Developing a Poly-Chronic Care Network: An Engineered, Community-Wide Approach to Disease Management

289 Pages·2012·1.918 MB·English

by  Pierce Story MPHM

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Healthcare Management / Quality & Patient Safety Developing a
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Although much has been achieved in care coordination and accountable care, r
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healthcare leaders need additional, game-changing innovations to deal with
Poly-Chronic
constraints in clinical resources, care capacity, and cost that have not yet been fully
addressed. This need for innovation is especially great in the care of the chronically
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ill: the most costly, highest-risk segments of our populations.
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Filling this void, Developing a Poly-Chronic Care Network: An Engineered,
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Community-Wide Approach to Disease Management reconstructs and augments
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traditional chronic care delivery models. The proposed solution—the Poly-Chronic o An Engineered, Community-Wide
Care Network© (PCCN)—is a specific iteration of the Care Circle Network© (CCN) p
Approach to Disease Management
concept that creates a sustainable community-engaging response to the complex- i
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ity, cost, and outcomes of chronic diseases. By dynamically engineering all the
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elements of a community’s “Capacity to Care” directly into short- and long-term

patient care processes, the PCCN expands care capacity and physician “reach,” and
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improves quality and outcomes, without increasing the total cost of care.

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The book describes the fundamental concepts, principles, and requirements for the o
PCCN and explains how this care model could augment and enhance other new l
y
business models, such as Accountable Care Organizations (ACOs) and Patient-
-
Centered Medical Homes (PCMHs). In addition to a detailed description of C
implementation steps and organizational structures, the text provides useful insights h
into technologies that can aid and enhance implementation, including home/virtual r
monitoring, social networking, and dynamic simulation. Importantly, the book o
includes both detailed examples and a flexible how-to guide for setting up a PCCN n
or other CCN, offering readers step-by-step guidelines and options for combining i
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readily available communal resources with simple technologies in the design of

