Published on Wednesday, May 30, 2017
Bluestone Physician Services focuses on assisted living communities and group homes, meeting the healthcare needs of elderly patients with multiple chronic conditions, many of whom have dementia and cannot speak for themselves. CEO and founder Dr. Todd Stivland and Chief Clinical Officer and President of Innovative Care Sarah Keenan explain how they use CCM and eClinicalWorks to promote value-based care.
“One thing we’re very proud of the work we’ve done with eCW is really intentionally integrating the work that the care coordinators or case managers are doing, so that it’s not over to the side of what our providers are seeing with eCW, but it really is an exchange of information that makes the work the care coordinators are doing and the work the providers are doing more meaningful and more efficient.”
Sarah Keenan, Chief Clinical Officer and President of Innovative Care at Bluestone Physician Services
Quality measures in the Merit-based Incentive Payment System (MIPS) are not designed with 87-year-old patients in mind, but that’s the average age of those cared for by Bluestone Physician Services. Bluestone spends a lot of time working with medical providers to identify the most appropriate quality measures, and working creatively with those measures in order to help their clients show the quality care they are providing.
Bluestone’s approach to care is a relational one, which includes in the definition of the care team each member of the staff at each of the communities they serve. “We always say, if you’ve seen one assisted living, you’ve seen one assisted living,” CCO Sarah Keenan says. “It really is the patient’s own home.” The team’s approach to care must, therefore, involve everyone.
Bluestone Physician Services has gone well beyond their service area in their efforts to improve the quality of healthcare for elderly Americans with chronic conditions. Their testimony before the Senate Finance Committee led to the adoption of language and regulations that more accurately reflect the realities that face providers each day — meaning a more logical, responsive, and useful formula for determining what factors are weighed in calculating a MIPS Final Score.
As practices come to terms with the challenges of the shift from fee-for-service to value-based care, they must choose how to engage with the world of MACRA and MIPS. “We are very determined to be very successful with MIPS, which is saying something, because we have a very unusual population,” says COO Sara Keenan. But Bluestone is also planning to eventually tackle the higher risks and rewards that come with APMs — Advanced Alternative Payment Models.
When the Centers for Medicare & Medicaid Services first came out with their Chronic Care Management (CCM) reimbursement module, Bluestone was excited, viewing it as a long overdue paradigm shift, and recognition of the incredible amount of work that goes into coordinating care for elderly, chronically ill patients. And they had another thought: CMS’ 20-minute standard wasn’t enough. Through their work, the standard has been raised to 60 minutes for complex, chronically ill patients.
eClinicalMobile has been the single most indispensable tool for Bluestone Physician Services, whose work takes them from one senior living community to the next. Because their work is completely mobile, they face the usual need for accurate and comprehensive documentation, along with added, practical challenges such as picking up internet or phone signals from deep within medical facilities. eClinicalMobile has met those challenges.
Adam: eClinicalWorks prides itself on its efforts to advance the quality of care through innovative technologies, but the success of those efforts depends on the people who help deliver that care – some of whom use those tools available to innovate in ways that even we at eClinicalWorks didn’t think of. Welcome to this edition of the eClinicalWorks podcast, I’m Adam Siladi, and here to speak with me today are, from Bluestone Physician Services, Doctor Todd Stivland, CEO and founder of Bluestone, and Sarah Keenan, Chief Clinical Officer and President of Innovative Care – I like that title, it’s very original there. So, welcome guys, welcome to the podcast.
Sarah: Thank you, thanks for having us.
Adam: You came all the way from Minnesota, right?
Sarah: Yes, we did.
Adam: I hope the trip was good. Tell us a little bit about Bluestone.
Todd: We’re a little bit of a unique organization. We focus solely on assisted livings and group-home communities. So what we really are trying to do is find those people in the community who are falling through the cracks in traditional medicine, and for the last 11 years we’ve been doing on-site care for residents who have multiple chronic conditions, an average age of 87 years old, and really at the end of life. So a lot of what we’re doing is palliative care, care planning, end-of-life planning, integrating with the families, with the staff at the communities that they live in, and also with a lot of other service agencies. So if you look at our typical patient, they are going to have seven to eight chronic conditions, and a life expectancy of less than two years when they come on to our services.
