Thunderbird Internal Medicine in Glendale, Ariz., started 2016 with 17 internal medicine physicians and was on the cusp of adding one more doctor. The group had more than 150 employees, including six specialists covering neurology, podiatry, colorectal surgery and audiology.
Amid the shift to value-based arrangement, the increasing workload and burden on providers – coupled with mounting patient expectations – forced practice leaders to take inventory of their goals, determine what they were doing to achieve them and figure out how to leverage staffing to reach those goals.
Rachael Vasko, RN, BSN, MHI, clinical operations director, Thunderbird Internal Medicine, said the group organized internal focus groups among physicians, medical assistants and leadership to address the need for a staffing model change to meet heightened expectations on multiple fronts.
“Medical assistant tasks can be overwhelming” given that the internal medicine physicians see up to 25 patients a day, Vasko said. “Rooming the patients, assisting the providers — EKGs, injections, vaccines — working the task list, trying to make those lab callbacks in between rooming patients,” all led to providers sometimes waiting for the next checked-in patient, since MAs could often be caught answering patient questions, calling in medication refills or carrying out other various tasks. MAs also were responsible for generating their own referrals.
This also meant that MAs had no additional capacity to assess the quality metric reporting of the patients being seen, such as ensuring a tobacco screen is done. The increasing demands of shifting to value-based reimbursement also meant providers were working much longer hours.
“It was not uncommon to have our parking lot full of physician cars at 4:30 in the morning because they were in their offices prepping their charts for the day,” Vasko said.
Making a change: Division creates unity
To make a significant change for the providers, Thunderbird split the back office between face-to-face MA duties — working with providers, rooming patients, engagement and quality metrics reporting — and a care coordination department of non-face-to-face work. This involved forms, referrals and other non-patient-facing duties, including refill coordination. The department included support staff for the MAs for duties such as voicemail transcription.
One of the key tasks of the care coordination department was handling refills. Vasko says the group processes about 3,000 refills a month with two MAs serving as coordinators working from a protocol for routine medications, ensuring consistency with doctor orders and sufficient quantities for the patient until his or her next appointment.
Another important role within the care coordination department is an employee dedicated to prior authorization for patients. This employee also fills out FMLA disability forms, as needed, which previously was handled by a patient-facing MA.
In addition to staffing, the reconfiguration involved a telephone triage system to route incoming calls to care coordinators. This further helped drive work away from patient-facing MAs. The care coordination team handled callbacks for lab, imaging and procedure results and telephone encounters, with an instant messaging system in place to streamline any communications for the physicians they might receive.
Tiffany Turner, CPHQ, BSBM, quality coordination manager for Thunderbird, said each care coordinator medical assistant (CCMA) — usually a senior MA with the group — was assigned a primary set of providers to offer consistency for both the doctors and patients.
Pods of providers and patients then were formed with data on volume relating to incoming appointment requests, refills and referrals. Those pods were phased in over a period of six months to conduct initial meetings with a care coordination manager, clinical director, providers and chief executive officer.
Kick-off meetings were scheduled with the care coordination manager, back-office manager and MAs to advise them of the shift, followed by weekly huddles with the provider pods to review what was working and identify areas for improvement. Turner said these eventually shifted to monthly huddles once a workflow was established.
With familiarity among the providers came development of standing orders for each provider, based on preferences, as well as chart prep criteria.
As each pod developed those pieces of the work, the care coordination department was able to be centralized in a single physical area of each facility to share best practices and learn from each other. “There’s a lot of teamwork being established,” Turner said. Even if they may work in different pods, “they’re still there to help each other out when needed.”
Challenges and benefits
According to Turner, dedicating team members to tasks related to documentation and the EHR allowed care coordinators to focus on leveraging the EHR portal to communicate with patients, as well as collaborate with payers and third-party case managers; for example, arranging Meals on Wheels or transportation. “Ultimately that’s empowering the patients to have more control over their care, because there’s someone there to help them along the way,” Turner said.
While there was a clear benefit to patients, the group still faced internal challenges, Turner said. “Not everything was rainbows and glitter,” she said. Lack of standardization occurred as some pods created their own specific processes, which caused confusion at times.
One key challenge in implementing care coordination is finding the right MAs who are willing to work behind the scenes rather than face-to-face. “Medical assistants, they want to be on the floor … they want to be running and they want to see that they’re making a difference in a patient’s life,” Turner said. Finding the right personality for that role — behind a desk and not directly working with patients — can be difficult.
Turner also noted that clearly communicating changes and refinements of processes throughout implementation is essential for the remainder of the office staff, as well as delineating roles and responsibilities as they are updated.
The inherent challenge of any change in a medical group such as this is securing the willingness of employees to embrace the change. In the first year, MA turnover rose 11.5% amid the shift to care coordination. However, the following year saw the MA turnover rate fall to 61% of the original rate as employees became comfortable with the new staffing models.
Making these changes budget neutral meant bringing in additional revenue for the added FTE staff, Vasko said. At first that meant five CCMAs, but a sixth was added shortly thereafter. In terms of FTEs per internal medicine providers, Thunderbird grew from 5.2 to 6.4 in the first year.
To that end, Vasko said that using G codes to bill for additional depression and alcohol screenings helped quadruple those revenues in the first year: From $49,178 to $213,424 for depression screenings and $33,564 to $212,569 for alcohol screenings.
Other areas where revenue increased in the first year included:
- Annual health assessment form revenue grew from $259,201 to $343,300.
- Hierarchical Conditional Categories recapture forms revenue grew from $181,995 to $227,700.
These areas of growth in both patient volume — the number of encounters by FTE primary care physicians grew by 5.6% in the first year — and quality metrics reporting resulted in a rise in profit-per-encounter average of $1.60 in a single year.
The changes also created numerous clinical improvements. Documented flu vaccinations grew by 43.4% in a year. In terms of patients’ A1c control:
- Patients with an A1c under 7.0 rose from 74% to 80%.
- Patients with a 7.1 to 7.5 A1c decreased from 12% to 8%.
- Patients with an A1c 7.6 or higher fell from 14% to 12%.
With a year and a half of this new model in place, Thunderbird had one care coordinator in place for every two doctors.
“We do have providers who are going to be ramping up their volume … that’s why we need to grow the department, because we’re going to have more providers that are going to be onboarded,” Turner said. Scaling the work means that Thunderbird ultimately intends to have a single care coordinator for each provider, but not until the volume merits it, according to Vasko.