Good day. Welcome to the module focused on developing a specialty clinic. One of the things we've spent a lot of time over this course going through very specific operational topics, whether it's revenue cycle or schedule management or people management. And I get to wrap up at the end here with what I would think is the fun stuff or what I consider the fun stuff. So the concept with this module is when that physician or other leader administrator comes to you and says, I would like to build a new clinical program. We should start taking care of amyloid patients in a specialty clinic, or we want to start doing a cardio oncology clinic or a cardio metabolic clinic. It starts as an idea and you say, oh, we already take care of those patients, but we don't really have a focused approach in the way we manage those patients. So my goal is to really walk you through a structure or a framework that allow you begin to put that clinical program together and all the different considerations. And these are my disclosures. So let's jump in. But honestly, the development of a clinical program or a new specialty clinic starts with what are the care objectives? What are we seeking to achieve with this particular patient population? And what are the things that we need to consider? So I want to walk you through a couple definitions. The first one is care pathway. So what is a care pathway? Well, a care pathway are schedules of medical and nursing procedures, including diagnostic tests, medications, consultations designed to affect an efficient, coordinated program of treatment. So the concept is this. I have a heart failure patient. There are specific things that we need to think about from a diagnostic perspective, from a treatment perspective, from a patient education perspective. And all of those things can be rolled up into a care pathway that really defines the what, the when. And then we're going to take it a step further and describe the who and the how. And once you start with that real clinical plan of what these patients deserve as part of the program, it allows you then to basically place the operational pieces on top of it and give you a roadmap that's required in order to implement or execute on that clinic program. Care pathways determine the locally agreed upon multidisciplinary practice based on guidelines. So you typically are going to work with a physician champion or maybe there's an APP that's going to be identified as the key clinical leader for the program. But you're going to start with that clinical expert and their vision, as well as the guidelines for these particular patient populations and or treatment requirements, if you will. So the aim of that care pathway to me is really it gives you the definition of what is required to get the outcomes that you're seeking for that patient population. The aim is to enhance the quality of care by improving patient outcomes, promoting patient safety, increasing patient satisfaction and optimizing the use of resources. That's a lot, but you can basically simplify that to say it tells me what every single patient that comes through my program deserves. And my job now is to operationalize that and create an environment where we make it easy for our staff and our people to do the right thing and those patients to get what they need. So it really provides the definition of what needs to happen. So care pathway characteristics are several things that you need to consider. Number one, it's an explicit statement of the goals and key elements. It needs to be written down. So we start by writing those things down. What happens when we identify a patient? What are the diagnostics that are required? What are the interventions that would be included? And begin to develop the clinical strategy for these patients that then allow us to figure out what resources, tools, people do I need to support those things. It also allows the facilitation of the communication, coordination of roles and sequencing of activities. So you're going to see an example I provide today. We are literally going to create a longitudinal care plan that when a patient enters into the program, we know what's going to happen with that patient throughout the next set of time. It could be months. It could be years. So we're going to walk through that. The documentation, monitoring and evaluation of variances and outcomes. Again, another way to simplify that is to really maps out what you're seeking to achieve and the different areas of care objectives or coordination of care that needs to happen in order to get there. And then it allows you as the developer of the program or the manager of the program to identify those appropriate resources. And that's really your people, your processes and your IT that are required. So another way to look at this is think about your patient and I'm going to get I'll apply this to an example and maybe it'll make a little bit more sense. But you have your patient in the middle. And what are the things that that patient deserves? And based on that, we start to develop our clinical standards out of our clinical standards. We can develop our protocols and all of that gets wrapped in underneath that pathway. And then once we know what the pathway is, we can identify the capital, the people and the information technology infrastructure that we need in order to deliver that care. So building the program, it starts with defining the who, the what and the when. So define your patient population. So today I'm going to use the example of cardiometabolic. We're starting to see more and more of those programs pop up. Your physician champion comes to you one day and says, Ginger, I would like to develop a cardiometabolic program. And I want to see patients that have cardiometabolic disease or have risk factors for