throughout the rest of the state. Hospitalizations
for
health center patients with depression dropped by 25% compared to 9% for
patients statewide. The estimated savings attributable to this
differential was in
excess of $814,158.
As part of the AHRQ study previously referenced there was a cost
effectiveness
analysis (CEA) conducted to try to confirm the economic impact as a result
of the
Collaboratives. Data were collected from a randomized controlled study
involving 34 health centers. They analyzed the impact of decreased
complications as a result of better controlled diabetes care. The study
concluded
that there is a positive difference of $49,334 savings per Quality of Life
Year
7


(QALY) for those patients benefiting from the HDC experience as compared
to
those who did not.
The tension between downstream savings versus upstream costs
It is becoming clearer that the HDC are having a positive impact on health
outcomes and that implementation of the Care Model has the potential to
save
the larger health care system significant resources over time.
Unfortunately, a
tension exists whereby the savings generated through improved outcomes and
less use of hospital and ED resources accrue not to the primary care
providers,
but to payers in the form of managed care organizations, state Medicaid
agencies, and the federal government. The dilemma lies in the fact that in
order
to generate these savings, the primary care providers must make a front
end
investment of time and monetary resources without any clear incremental
revenue stream to subsidize the costs.
During the Finance and Redesign Pilot the faculty and participating health
centers confirmed this dilemma and concluded that a primary care practice
is at
risk if they simply add the planned care work to their existing systems
without
stepping back and reengineering their organization.. Costs would be added
without the prospect of near term reimbursement. To address this challenge,
health centers need to rapidly move forward and reexamine their operations
to
find ways to generate a business case. The toolkit that follows was
designed to
assist health centers in doing just that. It reflects the work of health
centers that
found ways to generate their own business case and are now positioned to
take
leadership positions in the new health care environment that is emerging.
As long as the old rules of the reimbursement game persist there is little
incentive
for primary care practices to adopt the Planned Care Model as an
organizing
framework. However, while change has not been rapid thus far, the health
care
environment is complex and dynamic and some of the old rules of the game
are
being modified through the confluence of several market forces.
The first force that is driving change is the increased transparency
associated
with performance measurement and the greater accountability being demanded
by funding agencies. As resources continue to become constrained,
decisions
are increasingly favoring those who can use data to demonstrate their
improved
performance.
Linked to such efforts is the national wave of Pay for Performance (P4P)
initiatives in which funding is being tied to defined performance
measures. P4P
programs offer the opportunity for primary care organizations to generate
increased revenue as a result of better outcomes. Such revenue may be in
the
form of bonuses based on performance measures as well as increased patient
8


volume as a result of publicizing these measures. The downside of such
programs, however, lies in the potential for P4P programs to evolve into
economic credentialing where low performers start to become disadvantaged
in
both revenue and potential access to patients. To guard against such a
possibility, health centers must work diligently on improving clinical
outcomes ---a
clear objective that can be achieved through the implementation of Planned
Care.
Lastly, the improved outcomes achieved by those who have adopted the
Planned
Care Model are slowly resulting in changes to the reimbursement system.
There
are numerous payers who have been launching programs to reimburse for
portions of the Planned Care work. Examples include Dr. Mohler's practice
that
received $120 per diabetic patient per year from a local health plan as an
additional care management fee.5
Wellmark of Iowa has also been
experimenting with varying reimbursement schemes for proper chronic
illness
care.
It is likely that the overall reimbursement system will ultimately catch
up to the
changes being made in the care delivery system. Those who have positioned
themselves by adapting their systems in anticipation of this evolution
will be able
to seize the moment. Those who do not make efforts to stay ahead of the
wave
may find themselves at a competitive disadvantage.
Making Your Own Business Case and Creating the Resources to Fund the
Transformation
Can you really generate your own business case without dramatic changes in
the
reimbursement system? The answer to this question is yes. It requires
recognition that the work of Planned Care is intricately tied to the
financial
performance of the organization. One of the traps organizations fall into
is
seeing the Planned Care work simply as a clinical quality improvement
project.
When viewed in this light it just adds to the existing work of the care
team of
clinicians and support staff that are assigned to the project. Rarely does
the
team of those assigned to work on Planned Care include colleagues who work
in
the administrative and financial areas of the organization. As a result,
silos are
perpetuated and the full talents of the organization are not harnessed to
actually
redesign the systems and processes in order to deliver higher quality care
at
lower costs.
Those who have been successful in driving their business case have adopted
the
notion of "quality as business strategy. They have recognized that
implanting
the Planned Care model in their organization requires a total
transformation of
the organization. This work becomes an opportunity to understand the
intersection of administrative, financial, and clinical systems and to use
this
knowledge to redesign all of these processes toward a leaner and higher
9


performing organization. They realize that the traditional model of
primary care
delivery all of us have grown up with is perfectly designed to achieve the
suboptimal results it is achieving. Implementing Planned Care is not about
simply
tweaking our old systems to get them to perform better. Rather, it is
about
designing new organizations that produce better outcomes with fewer
resources.
Once armed with this knowledge, health centers have demonstrated they are
capable of making this transition.
To follow is a change package that represents the high leverage
opportunities to
generate the business case. Following the change package is guidance on
how
to get started and then specific toolkits aimed at facilitating the spread
of the
change package.
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II.
The Change Package and Model for Transformation
If one steps back and examines the Planned Care model from the lens of the
business case it is clear that every component of the model can have an
impact
either on cost or revenue. To follow are examples within each component of
the
care model to demonstrate the point:
Community Resources and Policies: Establishing new relationships in the
community can reduce costs for an organization by generating new
resources in the form of in-kind donations of supplies or , including
expanding the care team with external members from the community.
Influencing the policy of Medicaid and other payers can dramatically
change the revenue stream.
Organization of Health Care: Aligning internal recognition and reward
systems to support planned care work can enhance productivity which has
an impact on both cost and revenue potential; policies that facilitate and
encourage innovation and improvement can lead to new ideas to reduce
costs; on the negative side, lack of support from leadership can lead to
non-productive teams, significant rework down stream, and added cost.
Self-Management Support: One of the greater challenges of the Care
Model is self-management support. Because self-management support
requires care team member time, productivity and costs are impacted by
which member of the care team is assigned this responsibility. At10-20
minutes per patient visit over an entire patient panel, the difference
between a physician performing this function versus a nurse can be as
much as $50,000 -$60,000.
Delivery System Design: The access system is a huge driver of
productivity in a primary care setting. Advanced access can decrease no
show rates, thereby dramatically increasing revenue potential.
Clinical Information Systems: The management of data is a critical
function in organizations. Having highly skilled clinical staff perform
the
data entry function or requiring redundant data capture can add cost to
your system. Well thought through information systems can contribute to
clinical productivity.
Decision Support: Standardization of decision making can streamline flow
and reduce costs. Use of medication standing orders can reduce
interruptions or provider time, streamline flow, and avoid unnecessary
calls and lost productivity.
11


