EFFECTIVE UTILIZATION OF SUPPORT STAFF TO INCREASE PROVIDER PRODUCTIVITY

1. EFFECTIVE UTILIZATION OF SUPPORT STAFF TO INCREASE PROVIDER PRODUCTIVITY COMMUNITY HEALTH OF SOUTH FLORIDA, INC Mae K. Goins, Vice President for Nursing

2. OUTLINE Overview of CHI Productivity drivers Barriers to Productivity Strategies to improve productivity Efficient utilization of support staff within each productivity driver How to make it all happen Challenges to be anticipated Take home messages

3. OVERVIEW OF CHI • Patients • 71,000 users, 365,000 encounters • Ethnicity • 56% Hispanic, 28% Black, 6% Anglo, 10% other • Insurance • 59% Uninsured, 14% Medicaid, 2.4% Medicare, 2% Private, Other Public 22.6% • Income level • 60.9% (<100%), 9.3% (101-150%), 2%(150-200%)

4. Family Services Pediatrics Obstetrics and Gynecology Behavioral Health HIV/AIDS Program Oral Health Optometry Podiatry 2 Urgent Care Centers Lab 3 Pharmacies Radiology – 2 sites School based Health Care Services Health Connect Migrant Health Care Homeless Program Health Education Transportation Temporary assistance to the needy (TANF) WIC Services Marketing COMMUNITY HEALTH OF SOUTH FLORIDA, INC- Services and Programs

5. OVERVIEW OF CHI • Staffing • 600 staff members • 30 different cultures! • Providers • 60 Practitioners • Specialties: FP’s, Internists, Pediatricians, Ob/Gyn MD’s, CNM’s, ARNP’s, Dentists, Radiologist, Optometrist, Psychiatrists

6. E.H.R. and E.O.H.R. • Implemented E.H.R. and E.O.H.R through integration effort • E.H.R. • Sage’s Medical Manager • Commenced upgrade to Intergy product • All Providers and services paperless except OB and BH (in few months) • Includes lab interface, prescription writing, e-documentation, imaging, etc • E.O.H.R. • Dentrix • All Dental Providers and all dental sites • Including digital imaging

7. WORK ON PRODUCTIVITY • Focus on Productivity in past 2 years • Explored innovative, sustainable approaches • Tested some strategies in some sites • Rolled out and continue to roll out lessons learned • Will share the reasoning behind our activities and specific strategies implemented with support staff

10. PRODUCTIVITY – the CHC dilemma • Continues to be a hot topic in many CHC’s • Many below goal • Different opinions about reason for below average numbers • Multiple unsuccessful attempts to improve • Consultants also utilized • Unsustainable solutions • Implications? • Need for a completely different approach • Learned about the value of using Models to improve chronic disease care in BPHC Collaborative Inialtives • Basis for consideration of use of a “Productivity model”

11. WHY A PRODUCTIVITY MODEL? • Models • Framework approach to problem solving • Entire horizon addressed • Less “shooting off the hip” • Minimizes destructive passionate positions • Reduces potential for blame games and finger-pointing • Decreases bias • Increases buy in • Increases chances for sustaining change • Especially with pROduCtIviTY

12. PRODUCTIVITY DRIVERS Productivity =k# of hrs worked x Patient supply x Provider speed Total Provider Work Volume Productivity drivers: • # of Hours Worked • Patient Supply • Provider Speed • Total Provider Work Volume • What issues do FQHC’s have with each of these?

13. Productivity =k Hours x Pt supply x Doc speed Total Work Vol. PRODUCTIVITY DRIVER #1: # of Hours Worked:

14. PRODUCTIVITY DRIVER#2: Patient Supply: • Patient supply • # of Patients seen by end of day =(Scheduled patients) – (No shows) + (Walk ins) Productivity =k Hours x Pt supply x Doc speed Total Work Vol.

15. Productivity =k Hours x Pt supply x Doc speed Total Work Vol. PRODUCTIVITY DRIVER #2: Patient Supply:

16. PRODUCTIVITY DRIVER #3: Provider Speed: Productivity =k Hours x Pt supply x Doc speed Total Work Vol.

17. Productivity =k Hours x Pt supply x Doc speed Total Work Vol. PRODUCTIVITY DRIVER #3: Provider Speed:

18. PRODUCTIVITY DRIVER #3: Provider Speed: Productivity =k Hours x Pt supply x Doc speed Total Work Vol.

19. PRODUCTIVITY DRIVER #4: Total Provider Work VolumeExamples of “shiftable” work Productivity =k Hours x Pt supply x Doc speed Total Work Vol.

