The Cleveland Clinic’s Journey from Volume to Value in the Era of Healthcare Reform

The Cleveland Clinic’s Journey The Cleveland Clinic’s Journey from Volume to Value in the from Volume to Value in the

Era of Healthcare ReformEra of Healthcare Reform

The Cleveland Clinic’s Journey The Cleveland Clinic’s Journey from Volume to Value in the from Volume to Value in the

Era of Healthcare ReformEra of Healthcare Reform

David L. Longworth, M.D.David L. Longworth, M.D.

Chair, Medicine InstituteChair, Medicine Institute

Associate Chief of Staff, Clinical Integration DevelopmentAssociate Chief of Staff, Clinical Integration Development

Cleveland ClinicCleveland Clinic

About Me…About Me…About Me…About Me…

• Practicing internist and ID Practicing internist and ID physician for 32 yearsphysician for 32 years

• Cleveland Clinic 1986-Cleveland Clinic 1986-2002, 2011- present2002, 2011- present

• Massachusetts 2002-2011Massachusetts 2002-2011

• Doctoring and medical Doctoring and medical education my core skillseducation my core skills

• No disclosuresNo disclosures2

AgendaAgendaAgendaAgenda

• Our imperativeOur imperative

• Our strategyOur strategy

• Transforming the care delivery Transforming the care delivery modelmodel

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• Cost

• Price

• Outcomes

• Transparency

• Growth strategy

Our Burning PlatformOur Burning Platform

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The Value ImperativeThe Value ImperativeThe Value ImperativeThe Value Imperative

Volume Value

The shift to value is the centerpiece of our strategy

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Value DefinedValue DefinedValue DefinedValue Defined

Value = Outcomes Cost

Outcomes QualityHealth StatusProcess Experience

CostEvent Episode Per Capita

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Reducing Unnecessary Reducing Unnecessary VariationVariation

Reducing Unnecessary Reducing Unnecessary VariationVariation

• Improves quality

• Decreases cost

• Demonstrates value

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Value-Based Care: Central to StrategyValue-Based Care: Central to Strategy

Care System

Retail Venues Home

CC ClinicCommunity- Based

Organizations

Ambulatory D&TIndependent Physician

Offices

Hospitals

Rehab

Skilled Nursing Facilities

MyChart

EmergencyPost-Acute(other)

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Care System

Cleveland Clinic Integrated Care ModelCleveland Clinic Integrated Care Model

Retail Venues Home

CC ClinicCommunity- Based

Organizations

Ambulatory D&TIndependent Physician

Offices

Hospitals

Rehab

Skilled Nursing Facilities

MyChart

EmergencyPost-Acute(other)

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Transforming CareTransforming CareTransforming CareTransforming Care

• Evidence/Experience

• Standardization

• Hand-offs

• Continuum

System of Care

• Pt Experience

• Quality

• Safety

• High Reliability

• Efficiency

VALUE 10

Tool: Care PathsTool: Care PathsTool: Care PathsTool: Care Paths

• Standardization vehicle

• Integration mechanism

• Led by Clinical Institutes

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Care Path DefinedCare Path DefinedCare Path DefinedCare Path Defined

• Multidisciplinary

• Optimizes value

• Reduces unnecessary variation

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Care Path DefinedCare Path DefinedCare Path DefinedCare Path Defined

• Evidence or experience-based

• Not always a single approach

• Expected practice yet allows judgment

• Some clinical activities will not apply13

Care Path Development Care Path Development Care Path Development Care Path Development

1. Disease Identification

2. Care Path Guide

5. Programming/Build

3. Technical Specs & Workflow

4. Mapping

6. Production14

Care Path ApproachCare Path ApproachCare Path ApproachCare Path Approach

1.Disease Identification

• Enterprise Criteria• Scope/Episode

2.GuideClinical Narrative

• Purpose• Background and Significance• Clinical evaluation and Documentation• Workflow Narrative and Tools• Outcome measures• Citations

3.ContentKnowledge Base

• Visit/Venue Matrix• Workflow Diagrams• Documentation• Orders• Metrics• Snapshots• Reports

4.MappingData Definition

• Map to ontologies• Data sources• Data storage• Rules• Mock Ups

5.ProgrammingBuild

• Epic configuration• Orders/Order Sets• Factors• Forms

Move to ProductionNear-term work

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Fully Mature Care Path Guide Fully Mature Care Path Guide Will Address:Will Address:

Fully Mature Care Path Guide Fully Mature Care Path Guide Will Address:Will Address:

• Quality metrics

• Appropriateness criteria

• Screening & prevention guidelines

• Health status measures

• Cost

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Care Path GuideCare Path GuideDevelopment ApproachDevelopment Approach

Care Path GuideCare Path GuideDevelopment ApproachDevelopment Approach

• Driven by Clinical Institutes

- > 750 caregivers

• Collaboration - Cross-Institute, Cross-Venue & Quality Alliance

• Wave 1: 50 Care Path Guides by 12/31/13

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We are building Vespas and We are building Vespas and Maseratis…Maseratis…