These are a few example of the interconnection of each component of the
Care
Model with the business case. Every change concept introduced with the
Care
Model likewise has elements of the business case underpinning it.
Leadership
must be diligent in the roll-out of the Care Model to ensure that
resources are
being properly utilized and that changes are evaluated in terms of their
return on
investment (ROI).where appropriate. In addition, it is important to
recognize that
there are some changes that represent greater opportunities than others to
impact the business case. At the end of the day, the business case comes
down
to that simple formula:
Margin = Revenue minus Expenses
And to make revenue meaningful, it must be collected. The faculty and
teams of
the Finance and Resign Pilot identified four high leverage opportunities
to
influence this formula and drive the business case in primary care
organizations.
In addition, a framework was developed to assist health centers with
implementing these high leverage changes. The high leverage opportunities
include:
Optimizing the Care Team: Labor typically represents more than 60% of
the expenses of a health care organization. How staff are utilized to
provide and support care delivery can therefore drive much of the
economics of an organization. Matching skill sets with the work that must
be done and allocating staff to support maximum productivity of the
provider allows for greater panel sizes and ultimately greater revenue.
Eliminate waits and streamline workflow: The traditional system of
outpatient scheduling drives significant inefficiency, results in
inordinately
high no-show rates, and is a silent drag on the economics of an
organization. Implementing advanced access principles wherein capacity
and demand are balanced on a daily basis and today's work is done today
can result in dramatic reductions in no show rates and consequent
improved revenue.
Enhance Revenue: Revenue is impacted by how many services are billed,
how much is billed for each service, and how much of the billings is
actually collected. Service volumes, coding practices, documentation,
billing systems, and processes for management of receivables all come
into play. When these systems undergo close scrutiny, there are
opportunities to generate both short and long term gains in revenue.
Eliminate waste and reduce costs (Creating a Lean Organization): A
strong evidence base has existed around a change package associated
with the principles of "Lean generated out of the Toyota Production
System (TPS). These principles can easily be applied to healthcare and
can be used to streamline flow, manage inventories, and minimize
12


unnecessary motion of people, information and technology in order to
recapture significant waste that occurs from the design of our existing
care
delivery systems.
To assist with the implementation of these broad concepts a specific
change
package was crafted through the harvesting of the Pilots focusing on the
business case underpinning Planned Care. To facilitate tracking of these
concepts they were organized under the "Delivery System Design and
"Organization of Health Care components of the Planned care Model. It is
important to re-emphasize that many opportunities for influencing the
business
case transcend all components of the Care Model and these other components
should not be overlooked. A comprehensive explanation of the change
concepts
appears in the toolkit in Appendix A where each idea is expanded and
examples
and helpful hints provided.
The change package is summarized in Figure 3 below.
Figure 3: Business Case Change Package
ORGANIZATION OF HEALTH CARE
• Use data to understand your practice and its business case
• Focus leadership attention on improvement
• Enhance revenue*
• Eliminate waste and reduce costs*
DELIVERY SYSTEM DESIGN
• Optimize the Care Team*
• Eliminate waits and streamline work flow*
• Provide seamless and coordinated care to patients
*Items in blue represent high leverage change concepts and economic impact
drivers
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(back to Table of Contents)
III. GETTING STARTED
The implementation of the Planned Care Model is a daunting task for any
organization. Adding the lens of the business case to this process
increases
complexity and provides additional challenges. A framework to assist
organizations with implementing the change packages was developed and is
presented in Figure 4. Before exploring the framework, however, a few
observations on sequencing should be contemplated.
Sequencing Changes in Your Organization:
Early in the history of the Collaboratives, HRSA was supporting two
different
approaches to changing practice. The first was known as the Cycle Time
Collaborative, focusing on office visit cycle time; the other was the
Health
Disparities Collaboratives, focusing on the Planned Care Model. In
addition, the
Institute for Healthcare Improvement (IHI) was supporting a Breakthrough
Series
on Idealized Design of Clinical Office Practice with a heavy emphasis on
improving access. Health centers became exposed to these three different
approaches and began asking: "which one should we do?" The direct answer
to
the question was that at some point an organization needs to address all
three
areas of focus---the care model, access, and cycle time or flow. This
immediately
raises the question as to whether there is a logical sequence to follow.
As with any debate worth pursuing, one can find proponents in each of the
camps. There are health centers who first participated in the Cycle Time
Collaboratives and remain convinced that this is the logical starting
point. There
are those who believe that Access is such a driver of a practice's
economics and
efficiency that implementation of Advanced Access is a prerequisite to
generate
the resources to pay for Planned Care. Finally, there are those who
started with
the HDC and the Planned Care Model and found it to be the solid foundation
and
organizing framework necessary to guide all the work. The right approach
will be
dictated by local circumstances and the specific needs of the health
center.
The Faculty guiding the pilots addressing the business case probed the
participating teams to determine the logical sequencing for the work. In
the end,
the pilot teams factored in all the considerations they could and then
recommended the following sequence:
•
Care Model: Start with teaching the organization the Care Model and how
to make rapid cycle changes through use of the Model for Improvement
developed by Associates in Process Improvement. Use the Care Model as
the overall organizing framework.
14


•
•
•
Cycle Time and Flow: Understanding lean thinking and flow through such
tools as process mapping facilitates the ability to evaluate any system
and
to introduce efficiencies into daily practice.
Optimize the Care Team: Care team roles will inevitably change as the
Care Model is implemented; having the context of the Care Model, along
with some of the principles of lean provides context to facilitate the
challenge of examining and changing the roles of the players in an
organization
Advanced Access: Improving patient access can have a dramatic impact
on the organization; however, this change can often be the most
challenging to tackle without the external support of a Breakthrough
Series
or a coaching model.
Getting Started: A Framework for Making Change
Figure 5 presents a model for driving a business case with Planned Care.
The
model starts with understanding where you are, then identifies where you
want to
be and establishes priorities and an action plan for getting there. The
first step in
the process is to put together a comprehensive assessment of the current
state
of the practice across several measurement dimensions. It is only through
this
type of assessment that a rationale plan for implementing and tracking
improvements can be made. Measures that should be included in the practice
assessment include measures of patient characteristics such as payor mix,
diagnosis distribution, and demographics; clinical process and outcomes
measures, such as those that are tracked as part of the HDC initiative;
measures
of access, such as time to third next available appointment; measures of
cost,
revenue, and profitability by type of patient/service and overall;
measures of
patient and staff satisfaction; efficiency measures such as visit cycle
time. In
short, you need to understand where you are and where you compare to
benchmarks and goals in order to know where to place your priorities. As
this is
done, the measures and data collected in the initial practice assessment
can also
become the basis for an ongoing set of system-wide performance measures
that
can be used to track a practice's improvement and progress toward
transformation. A list of potential measures for the initial practice
assessment
and ongoing performance tracking can be found in Appendix B.
15