that in a very concentrated programmatic fashion. I want to be able to market our program. I want to add additional resources for these patients. And I need that all wrapped up in a program. And I need you to help me build that. So we define who are the patients. So your first question back to that physician champion are, who are these patients? Do you want patients that are already diagnosed with cardiometabolic? Do you want patients that are at risk? And if you want patients that are at risk, what are those at risk characters? Is there a particular hemoglobin A1C, a particular lipid panel, a particular event in which these patients will have that triggers their ability to identify them for referrals into this program? So that's number one. We need to know who are the patients we're seeking to target with our new program. Number two, we need to define the objectives of care. So within our program, are we going to be looking to make a diagnosis or do any sort of risk assessment? Are we going to be seeking to treat them and manage them? And are we going to do pharmacologic management? Is there any procedural care associated with this? Is there any sort of behavioral or lifestyle interventions that we're going to be seeking to achieve? And you're going to see when we get into cardiometabolic, we're going to roll all of those things in. And then based on that, we need to align roles and responsibilities. So let's walk through what this looks like. And again, we'll use the cardiometabolic clinic. So first of all, defining your patient population. This is a very busy slide. But what I will tell you is that just about for every one of the disease management processes slash disease entities, the types of patients that we manage in cardiovascular care areas, you're going to find a set of guidelines that identify who those patients are based on clinical criteria. And then what are the guidelines that support the appropriate care in that patient? So what I pulled here is an example of a metabolic syndrome classification and management recommendations that was put together by the Cardiometabolic Health Alliance several years ago. But this makes for a great place to start to develop that care pathway. We've identified in this case, we show four different progression of the cardiometabolic disease that stages it from A, B, C, and D. We have identified what are the definitions related to those particular stages. So based on certain criteria, a patient would meet that stage. And then this has identified therapeutic interventions that would be focused on each of those stages. So what this starts with is that framework to go back to that physician champion and say, OK, where do we want to start? Do we want to start with stage A where we're really getting those patients that are at risk, but not necessarily have developed any of the end organ damage or progressed into true cardiometabolic disease? Or what about stage B? What about stage C? So as you define that, it allows you then to start to look at, OK, what are the therapies that I need to now start to roll into my care pathway? So it really starts with that patient population, patient definition, and the care objectives that are required for that particular type of patient. So a few questions you can walk through. What is your objective? And so when I, again, I think about this cardiometabolic patient population, there are several potential and I'll kind of spoiler alert. These are the objectives that we rolled into the model that or the clinic model that I'm going to show you here in just a minute. Number one, decrease cardiovascular disease risk through multidisciplinary management. Multidisciplinary management means I need more than a doctor. What are the other things that I need? And you're going to see we need nutrition. We need pharmacy. We need APPs. We need nurse coordination and nursing care. We're going to define all of that based on the care objectives that we're seeking to achieve. Number two, we've decided we want to manage lifestyle with these patients. That's a really important piece for intervention. And so we need to be able to provide them nutrition and lifestyle activity support. The goal related to weight loss or weight management and then good nutrition to manage their their cardiometabolic disease. The third one is cardiometabolic disease. And I'll give you a little bit of background here is really a culmination of four significant risks wrapped up into a patient that has them all. It significantly increases their risk of developing cardiovascular disease. So we are going to manage all four of those key areas or risk areas within our model. So hypertension, hyperlipidemia, hyperglycemia, insulin resistance or full on diabetes and then obesity. So, again, identifying those needs that we're going to manage are going to then help define what sort of resources do we need to have in place in order to do that. And then the fourth piece of this one has to do with these patient comorbidities. They've got many of them have additional challenges related to sleep apnea, atrial fibrillation, heart failure, diabetes, fatty liver, kidney dysfunction. Knowing that, then we're going to need to work through do we need to have referrals to other specialists? Do we need to have additional interventional touch points or additional screening to look for some of these other comorbidities that tend to go along with this disease process? So, again, the idea here is we're taking a clinical disease, if you will. We're identifying for our program which are the patients we want to manage and what are the key things that we're going to manage within our program. And we're starting to simplify it in a way that we can now start to pull together the tools and resources that we need in order to care for these