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Transcript of From the Frontline of Care Improvement – How to do it Right Webinar #3 - Diabetes Care Improvement...
From the Frontline of Care Improvement – How to do it Right
Webinar #3 - Diabetes Care Improvement Series
Chris Cammisa, MD. Medical Consultant, California Quality
Collaborative (CQC).
Farhan Fadoo, MD, MS. Chief Medical
Information Officer, San Joaquin General
Hospital (SJGH).
David Eibling, MD. Medical Director, Health Plan of San
Joaquin (HPSJ).
January 18, 2013
Agenda for Today’s Webinar
• Describe a couple of simple improvement models useful to small group practices
• Provide some improvement strategies from our work in a diabetes collaborative in Southern California
• Highlight a local best practice
• How HPSJ supports practices
2
The Model for Improvement
• An approach promoted by IHI
• Three basic/key componentso Aim Statement – What are we trying to
accomplish?o Measure – How will we know if we have
accomplished our goal?o Change – What are some interventions we can try
to move toward our goal?
• A really good way to help us focus on the work of improving
3
The Care Model
• Developed by the Institute for Healthcare Improvement (IHI)
• Five Key Componentso Clinical Information Systemso Delivery System Designo Organization of Health Careo Self management and adherenceo Maximizing the use of community resources
• The two keys are a Prepared Practice Site and an Engaged Patient
4
The Concept of PDSA
• Stands for plan, do, study, act• After setting a goal and a measurement strategy• Try an intervention as a small pilot test• Then evaluate how it went before spreading the change• Implicit in this process is the idea of teamwork• www.ihi.org
5
The CQC Collaborative
• Five medical groups/IPAs in the Inland Empire Area
• Ran over a 15 month period from late 2010 to early 2012
• Utilized expert faculty for content
• Cindi Ardans and I were the co-leads
6
Objectives of CCC
• Achieve 20% relative improvement in selected diabetes measures
• Three core measures & four optional to track progress
7
Structure
• IHI Breakthrough Series College structure
• Four in-person learning sessions
• Action periods between LS
• Coaching calls with CCC co-leads
• Webinars on related topics
• TA support as needed
• Two site visits
8
Action Periods
• Team leader convenes team periodically
• Operationalize work plan
• Conduct PDSA cycles to test changes
• Measurement cycles to assess progress
• Communicated & celebrated progress!
9
Outreach Interventions
Activity BFMC DOHC Epic NAMM UFC
Group/sends letters to patients
Group/IPA does outbound calls to patients
Site visits/phone calls to practices
Gap reports to practices
Health ed materials to practices
Health ed materials to patients
Health educator/CDE consults
10
Other Interventions
Activity BFMC DOHC Epic NAMM UFC
Registry operational IP
Intensive pharmacist intervention
Financial incentives to practices
Automated lab order entry
Use of CPT Category II codes for BP
Promote diabetes care at health fairs, etc.
