Geographic Deployment and Multi-Disciplinary Care Teams:

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Geographic Deployment and Multi-Disciplinary Care
Teams  The Practicals and Challenges

• Jerome C. Siy, MD, SFHM
• May 6, 2010

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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

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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

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Poll Question 1
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Before Geographic

• Each hospitalist admitted to all hospital units
• 8 MDs 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
• MDs definitely got their 10,000 Steps in per day
• No teamwork

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Principles of Geographic Assignment

• Assign hospitalist service based upon location of
  the patient in a unit versus whos up next
• Principle of keeping fewer MDs 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

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After Geographic

• 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

• 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

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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 MDs
• 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

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Poll Question 2
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Care Team Rounds

• Once you have MDs 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

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The Care Team

• 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 Commissions Interdisciplinary Care
  Plan
• Facilitate early discharge and discharge planning
• Leverage systems, other than the physician, to
  coordinate care

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Poll Question 3
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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

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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)

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Content of RoundsNot 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

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Content of RoundsContinued

• 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

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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 900am 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

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Key Measures of Success

• Patient satisfaction
• Communication scores in HCAHPS
• Willingness to recommend
• Discharge readiness
• Orders written before 900am
• Discharge time (earlier in the day is better)
• Decrease in Milliman Potentially Avoidable Delays
• Employee survey results
• MGMA Physician Satisfaction
• HealthPartners All Employee Survey

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Questions Discussion