Dr. Anne Pendo: Well, welcome today to another podcast. I'm Anne Pendo, and I am a medical director and practicing internist with the Intermountain Medical Group. I'm really excited today because we have time to talk about some great work that we're doing for our patients around care in the primary care setting and today I've got two guests. One is Tim Johnson, MD. He's a practicing internist and our Senior Medical Director for the Intermountain Medical Group, and Shauri Kagie, an RN who is responsible for the Intermountain Medical Group clinical management.

So, we're excited to have both of them here today and we are going to talk about the recent recognition that Intermountain received: all 83 Medical Group Primary Care clinics have achieved NCQA recognition, and that means that the National Committee for Quality Assurance, that's the NCQA, has recognized that the work we're doing for our patients is around being Patient-Centered Medical Homes. And I wanted to start with you, Shauri, because I think we all have really great stories about how this had made a difference for our patients, our caregivers, and really, our whole Intermountain system and the way we think about delivering care in a little bit of a different way. I was hoping you might have a couple stories to start us off with.

Shauri Kagie, RN: Sure, and first I want to jump in and in Patient-Centered Medical Home, that is what the recognition is—it's all about the patient. And it really is about transforming our primary care practices into what patients want and focusing on patient needs and really supporting them with their preferences and encouraging them to engage in managing their own health. And so we really have great teams of physicians, nurse care managers, licensed clinical social workers, health advocates, care guides, mental health professionals, all of these professionals working together to help patients manage their health.

Dr. Anne Pendo: I love that.

Shauri Kagie, RN: And it's great. It's coordinated. It's accessible, comprehensive and really focused on quality and safety for our patients.

Tim Johnson, MD: And I'll just jump in here. So Shauri is a nurse, but she actually, prior to this particular role, she was a nurse care manager, so she has frontline experience with this.

Dr. Anne Pendo: Oh, that's great. So, tell me a story.

Shauri Kagie, RN: Sure, so I am going to go back to my days of being a nurse care manager at Memorial Pediatrics. I worked with a lot of patients with chronic conditions and, there's this one family that I remember where this cute little eight-year-old had pretty severe asthma. She had been admitted to the hospital probably eight times in the past year.

Dr. Anne Pendo: Wow. That must have been pretty scary for her and her family.

Shauri Kagie, RN: It was. And part of the challenge is that she had kind of a social background. Her parents were split and grandma was taking care of her, so some issues with the disjointed caring for her. I developed a pretty strong relationship with the grandma who always brought her in. Never really met the parents, always talked to them on the phone and most of the work was helping the grandma understand the importance of the medications that she was taking and why she needs to take the medication and making sure that she had the finances to do so, which is often a barrier for patients. And once I had that relationship, every time she even thought that she was getting into trouble she would call and, do I need to come in, and we would get her scheduled to see the provider. And the following year she was in the emergency room and hospital twice.

Dr. Anne Pendo: Wow. That is pretty impressive.

Shauri Kagie, RN: It is. And the relationships are just amazing that you can build with these patients and supporting and helping them-

Dr. Anne Pendo: That's great.

Shauri Kagie, RN: Live with their chronic conditions.

Dr. Anne Pendo: I'm thinking about, you talked about teams, and teams working together to focus on the patient and what their needs and wants and goals of care are. I'm just reflecting that, as a clinician having the support of a care manager or care guide that can help guide our patients, and we are all working together for that common goal. It's kind of a different way of thinking about how we've practiced care in the past.

Shauri Kagie, RN: It is.

Tim Johnson, MD: It makes me laugh a little bit about our care managers when they first got introduced into the clinics, and you probably had the same experience in your clinic, I wasn't quite sure what I was going to do with my nurse care manager. They said, hey, here's this resource and she can help us with some of our difficult patients and we said okay, how do we use her? And over the past three to four years we've learned how to use her effectively and now we can't imagine taking care of our patients without her, so ...

Dr. Anne Pendo: That is very true. I can't imagine going back to those days where it all rested on the clinician and how much better it is for our patients. So, I mean this is a big deal, this recognition. Tim, maybe you can talk a little bit about why we participated in this particular program and what benefits you think that gives Intermountain and our caregivers and our patients.