20. PRODUCTIVITY DRIVER #4: Total Provider Work VolumeExamples of “shiftable” work Productivity =k Hours x Pt supply x Doc speed Total Work Vol.

21. PRODUCTIVITY DRIVER #4: Total Provider Work VolumeExamples of “shiftable” work Productivity =k Hours x Pt supply x Doc speed Total Work Vol.

22. SUPPORT STAFF UTILIZATION TO INCREASE PROVIDER PRODUCTIVITY • Which • Which support staff? • How • How can they be best utilized to maximize productivity? • In the context of CHI’s experiences!

23. WHICH SUPPORT STAFF? • Staff whose function have a direct or indirect impact on patient flow • Direct support: Nursing staff, Front desk staff • Indirect support: Medical records staff, Allied Professional staff, MIS staff

24. UNIT STAFFING STRUCTURE • Multi-Provider units and Single-Provider sites • In Multi-Provider units • 2 Providers • 4 Patient Care Technicians (PCT) • 1 LPN • 1 Patient Financial Services Specialist (PFSS) • In single Provider sites • 2 PCTs, 1LPN and 1 PFSS • PCTs cross-trained to perform most PFSS functions • RN’s serve as Clinical Coordinators

25. MEDIAN # OF SUPPORT STAFF PER FTE FP -as per MGMA MGMA 2001 Cost Survey

26. EFFECTIVE SUPPORT STAFF UTILIZATION – HOW? • Long list of options • Utilization of productivity model presents effective structure to understand utilization and to facilitate discussion

27. WHAT ROLE DOES SUPPORT STAFF PLAY WITHIN EACH OF THE 4 PRODUCTIVITY DRIVERS? Provider productivity depends on: # of Hours Worked Patient Supply Provider Speed Total Provider Work Volume Productivity =k Hours x Pt supply x Doc speed Total Work Vol.

28. PROVIDER WORK VOLUME Issue: Costly and inefficient to use professional/higher paid staff to perform work that someone else could GOAL Move all “shiftable” work to the less expensive staff OR to patients Strategy Outside the box thinking Look for best practices in other centers and in private sector Productivity =k Hours x Pt supply x Doc speed Total Work Vol.

29. PROVIDER WORK VOLUME 6 areas consume majority of Provider’s patient encounter time and can be performed by others Ensuring availability of reports Consults, labs, procedures, etc Obtaining patient histories Interval histories Assessment of compliance with preventative health and disease specific guidelines Completing defined components of physical exam Patient education Completion of requests for tests and procedures Support staff can make a difference CHI’s experience Productivity =k Hours x Pt supply x Doc speed Total Work Vol.

30. UTILIZATION OF DIRECT SUPPORT STAFF IN CHI- Check in/Registration process • ALL patients • Review “quality care sheet” • Established patient • Due for Depression screening  PHQ-9 given to patient • Due for Learning Needs Assessment  Form given to patient • Advance Directives not formulated  Form given to patient • New patient • New patient history form • Health maintenance education sheet • + Depression screening, Advance Directives as well • New patient labs • Planning to implement • Disease specific hand out printed for patient • Patient decision support • Taking advantage of patient wait

31. EXAMPLE OF QUALITY CARE SHEET

32. HEALTH MAINTENANCE EDUCATION SHEET

33. UTILIZATION OF DIRECT SUPPORT STAFF IN CHI- Nursing Encounter • Patient history review and update • Compliance with • Medication, Diet, Exercise, etc • Recent tests or procedures since last visit • Recent visit to E.R or Hospital • Recent surgery • Entry of information from paper forms into E.H.R. • New patient history form, PHQ 9, Learning needs assessment, etc Value of use of E.H.R.’s documentation templates

34. EXAMPLE OF CUSTOMIZED E.H.R. TEMPLATES

35. UTILIZATION OF DIRECT SUPPORT STAFF IN CHI- Nursing Encounter • Review of “quality care sheet” and Assessment of compliance with • Procedures e.g. Pap, Mammogram • Tests e.g. HbA1c, Lipids, Creatinine • A1c done at point of care • Specialist referrals e.g. Podiatry, Optometry • Procedures, Tests or Referrals ordered • Documented in record • Forms completed • Initiation of self management goal setting process • Tool presented to patient

