The Challenge: HealthPartners Medical Group, part of the Minnesota-based HealthPartners system of health care organizations, has for many years been providing excellent care when compared against national benchmarks. But having reached a high plateau of performance over the past several years, the improvement had leveled off. “We weren’t getting any better,” says Beth Waterman, vice president of primary care and clinic operations, and project director for Pursuing Perfection.
Additionally, HealthPartners’ leaders weren’t happy with the reactive, visit-by-visit form of care. HealthPartners believed they weren’t adequately anticipating patients’ needs or building continuity with patients, and wanted another model of care that would improve outcomes, enhance the patient’s and provider’s experience, and advance the organization’s vision of becoming the best and most trusted group of health care providers in the nation.
The Background: HealthPartners Medical Group (HPMG) has about 580 physicians practicing in more than 50 primary and specialty care clinics in Minneapolis/St. Paul and St. Cloud, Minnesota. HealthPartners (HP), HPMG’s parent company, is a consumer-governed non-profit health care organization recognized nationally as a leader in the pursuit of better quality care and service. Its health insurance plans were the first in the nation to reward physicians for meeting specific clinical quality standards. HealthPartners also operates a 435-bed tertiary care teaching and research hospital, training more than 500 residents annually.
HPMG was awarded a Pursuing Perfection grant in 2002, enabling it to strengthen its ongoing commitment to improving care. The HP board of directors and CEO Mary Brainerd were already in the process of creating goals that would translate the quality aims of the Institute of Medicine (IOM) across HP organizations. Those six aims, spelled out in the IOM’s landmark 2001 report, “Crossing the Quality Chasm: A New Health System for the 21st Century,”
challenge health care leaders to provide care that is safe, effective, patient-centered, timely, efficient, and equitable.
and the HealthPartners leadership saw the Pursuing Perfection project as an opportunity to take advantage of the highly integrated nature of their organization. They recognized that successfully transforming care and culture in the HealthPartners Medical Group, in many ways the core of the HP enterprise, would require the support of the organization’s other entities. At the same time, they saw that Pursuing Perfection could serve as a catalyst to promote positive change across the entire HealthPartners system.
With Pursuing Perfection, HealthPartners launched a comprehensive system-wide improvement initiative that spawned literally hundreds of improvement efforts. In the Medical Group, the focus was on transforming patient care by implementing a new “Planned Care Model.”
The Solution: Most Pursuing Perfection organizations begin the improvement journey by focusing on a few conditions, such as diabetes and asthma. The idea is to then spread new models of care to other conditions and settings during subsequent months and years. But HPMG decided instead to redesign care at the outset for multiple conditions, spreading improvements across locations regardless of the specific health problem. This would require a “disease-neutral” model of care.
In a two-day Rapid Design Session (a high-involvement approach for designing solutions over a short period of time), a team representing all aspects of a patient’s visit to a health facility created the HealthPartners approach to the Planned Care Model, to be tested at three pilot sites. The Model combines a team approach to patient care and a way of thinking about interactions with patients that encompasses far more than just the visit.
“The Planned Care Model calls for a prepared practice team that anticipates the needs of patients prior to their arrival,” says John Wheeler, MD, who, until his retirement last year, served as HP’s co-director of Pursuing Perfection and medical director for primary care. The model also calls for involving patients more in setting goals and creating the care plans, says Wheeler. “We don’t want them to be passive recipients of care, but actively involved and engaged,” he says.
The prepared practice team is an important part of the Chronic Care Model
developed by Ed Wagner, MD, and colleagues at the MacColl Institute in Seattle, Washington. The Institute for Healthcare Improvement promotes use of the Chronic Care Model to provide effective, patient-centered care.
At HPMG, prepared practice teams include physicians, registered nurses, licensed practical nurses, and clerical staff such as receptionists. A diabetes nurse specialist, nutritionist, and/or pharmacist are added to teams as necessary. The HP Planned Care Model puts the patient at the center of the team, and begins with a clear aim: “To have prepared practice teams interact with informed, activated patients through continuous healing relationships supported by the ongoing availability of health information.”
“In the old model, the physician was the sole agent of success or failure,” says John Wheeler. “Today, we need to see ourselves in a true team setting where we understand everyone’s role.” In the HP Planned Care Model, each team member has a clear set of responsibilities and tasks to perform.
The teams follow a simple set of rules:
- Patient care is designed to meet patient needs and respond to individual patient preferences and choices.
- The team’s work is organized around the processes of the pre-visit, visit, post-visit, and between-visit care. Patients will experience proactive care, not just reactive assistance.
- Team members will cooperate and coordinate their work fully with each other and with the patient.
- Patients will understand that there are a number of ways to get care and that a visit with the primary provider is not always needed (because other members of the care team have clear roles to play in providing care).
