HIMSS Davies Award...CASE STUDY #3: Care Redesign VALUE Cost Improvement (FY17 Year End versus FY18 YTD thru Qtr 2 DUHS) $4.7 million in cost improvement in FY18 YTD Wave Team Performance

HIMSS Davies Award Davies Enterprise Committee Site Visit

Duke Health

June 7, 2018

Case Study #3:DUHS Care Redesign

George Cheely, MD, MBADavid Attarian, MD

Jennie Wahl PTHeather McLean, MD

George R. Cheely, Jr. MD, MBAAssistant Professor of Medicine and hospitalist physician, Duke University HospitalMedical Director for Care Redesign at Duke University Health SystemFaculty expert in the Margolis Center for Health Policy

EDUCATION:MD, University of Pennsylvania School of Medicine, 2009MBA, The Wharton School, University of PennsylvaniaRESIDENCY:Internal Medicine, Duke University Medical Center, 2012BOARD CERTIFICATION:American Board of Internal Medicine, Internal Medicine

PHYSICIAN PROFILE

CASE STUDY #3: Care Redesign

PROBLEM Affordable Care Act has Accelerated Pace of Change

DGMH15

Slide 4

DGMH15 need original of this to update from preferablyDr Genie McPeek Hinz, 6/1/2018


PROBLEM

OPPORTUNITY: In response to the evolving payment models, a Care Redesign Oversight

Committee was established in 2011. The goal was simple--improve the care experience and population health while reducing the cost of care

PROBLEM: Government and commercial pressures to reduce reimbursement by as much as

20% in North Carolina .

Care Redesign Focus: Process to Get the Care Right First


Focus on Value

Identify Variation

Physicians & Nurses Lead Teams

Data and Evidence Informs Change

Design and Implement Improvements

Hardwire in Maestro Care

Monitor Impacts

DESIGN

Care Redesign Oversight Committee Responsibilities


• Provide oversight for the Care Redesign program

• Review and approve Team Charters

• Review and approve design initiatives

• Hold teams accountable to achieve milestones

• Review progress to ensure initiatives are on track

• Resolve barriers to making progress

• Drive acceptance across organization

• Support prioritization of implementation efforts

DESIGN

CASE STUDY #3: Care RedesignOverview of Process • Analyze current processes and data

• Launch multidisciplinary core team

• Brainstorm improvement strategies• Prioritize improvements

• Design initiatives along with metrics• Develop management tool

• Deploy EHR build• Define process changes, create communication plan

and education

• Monitor and adjust performance with teams• Update content as needed

Define Problems

Analyze Opportunities

Develop Solutions

Deploy Changes

Refine & Sustain

Care Redesign: Tactics Focused on Patient Care



Improving Episodes of Care: FY13‐FY14Clinical Teams

FY13: Prepare for Bundled Payments• PCI• CHF• Total Hip• Total Knee• Hip Fracture• CVA• TIA

Improving Episodes of Care: FY13‐FY14Clinical Teams

FY14: Spread Outcomes/Cost Improvement

• Atrial fibrillation Ablation• CABG• Cardiac Valve Replacement• Bariatric Surgery• Total Laparoscopic Hysterectomy• Cystectomy• Colorectal Surgery• Peds Asthma• COPD Exacerbation

Care Redesign Caselets


Transforming Our Future: FY14-FY17

Clinical TeamsWave 3• Heart Transplant and VAD • Kidney and Liver

Transplant• Pediatric Cardiac SurgeryWave 4•PCI Diagnostic Cath •Cerebrovascular Disease•Renal Failure


Clinical TeamsWave 5•Colorectal Surgery•Lung Transplant •Psychological and Behavioral DisordersWave 6•Nephrectomy and Prostatectomy


Clinical TeamsWave 1

• Hip and Knee • Septicemia - Adult • Hematological Malignancies

• SpineWave 2

• Complex ICU – Adult • Complex ICU and Septicemia - Peds

• Neonatology • Obstetric Deliveries


DESIGN Improved Workflow

DataAvailability

Improved Communication

ReducedVariation

Care Redesign and making work easier: for documentation


DESIGN

Care Redesign and making work easier: for communication of patient specific needs

Improved Workflow

DataAvailability


ReducedVariation


DESIGN

Care Redesign and making work easier: for protocol and standardized care

Improved Workflow

DataAvailability


ReducedVariation


DESIGN

Care Redesign and making work easier: for data access

Improved Workflow

DataAvailability


ReducedVariation


HIT: Dashboards


VALUE

Days SavedLOS Index Changes

from FY13 to FY16

- 500 1,000 1,500 2,000 2,500 3,000 3,500

Complex ICU - AdultsComplex ICU - Peds

Heart Transplant / VADHematologic Malignancies

Hip & KneeKidney / Liver Transplant

ObstetricsPCI and Diagnostic Cath

Renal FailureSepsisStroke

DUHS Hospital Days Avoided(FY13 to FY16 LOS index changes, MS-DRG defined)


