Transcript of Cyberseminar

Getting Practical on Teamlet Management of Workload, Continuity, and Access: 

An Exercise in Three Dimensional Thinking 

Lisa V. Rubenstein, MD, MSPH

Characterizing Primary Care Provider Activity in Routine Practice 

Steven C. Marcus, Ph.D 

Christian Terwiesch, Ph.D 

July 11, 2012

Transcript of Cyberseminar

July 11, 2012

Moderator: We are at the top of the hour. I would like to introduce our three presenters for today. Presenting first, we have Dr. Lisa Rubenstein. She is the director of the VA Health Services Research and Development of Excellence for the Study healthcare – I am sorry – for the Study of Health Care Provider Behavior. And a professor of medicine at VA Greater Los Angeles and at University of California in Los Angeles. 

Presenting second is Dr. Steve Marcus. He is a Ph.D. and core investigator at the VA Center for Health Equity Research and Development, known at CHERP. And part of the CEPACT demonstration lab located at – in the Philadelphia VA Medical Center in VISN 4. He is also a research associate professor at University of Pennsylvania School of Social Policy and Practice. 

Joining him is Dr. Christian Terwiesch. He is an Andrew M. Heller professor at the Wharton School; and Senior Fellow, Leonard Davis Institute for Health Economics, also located at University of Pennsylvania. 

At this time, I would like to ask Dr. Rubenstein, are you ready to share your screen?

Lisa Rubenstein:I am, go ahead. 

Moderator:That is right. And I see a popup now. Please accept that.

Lisa Rubenstein:I show my screen, yes.

ModeratorCorrect, thank you.

Lisa Rubenstein:My... Ok, are we – are we set?

Moderator:You are live.

Lisa Rubenstein:Great. Well, I am going to talk about getting practical on teamlet management of workload, continuity, and access. I have called it an exercise in three dimensional thinking. Because I think as we have explored this through the demo lab, it has been mind bending to try to incorporate all of these things into seamless performance. 

Alright, it is not coming forward. I want to acknowledge the many people who participated in our lab. But particularly in this case, Timothy Dresselhaus, Justin Sivill, and Susan Vivell, all of whose work – all of whose work, computers and this presentation, but none of whom are responsible for any errors that I make. And also, Jim Jackson, who is now retired, but originated much of the thinking for the issues about access in a very useful tool.

Managing clinical work is what has to be done to achieve PACT goals. Here we are taking three different aspects of that at kind of a high level capacity and workload. How many patients can a site care for? Or can an individual clinician care for? Continuity; we are seeing the same provider over time. 

It is strong evidence, probably the strongest evidence related to patient center and medical home, or PACT, around the effects of continuity on cost and quality. Highly valued, particularly by patients with chronic diseases. It is a little bit less  valued by healthy, younger patients who are – tend to be more concerned with access. 

There is new evidence coming out of the CMS demonstration that further confirms the impact of continuity as patient centered medical home feature that links to cost and quality outcomes.

Access means getting visit when they are needed. There are probably two main types of access; one for acute things. One for scheduled appointments; and both of these aspects of access have a strong relationship to patient satisfaction, both inside and outside the VA. 

So, we now have a brief poll and Molly is going to take you through it. Molly?

Moderator: Thank you, Dr. Rubenstein. I am about to launch the poll right now. This is a multiple choice poll. You can select all that apply. I apologize for my typo on the screen. The question is how many of you are based in sites that a, have adequate staffing capacity for providing PACT care; b, meet access goals; c, ,meet continuity goals; or d, have achieved all three. We have seen about ten percent of our attendees respond so far. We will give people more time to answer that. 

We do appreciate your feedback. It does help guide the presentation knowing how much – how many of you are based at sites that apply to these circumstances. We have had 50 percent of our respondents vote. Answers are still streaming in so I am going to leave it open for just a few more seconds.

We have had about two-thirds of our respondents reply. Answers are still streaming in. If you would like to respond, please do so in a timely manner as we would like to move forth with the presentation. Ok, and that looks like answers have stopped coming in. I am going to go ahead and close the poll and share the results. It looks like 28 percent have responded. Adequate staff, they have adequate staffing capacity for providing PACT care. Thirty four percent also report they meet access goals. Thirty one percent meet continuity goals. And eight percent have achieved all three. Thank you for those respondents. We are back to you, Lisa.

Lisa Rubenstein:Great, thanks for answering. I think that those responses speak to the difficulty in achieving all three. The PACT compass shows each part, but not the relationships between the parts. Really, the sweet spot is an intersection of capacity, continuity and access. It is somewhere in the three dimensional space that you can optimize all three. 

First, we are going to go through capacity. This claim is for this whole presentation are that it is really a work in progress. You should use it with some caution. The site A example that I am going to use is hypothetical. But it does combine information from several real sites. The aim of what we are doing is to create some tools that will assist sites in trying to find the sweet spot. Feedback is very welcome since we would like to do something useful. 