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Hip and Knee “Vespa” Development

“Vespa” WorkgroupDevelopment and Implementation

Leads: Morris, Spalding, Partin,Fogleman, Piar, Weber, ORI Clinical Expert(s), Coordinated Care, CI

StructuredDocumentation

Order Sets

Decision Support(ex: “Bundle Busters”)

CareCoordination

ProcessMeasures

OutcomesMeasures

Patient-EnteredData

Hip / Knee“Vespa”

Technology-ReadyComponents

Hip / KneeArthroplasties

Care Guide

Purpose of this Guide:

The Cleveland Clinic Orthopaedic and Rheumatologic Institute performs more than 1200 primary Total Hip Arthroplasties (THA) per year, making it one of the higher volume surgeries in the Cleveland Clinic. THA is also one of the most variable surgeries performed in the United States, with cost1 procedure, implant selection, length of stay (LOS), infections and re-admission rates, and post-operative management2 varying greatly between and within most systems. 19

Comprehensive Care CoordinationComprehensive Care CoordinationThe Second Key CompetencyThe Second Key Competency

Comprehensive Care CoordinationComprehensive Care CoordinationThe Second Key CompetencyThe Second Key Competency

• Aligned across the continuumAligned across the continuum

• Focus on high risk patientsFocus on high risk patients

• Primary and specialty carePrimary and specialty care

• Leverage technologyLeverage technology

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VBC = Care TransformationVBC = Care Transformation

Clinical Leadership is Critical21

ContractingContractingContractingContracting

• We are aligning contracting with the We are aligning contracting with the clinical enterpriseclinical enterprise

• Multidisciplinary contracting team with Multidisciplinary contracting team with Physician and Finance Co-ChairsPhysician and Finance Co-Chairs

• Subject matter content experts for Subject matter content experts for specialty carespecialty care

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The Cleveland Quality AllianceThe Cleveland Quality AllianceThe Cleveland Quality AllianceThe Cleveland Quality Alliance

Independent Physicians CC Institutes

Quality Alliance

Jointly-established quality standardsJointly-established quality standardsReward for quality and efficiency Reward for quality and efficiency

Drive to better outcomesDrive to better outcomesDrive to improve value for patients, providers and payersDrive to improve value for patients, providers and payers

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The Quality AllianceThe Quality AllianceFour Strategic ObjectivesFour Strategic Objectives

The Quality AllianceThe Quality AllianceFour Strategic ObjectivesFour Strategic Objectives

• Superior practice quality and efficiency

• Document high-quality care

• Recognize superior performance

• Distribution vehicle for CCICM 24

Over 5,000 Provider MembersOver 5,000 Provider MembersOver 5,000 Provider MembersOver 5,000 Provider Members

As of 1.11.13

Total Membership = MD/DO/DPM/Team-Health ED (3,545) + AHP (1,535)25

PCP37%Specialist

63%

Most providers are specialists

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We are moving to population We are moving to population management in all primary care practices management in all primary care practices

We are moving to population We are moving to population management in all primary care practices management in all primary care practices

• 260,000 lives260,000 lives• 240 providers240 providers• 39 practices at 29 sites39 practices at 29 sites• Team based careTeam based care

- Testing different models of PCMHTesting different models of PCMH- Embedded care coordinators, pharmacistsEmbedded care coordinators, pharmacists- Enhanced accessEnhanced access

• Epic registry functionEpic registry function• Advanced IT population management and Advanced IT population management and

analytic capabilities in developmentanalytic capabilities in development

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Other care transformation tacticsOther care transformation tacticsOther care transformation tacticsOther care transformation tactics

• Wellness widgetWellness widget

• E-visits E-visits

• Shared medical appointmentsShared medical appointments

• Distance healthDistance health

• Other lower cost sites of serviceOther lower cost sites of service

• Rationalizing sites of service Rationalizing sites of service distributiondistribution

• Preferred post-acute partnershipsPreferred post-acute partnerships

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… And we are teaching the young people these new skills

… And we are teaching the young people these new skills

• 126 IM residents moved to block rotations in population management in July 2012

• CCLCM curriculum implemented years 1, 2

• OU and South Pointe partnership

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The Cleveland Clinic’sThe Cleveland Clinic’sSecret SauceSecret Sauce

The Cleveland Clinic’sThe Cleveland Clinic’sSecret SauceSecret Sauce

• ModelModel

• LeadershipLeadership

• CultureCulture

• InnovationInnovation

• EngagementEngagement

• PridePride

Patients First30

““The strength of the pack is the The strength of the pack is the wolf, and the strength of the wolf wolf, and the strength of the wolf

is the pack…”is the pack…”

““The strength of the pack is the The strength of the pack is the wolf, and the strength of the wolf wolf, and the strength of the wolf

is the pack…”is the pack…”

Rudyard KiplingRudyard Kipling

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“The future belongs to those who believe in the beauty of their dreams…”

“The future belongs to those who believe in the beauty of their dreams…”

Eleanor Roosevelt

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Q & AQ & A

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