innovative care models for their communities. C
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With this book in hand, readers can confidently pick and choose specific compo- r
nents to match their community’s needs and capabilities, “amending the blend” to e
account for the size, scale, scope, and population of the community and patients
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they wish to serve.
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K15332
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Pierce Story, MPHM
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ISBN: 978-1-4665-5474-0
90000
www.crcpress.com
9 781466 554740
www.productivitypress.com
K15332_COVER_final_revised.indd 1 10/2/12 4:11 PM
Developing a
Poly-Chronic
Care Network
An Engineered, Community-Wide
Approach to Disease Management
Pierce Story, MPHM
CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742
© 2013 by Taylor & Francis Group, LLC
CRC Press is an imprint of Taylor & Francis Group, an Informa business
No claim to original U.S. Government works
Version Date: 20121012
International Standard Book Number-13: 978-1-4665-5475-7 (eBook - PDF)
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Contents
Preface ...........................................................................ix
Acknowledgments .......................................................xix
Introduction ................................................................xxi
1 The PCCN Concept: An Overview ............................1
PCCN Description ...............................................................1
PCCN as a Visual .........................................................2
Application Overview .........................................................4
An Engineered Approach ...................................................6
PCCN Components .............................................................8
Resource Pool ..............................................................8
Resource Training ...............................................12
Technology Infrastructure (TI) ...........................13
Palliative and End-of-Life Care ..................................16
Assimilation and Passion ............................................17
Capacity as Strategy ...........................................................17
Other Important Attributes of the PCCN ..........................19
An Additive Solution ..........................................................19
PCCNs and ACOs ...............................................................20
A Caveat to the Contents of This Text ..............................21
Two Missing Elements .......................................................22
Mental Health .............................................................22
The Bottom 50 ............................................................24
A Word on U.S. Privacy Regulations and
the PCCN Concept .............................................................24
iii
iv  ◾  Contents
Summary ............................................................................27
Endnotes .............................................................................27
2 A Brief History of Previous and Current
Healthcare Reforms ...............................................29
Been Here, Done This? ......................................................29
Whence Innovation? ...........................................................30
Accountable Care ...............................................................31
Precursors to ACOs in Europe ...........................................34
ACOs and HMOs ................................................................35
Can ACOs Save the System? ..............................................37
ACOs and PCCNs ...............................................................40
PCCNs and Other Business Models ..................................43
Summary ............................................................................45
Endnotes .............................................................................45
3 The Five Pillars of Healthcare for the PCCN .........47
Quality and Outcomes .......................................................49
Access .................................................................................50
Capacity ..............................................................................51
Cost .....................................................................................52
Participant Gratification .....................................................53
The Five Pillars and New Approach .................................54
Summary ............................................................................55
Endnotes .............................................................................55
4 Assessing the Community and the Patient
Population .............................................................57
Selecting Patients ................................................................57
Size, Scope, and Scale of Your PCCN ...............................61
Proximity of Space and Resources ............................62
Physician Participation ...............................................62
Technology Constraints ..............................................63
Patient Population Chosen ........................................64
Community Acceptance .............................................65
Assimilation Propensity .....................................................66
Cultural Barriers .................................................................69
Barriers to Assimilation ......................................................70
Contents  ◾  v
Summary ............................................................................71
Endnotes .............................................................................71
5 Care Strategies and Task Analysis .........................73
Establishing BDPs and Patient Involvement ......................74
Swimlane Mapping ............................................................76
Task Classifications ............................................................79
Task and Resource Considerations ...................................80
Risk .............................................................................81
Variation ......................................................................81
Process Variance .........................................................82
Process Time Variance ..............................................84
Process Time and the Impact of Variability ..... 84
Process Time Variance Example .......................84
Interdependencies and Variability .............................87
Process Time and Patient Attributes .........................88
Impact of Variance on Capacity ................................88
Tools for Analyzing Complex Systems ..............................89
Dynamic Standardization .......................................... 90
Data and Analysis of Current and Future States .......91
Process Data ...............................................................92
Demand Data .............................................................93
Analyzing Community Demand ................................94
Summary ............................................................................97
Endnotes .............................................................................97
6 Building the Communal Resource Pool .................99
Overview ...........................................................................99
Resource and Capacity Variance .....................................102
Dynamic Demand–Capacity Matching ............................103
The Demand–Capacity Continuum and
Simulation Capacity Analysis ...........................................105
Resources ..........................................................................107
Using the Care Strategies .................................................107
Resource Options .............................................................109
Resource Selection ...........................................................113
Selecting Physicians .........................................................114
vi  ◾  Contents
Creating a Care Circle Team ............................................117
Personalizing the Resource Pool .....................................118
Resource Assimilation ......................................................121
Resources for the Resources ............................................122
Resource Education ..........................................................124
Setting up Educational Programs ....................................125
Leadership and Core Values ............................................130
Group Dynamics™ for Resources ....................................132
Challenges and Obstacles ................................................134
Legal Hurdles ............................................................134
Too Many Cooks? .....................................................135
Summary ..........................................................................135
Endnotes ...........................................................................136
7 Build It and They May Not Come ........................137
Protecting the Herd ..........................................................138
Physician Participation .....................................................141
Risk, Payors, and the Government ..................................142
Future PCCN Model Alternatives .....................................144
Summary ..........................................................................145
8 PCCN Resources and Governance Structures ......147
Poly-Chronic Care Network Roles ...................................148
PCCN Management Team ........................................148
Chronicists ........................................................150
Governance Structures and the Chronicist ......152
Specialists ..........................................................157
PCCN Manager ..................................................158
PCCN Trainer ....................................................160
Patient’s Primary Communal Resource ............161
Education of the Community ..........................................163
Governance as a Practical Matter ....................................164
More on Governance Structures ..............................165
A Word on Group Dynamics™........................................170
Making Room for Skeptics ...............................................172
Governance as a Legally Binding Concept .....................172
Contents  ◾  vii
Summary ..........................................................................173
Endnotes ...........................................................................173
9 PCCN Technologies ..............................................175
Introduction ......................................................................175
Infrastructure Options: Overview ...................................176
Using the SCN ..................................................................178
Patient Connectivity .........................................................179
Patient–Resource Connectivity.........................................180
Resource–Resource Connectivity .....................................181
PCCN Management: Resource–Patient Connectivity ......182
Resource–Clinician Connectivity .....................................183
Example of a SCN Use Case ............................................184
Another SCN Use Case: Discharge and
Care Transitions ..............................................................187
Using Simulation ..............................................................189
Using the HIE ...................................................................190
Using the Chronic Disease Management
System (CDMS) ..................................................................192
Using Virtual Monitoring .................................................193
Who Pays for It? ...............................................................195
How to Save on Implementation Costs ...........................196
PCCN Resources and the Technology Infrastructure .....197
Summary ..........................................................................199
10 Financial Considerations of a PCCN
Implementation ....................................................201
Cost Analysis Assumptions ..............................................202
Creating Your Own Cost Analysis ...................................206
Impact of the PCCN on Hospital Financials ...................207
Impacts on Physician Office Costs and Revenues ..........209
PCCN Cost Justifications ..................................................212
Outcomes and Incentives ................................................216
Who Pays for What? .........................................................219
Summary ..........................................................................222
Endnotes ...........................................................................222
viii  ◾  Contents
11 PCCNs, Palliative Care, and End-of-Life
Planning ..............................................................223
Palliative Care: Definition and History ............................224
The Origins of Palliative Care .........................................227
Resources for Palliative Care............................................228
End-of-Life Planning and Care ........................................229
Example: Gunderson Health System ...............................231
Integrating EOL and Palliative Care in
the PCCN Model ..............................................................233
PCCN Process Evolution and Palliative and EOL Care......236
The Payor Role .................................................................238
Government and EOL Planning ......................................241
Summary ..........................................................................242
Endnotes ...........................................................................242
12 Final Thoughts .....................................................245
Imagine.............................................................................250
Closing Comment .............................................................251
Epilogue—The Latent Community ..............................253
Index ..........................................................................257
Preface
Kenji’s Dilemma
Kenji was frustrated. It should have been so much easier, so
much faster. The changes he expected to see weren’t there. He
found himself trying more and more often to prove to his boss
that his efforts were, or perhaps would, have an impact on the
bottom line. Though he could see, even sense, the change that
had taken place, the CFO couldn’t count it, so it might as well
not be happening.
It had been almost three years since the dream he had
while sleeping in a metal chair in an emergency department
(ED) waiting room rattled his cage. That dream, that night-
mare, had stirred something deep inside him that made him
leave the world he’d known since college, his manufacturing
comfort zone, and step out into a whole new world of health-
care. The work was different, very different, from anything
he’d seen in a factory. The intense work of analysis, the
preaching, teaching, begging, and arguing for every minor
incremental improvement, all seemed worth it when he
started. But now he was beginning to wonder.
His son, the reason for his late-night visit to the crowded
ED on that fateful rainy night, was so proud of him when he
announced that he was leaving the Toyota plant that had been
so good to him and his family. Toyota treated its employees
well, and there was never any real threat of unionization in
this traditional Southern town with its ingrained work ethic.
ix