In our view, the first step is to look at capacity. Is my site staffing approximately adequate for achieving PACT? What we do for that is in PCMM identify the number of primary care patients at the site. Then look in DSS. Identify the proportion of primary care face to face time for each provider in DSS. Some providers have .5 clinical time, and .2 clinical time, and .1 clinical time. Other providers are full-time clinical. Then at 1200 patients per panel, calculate the needed primary physician, MPPA need. And the teamlets and team FTEE for delivering PACT care.

For our example site a, site a has 16,000 patients in its population. Therefore, it needs, for example, 13 primary care clinician or provider FTEEs. Thirteen to fifteen each of RNs, LVNs, and clerks for these 13 teamlets. Four to eight teamlet pharmacists; a lot depends for pharmacists on how they are used at the site. And two team social workers. Those are not necessarily exact figures but somewhere in the ballpark. 

Looking at site a, this academic site has 18 individual PCPs that account for 11 FTEEs. And we said before they need 13. They have five MPs who work .1 to .7. And they have six MPs that work .1 to .6. That is why they have so many extra bodies compared to FTEEs. They have ten RNs and 12 LVNs. They have – since the RNs are full-time, they have ten RN FTEEs. But they have some part-time LVNs. So they also have ten LVN FTEEs. They need 15 of each of these to assure coverage since people may retire, may be absent or so on. 

ModeratorDr. Rubenstein, I apologize for interrupting. Can you please speak up just a little bit?

Lisa Rubenstein:Sure, tell me if I am? Is this better?

Moderator: Yes, it is much better.

Lisa Rubenstein:Ok, sorry. Please tell me again, if am – if I am not. They have one social worker where they should have two. We know from all the labs and also from other systems that staffing deficits are a known major cause for teamlet misfunction. It is coming through on qualitative and quantitative information at this point for a VA. If you do not; if you have full staffing of a good chance of achieving good teamlet functioning. If you do not, you may not. 

What site A did was first look at the PCP sufficiency. They re-evaluated and renegotiated PCP non-clinical paid time. So, they surveyed their PCPs regarding time allocation for specific committees, research, teaching, and QI. They looked through these and identified that there were some low priority committees that people had been sent to. There was unfunded research. That really did not necessarily show promise of getting funded. There was QI without. It was not really approved QI or a major site priority. 

They renegotiated clinical time transparently and changed the values in DSS. That led to hiring – still a need for hiring one new PCP. They looked at team and teamlet sufficiency as well. They reviewed all site functions and all staff in terms of what the work was that needed to be done. This included looking at specialty clinic quality and activities, procedure, location, and support. And, sort of common functions like patient information, greetings, MyHealtheVets that crossed many different clinical groupings. Through that they identified duplicated untargeted and a low use activity. In some cases, low volume specialty clinics could be combined in terms of their staffing. Releasing people that the pharmacists, social workers, RNs, and LVNs. In some cases for procedures, likewise, the same procedure was staffed through different clinics. Those could be combined.

The site A approach, I think – an approach that actually this is true for more than site A. Site A being the combinations of more than one site approach within the lab group. The decision has been to support high quality PCPs with .1 to .6 for example; FTEEs and clinical time. There is a theory that it is not good to support part-time clinicians. That it is more expensive and more cumbersome. It is a decision that sites seem to struggle with. Basically prior evidence shows equal or greater patient satisfaction for part-time PCPs. The teamlet structure and use of non-face to face visits should be able to enable part-time PCPs to achieve PACT goals.

However, these part-time providers do cost. Their higher coordinations demand on both clinics and the teamlet staffing. In general, though, there is a strong thought in these clinics. That that higher cost can be offset by the leadership, research, education, or QI that these individuals can bring into the PC environment. In other words to some extent it enables a parallel to the common subspecialty and specialty environment where these kinds of activities are supported.

But, efficient and effective use of time and clinic have to be achieved to justify part-time practice. And they could be a large of part-time practice individuals who need to either be assigned to a different type of role such as more of an urgent care role as some of the sites have used. Or other things like that because they really do not want to go to the extra effort of figuring out how to deliver continuity and access. It seems to be the case that these providers can achieve those goals with the support of their teamlets when they make adaptations. 

I just took a little extra time for that because I – from what I have heard its something many sites are struggling with. Ok, so moving from there to access. This is really yet another dimension of capacity. But really requires fine tuning the supply and demand. It means matching the expected to the actual available PCPs at the time. 

There are really nice formulas from Jim Jackson, Justin Sivill that can help with this using just the data. But in essence the expected supply is based on each teamlet and providers, DSS clinical time, and bookable primary care hours per week. For example, one reason there were a number of part-time nurse practitioners in the example I gave is that they were doing things like wound clinics or other types of activities like that, which do not really add to the bookable primary care hours. Then the patients per hour when in primary care clinic. 