Figure 5
Creating a Business Case
Understand your
Business Case
Gap Analysis
(Compare Where
you want to be)
Prioritize your
action plan
Change
Packages
(How to get there)
(Use data to under-
stand where you are)
Clinical Measures
Volumes
Patient Mix
Panel Size
Productivity
Revenue/Collections
Unit Cost
Margin/ Profitability
Cycle Time
Demand vs. Supply
Access
Patient and Staff
Satisfaction
Staff Turnover
Value stream analysis
Process Mapping
Unit Cost Analysis
Variance reports
Benchmarking
Access
Cycle time
Manpower/supply
Demand Management
Revenue
Enhancement
Cost/waste reduction
Improving Productivity
Influencing
reimbursement
Staff development
Leadership
Patient Recruitment/
Retention
Eliminate waste and
reduce cost
Optimize care team
Eliminate waits and
streamline workflow
Provide seamless,
coordinated care
Use data
Enhance revenue
Focus leadership on
improvement
Gap Analysis
After completing a baseline practice assessment, the next step is to
complete the
Gap Analysis. This phase focuses on your current state compared to
industry
benchmarks or to other goals that have been set. Some sample goals for
various aspects of your business case are cited below:
Cycle time
Access
Encounters per team/year
Panel size per provider
1.5 times visit length*
0 days to third next available appointment*
4817**
1325 (Family Practice)**
*benchmarks from IHI work on Idealized Design of Clinical Office Practice
**75th
percentile of UDS 2004
Comparative benchmarks can be obtained from a variety of sources including
UDS data, State Primary Care Associations, HDC national data, and Medical
group Management Association, to name a few.
Once you identify an area you want to focus on you can drill down further
by
completing a more detailed analysis of the priority area. Such tools as
unit cost
analysis, value stream analysis or process mapping (see toolkit) can
assist in this
effort. For process-driven areas, value stream analysis is a particularly
powerful
approach to flag your opportunities for improvement and to help you
quantify the
impact you might experience by focusing your energies in a particular
area.
Prioritize your action plan
Once your opportunities for improvement have been narrowed down, you can
prioritize your roll-out based on the specific needs of your practice and
its
underlying business case. Priorities, sequencing, and timeframe will also
depend
16


on how much of a foundation the organization has already developed for
accelerating change. The role of leadership in this effort is to assure
that there is
adequate capacity for improvement within the health center and that those
working on improvement are afforded the time, training, and tools
necessary to
be successful in this work. With issues relating to the business case, it
is
particularly important to focus on communication as well as to getting the
right
team on the bus for the improvement activities. For example, the care team
that
has been working on implementing the Plan Care Model may need to be
augmented by adding members that have greater involvement with a
particular
aspect of your business case. Working on collections might require back
office
staff and front desk staff as well as your care team. Scheduling and
advanced
access might require office management staff. A focus on cycle time might
need
to include medical records personnel, lab personnel or others.
Adding some of these non-clinical players to an established clinical
improvement
team may require up front preparation and training as many of these staff
may
not have been introduced to the three core models (the Learning,
Improvement
and Care models). It might also require opening lines of communications
that
have historically been compromised. Work on the business case requires the
involvement of ALL health center staff and the support and encouragement
of all
health center leaders.
Work on the Change Package
The last step of the business case transformation journey is to begin work
using
the change package and toolkit included in this document. The description
of the
change concepts has been designed to provide concrete examples of ideas
that
can be tried, resources to facilitate your efforts, and case studies from
the HRSA
pilot work and FQHC's participating in IHI's Innovation Community.
Specific
Toolkits contain information and resources related to a given topic area.
The
Health Disparities web site at www.HealthDisparities.net includes the
change
package and most of the tools in an electronic form to assist your
improvement
efforts. All of these can be accessed via links within this document or
through
the Business Case/Redesign Topics page on the website.
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(back to Table of Contents)
TOOLKIT INDEX
Use data to understand your practice and your business case
Focus leadership attention on improvement
Enhance revenue
Eliminate waste and reduce costs
Optimize the Care Team
Provide seamless and coordinated care to patients
Eliminate waits and streamline workflow
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(back to Toolkit Index)
Planned Care Component: Organization of Health Care
Change Concept: Use data to understand your practice and your business
case
Key changes you can make:
Complete a comprehensive diagnostic profile of your practice
Establish system level performance aims and use them to drive your
business plan
• Use a spider diagram to track performance against goals
• Post dash boards on data walls
• Review and analyze industry benchmarks for business and clinical
performance
Promote transparency of data
• Post financial results on an intranet site or virtual office
• Share reports on bill rejections with clinical and non-clinical staff
• Use run charts to track staff individual team performance
Case Study: Community Health Centers of Middletown, CT completed the pre-
work assessment tool for their participation in the HRSA pilot on Finance
and
Redesign. The organization had already implemented advanced access in some
of their clinics and had worked on cycle time as well. They had also made
good
progress with improving their clinical indicators. The data on their
practice
pointed them to explore their collections system where they saw great
opportunities for improvement. They focused on the change package for
collections. Self pay collections increased 23% in two months.
Contact: Stewart Joslin, CFO
Case Study: Clinica Campesina in Lafayette, Colorado developed system
level
aims for the organization. Each primary care site is set up in clinical
pods and in
the main area for all to see is a data wall where all the measures are
posted.
Staff are able to see their clinical and financial outcomes for the month.
The key
"Access and Outcome measures are also tied to group incentives.
Contact: Carolyn Shepherd, M.D.
Tools:
• Finance-Redesign Prework Assessment Tool
• RVU Manager available from American Express Tax and Business
Services, Curt Degenfelder, curtis.e.degenfelder@aexp.com
• Recommended measures from the HRSA Finance and Redesign Pilot
• RedeFin system wide measures spider diagram example
• Community Resource Documentation Template


•
•
•
•
•
•
•
•
•
•
•
•
•
Using Data to Drive the Business Case presentation
Assessing Your Practices and Outpatient Settings presentation
Clinical Microsystem Assessment Tool
Diabetes Impact Tool--March 2004
Chronic Care Outcomes Project document
Assessing the Impact of Planned Care Implementation tool
Testimony--Maine Govenor's Proposed Budget and FQHC's
Managing By Fact presentation
Modeling the Impact of Redesign Changes presentation
NCQA's Quality Dividend Calculator information
CareSouth System Level Measures Example (Leadership)
Employee satisfaction survey examples adapted from Gallup research
(Leadership)
Patient Satisfaction survey examples (Leadership)
Click here to view or download the above tools pertaining to 'Using Data'
from the HDC website Library. A few of the tools overlap between topic
areas and will be found elsewhere in the Library as noted.
References:
Health Systems Measures Kit (IHI Tool). February 18, 2005). Institute for
Healthcare
Improvement. [Electronic version cited 1 May 2006].
Houck, S. (2004). What Works: Effective Tools and Case Studies to Improve
Clinical
Office Practice. Boulder, CO: Health Press Publishing
Mosser, G., Scheitels S. (2004, November). Public Reporting of Health Care
Performance in Minnesota. Bloomington, Minnesota: Institute for Clinical
System Improvement
Move Your Dot. (2003). Institute for Healthcare Improvement (IHI). [
Electronic version
cited 1 May 2006].
Patient Cycle Tool. Institute for Healthcare Improvement (IHI). [cited 1
May 2006].
Smith, J. (2001, May). Redesigning health care: Radical redesign is a way
to radically
improve. British Medical Journal, 322. 1257-1258.
Trustees of Dartmouth College, Godfrey, Nelson, Batalden, IHI. Assessing
Your Practice
(a.k.a. "The Greenbook . (2003). [Electronic version cited 1 May 2006].
Business and clinical performance benchmarks available through sources
such as:
Centers for Medicare & Medicaid Services (CMS). www.cms.hhs.gov
20


