How West Moreton HHS operationalized its site-of-care shift strategy

Before operationalizing new care models, organizations must develop a framework for vetting proposals to ensure all care shifts meet mission-critical goals and priorities. Doing so will ensure a coordinated approach to shifting sites of care and a carefully curated service portfolio.

Go/no-go framework instills habit of vetting only programs that align with system-wide goals

To keep all investments tied to their goal of achieving sustainability, West Moreton HHS created a three-pronged decision-making guide to vet new proposals. This framework forces leaders to scrutinize potential shifts to ensure that they align with the health system’s goals.

Leaders greenlight proposals for new virtual care models only if they support at least one of the following three goals:

1. Hospital avoidance. One facet of West Moreton’s sustainability strategy is to proactively keep high-cost, high-risk patients out of the hospital. Models that support this include each of their seven longitudinal virtual chronic disease management programs:
   • MeCare for multi-morbid chronic disease patients
   • Covid Light Touch for Covid-19 patients recovering at home
   • Heart Health Hub for congestive heart failure patients
   • Live Well for patients with borderline personality disorder
   • Gestational diabetes virtual management program
   • Prostate cancer survivorship program
   • Breast care program
2. Hospital substitution. Another facet of West Moreton’s sustainability strategy is designing programs that substitute hospital care and service patients in community or home settings. Services that support this goal include:
   • Telehealth outpatient consults
   • Hospital in the Home program
3. Hospital flow. The last angle from which they approach sustainability is improving and maximizing internal efficiency by leveraging virtual care within the hospital setting. Such programs include:
   • Virtual wards
   • Remote monitoring of inpatients in acute units, ED short-stay beds, and intensive and critical care units

A decision-making framework such as this ensures that organizations are investing resources into programs and services that will help them address their most urgent priorities.

A go-to guide for greenlighting new care models also enables organizations to respond to sustainability pressures more efficiently. Having a list of criteria that every new care model must meet allows them to deny or approve (and then establish) new models faster.

Once organizations make site-of-care shifts a mission priority, they can identify and act on opportunities to shift services to alternative settings. West Moreton took a centralized approach to identifying and implementing these opportunities. They replicated a Center of Excellence model wherein a centralized team of non-clinical staff function as “site-of-care shift experts.”

Centralize expertise to develop and refine institutional knowledge

This centralized team, called the Virtual Support Team, consists of a core group that reports to executive director of rural and community services. It includes an administrative support worker, a project manager, a business analyst, and an IT architect. For each care shift, the Virtual Support Team partners with an executive sponsor and a clinical lead champion from the unit where the shift is happening to embed new care models.

The Virtual Support Team specializes in the following areas:

1. Data analysis. The team analyzes patient access data to identify services for which demand is increasing unsustainably. With this data, the team recommends specific cohorts of patients who may benefit from new care models or improvements to existing ones.
2. Financial forecasting and modeling. Team members project the long-term cost savings of potential new models to pinpoint opportunities with the greatest possible ROI.
3. Garnering clinical buy-in. The Virtual Support Team identifies clinical teams that already have an appetite for virtual care and works with a clinical lead champion to secure and maintain buy-in.
4. New care model implementation. The Virtual Support Team works with clinical teams to reconstruct workflows to include virtual and hybrid pathways.

Knowledge-building enables progressively faster, better responses to sustainability threats

Assigning ownership of site-of-care shifts to a dedicated group allows the staff on the team to deepen their expertise over time. This creates an institutional knowledge-base that West Moreton can tap into for any new care shift opportunity. Having a single team manage site-of-care shifts enables the system to consistently get better at proactively responding to demand pressures.

This highlights how every piece of West Moreton’s site-of-care shift strategy is thoughtfully constructed in response to current and future threats to the system’s sustainability.

After organizations identify and greenlight an opportunity to shift a service to a new site or modality, the last step is embedding and launching the new pathway. Rather than adding a virtual alternative to an in-person service, which would duplicate access points and increase costs, West Moreton instead works with clinical teams to reconfigure existing in-person pathways to become either fully virtual or hybrid pathways, depending on the proposed care model. This ensures that all new models are sustainable and scalable.

The process of reworking existing care models is a collaborative effort between the Virtual Support Team and the clinicians on the unit where the care shift is happening. Involving clinicians in the process of embedding new pathways is critical to securing buy-in and maintaining their engagement.

Repetition strengthens site-of-care shift skills and minimizes variation within care models

The Virtual Support Team follows the same codified set of steps for every care shift and new model they implement. Again, this is an effort to both reduce variation across their services and strengthen the skill set of the Virtual Support Team through repetition.

1. Secure buy-in with descriptive, not prescriptive, data

For every care shift, the Virtual Support Team first secures buy-in from the clinical team by presenting data that highlights inefficiencies in the clinical team’s current processes, such as long wait times and referral backlogs. The goal of this step is to get clinical staff on the same page and highlight the problem at hand and the opportunity to deliver better, more efficient care for patients—not to push a specific agenda that is solution-focused from the start. This approach ensures that clinicians don’t feel like change is being imposed on them.

2. “Unpack” the current workflow’s inefficiencies

The next step in the process is unearthing the root causes of the inefficiencies highlighted in step one. To do this, the Virtual Support Team breaks down the clinical team’s current workflows and conducts an in-depth root-cause analysis.

For example, in their virtual chronic disease management program for heart failure patients, the Virtual Support Team dissected clinical workflows and uncovered inefficiencies. The analysis revealed a lack of adequate staffing resources to meet rising demand, a lack of alignment to strategic priorities, inaccessibility of patient data, outdated technology, and other issues.

3. Collaboratively “repackage” new workflows

Once teams understand why current in-person processes are inefficient, they can create new virtual and hybrid workflows that solve for those root-cause problems. Collaboration between the Virtual Support Team and clinicians is especially critical in this step to ensure that the clinicians embrace the changes. To that end, the new model is staffed with clinicians’ preferences in mind. Clinicians who prefer to deliver in-person care continue to do so, while those with an affinity for virtual care operate the virtual pathway.

In the disease management program for heart failure patients mentioned above, the Virtual Support Team and clinical teams embedded new remote monitoring technologies and remapped nursing team hours under new hybrid in-person/virtual pathways to maximize efficiency. This enabled the clinical team to deliver care to more patients and do so even faster.

4. Start small and scale over time

Lastly, the Virtual Support Team and clinicians launch the new model. At first, clinicians see the same number of patients they saw under the in-person-only model so they can become accustomed to the new model. Gradually, the number of patients under each clinician increases.

West Moreton HHS has launched seven virtual chronic disease management programs (outlined under the first bullet on page 6) following the steps outlined in this section. This approach can be replicated to other site-of-care-shifts, not just in-person to virtual.

Following a templatized process for launching new care models reduces variation across new programs and builds on lessons learned. By repeating these four steps for every care shift, the Virtual Support Team is mastering their skills and consistently improving West Moreton HHS’s ability to respond to sustainability threats.