The actual supply is also based on how many weeks per year the person is in clinic. If they are out of clinic, a lot of weeks that takes away from how many patients they can really manage. Panel attrition rates, their level of continuity. Their return visit rates and their patient sickness and complexity.

And then sort of a simplified calculation that also is a little bit controversial, I think in terms of exactly how it is applied. Bookable appointment time is negotiated. DSS clinical time with the adjustments that I mentioned regarding things like wound clinics. Using the formula, the percent clinical primary care visit time for – times 40 hours times .9. Since only .9 is expected. Then .80 percent clinical time that becomes 28.8 bookable hours per week.

An example of site A findings were variations in teamlet provider return visit rates. Sometimes these look like they could be accounted for by variations in panel sickness. Particularly mental health, looks like it has an effect on how often people return their patients. So, patients with mental health issues tend to come back more often. It also affected by discontinuity and rates of non-face to face encounters. This continuity, for example, if you – if you just have your patients return, say once a year, then there may be many discontinuity visits in the interim. Then you may have a long visit in your goal. But you may be losing out on continuity. 

The available grid times per year for the – that whole thing also has to include things like missing weeks for travel and teaching and so on. There is sort of a year looking at it for a year also gives a more fined tuned view of the individual’s capacity. 

So, site A works with PCPs and teamlets, review teamlet scheduling grids, panel size, attrition, no shows, patient complexity, return visit rates. And tried to look for outlying value. Then review the available teamlet and primary care clinician – clinic visit slots per week and per year. And kind of adjust to the expectation. In this case, rather than taking a really rigid approach to it, the site really thought about each clinician. And how it works for them. But also, trying to be fair and transparent. And set a realistic panel site goal for each provider.

The site also aimed to try to achieve open access with 30 to 50 percent of slots unbooked at the start of a work day. I would say this has not been fully achieved in most of the sites that make up the site A example. This reflects the judgment or the theory of open access. Saying that rather than giving patients pre-booked follow up appointments for too much of the time, there should be a place for people to walk in in shorter periods. 

But that scheduling message, the sites found also may require some adjustment for part-time clinicians. I would say that is still a work in evolution and exactly how to best do that to enable continuity and access for part-time people. That we know from examples that it can be done.

And also emphasize non-face to face encounters, MyHealtheVet and support from the teamlets. Open access, just to be clear; generally in the open access world. It means open access for continuity teamlet, and PCP. Having some slots available for walk-ins. You have to have some slots available for non-continuity walk-ins. But most of them should be for patients that are on the same teamlet. And preferably with the same individual provider. 

It is easy to get open access if you do not care about continuity. Just let everybody walk in. really to get to that good balance spot, you need to balance continuity and access to try to make sure that anybody who needs to be seen gets seen. But at the same time, when possible that needs to be with the same provider. 

So, let us look at continuity. Again, it is easy to achieve continuity, if you do not care about access. And easy to achieve access, if you do not care about continuity. It is doing both of them that really challenges our system. You really have to focus on telephone answering, pharmacy refills, post  discharge, and post ED follow-up, for example. Scheduling, including how your residence and attending are scheduled. And how you use the non-face to face visits. In this site A example, the continuity interventions included the teamlet report card that can drill down to individual discontinuity visits. 

You can see if an individual is just – a teamlet can see if that teamlet’s discontinuity is for example due to ED visits. Due to a miscoding of some kind of visit like – I always give the example in my case. I had a patient in general psychiatry that was erroneously – the general psychiatrist was erroneously coded in primary care because historically that service had been delivered in primary care. So, that was a lot of discontinuity.

You can see if a walk-ins, discontinuity walk-ins are the – are related. So, that can really help. There was also a large focus on walk-in reduction. And the finding that many walk-ins were due to pharmacy refills. And the need for recapping a prescription due to an expiration that someone had not noticed. And that actually accounted for as much as 50 percent of the walk-ins at that site.

Moderator: Sorry, can you speak up a little more, Lisa. Thank you.

Lisa Rubenstein:Yes, It must be where I am relative to the phone. 

So, that – by engaging teamlets and pharmacists walk in for a refills were significantly reduced. It also led to large changes in resident schedules to maximize continuity. This is... There have been a variety of versions of the teamlet report card. This is a recent version. It is programmed in SQL. And it generates up to date results. The compass continuity measure reflects a full year of data. So, it takes a long time to improve if you have had low continuity. 

You have to kind of month by month; you drop off the old discontinuity and pick up the new continuity. This report card focused on the last. Well, it did a monthly a summary and a past-two-weeks summary. And you can see a couple of the providers. This is actual real data. And it seems to – this approach of these different activities seems to have markedly improved continuity at the site; which originally was 50 percent. And again, this is real data in this case. The purple line is site A. it went from about 50 percent up to about 75 percent. 