Health Disparities Collaboratives (HDC). www.HealthDisparities.net
The Institute for Healthcare Improvement (IHI). www.IHI.org
Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
www.jointcommission.org
Medical Group Management Association (MGMA). www.mgma.com
21


(back to Toolkit Index)
Planned Care Component: Organization of Health Care
Change Concept: Focus leadership attention on improvement
Key changes you can make:
Establish an Effective Communications Infrastructure
•
Use multiple media for communications
• Use an intranet for internal communication
• Establish a newsletter on your improvement efforts and get staff to
volunteer to work on it
• Set up a data wall for sharing reports
Include all staff in the communications plan and make it two-way
• Give computer access to all staff
• Use a virtual office as a work site for improvement that all staff can
contribute to
• Use video conferencing for meetings to connect outlying sites
Communicate improvement work as an agenda items in all
organizational meetings
Use communications vehicles to make the case for improvement,
explain where the organization is going (vision the change), and
each person's role in the change.
•
•
•
Visibly support improvement by aligning strategy, resources, and
priorities
for improvement
•
•
•
•
Include improvement as part of each report to the board
Establish a budget for improvement activities
Have members of senior leadership participate on improvement teams
Leaders include reports from improvement teams at regular staff meetings
Implement Leadership "Grand Rounds focused on improvement work.
Build Improvement Capability
•
•
•
Include care model and model for improvement in orientation of new
employees
Provide time for team activities, and periodic attendance and
participation
by senior leaders.
Develop leadership authenticity by building deep leadership knowledge
and capability – leaders become "coaches for improvement and
innovation.
22


•
•
•
Visit another high performing organization to see the on site
implementation of innovative improvements.
Include all levels of staff on improvement team
Create a culture in which all staff are appropriately empowered for
improvement
Develop staff to maximize their potential and create loyalty
•
•
•
•
•
•
Diagnose and assess the current workforce state
Develop an action plan to develop a more engaged workforce
Develop leaders who focus on each employee's strength and individual
development
Develop the "human resource value chain of attracting, selecting,
orienting and developing employees.
Establish a fair compensation system
Use incentive systems to align individual goals with organizational goals
Case Study: CareSouth Carolina, Inc. In 2002, CareSouth Carolina began re-
organizing the agendas, meeting agendas, and frequency of all staff
meetings as
tools for effective improvement communication. Monthly Management meetings
whose agendas had been focused primarily on operational issues were
replaced
with monthly Senior Leader Improvement meetings whose sole agenda is
focused on improvement efforts as measured by system level measures.
(sample agenda attached).
In addition, bi-monthly half day staff meetings which include all staff
were
reorganized. These meeting agendas now have three components (sample
agenda attached):
• An opening plenary by the CEO with a focus on organizational
performance as measured by system level measures. Also during the
plenary are team presentations on improvements that have sustained and
spread. And finally, during the plenary, Innovation awards are made to
individuals and teams that have tested, using the PDSA model,
innovations which have sustained and proven to be ready for spread
throughout the organization.
• Division breakouts which are opportunities for department specific
training
and for implementation of innovations for spread.
• Team action planning where microsystem teams meet, review system
wide performance measures specific to their team performance, and plan
for team activities, tests of changes, and focused improvements.
Case Study: CareSouth Carolina recognized the need to elevate the
prominence
and visibility of their improvement efforts. Updates on all aspects of
improvement
work are now included in their board agenda and reports. A system-wide
dashboard is used to capture key trends and storyboards and team
presentations
23


at bi-monthly staff meetings are used to showcase focused improvement
efforts.
Contact: Ann Lewis, CEO
Tools:
• Executive Review of Improvement Projects: A Primer for CEOs and other
Senior Leaders
• Patient Brochure Example in English and Spanish
• Senior Leader Performance Improvement Sample Monthly Agenda
• CHIP Award Application example from Clinica Campesina
• Incentive Plans example
• Sample newsletters on improvements on the business case supporting
planned care
• Performance Management Business Case Study presentation
• Departmental Staff Meeting Sample Agenda from CareSouth Carolina
• Staff Satisfaction Survey Tool examples
• Strategic Plan Pyramid example from CareSouth Carolina
• System Level Aim and Measures example from CareSouth Carolina
• System Level Measures Assessment and Planning Tool
• Achieving Workforce Excellence Prework Handbook
• The Zen of Teams presentation
• Sample newsletters on improvements on the business case supporting
planned care
• Innovator Awards example from CareSouth Carolina
Click here to view or download the above tools pertaining to 'Leadership'
from the HDC website Library.
References:
Berman, S. (2005). From Front Office to Front Line: Essential Issues for
Health Care
Leaders. Chicago, Illinois. Joint Commission Resources.
Bisognano, M., Plsek, P., Schummers, D. (2005). 10 MORE Powerful Ideas for
Improving Patient Care. Chicago, Illinois. Health Administration Press
with the
Institute for Healthcare Improvement
Buckingham, M., Coffman, C. (1999). First Break all the Rules: what the
world's
greatest managers do differently. New York, NY. Simon and Schuster.
Buckingham, M. and Clifton, D. (2001). Now, Discover Your Strengths. New
York, NY.
The Free Press.
24


Chaufournier, R.; St. Andre, C.; Kabcenell, A.; Hupke, C.; Davis, Connie;
Wasson, John;
Jones, Carol. The Business Case for Planned Care (2003, September). The
Institute for Healthcare Improvement Pursuing Perfection Monograph.
Coffman C., Gonzalez-Molina, G. (2002). Follow This Path: How the world's
greatest
organizations drive growth by unleashing human potential. New York, NY.
Warner Books.
Kotter, J.P. (1995). Leading Change: Why Transformational Efforts Fail.
Cambridge,
Massachusetts. Harvard Business Review Press.
Leadership Leverage Points Self-Assessment Tool for System Level Aims. (
2005).
Institute for Healthcare Improvement. [Electronic version cited 1 May 2006]
.
Nelson, E., Nolan, K., Nolan, T., Long, D., Jarman, B. IHI's Health System
Measures
Kit: Version 1.4. (February 18, 2005). Institute for Healthcare
Improvement.
[Electronic version cited 1 May 2006].
O'Reilly, C and Pfeffer, J. (2000). Hidden Value: How great companies
achieve
extraordinary results with ordinary people. Harvard Business School Press.
Boston, MA. 2000.
Ransom, S.B., Joshi, M., Nash, D. (2004). The Healthcare Quality Book:
Vision,
Strategy and Tools. Chicago, Illinois. Health Administration Press.
Reinertson, J. (May 2003, revised January 2004). A Theory of Leadership
for the
Transformation of Healthcare Organizations. The Reinertson Group.
System-Minded Design: Optimizing the Microsystem for Workforce
Development.
Institute for Healthcare Improvement. [cited 8 May 2006].
Workforce Development. (2004). Trustees of Dartmouth College. [cited 1 May
2006].
25