Adam: Well, it sounds like they are certainly in good hands with you guys, and your organization seems to be kind of breaking the mold a little bit, providing that care, like you said, for people who are falling through the cracks, maybe, of traditional medicine. And this is coming at a time where the healthcare industry in general is trying to change what’s expected, as well. So what are some of the challenges and opportunities that you see in the next two to three years?
Todd: Well, you’re right, we’ve been doing this for 11 years, and when I started this company, no effort was really being made to find people who were in assisted livings and in, kind of, alternative residential care communities. A lot of effort has been made in the nursing home, but what we’re seeing is an enormous growth of alternative care systems out there that are taking care of the sickest people in our communities. So there wasn’t really any mold to follow when we started doing this. A lot of what we’ve had to do, we’ve had to build out of necessity, and we’ve been electronic since the day we started, we’ve been on eCW now for over three years, but we’ve never had a paper chart in the clinic. And one of the biggest challenges was how do we communicate with people who weren’t on an electronic system, or on electronic systems that didn’t communicate with each other, like a hospice nurse who is doing a majority of the care, but we had no way to communicate with them, or an assisted living nurse who needed an order within minutes, but we had no way to get back to a fax machine and send that to the pharmacy. So those were some of the biggest initial barriers that we really worked hard to overcome and get everybody communicating simultaneously on the patients, and also, how do we improve the way that we bring all that together?
Adam: Well, we always talk about how it’s hard to be behind the curve, but it sounds like maybe if you’re ahead of the curve it can be difficult, as well, in other ways, because other people have to catch up to the care you guys are delivering. So you talked about your patient population, and how they have so many chronic conditions — what are some of the most prominent conditions and what are some of the methods you’re using to care for those patients?
Sarah: Well, the most prevalent condition, by far, is dementia. Eighty-two percent of our patients on the assisted living side have a diagnosis of dementia, so we really are a leading edge in the tsunami of Alzheimer’s and related dementia care that is coming. So the statistics are somewhat staggering both in the impact that has on people’s lives, the lack of preparation that the healthcare system has for people with dementia, and the cost impact of people with dementia. So, the things we’re doing are really developing a team-based model. Dementia is a care-defining condition, it impacts every aspect of both the patient’s life, the way the staff at the communities and our providers care for those patients, and, of course, the families. And as Dr. Stivland mentioned, the care team that surrounds that patient. So almost by definition, when we’re talking about this chronic care patient, whether it is somebody with dementia, which, again, is the norm, but also people with chronic conditions, there’s a care team that surrounds those patients, and the tactic that we’ve taken over the years is to do everything we can to include those folks into the care-planning process. So then you get into a lot of challenges around data and around documentation and how do we bring in the good work that’s done by the home care nurse and the care coordinator or case manager – the word-of-the-day – and specialists and behavioral health. So how do we bring all of that in and exchange information? Not only the common complaint around information exchange is patients are having to tell their stories over and over again – with our patients, sometimes they can’t tell their stories over and over again, particularly when they are going into the emergency department or into an acute stay. The stories are sad and all too common in our healthcare system of what happens to a dementia patient when they hit that. So we spend a lot of time trying to be proactive, a preventative model, as opposed to a reactive model in helping folks kind of get off that treadmill.
Adam: And certainly the proactive part of things is a huge focus in a lot of the changing environment. You mentioned the team. I’m sure with your focus on care in assisted living facilities, your teams might look a little bit different, or function a little bit different than other teams in traditional settings. Tell us about how the teams work.
Sarah: Sure, so our team is a physician, nurse practitioners and PAs, clinical support staff, usually LPNs or NAs, and then some administrative staff. And again, we have no brick and mortar clinics, so everybody’s together, so they have a team that travels. They have a set communities that they serve. It’s very, very relational, so that would be the Bluestone team that’s going into the communities, but we include in that definition of team, the staff at the communities, as well. So we work very intentionally to integrate into the processes. Assisted living, unlike perhaps some nursing facility care is – you know, we always say, “If you’ve seen one assisted living, you’ve seen one assisted living.” So it really is the patient’s own home. And every assisted living is set up a little differently, there’s different staffing models, so it’s on us to learn what that community is functioning. So, that’s the team. So our Bluestone team also includes, for certain patients, a care coordinator. So we are a healthcare home in the state of Minnesota, so we have that function of care coordination, and then we work a lot with special needs plans, so we’ll have care coordination there, as well. And, one thing we’re very proud of the work we’ve done with eCW is really intentionally integrating the work that the care coordinators or case managers are doing, so that it’s not over to the side of what our providers are seeing with eCW, but it really is an exchange of information that makes the work the care coordinators are doing and the work the providers are doing more meaningful and more efficient.