The site B, I mean, the site C, the blue line on top, for example. It is a smaller clinic that has a very stable provider and small provider base of very different kind of clinic. The sites differ in terms of where they were before. But you can see the improvement in the one site. So, I think the overall lesson that we will continue to learn is that it takes a village. 

The whole process, all the part of the teamlet is dysfunctional because no one, there is no one to, really to organize how the flow of patients is managed. So, we are very careful to present everything in terms of the teamlet. Performance is not the provider’s performance. It is the whole teamlet’s performance. If the scheduling system is too rigid, then providers are not able to adapt to patient needs readily enough. And if it is too lose, providers end up doing odd things with strange starting points. And strange configurations of appointments that are costly and not efficient. If schedules are – schedulers are free to put non-continuity patients into any open slots anywhere. It generates full panels. It is hard to get to open access. And it reduces continuity. 

So, there needs to be some sort of a management of patients who need to walk in. Or have quicker visits; I mean, more sooner visits that involve helping the schedulers deal with these issues without destroying continuity or providing disincentives for providers to have open slots. There – if there is no good system for walk-ins, that in a related point. Those walk-ins are going to end up being shoved into anyone’s schedule. And that will again reduce continuity. But the teamlets have to function equitably. 

So, people have to take each other’s walk-ins. For example, when needed or cover each other; otherwise, the system also will not function. So, if the teamlets do not function, and, or do not back each other up, patients are at risk. So, open access, continuity, and capacity remains a three dimensional puzzle that all of these sites are still working on. As it sounds like the people in the audience are. But we are starting to learn enough, we think, to be able to see that there is a pretty picture waiting. Thank you. And I think we are – we are going right on.

Moderator: Thank you very much, Dr. Rubenstein. And Dr. Marcus, I am now sharing or giving you the opportunity to share your screen. Please click show my screen. Thank you very much.

Steven Marcus:Alright. Greetings and salutations from VISN 4. Thanks for joining us today for our talk on characterizing primary care provider activity in routine practice.

Moderator: Dr. Marcus, I apologize for interrupting. Can you please possibly pick up the handset to speak? It will come through a lot clearer.

Steven Marcus: Done.

Moderator: Or the handset, I am sorry. Thank you.

Steven Marcus: Is this alright? Like that?

Moderator: Much better.

Steven Marcus:Ok. So, today we are going to be talking about understanding primary care provider roles and activities during patient encounters. And explore opportunities for productivity improvement in care teams. The two ways that we are looking at – the three ways we are looking at doing that is ..... is by first looking at what types of care occurs during the patient provider interaction? Up until now it has sort of been a black box. And we do not really know what happens once the patient enters the room. And once we peer into the black box a little bit, we would like to be able to quantify not only what happens there, but how much of what is happening is happening there. 

And together that should be a first step for us to be able to identify places to intervene. Second, we would like to learn a little bit more about who could be providing the care that occurs during the visit. Can you rely more on PACT model by doing extenders and teamlets? And third, learning a little bit more about could the care occur potentially off-site by allowing a more streamlined use of provider time. And making use perhaps of phones and, or e-mail. And together, I think that also includes patients in the PACT model to be able to allow them to not have to come to the VA and see quite so frequently.

The way that we are doing that is by doing video taping of days in the lives of primary care providers at the PVAMC. And we have sampled the set of providers in our primary care clinic. We videotaped either a half or a full day of the patients’ encounters. And we have consent from both the patients and providers to do this. And we set it up so that we have a camera pointed at the provider, not the patient, but the provider and the provider’s computer screen to be able to learn more about exactly what they are doing during the encounter. 

We are reviewing the tapes of these encounters to develop a taxonomy of activities that occur during the visit. And we are doing this in conjunction with three primary care physicians who have experience working with the VA along with our research team. We are then characterizing the encounters by having the physicians quantify the amount of time in each visit that could be done potentially remotely or by an extender. Using their clinical judgment to be able to understand what can be moved off-site potentially. And who could be doing it off-site, a provider or an extender? And finally, we are describing the physicians’ assessment of what they believe is an appropriate time to the next appointment. 

And we are using that to be able to begin to understand the possibility of easing case load by reducing the frequency of visits, further relying on the PACT team’s model. So next, we have what has often been used for describing physician or provider activities during a patient’s visit. And this is extracted from CPRS. It provides a nice overview of what it is that the patient’s history has been up until now. And a good summary of what happened during the provider encounter. However, we are hoping to get a little bit more of a granular understanding of what it is that is going on. 

So, what we are doing is actually creating and having our team go through each and every provider encounter that we have taped. And create time lines to the minutes and seconds. Describing each of the discreet activities that occur during each encounter. And these are just broad descriptions of just what it is happening on the tape at each time point. We then as a team reviewed the long list of categories that were created in the prior example. Just to create a typology to be able to aggregate all of those activities into broad groups. 