In this model there are four phases of engagement with patients — pre-visit, visit, post-visit, and between-visit — and each comes with its own set of tasks and expectations, many of which take the burden of extraneous tasks off the medical appointment itself, leaving doctor and patient with more time for meaningful interaction.
A True Team Setting: Daily Multidisciplinary Meetings
For example, pre-visit planning might include getting or providing additional information from or to patients via mail, email or telephone. For some patients, it could mean having lab tests completed so that results are available for review by the time doctor and patient next see one another.
On appointment days, teams usually meet in the morning — and keep in close touch during the day as needed — to quickly review the day’s schedule, and share information about patients’ specific needs or special concerns. For example, the receptionist/medical assistant will have reviewed all records of patients with cardiac disease, chronic pain, diabetes or stroke (all known to be at higher risk for depression) to see if they have had a depression screening during the past year. If they have not, a note is made in the patient’s chart and the nurse administers the screening test at the beginning of the visit and passes the results on to the doctor before he or she sees the patient.
One HPMG physician tells the story of a wife who called prior to her aging husband’s regular checkup to convey some concerns about his recent behavior. Before planned care, says the physician, he might not have gotten the message in time, or understood the importance of speaking with the wife. Because of the Planned Care Model, the nurse made sure the doctor and the wife spoke, and the doctor learned some valuable information that led to further tests and the discovery of an operable brain tumor.
This gets at the heart of what it means to be truly prepared for each patient visit, says John Wheeler. “This model means that more can be accomplished during the visit. Physicians can take care of any screenings the patient might be due, or refill prescriptions. Because most patients visit three to four times a year, this encounter-related approach to health maintenance is becoming more effective than the traditional annual check-up.” Patients are given a discharge summary after each visit that summarizes the visit and care plan.
Post-visit tasks include any specific follow-up identified during the visit, and/or preparation for visits to other parts of the care continuum such as a specialist or hospital. Between visits patients may be working on lifestyle changes they’ve agreed to in the care plan.
Key to the success of the Planned Care Model has been HP’s implementation of electronic medical records (EMR) throughout primary care in 2004, spreading to specialty care in 2005. “The EMR is an instrumental tool in this model of care, providing important reminders and discharge summaries,” says Beth Waterman.
The Results: The Planned Care Model at HPMG has spread beyond its original three pilot sites to nearly the entire medical organization, with the final phase planned for the spring of 2005. HP’s Pursuing Perfection lead Beth Waterman reports that “patients love it; they feel cared for by the whole team.” In addition, she says, “It has improved staff morale, because people like being part of a team.” John Wheeler says that there is a sense of community that has built up around the team concept, and a growing relief among physicians who are happy to share the load. “The biggest thing for physicians is to realize they don’t have to struggle through this heavy schedule of patient care alone,” says Wheeler. The model also holds the potential to reduce variation in practice, says Wheeler. “Teams begin to notice that other teams may have better results, and before long those best practices spread and become standardized.”
All this is good news, notes Wheeler, but there is only one real bottom line. “If you are not getting results for patients, it’s not worth a hill of beans.” But there too, the news is good.
Data in the charts below show that the HP Planned Care Model improves care not only for patients in need of routine preventive screenings, but also for patients with chronic conditions. More patients are receiving the complete set of appropriate screening tests for their age group. For patients with diabetes, more patients are reaching all five critical clinical milestones, including healthy levels for blood sugar, blood pressure, and cholesterol.
For all HPMG&C patients with Diabetes, the percent that had an HbA1c screen in last 6mths with a value <7%, annual screen for LDL with value <100mg/dl and last recorded systolic blood pressure <130, documented non-tobacco user and documented regular aspirin use. This is a very ambitious goal, and few organizations can meet all five criteria for their patients with diabetes.
Health Maintenance opportunities include:
*Age and gender appropriate preventive services (chlamydia, pap, cholesterol, mammogram, colorectal)
*Diabetes screening (HbA1c and LDL screening)
What the Team Members Said: “When physicians begin to take a radically different attitude about their role in care delivery, when they connect with other staff as team members, it’s a morale booster for everyone. They can acknowledge that there are some things the nurse does better than they do, and that’s good for the physician, the nurse, and the patient.”
– John Wheeler, MD, former co-director of Pursuing Perfection at HPMG and medical director for primary care
“We are a large organization, and implementing this across the system has not been easy. We had already introduced Advanced Access in all our sites, and that gave us confidence that we could take a similar approach to spreading prepared practice teams. We used a Collaborative approach in which teams from each clinic would meet in Learning Sessions, test changes during an Action Period, and implement what worked. It really is a fundamental change to the way we deliver care, and that requires a lot of commitment.”
– Beth Waterman, HPMG vice president of primary care and clinic operations, and project director for Pursuing Perfection