The concept of total employee health management achieves new heights at Group Health Cooperative (GHC), where the occupational health program has earned a quality seal of approval from the National Association of Occupational Health Professionals.
The Group Health at Work Occupational Health Services Department received a certification score of 97.8 out of a possible 100 percent compliant with NAOHP standards following an onsite review in March. The award acknowledges that Group Health, based in Seattle, Wash., offers an exceptionally high level of occupational health-related services to employers and employees in the markets it serves.
The occupational health program was recognized for “Outstanding Achievement,” with particular accolades from NAOHP site surveyor Donna Lee Gardner for comprehensiveness, standardization and performance measurement. “Group Health has taken total health management to a new level using their experience with an integrated care and coverage delivery model,” she said.
Outreach Impact
GHC is a large healthcare delivery system serving multiple markets in Washington and Idaho. Occupational health is embedded at 12 primary care and multi-specialty practice locations in the Puget Sound region; two additional locations are planned for 2011. Occupational health is a relatively small unit, but it plays a large strategic role because it has the potential to reach significant numbers of current and prospective Group Health plan purchasers and members.
The program has 10 board-certified physicians, one board-eligible physician, one urgent care/family practice physician, and five physician assistants with advanced training in occupational medicine. The same providers support an internal total health management program by providing medical services to Group Health’s vast workforce.
In addition to complex nurse case management for any patient who is discharged from any hospital in the system, GHC employs workers’ compensation case managers who are trained in vocational counseling. The case managers typically deal with cases involving barriers to recovery and/or time loss, surgery and other mitigating factors by facilitating communication among all relevant parties. “They are a great asset and one of the main reasons why Group Health at Work Occupational Health Services is so successful,” said Christina Lombardi, director, of Occupational Health Services.
The delivery model has evolved over time. More than a decade ago, occupational medicine was first introduced in the system as a consultative specialty for handling complex cases. Care tended to be fragmented because the focus was not on early encounters. “Initially we trained teams of family practice providers to treat injured
workers in most primary care locations. Over time, we have placed dedicated occupational medicine providers in primary care settings,” Ms. Lombardi said. “Directing patients/employees to the right provider for the right care has significantly lowered total medical claims costs. Employers who compare us to other entities say their claims and time-loss costs are always lower when their employees see our providers. Our own risk manager also has noted a dramatic decrease in workers’ compensation costs and quicker return to work.” High patient satisfaction is another byproduct of appropriate early intervention. Group Health data show that 32 percent of non-plan members who touch occupational medicine enroll in a Group Health plan within a year.
Consistency Necessary
Given the size of the organization, it’s understandable why Group Health management is obsessive about standardization. “If we didn’t have consistency and standards to measure quality, service, and cost it would very difficult” to deliver quality care, Ms. Lombardi said. GHC has adopted a lean management structure and philosophy as the foundation for operations. In occupational health, standards and process measures go hand-in-hand. “When you try to manage to variation, it increases costs,” Ms. Lombardi explained. “With the lean philosophy, when you implement standard work, you also implement process measurements so you can intervene as soon as you see a variance.” The lean structure is particularly helpful for GHC occupational medicine specialists who practice in primary care facilities without direct day-to-day oversight. While there are local clinic operations managers, to ensure consistency, occupational medicine management regularly performs “rounding” at each site, checking for deviations from standards. “Linked checking” is another critical related activity. Links in the chain of command include frontline staff, occupational health department managers, the primary care division and Group Health executive leadership. “For instance, if we are tracking how consistently we complete after visit summaries at various locations, the findings go from the department level to the division level to the executive level,” Ms. Lombardi said. “It’s meaningful to the entire organization in the context of our goals: affordability, quality, growth, and people.” Consistency among all delivery locations also is supported by bi-weekly phone huddles for nurses and physicians, and quarterly, in-person department meetings.
Clinical Performance
Ms. Gardner said she is impressed with how the Group Health at Work team uses a performance matrix to clearly define expectations and competencies for its clinical staff. In addition, Ms. Gardner said she appreciates the way a GHC “chief’s manual” defines the role and responsibilities of departmental medical leaders. Abid Haq, M.D., the occupational medicine service line chief, is responsible for day-to-day operations such as clinical staff scheduling, time on task (e.g., patient care, education, documentation) and performance reviews. The chief works with Ms. Lombardi, Associate Director Dan Perrow and Clinical Operations Manager Jan Schumann, R.N., to ensure decisions align with medical practices.
In addition, Group Health at Work uses a training matrix (Excel spreadsheet) that lists all procedures routinely performed by nurses. The matrix notes whether a nurse is trained/certified on a specific task, has demonstrated competency and, if they have an exceptional level of skill in a certain area, are qualified to serve as a specialized resource.
Physician Advisers
The program also utilizes a structured Physician Advisory Group to provide clinical guidance. Members include four occupational medicine physicians, one physician assistant, Dr. Haq and Mr. Perrow. “Creation of a formally organized Physician Advisory Group came about as a result of applying for NAOHP certification,” Mr. Perrow said. “Previously, it was an ad-hoc activity. It is one of the great takeaways of certification. The providers are very engaged and feel there is tremendous value.” The group successfully undertook the development of an occupational medicine chart review/electronic health record process to make it more applicable. Group Health at Work is required to use EPIC, a global information management and electronic medical record-keeping system that is not designed for occupational medicine, so some adjustments have been necessary. The group is currently working on standardizing processes for performing Department of Transportation medical exams. The group invites specialists to participate on a consulting basis. For example, the service line chief of pulmonary medicine recently provided guidance on managing sleep apnea in drivers. Between quarterly meetings, members exchange phone calls and emails to resolve issues as they arise.
Leveraging Certification
When the NAOHP first introduced the site certification program, the Group Health at Work team viewed it as an opportunity to validate their department’s performance, its broader role within the cooperative, and its impact in the marketplace. Staff began preparing for the NAOHP site survey at the beginning of 2009, took a temporary hiatus while working on other projects, and resumed preparation last November. Individual staff members were assigned to gather documentation and other necessary materials relevant to their areas of responsibility.
“The certification process has helped us gain greater clarity on reporting financial performance, quality, consistency, patient outcomes – all of our metrics,” Mr. Perrow said. “Certification also has helped us become better organized, pulling together all of our training manuals and processes. Standardized resources are in place now for orientation and ongoing training.” During her site visit, Ms. Gardner was able to access all required documentation via an electronic table of contents.
“We used SharePoint® (a Microsoft Office product) to store index files, service agreements, company protocols, and other information,” Mr. Perrow said. “Instead of a bookshelf of manuals, we had it all stored online. That makes it much easier to update and link with other Group Health processes.”
Moving forward, GHC is working with its Employer Advisory Group to increase program visibility and its health plan sales department to further develop a consulting role with brokers and purchasers relative to non-occupational care and the integration of disability and workers’ compensation care management.
“We want to determine what we, as a cooperative, can do to impact outcomes and offer strategies to employers,” Ms. Lombardi said. “We believe we have the right model in place. Effective injury care and a focus on injury prevention and safety in the workplace, combined with the total health of the employee, will have the biggest impact. This is our future in occupational health.”