36. EXAMPLE OF CUSTOMIZED E.H.R. TEMPLATE

37. UTILIZATION OF DIRECT SUPPORT STAFF IN CHI- Nursing Discharge • Review of Provider’s Care Plan • Additional referrals, tests ordered • Print out of patient education handouts • Links to hand outs e.g. www.familydoctor.org • Print out of patient medication list • New patients, change in meds, etc • Education on available educational programs • Diabetes education; Chronic Disease Self Management Program for elderly, etc

38. UTILIZATION OF SUPPORT STAFF IN CHI- Post-Discharge • Patient tracking • Abnormal labs and tests • Referrals • Management of Patient Registries • Selected diseases e.g. DM, HTN • Overdue for specific labs e.g. Lipids, HbA1c • High risk e.g. elevated BP, abnormal paps • Patient calls • Appointment reminders, follow up on treatment or invite to group medical visit or patient education sessions

39. PROVIDER WORK VOLUME Summary of use of support staff in CHI during a patient’s visit Productivity =k Hours x Pt supply x Doc speed Total Work Vol.

40. Productivity =k Hours x Pt supply x Doc speed Total Work Vol. # OF HOURS WORKEDGoal: To ensure Providers are seeing patients max hours

41. PATIENT SUPPLY Goal: maximize # of patients seen # of patients seen = scheduled – no shows + walk ins Role of support staff No shows Educate patients on no show policy Call patients >2days prior to appointment Notify Providers of cancellations Follow up on no shows Walk ins Ensure all walk ins sign in Facilitate visit with effective triage Obtain as much info as possible Manage waiting time expectations Productivity =k Hours x Pt supply x Doc speed Total Work Vol.

42. PROVIDER SPEED Goal: Increase # of patients a Provider can see per unit time Role of support staff: Ensure Minimum interruptions possible Each Provider has and utilizes at least 3 exam rooms All exam room fully equipped and similar All support staff available during patient care time Providers are respectfully nudged along Providers are aware of accumulating backlog Proactively inform patients of backlog and importance of keeping visit focused for sake of patients waiting Environment for Providers to perform best work Productivity =k Hours x Pt supply x Doc speed Total Work Vol.

43. IN SUMMARY Support staff can be effectively utilized to increase Provider productivity through their ability to positively influence all 4 productivity drivers! • # of Hours Worked • Patient Supply • Provider Speed • Total Provider Work Volume

44. INGREDIENTS FOR SUCCESS Adequate Provider:Support staff ratio Effective deployment of support staff Training Supporting policies and procedures Inclusion of key components of expectations in job descriptions and evaluations Commitment to success Productivity =k Hours x Pt supply x Doc speed Total Work Vol.

45. MODELS OF EFFICIENT DIRECT SUPPORT STAFF UTILIZATION • Provider assignment models • Exam room assignment model • Broad roles model • Hybrid models

46. MODELS OF EFFICIENT DIRECT SUPPORT STAFF UTILIZATION • Provider assignment models • Support staff assigned to: • A particular Provider • Used in CHI’s single Provider sites • Group of Providers • Used in CHI’s multi-Provider units • Benefits of both types of Provider assignment models • Provider, Support Staff and Patient satisfaction • Easier to train staff

47. COMPARISON OF THE 2 TYPES OF PROVIDER ASSIGNMENT MODELS

48. MODELS OF EFFICIENT DIRECT SUPPORT STAFF UTILIZATION • Exam room assignment model • Support staff assigned to particular exam rooms regardless of Provider using room • Utilized in CHI’s Doris Ison Urgent Care Center • Benefits • Less distraction of support staff away from exam rooms for other duties • Support staff has better oversight of needs of patients in rooms; potential advantage with waiting time • Disadvantages • Potential patient dissatisfaction with inconsistencies in assigned support staff and Providers

49. MODELS OF EFFICIENT DIRECT SUPPORT STAFF UTILIZATION • Broad roles model • Support staff responsible for all the services and care for a given patient on day of visit • (Receptionist only welcomes patients) • Nursing support staff calls patient to an available exam room • Checks in patient • Collects co-pay • Completes vital signs and assessments • Performs lab work, procedures, etc after Provider encounter • Collects additional fees • Discharges patient • Works with another patient while Provider is with patient

50. INGREDIENTS FOR SUCCESS Adequate Provider: Support staff ratio Effective deployment of support staff Training Structured and repetitive Supporting policies and procedures Required to sustain change Inclusion of key components of expectations in job descriptions and evaluations Critical to sustain change and to hold accountable Commitment to success Probably the most critical factor Productivity =k Hours x Pt supply x Doc speed Total Work Vol.