Dave Moen, M.D., is leading Fairview’s efforts to change the way health care is delivered.

Photo by Janna Netland Lover

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January 2010 | Back to Table of Contents

Pulse

Fairview’s Big Idea

Fairview Health Services is attempting health care reform from the inside out.

A year ago, when you called the Fairview Eagan Clinic to ask about your sore throat, you’d talk first to a scheduler. If no appointment was available, you would be referred to a triage nurse, who would tell you she’d talk to the doctor and call you back. Then the nurse would send a note to the physician. Depending on how busy he or she was, the note might sit for hours before the physician would see it and send a note back to the triage nurse, perhaps telling the nurse to add you to the schedule. The nurse would call you back, and when you came in, the doctor would have to see you before ordering a strep test. Then you’d wait for results, and if they were positive, the doctor would finally write you a prescription.

Not only was this system cumbersome and time- consuming for staff and patients, it led to communication breakdowns and dissatisfaction, according to the clinic’s administrator, Katie Holley-Carlson. She says every day at least one staff person would call or come to her office complaining about how someone handled something—or failed to. She observed that at the end of clinic hours, after seeing 20 or more patients, physicians still had to deal with letters, prior authorizations, patient phone calls, and test results—tasks that could extend their day well into the evening. “It was not a satisfying way to work,” she says.

Holley-Carlson wasn’t the only one at Fairview noticing problems in their health care delivery systems. Company officials had been making similar observations for some time. “There was a general idea care delivery needed to change,” says Loie Lenarz, M.D., then Fairview’s chief clinical officer. The problems were particularly obvious, Lenarz says, when a patient moved from one environment to another—from the hospital to the clinic, from the primary care physician to the specialist, from home health to a nursing home. “Health care organizations typically do a pretty poor job of managing that care over time,” she says.

In addition, Fairview leaders were grappling with the same issues that health care providers across the nation were—the high cost of care, the shortage of primary care providers, and the large number of patients who had chronic, lifestyle-related diseases. Yet, as they thought about making changes, Lenarz says, they “ran up against all the factors internal and external to prevent us from changing,” the biggest of which was the fee-for-service reimbursement model.

Fairview officials discussed some of their concerns with leaders at Medica. Eventually, all agreed that change needed to happen, and that Fairview should lead the change. Medica agreed to support Fairview as it tried to reinvent the way it delivered care. (Fairview leaders won’t say exactly how much Medica has allocated for the work or how they are paying Fairview, only that their contract with Medica has made care innovation feasible.)

Piloting a Concept

Dave Moen, M.D., was put in charge of Fairview’s care reform initiative. A former emergency physician who is now medical director of care model innovation, he had noticed in his own practice that something was radically wrong with health care delivery. For example, he observed that most patients who ended up in the ER were not experiencing emergencies. “They were experiencing a lack of access to care, or they had fallen between the cracks of a system that is not integrated, or they didn’t have access to what they needed any other way than in the ER,” he says.

Over the years, that observation turned into a recognition that the best people to change the system were the ones doing the work. “I believe strongly that the best solutions lie in the minds of clinicians and patients,” he says, adding that many of the people who’ve been making decisions about health care (both in Washington and in industry boardrooms) are in neither of those categories.

Moen sat down with the staff at the Fairview Eagan Clinic last January, telling them: “I don’t know how to fix the clinic, but I know that you know how to do it better than anybody, so let’s get started.”

Working with a project manager provided by Fairview, Holley-Carlson and others from the clinic began to talk about possible approaches, one of which was an idea borrowed from Thomas Bodenheimer, M.D., of the University of California San Francisco—to form small teams consisting of a provider, a nurse, and support staff, who would care for a population of patients. The idea was to extend care beyond what a physician could do in a typical 15-minute office visit by having nurses and other staff perform some of the tasks that physicians had been doing. In addition, they would make better use of e-visits, email, and online tools to provide care.

But the clinic wasn’t structured to work that way. The schedulers sat in an area of the building far from the providers. The two RNs who did phone triage sat next to them. Those RNs did not participate in face-to-face patient care. Each medical assistant worked with only one provider.

The Eagan group decided to build teams of two to three physicians or midlevel providers, an RN, a scheduler, and two to three medical assistants. Any patient coming to the clinic would be cared for by a team, not just the doctor. The team members now sit at the same station so they can talk to one another and handle patients’ problems together as they arise. In addition, the clinic has hired more RNs, and all the RNs have been trained to do more direct patient care as well as phone triage.

To ensure that the care provided by the RNs is good, Fairview has introduced protocols for relatively straightforward problems—the uncomplicated strep throat case or urinary tract infection, for example.

Now when you call about your sore throat, you reach your provider’s station and talk to the scheduler, who might refer you to the team’s RN. If you meet certain criteria, the RN might even be the one to see you, schedule a strep test, and write the prescription under physician supervision.

Rolling It Out

Once the changes were underway at Eagan, Fairview decided it needed to pilot care reform at clinics with different demographic profiles. Last July, Moen introduced the idea to clinics in Rosemount and Minneapolis. One was the Hiawatha Clinic in south Minneapolis, where family physician Lisa Spatz, M.D., practices. “We’re an urban clinic and very mixed in terms of the payer base,” she notes.

The staff at Hiawatha knew about the team approach Eagan had implemented and decided to try something similar. It moved three of its schedulers from a front desk to three stations in the patient-care area, where they now interact with RNs, physicians or midlevel providers, and medical assistants. Spatz says nurses do some of the patient care, freeing the physicians and midlevel providers to spend more time on complicated cases. In addition, support staff are picking up some of the tasks physicians once did such as sending faxes.

Tracking Progress

Redesigning care has required an initial outlay of dollars—largely to hire more RNs. And because some patients’ problems are now being handled by nurses or through e-visits or online care, Fairview is likely billing payers less than it used to. (Medica is filling the financial gap for now.) Spatz argues that this investment in primary care will save money in the long run. “If we put as much money into primary care as we do into the specialties, we wouldn’t have half the problems we have with our [health] care system,” she says.

Fairview is monitoring costs and keeping a close eye on whether the new system is increasing capacity at the clinics. Holley-Carlson says the Eagan clinic wants to be able to improve outcomes, increase patient engagement, and increase the size of its patient panel by 50 percent. Thus far, the Eagan clinic has seen its quality and patient satisfaction scores inch upward. But many questions about cost and effectiveness remain.

That fact does not seem to concern Moen, who views Fairview’s foray into care innovation as an ongoing process that will involve the entire organization, not just a few clinics. As much as he wants to arrive at the right clinical or business model, he hopes to impress upon clinicians that they need to be the ones to lead health care reform efforts. And he wants those efforts to stay focused on how care is delivered, not on how it is paid for.

On these points, he thinks they’re already succeeding. “We’ve engaged clinicians in leading instead of following. We’ve ventured forth and attempted to answer difficult questions. And we’ve taken ownership of a difficult problem.”—Carmen Peota

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