CCLC/SNI/Kaiser

Chronic Care Learning Communities Initiative

Collaborative Final Outcomes Congress

December 9, 2005

Santa Clara Valley Medical Center

CCLC/SNI/Kaiser

SCVMC: Stroke Prevention

• Location: Northern California - Tertiary Regional Medical Center - Silicon Valley Administered by County of Santa Clara.

• Size: Metropolitan Area of Santa Clara County Has a Population of 1.7 Million Residents; 50% Live in the City of San Jose, the County Seat; identified 250 patients with multiple risk factors from 9,000 patients in diabetes registry

• Population Served: 44% European American; 26% Asian American; 24% Hispanic/Latino; 3% African American; <1% Native American. Over 34% Residents “Foreign Born”; Over 50% Speak Language Other Than English; Over 10% Speak No English.

CCLC/SNI/Kaiser

DeliverySystemDesign

Decision Support

ClinicalInformation

Systems

Self-Management Support

Health System

Resources and Policies

Community

Organization of Health Care

• Registry• Care reminder• Subgroups• Care-planning• Data mining

• Team roles & tasks

• planned visits• continuity• follow-up• Team building

• Guidelines• specialty

interaction• provider

education• guidelines

for patients

• interventions• care-planning

& problem solving• Relationship building• Assessing needs,

expectations and values

• Information sharing• Goal setting• Action planning• Problem solving

CHRONIC CARE MODEL

CCLC/SNI/Kaiser

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

Functional and Clinical Outcomes

•Goals: create business plan for CCM•Coordinate care delivery efforts among providers•Introduce and discuss provider incentives•Senior leaders created framework to study CCM

Health System

Resources and Policies

Community Organization of Health Care

•TCOYD•Kaiser, SNI, Diabetes Coalition•Establish liaison with industry

Chronic Care Model

CCLC/SNI/Kaiser

Key intervention:•Assessment of patients at high risk for cardiovascular event•Design and delivery of educational module for stroke self-management SAVED (sensation, ache, vision, expression, dizziness)•Protocols published and care managers certified•Collaborative Plan formulated with each participant, based on PCP input and participant’s readiness is in role out phase•Self-Management support was emphasized•Proactive follow-up for one year

Informed,ActivatedPatient

ProductiveInteractions

PreparedPractice Team

Risk factor intervention for Cardiovascular complications

CCLC/SNI/Kaiser

Clinical Information Systems

• Registry– Filemaker workgroup based design

– Process flow from encounter to remote entry

– Care reminders

– Outlier reporting to identify patients in need of test

– Emails and IVR produced from registry

• Patient subgroups– MDs receive lists of patients with hgba1c > 8.0%

• Care-planning– Lists generated for those with missing labs

CCLC/SNI/Kaiser

Decision Support• Guidelines

– Provider agreement to adopt guidelines HEDIS, ADA– Published on the intranet/extranet– Registry programmed to alert clinician

• Specialty interaction– Design and pilot a referral form– Transmit retinal scans to ophthalmology

• Provider education– Meet with primary care monthly– Educational seminars, TCOYD

• Guidelines for patients– Wallet cards with meds printed on back

CCLC/SNI/Kaiser

Delivery System Design• Team roles & tasks

– Nurses/PA-C/PharmD use medication adjustment protocols

– MD refers to educator who records patients goals– Care manager offers education and/or management

• Planned visits– Registry printout shows current lab– Alert PCP and patient labs before appointment

• Continuity– Prompts for specialty MD contact from referral form

• Follow-up – CDE calls patients regularly

CCLC/SNI/Kaiser

Self Management Support

• Emphasize patient role– Multiple providers send this message to patient

• Assessment– Downloaded assessment from website– CDE assesses patient at planned visit

• Interventions– CDE trained through chronic disease self-

management program

• Care-planning & problem solving– Use of motivational interviewing techniques

CCLC/SNI/Kaiser

Community Resources• Effective programs

– Identified community resources at Diabetes Coalition

– Co-sponsored TCOYD conference

• Partnerships– Kaiser community benefits program

– Outreach to SCC medical society and physician IPA

• Coordination– Recognize Diabetes Society as an educational resource

CCLC/SNI/Kaiser

Organization of Health Care • Teams

– Link care managers to PCP’s within geographic area

• Benefits– Partner with division of primary care quality programs

for shared goals and processes

• Provider incentives– Introduce BP surveillance and goals

• Senior leaders– Approved involvement in CCM pilots and spread teams

on tracking and reporting on collaborative measures– Sanctioned a study comparing traditional care to care

delivered via the chronic care model

CCLC/SNI/Kaiser

Functional and Clinical Outcomes

Baseline STUDY

Hba1c Q 3-4 04 Q1 v Q2 05

– Pre intervention 8.5 8.0– Post intervention 7.5 7.5

CCLC/SNI/Kaiser

BarriersCollaboration Not Dictation

• Difficulty with centralized department sending “delinquent” lab monitoring notices to the PCP– Send reminders not delinquent notices– Create a team of care manager and 3 PCP’s– Introduce the possibility of pay for performance

CCLC/SNI/Kaiser

Stroke Reduction Education Referral

0102030405060708090

100%

Pts

. Re

ferr

ed

% referred 0 0 0 0 4 6 7 26 29 33 48 54

Goal 100 100 100 100 100 100 100 100 100 100 100 100 100 100

# all pts. 252 252 252 252 252 252 252 252 252 252 252

Oct 04

Nov 04

Dec 04

Jan 05

Feb 05

Mar 05

Apr 05

May 05

Jun 05

Jul 05

Aug 05

Sep 05

Oct 05

Nov 05

CCLC/SNI/Kaiser

A1c Test

0102030405060708090

100

%t

Pts

. w

/A1

c T

es

t

% w/2 ts ts w/in yr.≥3m nths apart

8 58 63 68 83 81 81 75 78 78 79 79

Goal 90 90 90 90 90 90 90 90 90 90 90 90 90 90

# all pts 252 252 252 252 252 252 252 252 252 252 252

Oct 04

Nov 04

Dec 04

Jan 05

Feb 05

Mar 05

Apr 05

May 05

Jun 05

Jul 05

Aug 05

Sep 05

Oct 05

Nov 05

CCLC/SNI/Kaiser

Detail of Hba1c Testing

Hba1c % <7Q1 62Q2 57Q3 46Q4 47

CCLC/SNI/Kaiser

Detail of Hba1c Testing

Hba1c % <7 # testedQ1 62 86Q2 57 121Q3 46 89Q4 47 214

CCLC/SNI/Kaiser

Detail of Hba1c TestingScalability

Hba1c % <7 # tested #<7Q1 62 86 54Q2 57 121 69Q3 46 89 41Q4 47 214 100

CCLC/SNI/Kaiser

Spreading Chronic Care Improvements

• Complete buy-in.– To study of the proof of concept.– Support a trial comparing outcomes traditional

ambulatory care the chronic care model.– Compare total expenditures and resource utilization

(hospitalization, emergency and urgent care utilization and laboratory/ancillary care costs) within a closed system.

CCLC/SNI/Kaiser

A Patient Voice