VALUE

Finance Cost Savings (Transforming our Future Benefit Close-Out),$20.3M

Wave and Team Total ToF Benefits Wave 1Hematologic Malignancy 942,132Hip & Knee 107,258Sepsis 841,881Wave 2Complex ICU – Adult 291,031Complex ICU – Peds 943,312Neonatology 204,263Obstetrics 521,843Spine 68,880Wave 3Heart Transplant / VAD 2,133,869

Kidney / Liver Transplant 659,882Peds Cardiac 479,488Wave 4PCI / Diagnostic Cath 1,134,104Renal Failure 628,874Stroke 1,258,583Care Management LOSGrand Total 20,284,975


VALUE

Cost Improvement(FY17 Year End versus FY18 YTD thru Qtr 2 DUHS)

$4.7 million in cost improvement in FY18 YTD

Wave Team Performance to Target

Wave 1

HEM MAL 1,136,691 ORTHO 386,692 SEPSIS (898,940)SPINE (2,321,960)

Wave 2

ADULT ICU 1,146,598 NICU 703,461 OBSTETRICS (172,977)PICU 828,761

Wave 3

HEART TRANSPLANT VAD (719,578)KIDNEY TRANSPLANT (210,026)LIVER TRANSPLANT (165,283)PEDS CARDIAC SURGERY (402,418)

Wave 4PCI 487,140 RENAL FAILURE (31,606)STROKE 78,045

Wave 5COLECTOMY (ERAS) (31,003)PROCTECTOMY (ERAS) (13,370)LUNG TRANSPLANT 1,975

Wave 6 NEPHRECTOMY (ERAS) (45,709)PROSTATECTOMY (ERAS) (143,179)Total 4,769,364


VALUE

Improvement in patient outcomes and satisfaction

Multi modal process improvement with HIT across large clinical diagnoses and processes

Significant savings in terms of ALOS, readmission rates and cost per case

CASE STUDY #3: Complete Joint Replacement

Total Joint Hip and Knee Care Redesign

David Attarian, MD, FACS, FAOADuke PDC, Chief Medical Officer

Professor and Executive Vice Chair–Department of Orthopaedic Surgery

Jennie Wahl, MBAAdministrative Director

Musculoskeletal and Spine CSU

June 7, 2018

David E. Attarian, MD, FACS, FAOAChief Medical Officer, Duke Private Diagnostic Clinic (SOM Clinical Faculty)Professor and Executive Vice Chair, Department of Orthopaedic Surgery

EDUCATION:MD, Duke University School of Medicine, 1980BA, Biochemistry, Princeton University, 1976RESIDENCY:Surgery and Orthopaedic Surgery, Duke University Medical Center, 1980-1986BOARD CERTIFICATION:American Board of Orthopaedic Surgery, Orthopaedics

PHYSICIAN PROFILE

Jennie E Wahl, MBAAdministrative Director, Musculoskeletal and Spine Clinical Services, Duke University Hospital

About Jennie:Jennie first started at Duke in 1990 as a Physical Therapist, where she spent over 20 years treating patients and providing supervision of therapists and students. Jennie now provides oversight of all quality and performance improvement initiatives and helps with strategic and business planning efforts. Jennie has successfully leveraged process improvement tactics to lead several teams in improving quality and efficiency indicators.

EDUCATION:BS in Physical Therapy from West Virginia UniversityMBA from The University of North Carolina’s Kenan-Flagler School of Business

CERTIFICATION:Six Sigma Black Belt

PRESENTER PROFILE

Devices and Supplies50%

Room and Board14%

Ancillary Therapy4%

Lab2%Imaging

1%Trauma and Emergency

0%

Unmapped0%

Pharmacy14%

Periop14%

DomainsDevices and Supplies

Pharmacy

Periop

Room and Board

Ancillary Therapy

Lab

Imaging

Trauma and Emergency

Unmapped


PROBLEM

Direct cost data from FY13 Devices and Supplies – 50% Pharmacy – 14% Periop – 14% Room and Board – 14%

CJR Cost Attribution Before


PROBLEM: CJR Opportunities

DRG DRG Description Discharges

0461 Bilateral or Multiple Major Joint Procs of Lower Extremity w MCC 2

0462 Bilateral or Multiple Major Joint Procs of Lower Extremity w/o MCC 56

0466 Revision of Hip or Knee Replacement w MCC 10 0467 Revision of Hip or Knee Replacement w CC 133 0468 Revision of Hip or Knee Replacement w/o CC/MCC 197

0469 Major Joint Replacement or Reattachment of Lower Extremity w MCC 62

0470 Major Joint Replacement or Reattachment of Lower Extremity w/o MCC 2,399

Duke University Health System Total 2,859

Key Tactics• Premium implant

usage standards• Vendor consolidation• Lower cost

medications• Improved pain

management• Planned support to

return home


DESIGN Focus

Leveraging data to set priorities and direction Risk stratification of patients before surgery to direct

post operative management options Measure performance and impact of initiatives Dashboards: inclusive and functional; allows for a

strong emphasis on continuous feedback and transparency for specific interventions


DESIGN – Risk Stratification Developed Risk Stratification tool to identify patient status up front –inpatient versus outpatient

What factors are important? What does not matter?