patients effectively. All right. I mentioned multidisciplinary care. So I want to spend a little bit of time talking about care teams. In many of your clinics and programs, it isn't just a physician and an MA or a physician and a nurse that are managing these patients. You've got APPs. We're seeing more with nutrition. We're seeing more with pharmacy. We're seeing very significant role with nursing and the medical assistant. So we have to get really good at working with teams and understanding the different roles within the team. So I want to walk you through a couple of key pieces related to that, and then we'll get back into the cardiometabolic. So advantages of care teams. Why should we do this in a team-based model versus in a more traditional one physician model? So from a patient perspective, our teams improve care coordination. We have a broader width of scope or breadth of different key skill sets within our team. And we have an ability to manage the patient beyond just an office visit. If I just am relying on my physician and whatever happens during the office visit, what happens to all the stuff in between? So this allows us to improve care coordination. It also allows us to improve care integration because there's, again, oftentimes there's different skill sets. And that coming together, the whole is greater than the parts. And then I think it allows us, I'm going to talk you through kind of top of license. We want to use everybody's role efficiently. And when we come to this with a team and everyone has a very specific role and responsibility, it allows us to be much more efficient with people's time. From a healthcare professional, I believe it increases professional satisfaction because we're all taking part in the care of this patient population. And we all have a very specific role of what that looks like and value that we're providing to that overall care. We have the ability to shift from being very reactive to, I think, being much more preventative and being proactive with our patient care. And starting to look for risks and look for other things within our patient populations that we can manage proactively. And then I think it allows us all to focus on the areas that we're good at or the skills that we have based on the license, and that's a very rewarding environment to be in for sure. And then for the health care system, those that are funding the teams, we see more efficient care delivery. We have the right people doing the right work. We're maximizing our resources, and in some cases, facilities. If we can do some of this work virtually or other ways of communication, we can just manage our patient populations a bit more effectively and utilize our resources better. And then I think teams, we always do better if we put our heads together, and so facilitating that continuous quality improvement and seeking to constantly improve or see where there's areas of opportunity. So what is a care team? Well, a care team is, and I'm just going to hit the bulleted here, it's a group of health professionals that are focused around a patient or a particular type of patient with the goal to provide high-quality, coordinated care specific to patients' clinical needs. So you'll see in here we have physicians, advanced practice registered nurses, physician assistants, clinical pharmacists. The list is long. The list should also be customized to the patient population that you're seeking to achieve. So not every team would have a pharmacist. Not every team may have an APP. It really has to do with the care that you're seeking to provide. And then who's best based on license, based on skill set, based on resource availability, who would be best to provide that portion of the care objective. Some considerations when it comes to putting together teams. You certainly have to think about culture and making sure that every, you know, that's trust, that's transparency, that's value of why we're doing this together, that's vision. We need to accept evidence-based scientific guidelines. One of the ways that our teams work much better together is if we've aligned on the care that we're providing and what needs to happen with these patients. And if we've all agreed upon that on the front end, it gives us much more clarity around what is my job today, what needs to be done, which medication, which test. You know, it gives us all a roadmap in which to do this work. Number three, with multidisciplinary leadership, adopting best practices as standard work, train teams to create expertise and establish metrics for performance management. There's a lot of definition that goes on in order to get a team working well, who's doing what, who's accountable for what, and then creating standards around that so we can manage expectations and accountability. Number four, I mentioned earlier, not every team is going to include every type of cardiovascular clinician or team member. You really want to start with the needs of your patients first and then define the team based on the care objectives that need to be met and who has the best license or clinical competency, the skills for that. I mean, I oftentimes chuckle. I can have my physicians answer the phones. They're going to do a really good job answering the phones, but I have other things that only their license allows them to do. I probably shouldn't be using them to answer the phones. So when you start to think about some of these different care objectives, you go think about it through the lens of who on the team has that skill set, and sometimes it's license-defined, but that's how you start to define the appropriate team members. Number five, employing continuous process improvement. Again, team meetings, team huddles. Let's talk about what's going well, especially during the initial startup phase. You're