After extensive conversations, we were able to get it down to 12 categories that are listed here, which were based on our examinations of 21 encounters from five providers. Then we had the team go back through the list of all the events that we had collected to be able to assign each of them to one of the 12 categories that we had identified. And on the next page we have a description of what it is that we found. The average visit for our 32 encounters was approximately 20 minutes. And of the 20 minutes, it is distributed in these 12 categories in this way. And I think that what is very interesting about this. There are many things that are interesting about it. 

But one of the things that it is interesting about it is that the amount of time that is spent reviewing and discussing existing conditions. And things that we already know about prior to the visit including medication reviews. And perhaps these point to some places where PACTS could help fill in. Only ten percent approximately of the visit is spent on hands on examinations of the – of the patient. Though, I think that looking at these broad groups and the amount of time that is spent in each of the activities provides a foundation for beginning to understand the structure of the business and when we do intervene, giving an idea of how much we can offload potentially or the impact that we will be able to make. 

I am going to turn it over to Christian to talk about our next set of slides. 

Christian Terwiesch:So, we are moving now from the analysis and the description of what is actually happening during these encounters to the question of peer delivery design; which is really about thinking who should carry out these tasks that we had just identified? And where should these tasks be carried out? And the way that we went about building, I guess a taxonomy of care, and how, and where this needs to be delivered  we created the two by two matrix that you see in front of you. Care can either be delivered on-site or it can be delivered remotely. And the care can be either provided by the doctor or by a physician extender. Now, like in the nature of our research design that right now everything that we empirically observed is in the upper left cell. Right, and everything that we observed was carried out by a doctor on-site. 

And take some of the work down, meaning down going from doctor on-site to doctor remotely. Or we can move some of the work to the right going from on-site doctor to on-site extender. And in the extreme case you can have the extender do the work remotely. Now, I want you to invite... I want to invite you to think about these tasks and these activities that we have looked at in the typical encounter. Just browse through them and ask yourself how would you take the work. In this case it is 22 episodes of care within a visit. 

How would you distribute them over the four boxes? What is to be done on-site by the doctor? What could be offloaded? Now, instead of us sitting there and then doing that allocation of these 22 episodes into those four boxes, we asked our clinicians to use their clinical judgment and distribute the work into these four boxes that we had identified. Again, these are the folks, they are physicians. They are practicing at the VA. 

The way we went about this is we basically showed them these video encounters. And then asked them to take each of these micro segments and classified them. In some cases, as you can imagine, we had disagreement among the physicians. We had three physicians scoring each of these episodes. We have a disagreement that means two vote one way, and one votes the other way. We went with the majority vote on that matter. 

So, here is what comes out of this analysis. So, remember that right now as we describe the current care delivery model, 100 percent is done by the doctor or, and is on-site. Now what is fascinating here to see is that based on the clinical judgment of our physicians, only 20 percent, 19 percent to be exact, have to be delivered by the doctor on-site – 19 percent. 

Now, where does the rest go? So some of that can be off loaded from the doctor to the extender. And so, if you still look at the total time, you see that roughly 78 percent of the work that we document in our video should be carried out by the doctor. And about 21 percent should be carried out by the extender. 

Now, if you slide that the other way, you see that actually these bigger opportunity or leverage for redesigning the care delivery is moving the work on-site to off-site. Instead of having the doctor provide the care on-site, we see that 78 percent of the total care could in the eyes of the clinicians behappening off-site. 

Steven Marcus:And I just wanted to add on that slide that this is based on only nine encounters from some seven providers. But we still have some work to do there to make that a little bit more robust of a finding. So for our next analysis, we – for the prior analysis, looked at ways to make the current visit more efficient. But perhaps one way towards efficiency is to see if perhaps the visits don’t need to happen at all. Or could potentially be spaced out so that the doctor does not need to be seeing patients as frequently. 

So, in most cases, these appointments were made a long time ago. And the best way to have more efficient use of provider time is for them not to see the patient if it – if it is not necessary. But we wanted to first see given the clinical information at hand whether our three physicians could assess when they would see that patient again next. And they had in front of them the clinical history for these patients. And also all of the information about the current visit based on the tape that they just had examined. 

We asked each of them when they be with patients next? And if you look on the slide, you can see that there is great variability, very great variability in fact, between the physicians on when they want to next see this patient back again even though they have the exact same information at their disposal about the clinical condition of the patient. So, in our anecdotal conversations with them to try to be able to understand this a little bit more, it came up that really in our current model at Philadelphia. And this information was done before PACT was implemented – is that there was really a lot of discussion about if the physician does not see the patient to monitor them. Then who is going to see the patient to monitor them? So, this is one area that really involves a lot more research to be able to understand whether the PACT model, when it is in place is going to provide more incentive to the physicians or more confidence to them. That the patient will be appropriately monitored. And so the frequency between visits could be expanded.