Tim Johnson, MD: Okay. I'm going to go back a little bit to give a little bit of history.

Dr. Anne Pendo: Great. Thanks.

Tim Johnson, MD: So, in 2009, Dr.Linda Leckman, who was the CEO of the Medical Group, actually asked Dr. Briesacher to take a look at our primary care clinics and evaluate if there's a better way to care for our patients. In particular, to take a look at Patient-Centered Medical Homes. So, Mark did that work and looked at actually a lot of different organizations, and the organization that seemed to align most closely with Intermountain's mission, vision, and values was NCQA. He went back to Linda and said, “Hey, I think this is what we should base our care on and put this particular model in place,” and Linda gratefully said, “Yes, please go do that.”

So, in 2010, Mark Briesacher and his clinic, the Holiday Pediatric Clinic, and then Dr. Brett Muse in the South Ogden Clinic, they were our first two pilots and they started running with the Medical Home. We got some experience. Things went really well, and shortly thereafter Linda went back to Mark and said, okay, things seem to be going really well, help us develop a plan to roll this out in all the Medical Group clinics. Susan Brown, one of our nurses, got involved at that particular point to help out and basically, from 2011 until now, we've worked on that, implementing the NCQA model in our clinics.

I would say early on we didn't necessarily think that NCQA recognition was important. We decided to base our model, our PPC model on NCQA, but we really didn't pursue certification or recognition. That changed a little bit as we, as some of our payment structures changed. It became apparent to us that becoming NCQA recognized may be a good thing for us. One of those things was the passage of MACRO, that particular piece of legislation, if we were NCQA recognized as a Medical Group, that allowed us to get paid more appropriately from the government for the services we were providing, so that was one of the things that made us think about becoming NCQA recognized.

The other factor here is that we had care managers in our clinics who were care managing patients, Select Health patients in particular, and Select Health also had care managers that were managing the same or similar sets of patients. Select Health was NCQA accredited, so health plans are accredited, and medical groups are recognized. Select Health was NCQA accredited, and to remain so they had to have their care managers doing the care management unless the medical group they were working with was recognized. And we weren't recognized. So, there was some confusion and some frustration both for patients and care teams because care managers from Select Health would be calling them, care managers and our care team members would be calling them from our clinics, each of them trying to do the best job of taking care of the patient, but sometimes getting conflicting messages.

So, we realized that by becoming NCQA recognized, we actually may be able to reduce duplication and make it less confusing for our patients and actually less confusing for our care teams and streamline things there. So, those are probably the two main reasons, there were some other reasons, but those were the two ones that said listen, we better look at pursuing NCQA recognition. So, we started in earnest in 2016 and then, through the year 2017, there were some things we needed to change. We had some members of our care teams that were doing things that were great for patients, but not necessarily helping them function at the top of their license.

So, there was a little bit of a cultural change where we got care managers doing care management level work, and we had our care guides and health advocates doing that level of work. Shauri and her team, really the care management regional consultants worked really hard in 2017 to make sure we were meeting those standards, and then, by the end of 2017, all 83 of our Primary Care Clinics were recognized, which was terrific work, really, for the care teams, because they're the ones doing the work, Shauri and her team. We've just been really pleased with that particular effort and recognition.

Dr. Anne Pendo: That's great. I know that in the conversations that we had at the Avenues Internal Medicine Clinic, I particularly enjoyed thinking about the patient first and what do they need and the components of the certification focusing on that. How do we get our patients in when they need to be seen? How do we provide that bridge between an emergency department visit and coming for follow-up? How do we make sure that the patients that we're referring for consultations or procedures, how is that loop being closed? And the one word that keeps coming to my mind is coordinated. That we're all coordinated. We all have the same goal, and I'm wondering if that's what your, both of your experience has been as we've worked on getting this throughout our whole system.

Shauri Kagie, RN: Absolutely, and I also see it's proactively notifying patients of the things they need and that's another story I'd like to share.

Dr. Anne Pendo: Oh, yes, please do.