Adam: I’m sure that adds some challenges to the charting part of things, as well, right? Now you don’t have stations, nurses’ stations where people are kind of documenting, right? You’re kind of in someone else’s space. How does that charting component work? What do you use from eClinicalWorks to help with that?
Todd: Well, the first thing is getting devices that are portable, because we’re going room to room. So we’ve kind of led the charge with iPad use, and gotten to know Greg extremely well, so I don’t know if he likes that or not, but we’re always pushing for ‘How do we get more mobile?’ The other thing, you go into a large, concrete metal building, it’s pretty hard to pick up a signal from that building. So a lot of the challenge is how do we just get an internet signal or a phone signal coming down to our devices so we can move throughout that building? You get to the third floor, in the middle of all these buildings, that can be a big challenge, as well. So sometimes just the hardware and connectivity, which you don’t have in the office space system, becomes a big challenge. The other thing with documentation is that we really don’t have documentation tools built for chronic disease. If you look at how medicine is taught, how medicine is built and coded and paid for, it’s an acute basis. What’s that patient’s chief complaint? What’s the history of their present illness? And at the very bottom we say ‘Well, what’s our plan?’ It’s been interesting as we’ve been doing this, and I learned a lot from our nurses. They say ‘Well, why are you ending with the plan? We always start with the plan.’ And I’m like ‘Oh, that’s a really good idea! Let’s flip that note up on top.’ We know what the diagnosis is, I don’t have to do a differential diagnosis. These people have been diagnosed for years by the time they hit us. So, what we’ve been working on now, which has been really exciting, my latest project with eCW is how do we create a Note that’s preventative and not reactive, and we were actually just in D.C. for the last two days pitching the idea to CMS saying ‘You have to reimburse on how do we do good chronic care, not episodic, acute care. But right now, the payment system is based on ‘What’s your acute problem today?’ So you see a lot of programs and a lot of clinics, they’re set up to say ‘Well, we’ll wait until someone has a problem, then we’ll react to it, then we’ll do post-acute care.’ We’d rather do pre-acute care and have the documentation, the communication follow that through. As Sarah was talking about our teams, in the Minneapolis metro area alone we have 300 service partners who provide care to our patients in one form or another, whether that’s wound care, nutritional care, physical therapy, home care. Three hundred different agencies that do that. That’s a lot of people to keep track of, but they’re doing the lion’s share of the work, and if we don’t, we miss a huge amount of information and opportunity with the people that we serve.
Adam: Well, I hope you have luck with that paradigm shift. I think you’ve also been part of another paradigm shift with relation to the CCM program. I was watching a demo, just not too long ago, where they were talking about the new codes for 60 minutes of non-face-to-face time, or care coordination time, and then every 30 minutes beyond that. I think you guys had something to do with that? That’s what I heard.
Todd: We think of it as being extremely out on the limb.
Sarah: We do, we were very excited when CCM originally came through, with an exception of a few other case management codes that CMS had put up through the years, it was the first time that we saw CMS recognizing the value of the work that’s done between visits, which, for chronic care, is where it’s all at. So, our visits might not be these incredibly long, cumbersome visits, and then it’s followed up by an incredible amount of coordination of care. So when CCM, Chronic Care Management, first came out, we were very excited because we looked at that as a paradigm shift on behalf of CMS. And, we didn’t think it was quite enough. So the 20 minutes is generally because of our model, we’re a very high-touch. We identify only high-risk patients. We’re a very high-touch, communicative practice. Many of our patients, we easily hit the 20 minutes and beyond. So, we did a lot of work with the Senate Finance Committee a few years ago, spent a lot of time in D.C. really making the case for this patient that we’re serving. So certainly not all patients in traditional practices are hitting that 60 minutes, but certainly with the tracking within eCW and some additional tracking mechanisms that we have, we actually are proving that we’re hitting the 60 minutes of care coordination time for a significant number of our patients. And then we’re looking at new programs as well – are there additional things, needs we can meet now because of these resources through care conferences and dementia education and those types of things? So this has given us the opportunity to explore that, as well.