going to be working out a lot of wrinkles, and the more the team works together on that, the better your clinic program is going to do and the outcomes that you're going to get. And then, of course, people then feel engaged because they feel like they're part of the program. They've got influence. They've got an ability to have a seat at the table when it comes to decisions and that kind of thing. And then finally, making the success of the care team and improved patient care central to each decision or process step. When things come up, should we do it this way? Let's take it back to our true north. Our true north is, is that what's right for our patient? Number one, will it improve our patient care, and will it improve what's needed for the team for the team to be successful? If the answer is no, maybe that's not what we should do. Maybe that's something, you know, it's, it might improve one individual, but if it doesn't have benefit for everyone, or if we have an improvement on one side, but it actually is detrimental to somebody else on the team. Again, we need to be using our true north as our way of making decisions and assuring that we've got our right objectives in mind when we do that. All right, so back to the cardiometabolic example. So I talked to you through kind of patient identification. We talked a little bit about some of those care objectives and what we've defined. Now we need to define our team. So in this case, we've defined physicians, and then we're going to actually bring together endocrinology and cardiology in this example. And you'll find that a number of these clinical programs, we end up cross disciplines with other specialists, which is a really fun thing to do when we bring together different physician clinical skills around these patients. So in this case, endocrine and cardiology, we're going to have a registered nurse who's going to manage care management, patient education, and clinic support. We're going to add a rehab exercise physiologist to help with activity, education with the patient, exercise plans, exercise coaching. We're going to pull in a dietician or nutritionist for patient education, assist with nutrition plan and coaching. And then we're going to add a pharmacist that's going to help with medication reconciliation, patient education, and medication optimization. So again, in this particular example, when we looked at the care objectives, these were the sorts of roles that we felt would be a great place to start for our team. So then we need to define the responsibilities. So we went through kind of all the things that are going to happen with this patient population, the referrals that come in and the initial consult and initiation, that's going to be owned by the physician. And then tracking electronic check-ins with documentation, reaching out to the patient in between those visits, that's going to be the registered nurse. So you can kind of look through as we develop, began to develop, what are all the different functions that need to happen? Let's decide who can manage those functions. And then we actually mapped it out. So we went through the longitudinal care plan for a sample patient, and we started at day zero with that initial visit. And then we mapped out all the things that were going to happen. And in this case, we went out 12 weeks. When do they need to come in by visit? When are we going to touch base electronically? When are we going to add additional support with education, with the dietician and the exercise physiologist? And we started to build all that up. We also provided objectives. So where we have other team members that are managing, we said, what are the things you should be doing during that visit or during that touch point? We started to build that out. So what that allows us to do, and I don't have one included here today, but you can begin to put together a business plan around this. You can look at which of these are billable encounters. You can look at your cost of the people that you need in order to provide these services. And then you can begin to put in volumes of patients and what you expect. How many days do I need to hold this clinic? What is the overall potential revenue generation of the clinic? And then what's the potential expense of the clinic? And again, as you start to then put together, if you end up in a role where you get to put together requests for adding these new services or new programs, it all starts right here. You can't put a pro forma together. If we don't understand the objectives of care, the people that are going to be doing it, which patients that might be coming through, how many patients might that be? How many days are we going to offer clinic? This allows you to answer all of those questions. And then another piece of this is tracking those patients. So this is where the technology comes in. Once we get those patients into the program, how are we going to track them across the program to look at their outcomes? And so this is where you go back to your EMR team or your information technology team and you lay out, this is the need. Is there a technology that we have access to that will help me with that need? And so in this case, we identified what are all the objectives. One is we got to identify the patients that are in the pathway. So if they're part of my program, I need to be able to pull a list of all the patients that are in my program and understand where they're at within the program. At a patient level, I need to be able to track milestones, inquiry for things that are past due. There's going to be a number of patient level activities. I've got to be able to follow up on those things if they're not being managed. Number three, the clinical information and the way we hand off between, I mean, there's a number