So, our next step that we are proceeding with right now is to be able to increase the sample sizes of all the phases of our study to be able to make the findings a bit more robust. But also being able to make comparisons about the use of on-site, off-site care. And the use of extenders across different sites within our VISN. Some of which have higher PACT use scores than others. And to be able to understand whether the presence of more PACT use is associated with a different allocation of physician utilization during a visit.

So, I just wanted to also acknowledge the people who have been involved in our study. Rachel Werner, our fearless leader of the demo lab. Our research team and the physicians who have been so helpful in our study. Thank you.

Moderator: Thank you very much, all of our presenters. And we do have numerous questions come in. We will hopefully to get to all of them before the top of the hour. It seemed like when the – when Dr. Terwiesch and Marcus picked up the phone, the audio was a lot clearer. So, perhaps, Dr. Rubenstein, you can also pick up the phone for the Q&A portion. 

I will remind all of the presenters that only one of us can speak at a time, or it does cut out the audio. For those of you joined us after the top of the hour, please use your Q&A function on your go to webinar dashboard to write in any questions and comments you have. The first question or the first comment was in reference to the poll question at the beginning. A couple of people did want to note that their PACT demo labs had not achieved any of the circumstances

So, we do take note of that.

First, would either of the presenters like to address that before we move on? No? Ok. The first question that came in. looking at capacity, we are at a small urban clinic. Our capacity, based on two rooms, which is erroneous. Lucky to not  have to argue about one. And an acuity that is normal for a high percentage of homeless populations. The capacity is 1,230 per provider that are .59 providers have capacities of up 948 patients. How can we correct these numbers, which falsely elevate numbers on panels and affect our PACT panel staffing?

Dr. Rubenstein, would you like to address it first?

We are not hearing your audio. Perhaps you need to unmute yourself?

Lisa Rubenstein:I am sorry, I was on mute.

Moderator: There you go.

Lisa Rubenstein:There I go. I would be happy to try to answer, but I do not really. I think I would need to know more about how that works in that clinic. It should be that the panel size equals. The panel size in the – in PCMM equals the total number of patients. And I got the sense from the question that it did not. In terms of what the panel size should be that would take going through the revisit rate, and the attrition rate, and so on, which might be quite different for high homeless populations. 

I think that would have to be done in a – in a pretty fine tuned way to really understand what the true workload capacity was. And I think it is a great thing for our homelessness researchers to pay some attention to. I will bring it up to them.

Moderator: Thank you, we do have a follow-up to that. There was some incorrect numbers given. I am sorry – we do have a comment in response to that. It was, one suggestion is for them to revisit the frequency for this – is for the physician to see how much patient utilized ED. And call the advice RN for health care needs. High utilizers, it should be seen sooner. So, I believe that was a comment and response to the first question.

Lisa Rubenstein:Excellent and good comment. 

Moderator: The next question that came in. Any suggestion on how to get senior administration to buy into looking at increasing more staff in primary care to reflect PACT models?

Lisa Rubenstein:Well, I think that is – that is something that again does not have an exact answer. I think the philosophy that our particular lab has taken is working with all levels of management. Really trying to get each site staffing as tight and in gear as possible. And then working with higher levels of management to show that process. And I think to go deeper than that would take probably more time than I should take answering this question. But it is a – it is an effort that takes engagement at all levels. 

Moderator: Thank you for that reply. Christian or Steve would you like to add to that before we move on?

Unidentified Male:No, I think that was an excellent answer.

Moderator: Great. Well the next question that came in?  One moment, we do have a lot that that have just come in. Ok, the next one. Since panel size is determined by room and staffing report, how can the RVI and BCG score play into studying panel size? 

Lisa Rubenstein:That is another great question that I do not have an answer to, but I will – I will work to find one with our group. Some of these questions I can get answers after the session. Molly has been so kind as to circulate the questions for written answers. If I – if you ask one, then I feel like I cannot give a good one – a good answer to I will stay take it up after the session.

Moderator: Thank you very much. We do appreciate you taking the time to address all of these even if it be off line. The next question; can you tell us a little more about the study that generated these data? And this came in early on. I believe it was still during your portion, Dr. Rubenstein.

Lisa Rubenstein:This is – we have a – one of the PACT demonstration labs. Our particular lab is a quality improvement oriented lab. It involves six medium to large sized clinics or primary care sites. Each of the sites contributes data and information. What I have given you is somewhat of a synthesis of one of the prioritized quality. Well actually two of the prioritized quality improvement projects that have been taken on by these individual demonstration-sites. 

