CLINICAL PROGRAMS: MANAGING CARE ACROSS THE CONTINUUM

Posted on Jan 7, 2015

CLINICAL PROGRAMS: MANAGING CARE ACROSS THE CONTINUUM

Mission Health is launching Clinical Programs – a way to organize and optimize care delivery processes system-wide, across the full continuum of care.

What are Clinical Programs?

Clinical Programs are a structure for organizing and delivering care by disease processes (like heart failure), by procedure type (like bowel surgery), or by preventive service (like healthy behaviors).

Why are they important?

This structure means patients are more engaged and get better outcomes. It also helps reduce costs and helps us keep clinical practices more consistent. And it supports providers in delivering best practice medicine based on proven protocols.

Clinical Programs are an important way to achieve Mission Health’s strategic goals and our BIG(GER) Aim, as well as the Center for Medicare and Medicaid Services (CMS) “Triple Aim” of better care for individuals, better care for populations, and reduction in overall healthcare expenses.

When will we implement Clinical Programs?

Several Clinical Programs (Primary Care, Acute Medicine and Heart) are launching now, with more to come in fiscal years 2015 and 2016. Some of those in phase two will be Women’s and Children’s, Orthopedics, Neurosciences/Spine and Surgery/Trauma.

How will this work?

Evidenced-based clinical protocols called Care Process Models (CPMs) are the building blocks of Clinical Programs. They define a set of disease-specific or procedure-specific guidelines that assure that all care delivered throughout Mission Health — regardless of the patient’s location — is evidence-based best practice, patient centered, and delivered in the right care setting at the lowest cost to our patients. CPMs are guidelines only, with the individual patient’s needs and care plan directed by the care team.

CPMs help us deliver consistent clinical care for all Mission Health patients; improve outcomes; and improve safety, communication and engagement between patients, families, and providers. They mean fewer differences across all settings and practices within Mission Health, and help us improve care delivery by repetition.

What’s in a CPM?

Each CPM includes a decision tree (called an algorithm) for providers, and resources for other disciplines for standards of care that cross the entire care continuum and transition points.

Each CPM also includes an overview of models of care, diagnosis criteria and staging, goals, risk factors, therapies, interventions, metrics and scientific publication references. Ancillary materials will include Power Plans (order sets), interdisciplinary nursing plans of care, patient and family engagement and education materials, and staff and provider education.

How will we learn more about this?

Clinical staff and providers will begin learning more about Clinical Programs and CPMs in their regular staff meetings and huddles, through resource materials in offices, in units, the physician portal, and via a new page on MOD — http://missionondemand.msj.org/cpmnew.cfm?id=7013&oTopID=7013 — that will serve as the central resource for all the materials and components. Reference materials will be linked to the EMR workflows associated with each individual CPM.

You can also watch this video to hear from Chief Medical Officer William Hathaway, MD, and other clinicians involved in the development of Clinical Programs. (This video can also be viewed on the MOD link above.)

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