Geographic Deployment and Multi-Disciplinary Care Teams: The Practical’s and Challenges

1. Geographic Deployment and Multi-Disciplinary Care Teams:  The Practical’s and Challenges Jerome C. Siy, MD, SFHM May 6, 2010

2. Presentation Overview • Make the case for geographic placement of your hospitalist practices at your hospitals • Learn how multi-disciplinary care teams improve communication, improve hand-offs, assist in early discharges and improve the overall leadership and accountability structure of hospital units • Create an open dialogue about the challenges and tactics to overcome those challenges in implementation of geographic placement and multi-disciplinary care teams

3. Background on our Care System • HealthPartners Medical Group • Integrated care delivery system aligned with hospital, medical group and payer • Approximately 700 physician multi-specialty practice • Approximately 50 locations in Twin Cities and Western Wisconsin • Hospitalist practice is 70+ providers practicing at 5 hospitals • Regions Hospital, St. Paul, Minnesota • 443 licensed beds • Regularly run 80%-90% of capacity • 14 hospitalist daytime services caring for patients • 4 Teaching Teams • Palliative Care • Medicine-Pediatrics • Surgical co-management • 24/7 Coverage • Tertiary care center for smaller community hospitals • Level I Trauma Center • Teaching affiliation with University of Minnesota • Inner city hospital with large proportion of uninsured, underinsured, Medicare and Medicaid

4. Poll Question #1

5. Before Geographic • Each hospitalist admitted to all hospital units • ~ 8 MD’s covering a 16 bed unit • Each MD covering on average ~6.5 units • Problems: • Very little nurse/MD collaboration • Poor communication amongst the care team • Very difficult to find a nurse or physician to talk with in person • High number of unnecessary pages • Lots of time wasted traveling from unit to unit • MD’s definitely got their 10,000 Steps in per day • No teamwork

6. Principles of Geographic Assignment • Assign hospitalist service based upon location of the patient in a unit versus “who’s up next” • Principle of keeping fewer MD’s covering the same unit • 80/20 Rule – 100% geographic is not feasible • Surgery schedule drivers • Teaching mix • Patient aggregation rules for nursing and other support • E.g. telemetry, progressive care, etc. • Since geographic deployment in 2005, hospital expanded in Fall 2009 moving from 12-16 bed circles to huge 36 bed “arms” • Continue to refine our model constantly

7. Physician Team R1-R4 Hospitalist Teaching Services HP5 and HP6 Hospitalist HP7 and HP8 Hospitalist HP9 and HP10 Hospitalist HP11 Peri-Operative Team HP12 Peri-Operative Team HP13 Palliative Care Team HP14 Triage / ED consults HP15 Medicine Pediatrics Primary Units South 6, 7, 8 South 6, C63 South 7 and South 8 Central 82, 91 South 9 (Beds 9401-9518) South 9 (Beds 9519-9636) Hospice patients n/a Central 54 After Geographic

8. Geographic Practical's: • Nighttime coverage: No geographic, pure admission service • We too hit points of surge where there could be some teams busier than others • In general, seeing patients in a timely manner trumps geographic • Transfers: in general, physician continuity trumps geographic • Compensation is not a key driver for daily census of the MD’s • Services are all busy enough (our overall staffing level is appropriate) • Productivity has remained stable for the physicians • Physicians rotate their service in the schedule to allow for variety of practice and patient mix adjustments • Due to nighttime assignment and surge, often by the end of the service week we do see slippage • On sign outs (Tuesdays) we go back to geographic • While not perfect, still better than the old method of covering 6+ units

9. Poll Question #2

10. Care Team Rounds • Once you have MD’s more available on the floors, it becomes easier to assemble the teams • Hardwire team meetings • All meetings occur between 9-10 • Availability for teleconferencing to accommodate disciplines covering multiple units • Some surgical / ICU meetings occurring again in the afternoon to accommodate surgeons or plan for the next day • Each patient should only take 2 minutes to review • All team members on the same page to progressing care and planning for discharge

11. Essential Participants Physician RN Nurse Manager Social Worker Case Manager Pharmacist Health Unit Coordinator Other participants may include: Chaplain Utilization Review Specialists Others Purpose: Exchange information critical to quality patient care First team to be approached for collaborative improvement efforts E.g. Joint Commission’s Interdisciplinary Care Plan Facilitate early discharge and discharge planning Leverage systems, other than the physician, to coordinate care The Care Team

12. Poll Question #3

13. Why include the pharmacist? • Better access for dialogue between MD and Pharmacist on medication discussions • Decrease the number of pages between the disciplines • More timely therapy adjustments provide enhanced levels of care • Better information sharing with whole team • Knowing the time of discharge helps align with the discharge preparation process • Preparing for home IV antibiotics and assessment of other high cost discharge medications

14. So, why the HUC, Case Manager AND the Social Worker? • These are the people with the planning skills to get the work done • Arrange for: • Patient education • Ride planning • Coordination with the family • Arranging in advance SNF or Home Care • Many SNFs are short on beds, often need longer lead times to place • Assist the patient in helping with finding financial assistance (e.g. applying for programs) • Coordinating transitions of care (e.g. setting up appointments in heart failure clinic)

15. Content of Rounds:Not every topic addressed due to time, only those of issue • Clarify demographic ambiguities • Identify primary or working diagnosis • Observation v. admitted status • Basic information: barriers, language • Discharge planning • Anticipated date/time/place • Plan ahead: Ride, home care, follow-up appointment needs, re-admission risk identification • Legal-Social Issues • Holds • POA, guardianship • Code status addressed

16. Content of Rounds:Continued • Resource utilization • Safety assistant • Telemetry • Isolation • Change in level of acuity • Lines and tubes (e.g. foley & central line removal) • Progression of care guidelines • Identifying needs related to ongoing acute care status • Current functional status/needs • Identify needs for care conference with family • Medication plan of care guidelines • Pain management • Progression to PO meds • Need for costly or complex medications (e.g. LMWH) • Outstanding orders that need to be completed and plan for follow-up

17. After Care Team Rounds • Improved patient and family satisfaction through consistent communication of plan of care and realistic discharge expectations • Improved flow by reducing discharge delays • Increased discharge order entry by 9:00am to facilitate earlier discharge (beat the ED rush) • Improved staff and physician satisfaction • Better access to physicians for clinical dialogue, particularly medications • Planful process for discharge activities that are not always clinical, but critical to discharge • Ride planning, SNF placement, patient education • Potential for improved patient safety with thorough, timely and improved communication • Everyone owns the care of the patient

18. Key Measures of Success • Patient satisfaction • Communication scores in HCAHPS • Willingness to recommend • Discharge readiness • Orders written before 9:00am • Discharge time (earlier in the day is better) • Decrease in Milliman Potentially Avoidable Delays • Employee survey results • MGMA Physician Satisfaction • HealthPartners All Employee Survey

19. Questions & Discussion