Moderator: Thank you for that reply. Drs. Marcus and Terwiesch, feel free to interject if you would like to add anything to these answers. The next question; what is the average panel size for primary care providers who are able to maintain even 20 percent of slots open at the beginning of the day. When we do the math about 1,250 patient panel can have about 1.8 visits a year and maybe less.

Lisa Rubenstein:That – I think that goes back to. I would like to direct that one to Steve, et al, because I think that the answer to that is how much you use non-face-to-face and other efficiency modalities to be able to reduce the revisit rate. What I have not done – the math that I have seen has not come out with that particular number. But again, I can revisit that after the – after the panel with some of the experts on that – those calculations. 

Steven Marcus:I think that I can certainly talk with Lisa off line about that. But it seems like it requires a little bit more data to be able to make an informed suggestion about that.

Moderator: Thank you, both. We will be sure to address these off line. The next question that has come in. Did any of the sites have a VA managed ER, a co-located?  Were you looking at the community ER visits to determine the continuity? 

Lisa Rubenstein:The – actually none of the sites. Let us see. None of the sites have a physically co-located ER. We do look at ED visits as part of continuity is the answer to that one. We also keep track of the ED visits and the reports separately so that people can see how often patients are visiting the ED. We have at times experimented with including or excluding ED visits from the overall continuity calculation.

Moderator: Thank you. The next question, what is an extender?

Lisa Rubenstein:I think that is for Steve.

Steven Marcus:An extender would be people on the teamlet, people who are not the medical providers. Who can be either medical technicians. They could be non-prescribing nurses. They could be potentially even clerks. Any people who are able to assist a hands on providers to do their job more effectively and efficiently.

Moderator: Thank you. The next question is what is a good walk-in system. Describe some elements, please. Is someone studying this issue?

Lisa Rubenstein:I think that is to me. I think what we.... one of our sub demonstration-sites is studying walk-ins in acute modality. It has been like studying an onion. Each layer uncovers another layer. But the first – and I do not know of anyone else who is specifically studying that issue. The first layer of the onion was the pharmacy issues. Basically what the study did was use the data collection form on its walk-ins to see what they were coming in for. That probably can be made available to people if somebody wants to ask us for it. 

The low hanging fruit was these refills. That really did make a big impact on reducing walk-ins to involve the pharmacists, and the nurses, and the clerks, all in how to manage refills and expired medications more efficiently. Walk-ins also became an issue related to how staff scheduling and attending scheduling in this particular site, which was an academic site. 

There were substantial efforts to redo schedules to provide better coverage at the attending level. There are issues in addition related to who covers the walk-ins. And how they are scheduled. Some of those are still... I do not think that they have gotten to a level of being a system. I thank you for the question. We will relay that to the site. We will be trying to pull together all of the lessons on the walk-ins sometime in the next several months.

Moderator: Thank you for that reply. We do have quite a few more questions. People are very interested. We do have a large portion of the audience still with us. This is great to get this dialogue going. This next question is for Marcus and Terwiesch. What were criteria for determining if activity could be done by extender or off-site? Were sequential dependencies between intra and counter tasks taken into account? For example, in the physicians’ examination of the patient may benefit from the physician having just have had a discussion with the patient about his or condition.

Christian Terwiesch:Yes, I think that point is certainly well taken. But the way that we have approached this issue is that the clinicians were watching this whole video encounter. So, they would apply their clinical judgment as the criteria to classify the episode of care into those four boxes. 

As far as any sequential dependence is in concern, that judgment was in the context of the video as it was unfolding. So, the physician would know if they had – they would not classify a task whether they approve what they had previously recommended. We have in part of our  study, we have also add into another question that we have in this point on here. We have also asked physicians to what extent that they felt that the entire grievance could have been handled remotely or by a physician extender? I think that in particular speaks to the question  that was asked. 

Moderator: Thank you for that response. The next question is directed. I think this is directed to also Steve and Christian. Can you let us know the disciplines and job titles of your collaborators you credited at the end? I believe it may be in reference to this slide here.

Steven Marcus:Sure. Rachel, our leader is an MD, PhD. The study team; Jennifer, Mary, and Dan are either bachelors or masters level researchers. And Lindsey Shrea and Jeff are all physicians. 

Moderator: Thank you. The next question; what do you mean by off-site workload?

Steven Marcus:In this context we are using it very loosely to infer anything that is not done in the patient provider encounter at the PVAMC. E-mail, telephone, just not on-site.

Moderator: Thank you for that response. We have...  We are just about approaching the top of the hour. At this point I would like to ask our presenters, if you are available to stay on for a few more minutes. Or if you would like make concluding comments and to answer the remaining questions off-line. We do have a large portion of our audience still with us.

Steven Marcus:I think we can stay for another ten minutes.

Lisa Rubenstein:Ok.