Establish model using comorbidities and demographic factors

Improves care delivery as the care path and transitions of care can be determined earlier based on the predicted patient status


HIT

Preoperative patient reported outcomes capture

Allows for standardized data capture to emulate best practice and reduce variation among providers

CASE STUDY #3: Complete Joint ReplacementHIT

Preoperative patient reported outcomes capture

Provides discrete data element documentation to measure performance over time


HIT

A Medicare patient had a hip or knee replacement at Duke. Within 90 days postop, she shows up to the ED where the diagnosis is S79.099P (or one of many other lower extremity fracture ICD‐10 codes). This

causes the BPA to display in the BPA section (not a popup). • The in basket message sends automatically to a pool.

• Provider has access to 2 consults, click Apply Selected then Sign. There are no requirement prompts in the orders to fill in.

• There’s also a “Does not meet CJR criteria” that hides the BPA to everyone for 24 hours.

CJR Bundle Best Practice

Alert

Real-time alerts so clinicians can make informed decisions in the moment


HITOther examples of how the joint replacement team leveraged HIT

• Pre and post operative order sets• Standardized nursing teaching plans and neuro-

assessments• Multi-modal pain algorithm• Risk stratification and predictive modeling• Meds to beds• Smart phrases• Alert banners and BPA’s• Duke MyChart functionality for patient outcome tools

(HOOS, KOOS, Promise)


Promotes Trans‐parency

Available to all

members

Aggregate and

provider level

options

Detailed view of priorities

VALUE: CJR Summary


VALUE: Total Joint Dashboard

PICase Review

Patient Level Detail

Provider Level Detail


VALUESelect

Initiatives Improvement Levers Intended Impacts

Improve Advanced Planning

•Standardized tactics to identify patients who could avoid extra hospital days through advanced planning

Reduction in length of stay/readmissions

Improve Discharge Facilitation

•Optimized and standardized discharge instructions (After Visit Summary, Certification for Home Health Services) and post discharge referral orders and processes

Reduction in length of stay/readmissionsIncrease in patients discharged to home

Enhance Patient Experience

•Standardized pre-op and inpatient teaching and scripting as well as clinical care/teaching plans

Aligned expectations among care team, patients and caregivers to streamline discharge process

Reduce Implant Utilization and

Negotiate Improved Pricing

•Conducted system-wide component utilization analysis •Developed an approach to maintain accountability for use of agreed-upon high cost implants

•Leveraged stakeholders to support vendor negotiations

Reduction of implant spend through utilization and pricing initiatives

$1.7+M Annual Cost Savings


VALUE

Impact of new Medicare ruling

Average Length of Stay over time


VALUE

HCAPS CategoriesFebruary 2017‐ January 2018

Claire HowellPerformance Services


VALUE

71%68%

71%

76%

10%

15%18%

14%18%

15%11%

9%

0%

10%

20%

30%

40%

50%

60%

70%

80%

2015 2016 2017 2018P9

% of Patients

Discharge DispositionPrimary Hip

HomeHome HealthSkilled Nursing

53%56%

63%

70%

23% 22% 23%

16%

21% 21%

13% 13%

0%

10%

20%

30%

40%

50%

60%

70%

80%

2015 2016 2017 2018P9

% of P

atients

Discharge DispositionPrimary Knee


VALUE

Duke Institute of Health Innovation


VALUE

Adapted Care Redesign monitoring tools with CMS Comprehensive Joint Replacement’s expanded project focus


Translating and sharing our work


Continuous EvolutionOnline videos for patient education Short vignettes addressing FAQ, patient testimonials Live web cast with total joint surgeon and team Increase POD 0 dischargesAnticipate OP hip and knee arthroplasty to represent 10‐15% of activity in futureManage new Medicare ruling for TKA: no longer on the inpatient only listWorking on pre‐surgical opportunitiesRisk stratification with Predictive modelingContinue to use Health information technology to navigate change and support clinical initiatives

30 day readmissionsReturn to ED (to capture outpatient volume)Real‐time informationAlertsReportsOptimize MyChart usage for registered patients

CASE STUDY #3: Asthma Care Redesign

Pediatric Asthma Care Redesign

Heather McLean, MD

Heather McLean MDVice Chair for Quality, Department of Pediatrics

EDUCATIONUniversity of Michigan Medical School, 1996RESIDENCYPediatrics, Children's Hospital Boston (Massachusetts), 1996-1999

PHYSICIAN PROFILE

Documents

HIMSS Davies Award...CASE STUDY #3: Care Redesign VALUE Cost Improvement (FY17 Year End versus FY18 YTD thru Qtr 2 DUHS) $4.7 million in cost improvement in FY18 YTD Wave Team Performance