ENGAGEMENT DETAIL & PURPOSE
Hattiesburg Clinic, a large multispecialty clinic located in Hattiesburg, Mississippi, engaged Stroudwater to assist with the development and implementation of a team-based primary care practice model. The clinic includes more than 350 primary and specialty care providers.
ORGANIZATIONAL CHALLENGES
Clinic leadership and the five pilot primary care teams identified a number of challenges under the current clinical model, including:
- Not achieving shared savings in ACO
- High readmission rates
- Lack of primary care access at some locations, particularly for same-day and urgent care appointments
- High volume of patient calls (more than 50 calls per day to some teams)
STROUDWATER’S APPROACH
Two Stroudwater consultants, a family medicine physician and a clinical operations expert with a background in nursing, conducted a thorough assessment of the five clinical practices selected for the initial team based care model pilot. Detailed data was gathered about the practices, including their operations and historical performance. Interviews were conducted with each of the practice teams to examine workflows and identify any concerns about the new model. Stroudwater provided direct coaching and support to facilitate implementation of the team-based care model pilot, including a day-long, onsite kick-off session. Stroudwater then spent two days onsite with each practice team and provided hands-on support to implement the core principles of team-based care. After 30 days, the Stroudwater consultants returned for a second onsite visit to assess progress and demonstrate further applications of the model. During monthly webinar follow-up sessions, Stroudwater reviews the practices’ quality, cost, and utilization data and assists the teams to finetune workflows, further enhance efficiencies, improve clinical results, restore the joy of clinical practice for the teams, and enhance the patient experience.
EARLY HATTISBURG CLINIC RESULTS
- Communicated lab test results to patients on same day; worked in-basket messages in real time.
- Nurses and medical assistants are now seen as an extension of the physician-led teams and are able to answer questions, thereby eliminating the need for multiple messages back and forth.
- Empowered receptionists to elicit more information from patients, answering questions related to prescription refills status and scheduling same-day appointments in available slots.
- Created more visit capacity through enhanced efficiencies in clinical workflows and early identification of available appointment slots for same-day and urgent appointments.
- Identified patients due for lab work and reached out proactively to ensure results were available for review at time of appointment.
- Reduced phone calls and messages in EMR by implementation of pre-visit planning; needs of patients and families are anticipated and addressed at time of office visit.
HATTIESBURG CLINIC LEADERSHIP, PHYSICIAN, STAFF AND PATIENT PERSPECTIVE
Physicians: One physician commented that the new model had already “changed her life” by enabling her to complete patient charting by the end of office hours each day. Another physician who used to take vacation days to catch up on paperwork reported that “[we’re] seeing high rates of depression and burn-out in healthcare workers. There’s a reason for that, but there are also fixes. This is one of those fixes.”
Patients: “I feel more taken care of.” “It’s like a family environment.” “Loved having all the focus on ME!”
Nurses: “I feel more directly involved in patient care and I am actually using my nursing skills.”
Jackie Parker, Primary Care COO: The COO reports that the changes made are allowing the clinic to reallocate time formerly focused on caring for a computer screen to more time caring for patients. Nurses and medical assistants are being trained on scribing and the clinic has added staff, some of whom came from other parts of the organization and others who are new hires. On her experience with Stroudwater’s consultants, Parker is enthusiastic: “Louise and Heidi were very knowledgeable and attentive.” Parker added that it was made clear upfront that the new model would continue to evolve over time as the staff took ownership and customized the model further to meet the practices’ needs.
ANTICIPATED FUTURE RESULTS
- Reduced total cost of care, with fewer hospital admissions for ambulatory-sensitive conditions, fewer readmissions, and reduced ED utilization
- Increased panel sizes
- Increased returns on investment as greater percentages of patient panels are enrolled in risk-based payment models
- Enhanced ACO performance as a result of increased attention to documentation
- Improved clinical quality and outcomes for preventive services and chronic disease management
Stroudwater provided direct coaching and support to facilitate implementation of the team-based care model pilot, including a day-long, onsite kick-off session. Stroudwater then spent two days onsite with each practice team and provided hands-on support to implement the core principles of team-based care. After 30 days, the Stroudwater consultants returned for a second onsite visit to assess progress and demonstrate further applications of the model. During monthly webinar follow-up sessions, Stroudwater reviews the practices’ quality, cost, and utilization data and assists the teams to fine-tune workflows, further enhance efficiencies, improve clinical results, restore the joy of clinical practice for the teams, and enhance the patient experience.