Moderator: Great, thank you very much. It is helpful to capture it for the archive. Are any of the teams in the first presentation university settings? How do you have continuity with residents and interns that are all .1 even when made associate providers? The attending provider is still responsible for continuity and the associate providers cannot see each other’s patients.

Lisa Rubenstein:The two of the – two of the sites have a substantial numbers of residents. All of the sites have a few trainees of various kinds. But, two of them – only two of them have larger numbers. They have somewhat different approaches. The sites that had the major continuity improvements has residents who are actually there only... do not actually have any continuity at the site. They come for block rotations for two weeks to a month. That was a real challenge. 

What they did was really tie the residents closer to the attending and the attending’s teamlet. There was a substantial focus on educating the residents about the teamlet. Orienting them and helping them work effectively with the teamlet as a whole; help the nurse, the LVN, and the clerk, as well as the attending. That really changed how patients were seen. It is actually – we do not know yet. There is another analysis of patient satisfaction and so on. But, so we do not know those final answers. But it appears that patient complaints related to discontinuity have been markedly reduced in that site. 

So, it looks like they are going in the right direction. It is possible and it seems to be that it is through the attendings that – and through like making the atttendings schedule. And through linking the resident to the attending’s teamlet that site achieves the increase. The other site already has somewhat better continuity. But their continuity; they have not focused on it in particular. Their continuity has stayed relatively flatter compared to the site that I showed increasing.

Moderator: Thank you for that reply. The next question; at our CBOC, RNs often cover two teams. What evidence can be used to justify hiring a per diem?

Lisa Rubenstein:I think the evidence for the nursing staffing will probably come out over the next several months from the lab. We have heard from the qualitative analysis people. That some of – there was a previous cyber seminar in this series that looked some at the – particularly the nursing, some of the nursing issues. We are hearing it from a second and third lab, qualitative results that the staffing makes a big difference in function. We are probably going to hear it from...  It looks like in preliminary results we are going to hear it from the provider surveys as well. And that – in a way, it seems to work like this. If you do the kinds of things that Steve Marcus was talking about in terms of delegating or moving work over to the side. You can – if you do not have staffing. If the staffing is inconsistent, that just does not work. Because you have delegated work or moved work to something that is not constant. It takes apart the whole concept of the teamlet to not have consistent staffing like that. 

Because if you were in a...  I mean, I think of it now as if you were in an ICU. Suddenly, you take a nurse away. All of those things that nurse was doing, if you do not have a replacement are left in abeyance. To the extent that you have a functioning team, you really – you really need that with staffing. If you do not have a functioning teamlet, then you are not likely to get to the PACT goals.

Moderator: Thank you for that reply. The next question we have, I think we will make this the final question. Then give you all a chance to make some concluding comments. I just want to note to the attendees that we have received your questions. And as Dr. Rubenstein mentioned, they will be addressed in writing. I will be sure to get them out to you in a timely manner. Also, many people have been asking for the slides. Those are available. I have been sending them to each one of you. You will receive a reminder e-mail in a few days with a direct link to the archive, which also contains the slides, audio, and visual. So, thank you. 

The next question; what data source do you recommend we use analyze return visit intervals? We have had some challenges with this as there are many data sources. And not anyone is clearly defined as RVI.

Lisa Rubenstein:I think I would like to take that one off-line. Because the questioner is right. I do not want to give the wrong answer among the different methods. We have also used a variety of methods to try to do this. The VISN 20 calculation seems to be a good one. I can provide more information about that off-line.

Moderator: Thank you and we do appreciate it. At this time, I would like to give you and Drs. Terwiesch and Marcus an opportunity to say some concluding comments before we wrap up.

Lisa Rubenstein:I would just say thank you to the attendees for your responses. I look forward to any of the ones that are going to come in – in writing. I think we all have to help each other out. Thanks.

Steven Marcus:I concur with that sentiment. And really think that as PACT really starts to get more involved in all of the care settings, I think that there is a lot of opportunity for really great things to happen. Thanks for everybody for listening.

Moderator: Christian, did you want to make any comments?

Christian Terwiesch:No, let me echo this and let me thank Lisa also for her presentation. I think there were some fascinating issues as one of the audience members have pointed out. That the intersection between our lines of research as we are improving productivity of the primary care providers. Of course, they would impact panel sizing. They would impact revisit intervals. Really get into that intersection of our project. It seems like a fascinating topic for further works. Thank you very much Lisa, and take care, every one else on the call.

Moderator: I would like to also send my thanks to all three of you for presenting your expertise today. Clearly, PACT is a very hot topic as it is by the large number of attendees we have been seeing and are still on the call. Please do as you exit the session, take the opportunity to fill out the survey. It will load automatically on your screen within a few seconds. It is important for us to receive your feedback so that we can continue to provide summer seminars that are of importance to your work.  

Thank you again to all of our presenters and attendees. This does formally conclude today’s HSR&D cyber seminar. Thank you.

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