(back to Toolkit Index)
Planned Care Component: Organization of Health Care
Change Concept: Enhance Revenue
Key changes you can make:
Bill accurately and completely
• Analyze coding patterns and train providers on coding accuracy
• Share bill rejection information with clinical and non-clinical staff
• Establish a cost-based charge master
• Verify demographic information at each visit
• Account for all encounter forms at the end of each day
Improve Collections
• Use process mapping to reduce bill cycle time
• Establish a collection plan for each payor
• Establish policies on up front collections of co-pays and self pay
amounts
• File claims electronically
• Facilitate patient application for any potential payment coverage
• Accept credit cards and debit cards
• Schedule appointments with financial counselor prior to a new visit
• Provide front desk staff a script for collecting money
• Establish a greeter position
Use data to influence payors and Policymakers
•
•
Ask your state Medicaid office to model total costs for health center
patients as compared to others
Approach self insured employers and model cost reduction and
productivity improvement
Seek New Sources of Revenue
•
•
•
•
Contract directly with self-insured employer groups
Establish on-site clinic services at employer worksites
Contract with local hospitals to set up chronic disease centers of
excellence
Use outcomes data to apply for grants
Case Study: White River Rural Health Center in Arkansas recognized a need
to
focus on revenue enhancement. They used the RVU Master to develop coding
profiles by provider and then used that information in provider training
on
appropriateness of coding. Because their charge master had not been
recently
26


updated, they also used the RVU Master and their cost report data to
develop
charges that were based on cost. As a result of both of these initiatives,
they
were able to dramatically increase their billings per encounter.
120
100
Dollars
80
60
40
20
0
Net Revenue per Patient Encounter
Contact: Greg Wolverton, CIO
Case Study: G.A. Carmichael Health center in Canton, Mississippi
discovered
that Nissan was considering locating a new plant in one of eight locations
in the
south. The executive director used their HDC data and the UKPDS study
metrics
to model the impact on fewer medical claims and lost days of productivity
if they
located the plant near G.A. Carmichael. The leadership of Nissan was so
impressed they located the plant several miles from the health center
brining
4000 new jobs into the community and new revenue opportunities for G.A.
Carmichael.
Contact: Eddie Anthony, CEO.
Case Study: St. John Valley Hospital in Maine learned of an aggressive
Medical
Services Corps provider working in an FQHC and recruited him to set up a
diabetes center for the local hospital. The business plan called for the
operation
to breakeven in 18 months. The new center opened and was breakeven within
9
months and had brought in $90,000 of new revenue to the hospital in the
first
nine months.
Contact: Dana Green, P.A.
Tools:
Revenue
• Getting Paid--Maximizing Collections presentation
• Northeast Valley Health Center case study on maximizing revenue (Action
Period 3 Update)
• Toolkit for Billing Accurately and Completely
• Billing and Collections in Health Centers presentation
• Care Management Procedure Codes document
• Improving Collections Toolkit
• Pay For Performance--An Introduction Toolkit
• An Introduction to Using RVUs Toolkit
• Using RVUs to Diagnose Costs presentation
27


Collections
• Third Party Payors policy example from CareSouth Carolina
• Bad Debt Policy and Procedure example from CareSouth Carolina
• Sample Guidelines for CHC Staff on Collecting Money from Middletown
• Patient Collection Override Sheet example from Middletown
• Front Desk Collections Flow Chart
• Billing and Collections example from CareSouth Carolina
• Credit and Collection Policies example from Rural Health
• Front Office Script example from Rural Health
• Payment Agreement example from Middletown
• Sample Verbiage for Payment Sign from Rural Health
• Front Desk Collections Policy example from Middletown
• Greeter Position Form example
P4P
• Pay for Performance Incentive Programs in Healthcare 2003 presentation
• NCQA's Quality Dividend Calculator information (Using Data)
• Diabetes Impact Tool--March 2004 (Excel tool to calculate savings from
diabetes care) (Using Data)
• Business Case Monograph (Leadership)
• Testimony--Maine Governor's Proposed Budget and FQHC's (Using Data)
• Simulating the Costs and Benefits of a Comprehensive Chronic Care
Program for Whatcom County presentation by Jack Homer and Gary
Hirsch
Click here to view or download the above tools pertaining to 'Revenue'
from the HDC website Library. Some of the above resources are located in
the 'Collections' and 'P4P' sub-folders within the Revenue folder. A few
of
the tools overlap between topics areas and will be found elsewhere in the
Library as noted.
References:
Endsley, S. M.D., Kirkegaard, M. M.D., Baker, Geoffrey, and Murcko, Anita
M.D.,
(2004, March). Getting Rewards for Your Results: Pay-For-Performance
Programs. Family Practice Management, 44-50.
Freking, K. U.S. Weighs Pay-For-Performance Medicare. (March 2, 2005).
Associated
Press. [Electronic version cited 1 May 2006].
Mohler, P. M.D., Mohler, N. (2005, November/December) Improving Chronic
Illness
Care: Lessons Learned in a Private Practice. Family Practice Management,
50-56.
Porter, M., Kramer, M. (1977). Philanthropy's New Agenda: Creating Value.
Harvard
Business Review, 6. 121-130.
28


Technical specifications for AMA Physician Consortium for Performance
Improvement
Measures endorsed by the National Quality Forum. (August 4, 2005).
American
Medical Association. [Electronic version cited 1 May 2006].
Weiss, H., & Lopez, M. (1999). New Strategies in Foundation Grantmaking
for Children
and Youth. Harvard Family Research Project. Cambridge, Massachusetts.
P4P
Endsley, S., M.D., Kirkegaard, M., M.D., M.P.H., Baker, G., Murcko, A.C.,
M.D.
Getting Rewards for Your Results: Pay-for-Performance Programs. (March
2004).
American Academy of Family Physicians: News & Publications. [Electronic
version cited 1 May 2006].
Guidelines for Pay-for-Performance Programs. June 21, 2005. American
Medical
Association. [Electronic version cited 1 May 2006].
Medicare Physician Group Practice Demonstration. (January 31, 2005).
Centers for
Medicare & Medicaid Services. [Electronic version cited 1 May 2006].
Terry, K. Pay for performance: A double-edged sword. (January 21, 2005).
Medical
Economics. [Electronic version cited 1 May 2006].
29


(back to Toolkit Index)
Planned Care Component: Organization of Health Care
Change Concept: Eliminate Waste and Reduce Cost
Key Changes you can make:
Apply Lean Principles to core processes.
• Complete a process map of each core process
• Standardize forms and protocols
• Evaluate and improve inventory
• Streamline communications
• Minimize movement in the system
• Evaluate Pull vs. Push Systems
• Error proof your systems
• Focus on leadtime reduction
• Eliminate waiting
• Eliminate rework and needless inspection
• Minimize overproduction
Exploit Technology
• Use fax machines for medication refills
• Use hand held devices for medication prescriptions
• Evaluate the ROI for purchase of HbA1c analyzer on-site
• Do electronic billing
Renegotiate Contracts
• Re-visit mortgages, leases and loan agreements and explore opportunities
to renegotiate for more favorable rates
• Standardize supply ordering to ensure that supplies are not being over-
ordered and that vendors are not overcharging
• Develop protocols for referrals to costly services
• Work with your suppliers to improve your existing contracts and
materials
management systems
Case Study:
White River case study for Reduce Expenses
White River Rural Health Center, Inc. (WRRHC) realized a problem existed
in its
supply chain and delivery when costs sky rocketed to nearly $1 Million
dollars
during 2004. Utilizing the "Lean Manufacturing" methodology, WRRHC was
able
to lower its supply cost by over a half million dollars in purchases
alone. As
growth continued WRRHC utilized other change concepts to streamline the
ordering and delivery process by educating clinic staff, supervisors and
leadership on "Just in time" inventory models and by sharing utilization
patterns
30


