Netting Better Results

Like many communities, Rochester, New York, is a study in contrasts. The upstate city, home to more than 250,000 residents, anchors the state’s third largest urban area and is legendary as a cradle of innovation: Bausch and Lomb, Eastman Kodak, and Xerox were all founded in Rochester. Yet evidence of a forward-looking metropolis is not equally reflected across the city.
In one part — the northeast quadrant — some 50,000 people face enormous obstacles, including poor health.  Residents here are 20 to 50 percent more likely to be hospitalized for asthma, diabetes, and hypertension than those living in Rochester as a whole, and four to five times more likely to wind up in a hospital bed for these conditions than nearby suburbanites.
With a median household income below $22,000, 35 percent of residents in “NE City,” as it’s called, live in poverty — and almost 50 percent of those under age 18 are poor. The community, predominantly African-American and Hispanic, also struggles with teen pregnancy, lead poisoning, hunger, family violence, and other burdens.
In 2003, in an effort to address many of these circumstances in a more integrated fashion, a coalition of Rochester civic and health care leaders launched “Reweaving the Safety Net,” a program to help link poorer residents with needed health care and social support services from any point of entry. One goal is to better coordinate outreach. For example, the same questionnaire seeking information about children in need is now distributed to parents, whether they’re sitting in the waiting room of a health clinic or receiving assistance with housing.
Extensive and ambitious, the initiative includes everything from enacting Medicaid payment reform, which allows providers to bill for more than one primary care service in a single office visit, to making sure people have same-day transportation to medical appointments and access to bilingual services.  “Rochester already has an abundance of community services,” says Alida Merrill, BSN, MPH, Strategic Development Officer for the Monroe Plan for Medical Care, an area health plan. “We just need to do a better job of connecting people to them.”
Underlying the broad effort is the Safety Net Clinical Transformation Project, which has been implemented at five primary care clinics and one mental health clinic: Clinton Avenue Family Practice Center, Rochester General Medical Associates, Rochester General Pediatric Associates, Rochester General Women’s Center, Rochester Mental Health Center, and Anthony Jordan Health Center. Based on concepts developed by the Institute for Healthcare Improvement (IHI) and the Institute of Medicine (IOM), the project’s goal, says L. Gordon Moore, MD, a family practice physician who directs the effort, is to redesign medical practice to significantly increase the efficiency and efficacy of care. “We believe better systems produce much better outcomes for patients,” Moore says. He identifies three key elements required to elevate medical practice, as described below.
A High-Functioning Clinical Team 
Time management studies show that as much as 50 percent of staff time is wasted on low- or no-yield activities, such as taking messages. In a high-functioning office, clinical team members are prepared and empowered to personally complete each task that comes their way.
This means designing work flow so that tasks are routed to the right person, but it also means making sure that person has the right training and the right tools. “It’s not enough to designate one nurse to look up lab results when patients call if they can’t immediately get online because there aren’t enough computers.” Call-backs waste everyone’s time, says Moore. “The system needs to encourage and allow everyone to do it now.” Taking full advantage of a staff’s collective skills and energy isn’t just good for office efficiency, it’s good for the team members who learn and grow and advance in their careers.”
Open Access
Impossible as it sounds, the best way to ensure that every patient who needs an appointment gets one is to offer same-day appointments. “When schedules are backed up, some patients are going to fall through the cracks,” says Moore.  “That’s bad.” Clearing space for same-day appointments in packed calendars may require hiring extra staff for a while, but as other efficiencies yield extra time, same-day appointments eventually become routine. “Not everyone will want one, of course,” says Moore, “but you’ve got to have room for the patients who need one.” 
Planned Care
No one physician can possibly know and do everything regarding a patient’s care.  To produce the best results, physicians need help from information technology and from patients themselves. Every exam room needs a computer with a broadband connection so physicians can access needed diagnostic and therapeutic information right then and there. “If you’re not sure what that rash is, you can probably find it on the visual diagnosis site.” Educating, motivating, and supporting patients in managing their own health problems is equally critical, says Moore. “That means partnering with them to set goals and problem-solve and providing resources like referrals to community services.”
David Lainoff, MD, who directs the outpatient clinic at Rochester General Hospital (staffed by Rochester General Medical Associates), oversees 46 residents in internal medicine and 10 other medical personnel. The large team often wasn’t sure who was working with whom. The result: wasted time as physicians left the examining room to track down patient charts, lab results, referral forms, or educational materials.
As part of their work in the Clinical Transformation Project, “We organized the whole process,” says Lainoff. Staff members were organized into smaller teams that always worked together, “so everyone knew who was responsible for what and even one another’s style and rhythms.” Teams reviewed the charts the night before to make sure they were complete, placed referral slips in examining rooms, and numbered educational materials so providers could identify which materials a patient needed and ensure they received them at the front desk at checkout.
The result is greater efficiency, says Lainoff, but also something more. “People have such clear responsibilities that they’re willing to take the initiative.” For example, says Lainoff, secretaries have learned to scan charts for overdue Pap smears or mammograms and point them out to busy physicians.
The Clinical Transformation Project has also had a significant impact at the Clinton Avenue Family Practice Center. Before joining the Project in January 2004, the office’s two physicians and two physician assistants (PAs) would see eight to 10 individual patients in a typical morning. Much of that time would be spent shuffling patients and providers in and out of examining rooms, drawing blood for lab work, and writing prescriptions. “At most, each patient might get seven to 10 minutes with the provider,” says James B. Sutton, one of the PAs. With coaching from Moore, the office revamped its care for patients with diabetes, who comprise 20 percent of Clinton’s 8,000 patients.
Now, Sutton schedules 90-minute group visits for eight to 10 diabetic patients at once. Two weeks beforehand, group members come in for lab work so their results are available during the visit. Some time is still taken up by administration — refilling prescriptions, taking vitals, noting address or insurance changes — but most of the time is devoted to answering patients’ questions and discussing their illness. “Everyone gets to benefit from everyone else’s care,” says Sutton, “and each patient is getting an hour or more of the provider’s time.” Results have been amazing, says Sutton, who tracked group members’ health status from two years before group visits to one year after. Blood sugar (A1C), blood pressure, and LDL cholesterol indicators had all improved significantly.



Mildred Santana, one of Sutton’s diabetes patients, is especially pleased with the group visits. “I used to be very afraid of the complications of diabetes, but now I can talk about it and get good advice,” she says.  “Mr. Sutton has time to listen to me and to answer. My family says there’s a big change in my attitude. I’m not afraid anymore.”


It’s not yet clear how much the Safety Net project has been able to reduce the high hospitalization rates for asthma, hypertension, diabetes, and other controllable conditions in the NE City. Insurance claims data, on which statistics are based, has a long lead time. “We won’t have complete 2004 data until later this year,” says Alida Merrill.


Still, says Moore, “We're thrilled to see early indicators of success. Our best-performing teams are showing a 14 to 24 percent decline in emergency room visits for their Medicaid patients. As more teams succeed, we expect to see a significant decline in hospital admission for conditions like diabetes and asthma.”




ED visits per 1,000 Members per Year
Clinton Avenue Family Practice Center and 
Rochester General Medical Associates


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