Public recognition of high performing physician practices
Process to update patient contact info
11
Diabetes Measures
Core (all groups)– A1c test last 12 mos– A1c > 9.0 or no test– LDL-C test last 12 mos
12
Optional– A1c <8.0– Nephropathy
monitoring– LDL-C <100– BP <140/90
Results
• Goals calculated as relative improvement 20% of gap between Q4 2010 baseline and benchmark
• Comparing Q4 2011 to Q4 2010, 7 of 8 measures met the goal and 1 measure was unchanged
• Though interventions have not spread to all practices, the ‘grapevine’ promotes adoption
• Interventions working – next steps are spread and sustain improvements
13
Lessons Learned
• Functioning registry is fundamental
• Good communication plan is essential
• Small practices may have advantage
• Using proven QI models = improvement
• Persistence, follow-up more critical than brilliant ideas
• Active collaborative participation = motivation
14
Changes You Might Want to Consider for Your Practice
15
Systems and Process Improvement
• What follows are suggestions to reorganize the practice
• The practice and the patient visit provide opportunities for improving the care
• Promoting a more prepared and proactive team
• Building more informed and engaged patients
16
Office Systems
• Identify and train clinical and office staff in their role as members of the diabetes care team
• Implement standing orders for common problems or patient conditions
• Hold a daily huddle prior to the opening of the practice with the office staff
• Trained medical assistants
17
Chart Prompts
• Help patients set self-management goals and provide a goals worksheet and daily log
• Develop a follow-up system• Keep a cheat sheet of the diabetes medication copays in
the exam room for health plans common in your practice
• Ask the patient about medication cost issues
18
Exam Rooms/Waiting Area
• Post a reminder list of proper procedures for patients with diabetes
• Post a reminder or checklist, visible to the appointment desk staff, providing procedural reminders for visits of patients with diabetes
• Implement regular staff meetings
• Staff conducts “messenger activities”
19
Building the Diabetes Care Team
• Attach foot exam results to charts
• Keep flow sheets and/or visit planners in the medical record
• Highlight out of range values for blood pressure, glucose and lipids
• Consider color-coding charts of patients with diabetes
• Review and update the disease registry regularly
• Record the patient’s language and race/ethnicity in the medical record
20
Patient Activation/Support
• Place educational posters in patients line of sight oThe information displayed can empower patients to
ask questions and/or remind healthcare professionals of routine care
• Have a brochure rack including diabetes-focused topics
• Information should be provided in multiple languages
21
Success in San Joaquin
Next it is my pleasure to introduce Dr. Farhan Fadoo, Chief Medical Information Officer at San Joaquin General Hospital who will talk about what his organization is doing to improve care for their members with chronic conditions.
22
Rethinking Primary CareLeveraging Population Management Tools to Enhance
Data Visibility and Impact Care Quality
Farhan Fadoo, M.D., M.S.Chief Medical Information OfficerSan Joaquin General HospitalJanuary 18, 2013
• 27 Clinics (4 Primary Care, 2 Peds, 2 OB/GYN, 19 Specialty)
• 3 Residency Programs (IM, FM, GS)• 200k OP encounters/year; ~100 providers (incl. residents)• Operational staff = 5 FTE• Vulnerable patient population – payer mix tilted towards
self-pay and medically indigent, followed by Medi-Cal• Challenges with Patient Access and PCP Continuity and
Patient Satisfaction• Tension between educational mission and patient care in
residency clinics• Striking appropriate balance with SJGH inpatient priorities• Uncertain climate around payment reform
SJGH Ambulatory Care Services
24
Operational• Delivery System Reform Incentive Program (DSRIP)• Patient-Centered Medical Home (PCMH)• Changes in rules governing residency programs
(ACGME/RRC)• Transition to FQHC-LAL (primary care)• Future??? An eye towards ACOs…
Technological• Meaningful Use (MU) and ARRA/HITECH• Community HIE• ICD-10 Conversion
Change is Upon Us…
25
PCMH: The Triple Aim1
• Improved Patient Experien
ce
• Lower per capita
