High Performing Clinical Model

01/25/2022 Compiled by Valmeek Kudesia; accumulated from experience

Adheres to Integrated Clinical Response

Integrated clinical response is best for risk-bearing care of complex population because:

• Affirms that [[prevention-of-disease-and-stabilization-of-chronic-disease-as-mechanism-of-utilization-management]]

• Anchored in identity and behaviors of a clinical-organization

• Affirms that clinical outcomes are emergent phenomena and therefore clinical responses must be knit together

• "Member/Patient is the pathway" 

  • Maintains longitudinal member/patient data and timeline 

  • Serves as mechanism for holistic sense-making and integrated response i.e. [[use-of-data-at-a-data-informed-org]], data-informed compassion-guided healthcare org, vision for use of data clinical org

• Each clinical touch is as efficient as possible (work is bundled, rework eliminated) and high quality i.e. [[maximize-the-work-not-done]]

Acknowledges of Consequences of Fragmented Clinical Response

Recognizes that colliding staff and initiatives (fighting over members/patients and staff) is Failure to Acknowledge Day-to-Day Reality [[failure-to-face-the-challenge]] and is fantasy thinking e.g. analogous to thinking antibiotic and anticoagulant do not interact in same patient.  This deficiency leads to the following consequences:

• Places burden of reintegration, prioritization on staff who always have to remember EVERYTHING (leads to burnout)

• Forces patient/members to bear poor outcomes (medical, social, behavioral health)

• Reduces likelihood of patient/member and org success

• Unable to identify value of individual initiative 

• Leads to "chase each initiative harder....in a circle"

• Reinforces "Failure Demand"

Deploys Learning Loop in Programmatic Design and Application

• Data-informed methods + clinical expertise identify appropriate mbrs/patients at earliest time in outcome trajectory

• Have programmatic offering available for relevant portions of trajectory

• Have eligible/valid offerings cross-matched against individual mbr/pt benefits

• Present needs/gaps/offering to right clinicians at point of action-planning and point of action

• Ensure patients/mbrs receive right services/actions efficiently; right process and documentation, integrated actions and group amplified

• Observe outcomes, gains [[knowledge-about-variation]], informs data-informed methods and programmatic design resulting in a learning organization and [[Individual-and-organizational-learning]]

• Traverses [[combined-value-stream and ]] and [[progression-up-virtual-value-stream]]. In particular accommodates [[physician-progression-up-value-based-care]] by providing enabling environment for best care/outcomes

Enduring Behaviors

• Seeks [[elimination-of-failures-vs-failure-demand]]

• Seeks [[minimize-total-cost]] and [[improve-constantly-and-forever-system-of-production-and-services]] on [[things-that-never-change]] through persistent focus on essential questions in healthcare and adherence to fundamental design principle for healthcare

• Embody [[foresight-primary-ethic-of-leadership]] and prepare "model as itself the path or the way" for future challenges

• Does Not Fail to Acknowledge Day-to-Day Reality [[failure-to-face-the-challenge]] , thereby avoids [[bad-strategy]]

  • Acknowledges that only "gain progress" from currently enrolled members or active patients i.e impactable as e.g. cannot intervene 5 months ago

  • Progress won or lost at level of daily actions

Outcomes

• Member/patient: ⬆QOL,⬆satisfaction, ⬇suffering

• Clinical staff/caregivers: ⬆QOL,⬆satisfaction, ⬇suffering