for various supplies such as drugs. This led to additional savings
through fewer
product expirations and better utilization of supplies throughout the
system. In
the last quarter of FY 2005, WRRHC has reduced these expenditures by 58%
and increased delivery flow by 22%, over the same period of 2004.
Contact: Greg Wolverton, CIO
Tools:
• Applying Lean Thinking to Financial Processes presentation
• HDC Cost of Process Waste Worksheet
• Lean Thinking and Value Stream Mapping to Improve Flow presentation
• Lean Thinking in Healthcare--December 2004 presentation
• Understanding Costs: Getting Beyond Expenses presentation
• RedeFin Toolkit: Pharmacy as an Opportunity
Click here to view or download tools pertaining to 'Cost Reduction' from
the HDC website Library.
References:
Going Lean in Health Care – Free. (2005). Institute for Healthcare
Improvement. [cited 1
May 2006].
Womack, James., Jones, Daniel T., and Roos, Daniel (1990, October) The
Machine that Changed the World.
Womack, James., Jones, Daniel T., and Roos, Daniel (2003, June, revised
and
updated) Lean Thinking: Banish Waste and Create Wealth in Your
Corporation.
Womack, James., Jones, Daniel T. (2002, March) Seeing the Whole: Mapping
the
Extended Value Stream (Lean Enterprise Institute).
31


(back to Toolkit Index)
Planned Care Component: Delivery System Design
Change Concept: Optimize the Care Team
Key changes you can make:
Assign a panel of patients for each provider and manage panel size and
scope of practice
• Use historical records to assign patients to a panel associated with a
care team
• Assure the PCP is identified in the scheduling system
• Assign responsibility for PCP assignment
• Develop scripts for appointment schedulers to reinforce the panel
concept
• Develop policies for closing panels and for assigning new patients to a
provider's panel
Match Work to an Individual's Capability and Licensure
•
•
•
•
•
•
•
•
•
Use medical assistants and CNAs rather than just LPN's and RN's
Maximize the use of nurses in clinical care
Add a lab tech or radiology tech to the team
Use bi-lingual MA and front desk staff
Use protocols for UTI/Immunizations and other high volume low risk
conditions
Use nurse visits
Cross train staff
Study how each care team member is spending time
Test ways front office staff can assist in managing patients
Redesign the Care Teams
•
•
•
•
•
Create consistent cross-functional teams around a panel of patients
Create a matrix reporting structure where staff report functional to a
care
team and line to a manager
Redeploy back office staff (medical records, scheduling, billing) to a
care
team
Cross train front and back office staff to allow for flexibility in daily
patient
flow and meeting various patient needs
Use promotoras or lay health case managers
Maximize Provider Productivity for Each Visit
•
•
•
Move unnecessary work away from the provider
Assign a panel of patients to each provider and schedule accordingly
Hold a huddle to review patient and care team needs prior to a visit
32


•
•
Ensure all equipment, data and manpower are available and the time of
the visit
Max pack where feasible
Case Study: Clinica Campesina in Lafayette, Colorado aggressively moved to
a
clinical pod concept. In their old paradigm the care team included a
clinician and
a nurse and medical assistant. They decided to move to a comprehensive
care
team around panels of patients. Their current ratio is 8:1. The teams
include
providers, medical assistants, casemanagers, social workers, medical
records,
nurses and front desk staff. A nurse leads each care team and they hold
huddles
daily to plan their work. Staff also report in a line model to their
respective
professional manager who is responsible for overall quality oversight and
staff
building and education. The organization has implemented a gain sharing
incentive system providing reward for improved organizational performance
and
teams are able to see how they contribute to that process.
Contact: Carolyn Shepherd, M.D.
Tools:
• Business Case Modeling Tool for Shifting Staff Resources
• Increasing ROI for the Care Team presentation
• Huddle List template
• Integrating Behavioral Health and Depression Management in Primary
Care presentation
• Medication Refill Protocols and Policy example
• Taking it to the Next Level: Optimizing the Workforce presentation
• Optimizing the Care Team in Clinical Office Practices presentation
• Optimizing the Care Team Toolkit
• Patient Self-Confidence in Managing Chronic Condition graph
• Pharmacy FAX Sheet Example from Community Health Centers, Inc.
• Pharmacy Toolkit
• Provider Fill-Time and Patients Turned Away Phone Worksheet
• Job Description: Referral Specialist example from Holyoke Health Center
• HRSA Redefin ROI calculator
• Medication Refill Standing Orders example
• Standing Orders: Chronic Medication Refills example
• Task Analysis Worksheet
• Incentive Plans PowerPoint presentation (Leadership)
Click here to view or download the above tools pertaining to 'Care Team'
from the HDC website Library.
33


References:
Chaufournier, R.; St. Andre, C.; Kabcenell, A.; Hupke, C.; Davis, Connie;
Wasson, John;
Jones, Carol. The Business Case for Planned Care (2003, September). The
Institute for Healthcare Improvement Pursuing Perfection Monograph.
Gibbs, M. (November 30, 1990). Compensation and Incentive Systems. [
Electronic
version – abstract cited 1 May 2006]. Harvard Business Online.
Dollman, R. (June 1996). Incentive Systems and Their Influence on the
Capacity for
Change. [Electronic version cited 1 May 2006] Journal of Extension.
Gans, D., MSHA, PACMPE & Walker, D., MBA, FACMPE. (April 8, 2004). (Audio)
Rightsizing the Medical Group's Staff: How many is too much, how few is
not
enough (CD) - #6134. [Electronic purchase information cited 1 May 2006].
MGMA (Medical Group Management Association).
Valenti, W.M., & Bookhardt-Murray, J., M.D. (2004, December). Advanced
Access
Scheduling Boosts Quality, Productivity, and Revenue. Drug Benefit Trends.
34


(back to Toolkit Index)
Planned Care Component: Delivery System Design
Change Concept: Provide seamless and coordinated care to patients
Key changes you can make:
Integrate Behavioral Health into Primary Care
•
•
Retain counselors and social workers and integrate them into your primary
care team
Administer PHQ screening to your chronic illness patients for early
detection and intervention
Create a planned visit for each encounter
•
•
•
•
•
Use the registry to plan a visit
Use registry reminder systems to reach out to patients and manage their
demand
Review registry data in huddles prior to a morning or afternoon panel of
patients
Use visit agendas and review them with patients
Daily huddles to plan care for patient's coming in
Use a Care Manager to Coordinate Care
•
•
•
•
•
•
Establish a care manager for a panel of patients
Regularly review panel and patient level data
Prepare for planned and acute visits using the registry data
Coordinate logistics and care team needs prior to the visit
Serve as primary point of contact for external case managers
Follow-up with local referral sources to collect data on patients
Maximize the use of specialists
•
•
Schedule specialists into the center for a half or full day rather than
making referrals
Establish a referral specialist to coordinate necessary referrals
Case Study: CareSouth Carolina recognized the impact behavioral health
related issues was having on the quality of care and on productivity of
the care
team. Social workers and licensed clinical counselors were added (expanded
from 4 to 12) with one per care team. Routine depression screening using
the
PHQ-9 tool was adopted. Care teams were formed to review panel level
outcome data and plan for visits for chronic illness. The organization
recognized
it had forgone an opportunity for a revenue stream as visits to licensed
behavioral health professionals was billable in their state. This
addressed a
35


major quality and productivity problem and increased revenues for the
organization. Contact: Liz Kerchner, LCSW
Tools:
• Care Manager Job Description example from CareSouth Carolina
• Using the Registry for Planned Care presentation
• Huddles--IHI 2004
Click here to view or download tools pertaining to 'Seamless Care' from
the
HDC website Library.
References:
Huddles (IHI Tool). Institute for Healthcare Improvement. [cited 8 May
2006].
36