Adam: So you mentioned when you’re doing some of this care coordination on behalf of your patients that you’re involving the teams that are already in place at the assisted living facilities. Who is doing that care coordination?
Sarah: Well, care coordination, again, is a very, overused term and one we spend a lot of time explaining so probably more than we need to because care coordination is a function or a person.
Adam: Like, if you do it this time, everyone will watch it, and then we can get the word out.
Sarah: Fantastic. So there is the role of care coordinator, so we do have nurses and social workers who work with Bluestone, who are integrated parts of our team, who go and take care of that whole person view, so they’re working with the patient to make sure that all of those – nutrition and housing, we do have a home-based program as well – that we bring in medical services, as more of a safety net provider. The care coordinator is a Bluestone employee. Then we have, as Dr. Stivland was talking about, the very intentional effort to be bringing in that community staff, who are also coordinating care, and really providing that necessary function. They’re there day to day, they know that patient inside and out. Our program relies heavily on the information that we get from the staff and the family and the home care and the hospice and the durable medical equipment providers – a hugely under-recognized team member. Then we have the challenge of bringing all of that information in and creating a comprehensive care plan, and then, as Dr. Stivland was saying, then our current mission is to get that care plan to the top of the Note, which really means to the top of the visit, to have the provider be able to come in and not have to search and dig through and literally not have the information of ‘Who else is involved in this person’s life?’
Todd: I think what we want to distinguish between, as Sarah was saying, you know, care coordinator, case manager becomes a program or a person that’s very specific, or we talk about Chronic Care Management. Well, all of a sudden that became a code, not a process. So, really, when we talk about this it’s like ‘How do we take care of this person?’ And the code is this one little slice of that. How you document for a regulatory body is another slice of that. Someone who’s assigned by a health insurance program is another slice of that. But the whole program, the whole process, involves many, many people, and that could be the daughter that’s doing most of the work, that could be a staff at the nursing facility that’s doing most of that work. It could be a neighbor. You really have to dig into each patient and say ‘What are the structures around this person? What’s their social structure? What’s their integration? Who’s the specialist that’s doing their dialysis? So we’ve got to make sure we get involved in this, so that really takes that upfront evaluation and initial interview to put that team together. It can’t be cookie cutter and say ‘Oh, we’re just here to get paid for a code,’ or ‘This is just one program that the insurance company put in place so we pop that person in.’ It has to be a longitudinal program with all these pieces put together to really make it work.
Adam: Well, I can see why the Senate Finance Committee took your side on this and added those codes, as well, to support the efforts that you guys are doing. I think you guys are doing a great job. With the changes that are coming, I think everyone’s got MACRA on their mind. What does your plan for MACRA look like? Are you looking at the MIPS track, are you looking at the APM track?
Sarah: Yeah, I think, as with many clinics, our end goal would be APM, but in the meantime, it’s MIPS. So we are very determined to be very successful with MIPS, which is saying something because we have a very unusual population. Quality measurement is not designed for an average age of 87. So we spend a lot of time working creatively with the measures and working with our providers to say ‘How can we make these measures best serve our patients?’ With that said, we’re very excited – we have two measures out of MIPS that we’re able to implement this year, hopefully, around dementia care. We’ve never been able to do that. We’re able to leave behind some of those measures that were completely inappropriate for our patients, things like colonoscopies and things like that. So we’re excited about MIPS, we’re excited about the CPIA’s, we’re excited about the Advancing Care Information and the Health Information Exchanges that that’s driving. So it’s a lot of intentional effort. It’s a lot of effort, and I think it’s one of the places that we’re very excited about – we’ve always had a partnership with eCW, but it really feels like a partnership with eCW around the development of MIPS dashboards and other tools we’ll be using.
Adam: Well we hope to continue to see your group at the vanguard of advancing healthcare, and we hope to continue to be a partner with you in that. Thank you so much for your time today, it was a great conversation. If you’d like to see more of our eClinicalWorks Podcast episodes, you can check those out on iTunes, YouTube or my.eclinicalworks.com. For the eClinicalWorks podcast, I’m Adam Siladi, thanks for watching.