Shauri Kagie, RN: We send out all types of letters to notify patients, and one of them was to get your mammogram. Get that done. And I had one of our providers in our Senior Clinic, Dr. Skibitsky, who forwarded emails stating that she recently saw one of her patients that said, I got that letter. I went and got my mammo and they found cancer. I've been treated and am in remission. So, all of that happened without the primary care provider even knowing. And so those little things that our care teams are doing to coordinate care really do make a difference for patient’s lives and are saving patients.

Dr. Anne Pendo: I love that.

Tim Johnson, MD: One thing I experienced, and Anne, like I said, you probably experienced the same thing. So, when we started on this journey, I think one of the messages we delivered to physicians is that by putting a care team around you, we'd be able to do a much better job of taking care of our patients, and I believe that's happened. The other message that we delivered is that somehow that would make a physician's life less busy, and actually, I don't think that's true. I think that in some ways it adds more work to our plates, but it adds the right work to our plates. So, even though I may spend more time coordinating with my care team, that's the work I want to be doing anyway. And so that little bit of extra work is benefiting our patients, and really, for me from a job satisfaction perspective, when I can see good outcomes, patient outcomes, that actually, that little bit of extra work is completely worth it.

Dr. Anne Pendo: That's great. That's so great to hear. We've barely been talking about the primary care setting, but our patients see specialists, have hospital stays, and maybe you could talk a little bit about the work that we do when those episodes occur. How does the Medical Home get activated? What do they do then?

Shauri Kagie, RN: Absolutely. So, referrals to specialists—oftentimes the provider refers the patient, and they may never know that that patient may not have gone to that specialist. And so that's one piece: referral tracking, making sure that patients are getting to the needed care that's been recommended.

Dr. Anne Pendo: Like a colonoscopy, or a referral to a cardiologist.

Shauri Kagie, RN: Absolutely.

Dr. Anne Pendo: So, where patients may not recognize the importance, or they'll, oh I'll do that later, you've got a team around them making sure that that's accomplished.

Shauri Kagie, RN: To follow-up. And there may be barriers that we didn't ask about or think of initially, so they may not have a car, or their job doesn't permit them to take much time off work, and so the care teams working with the patient can assess and identify maybe some challenges for that family to make it to that appointment, and I know that's often the case. Maybe transportation and a simple trying to help them figure that out is all that's needed. And then the other piece is, primary care is kind of the center of the spoke, and all of these different specialists reports and making sure all that information gets back to the primary care provider so they know, have a holistic picture of what's going on with that patient and ensure that there's not, everything is kind of coordinated together again.

Dr. Anne Pendo: We're using that word again, coordinated.

Shauri Kagie, RN: Coordinated.

Dr. Anne Pendo: I love that. What about when somebody's been in the hospital? Either hospitalized or been seen in the emergency department? What's your experience Tim, at your office around that work?

Tim Johnson, MD: Once, again, going back to the care manager, right? So, it's been great for us. We do get lists that tell us our patients have been in the ER, or they've been in the hospital and our care management team, either that's the care guide or health advocate, or the care manager, they actually call these patients to find out when do they need to be seen and how are they doing. And I think before the personalized primary care structure was put in place, this particular model, that was happening inconsistently. And now I can show up to work knowing that somebody's looking at that list. My patients are being called and sometimes they actually don't need follow-up, right? They went in and they're already being followed up by somebody else or there was really not an issue, and great, I don't hear about those. But other patients absolutely need to be seen and instead of relying on the patient to get in, which sometimes has been difficult for them, our care manager or health advocate care guide, they get them in and they're seen. So, it's been really, really nice to know that that's happening.

Dr. Anne Pendo: Yeah. I was thinking about a patient of mine that I shared with you at our retreat and he needed a hospital bed. And there were some steps that needed to happen on my end, adding documentation to the note that would allow that bed to be delivered and our care manager then stepped in to complete that task. So, I did my part, which is just the documentation that was needed and then she did the rest and we were trying to decide should he make all these follow-up appointments that were recommended at discharge and what we decided was it would be best to have him come, he was supposed to see me in two to four weeks, but we thought, you know what really a one week appointment with me would be best and then determine or prioritize those specialist visits.

And it was great to be able to do it with input from our patient to say, okay well these are the three appointments that they've recommended, but let's, where do you want to start and what are your goals? Should we focus more on hospice? Should we focus on palliative care? And he was like, nope I'm getting better and going back to my usual way, so let's do the full-court press.