(back to Toolkit Index)
Planned Care Component: Delivery System Design
Change Concept: Eliminate waits and streamline workflow
Key changes you can make:
Access & Efficiency Change Package
The change package for Access & Efficiency is a change package that has
been
well tested over the years by IHI and others. Many aspects of this change
package are integrated into this Toolkit. You can access the complete
Access &
Efficiency Change Package and useful tools on www.ihi.org.
Recalibrate the system by working down the backlog
• Eliminate unnecessary work!
• Pick a date (90 days into the future) and Establish a date after which
time
you only book future appointments for planned visits for preventive and
chronic care (about 30% of your future schedule); all other appointments
are given on the day of the request
• Comb the schedule and remove all unnecessary future visits from the
schedule.
• Temporarily add patient visit slots at the beginning or end of the day,
or on
weekends
Understand and balance capacity and demand on a daily, weekly and long
term basis
•
•
•
Use huddles to make mid-course adjustments real time
Study and decrease the number of appointment types
Use centralized scheduling
Plan for Contingencies
•
•
•
•
•
•
Cross train staff
Establish policies on vacations
Anticipate flu season and staff up
Use group visits for Drop In medical group Appointments (DIGMAs) and
school physicals
Use Locum Tenems to fill for sick vacancy and scheduled leaves
Use huddles to make mid-day corrections
Use Group Visits and other alternate visit types
•
•
Use drop in medial group appointments (DIGMAS)
Use group visits for chronic patients, physician and school exams, flu
group visits and other logical affinity groups
37


•
•
•
Use telephone and email visits
Schedule follow-up with a nurse instead of a physician for certain
protocols
Use care managers to go into the homes
Reduce Cycle Time
•
•
•
•
•
•
•
•
•
•
•
•
•
Decrease handoffs during the encounter
Move check out to the nurse's station
Check charts, encounter note printouts, lab work, etc before each visit
Telephonic or web registration
Use walkie talkies to communicate
Create line of site communication in the clinical pod so all staff can see
each other
Bring work such as blood draws to the exam room rather than asking the
patient to move
Increase clinician support
Start all visits on time
Standardize room supplies and equipment
Get all the tools you need
Do today's work today!
Eliminate unnecessary work!
Case Study: United Health Care of California studied their schedule and
realized
that with their 25 physicians there was enough sick leave, vacation and
education time to be filled by two fulltime Locum Tenems. The original
bias was
that locums would be too expensive. When they realized the loss in
productivity
and revenue they realized they couldn't afford not to hire two additional
fulltime
provider. The impact was in excess of $1M annual increased revenue.
Contact: Ron Yee, MD
Case Study: From the IHI Idealized Design List Serv:
"I am from a metropolitan area of over 500,000 and am the team physician
for
the largest high school in the county. We currently do school physicals
with one
of the local hospital clinics providing space and volunteer staff for
check in and
vitals. We have 10-11 local pediatric and med/peds residents do the
physicals
with myself. We do the high school and middle schools. Each one takes
about 3
hours, and we do about 300-400 kids each time. The kids pay $10 up front,
the
residents get a nominal stipend, and the school takes the rest. They take
in
$1,500-2,000 each time and use it for athletic equipment. It's a busy 3
hours, but
the schools love it. FYI, pharmaceutical reps bring dinner for the
residents. Tom Peterson, M.D.
Medical Director, MMPC
phone (616) 974-4455
tpeterson@mmpc.com
38


Tools:
• Advanced Access Scheduling: The "Who, What, Where, When ..."
presentation
• Advanced Access: Beyond the Basics presentation
• Advanced Access References
• Measuring Demand presentation
• Ongoing Management of Supply & Demand to Achieve Access Goal
document
• Group Visits In's and Out's presentation
• Comparison of Group Visit Models document
• Group Visits--Clinica Campesina presentation
• The Economics of a Group Visit comparison sheet
• Huddle worksheet
• "The Fifteen Minute Visit and the 45 Minute Wait: What's Wrong with this
picture presentation by Christine St. Andre from HDC2005 LS3
• Unplanned Activity Form
• Exam Room Checklist Example
• Rooming Criteria Example from Dartmouth Godfrey and Nelson
Click here to view or download the above tools pertaining to 'Access' from
the HDC website Library. Some of the above resources are located in the
'Group Visits' sub-folder within the Access folder.
References:
Beck, A., Scott, J., Williams, P., Robertson, B., Jackson, D., Gade, G.,
Cowan, P.
(1997). A randomized Trial of Group Outpatient Visits for Chronically Ill
Elderly HMO members: The Cooperative Health Care Clinic. Journal of the
American Geriatric Society, 45; 543-549.
Gordon, P., M.A. & Chin, M., M.P.A. (August 2004). Achieving a New
Standard in
Primary Care for Low-Income Populations: Case Studies of Redesign and
Change
Through a Learning Collaborative. The Commonwealth Fund. [Electronic
version
cited 1 May 2006].
Hammer, M. (1995). Reengineering Revolution. Harper Collins.
Hammer, M., & Champy, J. (2003). Reengineering the Corporation: A
Manifesto for
Business Revolution. Harper Collins.
Lorig, K., Scott, J. (1999). Group Visit Starter Kit – Improving Chronic
Illness Care.
Improving Chronic Illness Care. [cited 1 May 2006].
Masley, S., Solokoff J., Hawes, C. (2000) Planning Group Visits with High
Risk
Patients. Family Practice Management, 7,33-38.
39