of team members that I've got identified on here with different encounters. We need everybody be able to see all that information. So if their nutritionist or dietitian provides a visit, where's the documentation for that visit and does everybody have access to it? And then finally, my favorite is the patient engagement system. So do we have a way through our portal or through another software platform that we can engage these patients? We can maybe even educate these patients. We can remind these patients. There's a lot of different potential opportunities within that. As you start to think about your pathway and all of the different pieces that are associated, what do we need from an information technology to help pull all of that together? So as we start to kind of think about everything coming together and creating that, I think that there's a few other things for you to kind of use as your measuring stick. Am I getting this right? So number one, right processes. Did we start with that patient-specific care pathway? Did we get that defined? Do we know exactly what we're going to be trying to do with these patients and how we're going to go about that? Did we get an information technology platform that's going to allow us, can we use our EMR? And I would just, again, I will tell you there's some great, if you're an Epic shop or a Cerner shop or an Athena shop, there's some great functionality with those tools that allow you to track your patients. There's also some really great platforms that you can lay on top of your EMRs that allow you to do that. And then finally, do we have the right people that are identified, that are following through, that we're using to the right license? Are we using our physicians for the things that only the physicians can do and using our other experts for the things that they can do? And then finally, I wouldn't, you've heard about communication already in this course, but I have to just add one more piece here, and that is team communication. Because what's going to happen is this team isn't going to be in the clinic every time you have clinic. You're going to have some days where you have the nutritionist and you have other days, you might have the pharmacist. There'll be days you have the doctor and days you have a couple, but you may not ever have the team all together in one place, taking care of patients. So team meetings for program development and support are really important, especially during those first few months where we're just getting started and kind of testing out our new processes. I'm a big fan of daily huddles. Let's get together at the beginning of the day. Sometimes that's even virtual if we've got people doing things in different locations, but let's connect on what we have to do today and how we're going to go about that and if there's any unexpecteds in there or any things we need to be aware of. Detailed electronic health records, we all need to be documenting what we did with these patients, what we recommended, and then our maybe what we saw that day. One of the things, if you hear this in your clinic, that means your communication processes and your documentation has got some areas of opportunity. When your patients start saying things like, don't you people talk? That means we haven't done a good job of getting that patient documentation in the chart, in the way that everybody can see it. Don't ask the patients to be the conduit for our team communication. Make sure we've got that figured out on the front end. And then finally, that patient tracking to assure all care objectives are met. If patients are following through and getting things done, we need to be able to track that and we need to be able to know that. We need to be able to re-engage them and remind them. If you've got a program that has a lot of loss to follow up, I would suggest this because we haven't done a good job of engaging them and tracking things through. And our information technology systems have the ability to do that. We just have to build it or set it up appropriately and utilize those tools. So finally, a few key takeaways. Number one, start with defining which patients and objectives of care. So it all starts with if someone comes, knocks on your door and says, I want to start this clinic, your first question should be, okay, who are the patients and what are the care objectives that we're seeking to achieve? Step number two, now that I know that, who are the people on the team? What types of people do I have access to within my program? And who should I start engaging to see if we can't put together this clinic model and get the right people? And then finally, communicate, communicate, communicate, communicate with the patients, communicate with each other, documentation. Team-based care can be incredibly rewarding. I think outside of culture and identified roles and responsibilities, the third area that can break your team is poor communication. So just make sure you make it easy for people to communicate. You create venues for people to communicate and lots of follow-up on the back end to make sure that we are communicating effectively and everybody has what they need to do their jobs. So with that, I hope that was helpful. Please know you can reach out to academyatmedaxiom.com with any questions about this module or any of the other modules or the course. We would love to hear from you. Happy to answer questions related to the content. Also very happy for your feedback. So please provide any feedback that you might have. We're also always seeking to do better. So thank you for engaging with us today. 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specialty clinic setup

clinical program framework

care pathways

multidisciplinary teams

culturally aligned care

patient care objectives