Tim Johnson, MD: And that's what you focused on.

Dr. Anne Pendo: And that's what we focused on. So, I just think that's been great. Let's, we've got just a few minutes left, let's talk about the future. Room to grow, what do you see going forward for 2018 and beyond? I'll give both of you an opportunity to answer that.

Tim Johnson, MD: So, I'll jump in first, and Shauri, please add your thoughts. So, I think one aspect of our PPC clinics where we have room to grow is, we talked about coordination, but I still think we have room to grow and do a better job of coordinating. So, our care managers do spend a lot of time coordinating. They use their health advocates and their care guides to get a lot of that information. But, I still think there's some difficulty with, in particular when patients are outside of the system, right? So, if they're already in our system and they're using our electronic medical record, that information's there. If they're coming from outside of our system, and that happens fairly frequently, sometimes those patients, they come in, the appointment's been scheduled, which is great, but I don't actually have the information in front of me to make that appointment as effective as it could be.

So, I think we still have some room to grow in terms of maturing our coordination, our coordinating efforts. That's one area. Another area is, in some of our clinics we've started to use pharmacists. And they've been really helpful in the clinics where they've been employed, or deployed. But that's not through the entire system. And we're learning how to use them better, but I think a lot of the things we're trying to do in terms of diabetic care or high blood pressure or treating cholesterol, anti-coagulation, our pharmacists are really good at this and we just need to learn how to use them more effectively and then, so I see in the future that we'll probably be using pharmacists and making them a more important part of the team. Maybe a couple of things.

Dr. Anne Pendo: So, expanding the team and improving the coordination beyond just the Intermountain system for our patients who get care outside. How about you Shauri, what do you see?

Shauri Kagie, RN: I see improving the technology that we're using now.

Dr. Anne Pendo: Talk some about that.

Shauri Kagie, RN: We have limited care management resource and improving the ability to make it more efficient so we can care for more patients and do more with the limited resources that we have and there's a lot of manual work that our care teams have to do right now and how can we make that more automated to streamline the work that our care teams are doing so they can impact more patients and make sure that we're not dropping the ball or creating gaps in care for our patients.

Tim Johnson, MD: Can I jump on the technology component? I actually see our care teams being much more effective in terms of communicating with our patients with their mobile devices, right?

Shauri Kagie, RN: Absolutely.

Tim Johnson, MD: So, instead of just phone calls, sometimes actually talking to somebody and being able to see them gives us extra information. So, I see better use of mobile devices, that type of technology, to have video visits or that type of thing that not just our care teams, our care management teams, but also physicians. I see technology in that area.

Shauri Kagie, RN: Yeah, and even texting reminders, you know, if a patient is working on a goal and just that support and encouragement to help that patient work on that goal would be very helpful, and so there's definitely some work with improving technology. The other thing I see is, the NCQA updates their standards every three years, and so it's kind of this national standard, a benchmark of where we want our primary care and every time they update there's new, more, to do.

Tim Johnson, MD: Work to be done.

Shauri Kagie, RN: Work to be done. And I really love the new standards in that it really is looking more at improving how our care is more patient-centric. What access do our patients want and are we responding to that? Giving them more tools and support so they can start to self-manage their own care. So, a lot of great things with the new standards and I just see that where we're at right now with our new recognition is just a foundation for where we can go with continuing to improve and expand our care that we're providing to our patients.

Dr. Anne Pendo: So you all can't see, because this is a podcast, however, when Shauri is talking about the opportunity for the future, and Tim talking about what this has meant to his patients in his patients, they are smiling and animated and they are excited and engaged in this work, and I think that's a good picture of what we have to look forward to. Engagement, excitement, and the focus around our patients. So, I'll be interested to have us gather again in a year and see what progress we've made and share some stories of, really, how we, by implementing these processes have impacted our patients and our caregivers.

Tim Johnson, MD: And Anne, thanks for having us here today.

Dr. Anne Pendo: Oh, you're welcome.

Shauri Kagie, RN: Yes, thank you.

Dr. Anne Pendo: It's always fun.