Masley, S. M.D., Sokoloff, J. M.D., and Hawes, C. RN. (June 2000).
Planning Group
Visits for High-Risk Patients. American Academy of Family Physicians: News &
Publications. [Electronic version cited 1 May 2006].
McKenzie, M., Scott, J. (1998) Cooperative Health Clinics Delivery Primary
Care
in a Group Setting. Guide to Managed Care Strategies. Burns J &
Northrup LM; Editors. New York: Faulkner and Gray.
Noffsinger, EB., Scott, JC. (2000) Understanding Today's Group Visit
Models.
Group Practice Journal, 48(2); 46-48, 50, 52-54, 56-58.
Patient Cycle Tool. Institute for Healthcare Improvement (IHI). [cited 1
May 2006].
Report On Medicare Compliance – CMS: Medicare Billing Possible for 'Shared
Visits',
but Follow Parameters Carefully. (September 24, 2004). Podiatry Management
Online. [Electronic version cited 1 May 2006].
Sadur, CN, Moline, N., Costa, M., Michalik, D., Mendlowitz, D., Roller, S.,
Watson, R., Swain, B.E., Selby, J.V., Javorksi, W.C. (1999, December)
Diabetes Management in a Health maintenance Organization: Efficacy of
Care Management Using Cluster Visits. Diabetes Care, 22(12): 2011-
2017.
Scott, J., Robertson, B. (1996) Kaiser Colorado's Cooperative Health Care
Clinic:
A Group Approach to Patient Care. Managed Care Quarterly, 4(3);41-45.
Scott, J., Gade, G., McKenzie, M., Venohr, I. Cooperative health care
clinics: a group
approach to individual care (Abstract). (May 1998). Geriatrics. [
Electronic
version – abstract cited 1 May 2006].
Scott, J. Gade, G., McKenzie, M., Venohr, I. (1998) Cooperative Health
Care
Clinics: A Group Approach to Individual Care. Geriatrics,53(5);68-81.
Terry K. (1997, January 13) Should Doctors See Patients in Group Sessions?
Medical Economics, 74-95.
Thompson, E. (2000, June 5) The Power of Group Visits. Modern Healthcare.
Trustees of Dartmouth College, Batalden, Godfrey, Nelson, Hanover. (2004).
Unplanned
Activity Card. [Electronic version cited May 8 2006]].
Trustees of Dartmouth College, Batalden, Godfrey, Nelson, Hanover. (2004).
Rooming
Criteria Example. [Electronic version cited May 8 2006]].
40


(back to Table of Contents)
Topics Related to the Business Case for
Planned Care
May 8 2006
Disease Specific Topics
Asthma
Homer, C., Forbes, P. & Horvitz, Sm., et al. (2005). Impact of a Quality
Improvement
Program on Care and Outcomes for Children with Asthma. Archives of
Pediatric and
Adolescent Medicine, 159(5), 464-9.
Schonlau, M., Mangione-Smith, R. & Chan, K.S., et al. (2005). Evaluation
of a Quality
Improvement Collaborative in Asthma Care: Does it Improve Processes and
Outcomes of Care?, Annals of Family Medicine, 3, 200-8.
Diabetes
Chin, MH et al Quality of Diabetes Care in Community Health Centers. March
2000.
American Journal of Public Health. 90(3):431-4.
East, J., Krishnamurthy, P., Freed, B. & Nosovitski, G. (2003, July/August)
. Impact of a
Diabetes Electronic Management System on Patient Care in a Community
Clinic.
American Journal of Medical Quality, 18(4), 150-4.
Hupke, C., Langley, J., Little, K. & Chaufournier, R., et al. (2004).
Transforming
Diabetes Health Care Part I. Diabetes Spectrum, 17, 102-6.
Hupke, C., Langley, J., Little, K.& Chaufournier, R., et al. (2004).
Transforming
Diabetes Health Care Part II. Diabetes Spectrum, 17, 107-11.
Klonoff, D., & Schwartz, D. (2000, March). An Economic Analysis of
Interventions for
Diabetes. Diabetes Care, 23(3). 390-404.
Litaker, D, et al. (2003). Physician-Nurse Practitioner Teams in Chronic
Disease
Management: The Impact on Costs, Clinical Effectiveness, and Patients'
Perception of Care. Journal of Interprofessional Care, 17(3). 223-237.
Norris, S. et al. (2002). The Effectiveness of Disease and Case Management
for People
with Diabetes: A Systematic Review. American Journal of Preventive
Medicine,
22(4). 15-38.
41


Piette, J., Weinberger, M., & McPhee, S. (2000). The Effect of Automated
Calls with
Telephone Nurse Follow-up on Patient-Centered Outcomes of Diabetes Care: A
Randomized, Controlled Trial. Medical Care, 38(2). 218-230.
Porterfield, DS and Kinsinger, L. Quality of Care for Uninsured Patients
with Diabetes
in a Rural Area. February 2002. Diabetes Care 25(2): 319-23.
Ridgeway, N. et al. (1999). Improved Control of Type 2 Diabetes Mellitus:
A Practical
Education/Behavior Modification Program in a Primary Care Clinic. Southern
Medical Journal, 92(7). 667-672.
Rubin, R., Dietrich, K., & Hawk, A. (1998). A Practical Impact of
Implementing a
Comprehensive Diabetes Management Program in Managed Care. Journal of
Clinical Endocrinology and Metabolism, 83(8). 2635-2642.
Sidorov, J. et al. (2002, April). Does Diabetes Management Save Money and
Improve
Outcomes? Diabetes Care, 25(4). 684-9.
Wagner, E. et al. (2001, January 10). Effect of Improved Glycemic Control
on Health
Care Costs and Utilization. Journal of the American Medical Association,
285(2).
182-9.
Congestive Heart Failure
Capomolla, S. et al. (2002, October 2). Cost/Utility Ration in Chronic
Heart Failure:
Comparison Between Heart Failure Management Program Delivered by Day-
Hospital and Usual Care. Journal of the American College of Cardiology, 40(
7).
1259-66.
Cline, C. et al. (1998, November). Cost Effectiveness Management Program
for Heart
Failure Reduces Hospitalization. Heart, 80. 442-6.
Heidenreich, P., Ruggeria, C., & Massie B. (1999, October). Effect of a
Home
Monitoring System on Hospitalization and Resource Use for Patients with
Heart
Failure. American Heart Journal, 138(4). 633-40.
Jaarsma, T. et al. (1999, May). Effects of Education and Support on Self-
Care and
Resource Utilization in Patients with Heart Failure. European Heart
Journal,
20(9). 673-82.
McAlister, F. et al. (2001, April 1). A Systematic Review of Randomized
Trials of
Disease Management Programs in Heart Failure. American Journal of Medicine,
110(5). 378-84.
42


Business and Organizational Related Topics
Advanced Access (Also see below under Continuity of Care)
O'Hare, D., & Corlett, J. (2004, February). The Outcome of Open-Access
Scheduling.
Family Practice Management, 35-8.
Solberg. et al. (2005, November/December). Improved Primary Care Access:
How Does
it Affect Depression Care Quality? Annals of Family Medicine.
Steinbaure, J., Korell, K., Erdin, J., & Spann, S. (2006, March). Open-
Access Scheduling
in an Academic Practice. Family Practice Management.
Trustees of Dartmouth College, Batalden, Godfrey, Nelson, Hanover. (2004).
Unplanned
Activity Card. [Electronic version cited May 8 2006]].
Trustees of Dartmouth College, Batalden, Godfrey, Nelson, Hanover. (2004).
Rooming
Criteria Example. [Electronic version cited May 8 2006]].
Business Case for Planned Care
Chaufournier, R.; St. Andre, C.; Kabcenell, A.; Hupke, C.; Davis, Connie;
Wasson, John;
Jones, Carol. The Business Case for Planned Care (2003, September). The
Institute for Healthcare Improvement Pursuing Perfection Monograph.
Care Team
Chaufournier, R.; St. Andre, C.; Kabcenell, A.; Hupke, C.; Davis, Connie;
Wasson, John;
Jones, Carol. The Business Case for Planned Care (2003, September). The
Institute for Healthcare Improvement Pursuing Perfection Monograph.
Gibbs, M. (November 30,