Healthcare Cost
• Improved
Population
Health
1 Source: Berwick, D.M., Nolan, T.W., and Whittington, J. (2008)
At SJGH:Doing Better,
For More,With Less
26
Improved Population Health
• Decrease Overall Disease Burdeno Preventiono Wellnesso Screeningo Immunization
• Decrease Hospitalizations• Decrease Acute Illness• Improve Mental Health• Expanded Access to Health Care Services
27
Improved Patient Experience
• Self Management Support2
• Enhanced Communication• Decreased Waits/Delays
• Improved Patient Satisfaction Scores
• Coordination of Care
2 Source: Patient-Centered Primary Care Collaborative (2010).28
Lower Per Capita Healthcare Cost
• Decreased ED Utilization• Decreased Hospital Admissions• Shorter LOS• Case Management
Proactive
29
Population Management Tools• Unique Vantage Pointo Not just about individuals but populations
• Leverage Multiple Sources of Data• Reporting and Dashboardso Daily, Monthly, Quarterlyo Provider-specifico Disease-specific
• Goals/Targets
30
Population Management Tools
Computerized Chronic Disease Registry
• Powerful• Visible• Interfaced
• Actionable Reporting
= Paradigm Shift
31
Interface Spaghetti
32
• i2iTracks
• DEMOGRAPHICS
• VISITS
• CPT
• ICD-9
• APPOINTMENTS
• POINT
• OF
• CARE
• LAB
Disease Registry Interfaces
EHR Clinicals
Vitals
PharmacyImaging
33
Sep-
11
Nov-1
1
Jan-
12
Mar-
12
May
-12
Jul-1
2
Sep-
12
Nov-1
2
Jan-
130%
20%40%60%80%
100%
A1c <8 (Outcome) -Initial Population of
Focus
Sep-
11
Nov-1
1
Jan-
12
Mar-
12
May
-12
Jul-1
2
Sep-
12
Nov-1
2
Jan-
130%
40%
80%
BP <140/90 (Outcome) -Initial Population of
Focus
Sep-
11
Nov-1
1
Jan-
12
Mar-
12
May
-12
Jul-1
2
Sep-
12
Nov-1
2
Jan-
130%
20%
40%
60%
80%
100%
BP (Process) -Initial Population of Focus
Sep-
11
Nov-1
1
Jan-
12
Mar-
12
May
-12
Jul-1
2
Sep-
12
Nov-1
2
Jan-
130%
40%
80%
Depression Screening (Process) -
Initial Population of Focus
34
Diabetes and Obesity
6/1/2012 7/1/2012 8/1/2012 9/1/2012 10/1/20120%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Process: BMI >=27 with intervention
Percent of Patients with BMI >=27 who received interventionTarget >60%
35
Diabetes and Tobacco
Jun-12 Jul-12 Aug-12 Sep-12 Oct-120%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Process: Tobacco Screening
% Patients with Tobacco Screening
% Patients receiving Tobacco Cessation In-tervention
Target for Intervention >80%
n=62
n=70
n=66n=55
n=33
36
Registry Reports
37
38
• Aggressive empanelment activity• Building culture around datao Diabetes and Depression as Use Caseso Office of Panel Management and Specialty Referrals
• Strong Collaborative Partnership with HPSJ• Lean Healthcare Principleso Workflow Standardization / Minimizing Wasteo Risk Management / Root Cause Analysiso Care Team Models / Operational Efficiency
• NCQA Recognition – Diabetes (Aug. 2012)
SJGH PCMH Progress
39
NCQA DRP
40
The Physician Cup Runneth Over
41
42
• Deploy Integrated Ambulatory Practice Management System (PMS) and Electronic Health Record (EHR)o Scheduling, Revenue Cycle, Messaging, CPOE/CDS, E-Rx
• Expand Use of i2iTracks Disease Registry for Population Mgmt.o Asthma/COPD; Women’s Health; Immunizations; Pain Management
• Continue to Foster an Organizational Culture around Datao Deliver Value through Analytics and Business Intelligenceo Operational, Financial, and Clinical Dashboardso Participate in Community-Wide HIE
• Achieve NCQA Recognition for Level 3 PCMHo Advanced Access, Enhanced Continuity, Sophisticated Care Coordination,
Population Management
SJGH Ambulatory Care Services – Future Strategy
43
Takeaways• Healthcare reform will drive adoption of
“PCMH-like” models of care delivery that heavily leverage care teams• Progressive alignment of financial incentives• Data visibility is key to managing population
health• San Joaquin County’s population is poised to
receive innovative service deliveryfrom SJGH and its communitypartners
44
References• Berwick, D.M., Nolan, T.W., and Whittington, J. (2008). The Triple Aim: Care Health, and
Cost. Health Affairs. 27(3), 759-69. Retrieved on 11/11/12 from http://content.healthaffairs.org/content/27/3/759.full.pdf+html
• California HealthCare Foundation, (2004). Chronic Disease Registries: A Product Review. Retrieved on 11/11/12 from http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/C/PDF%20ChronicDiseaseRegistryReview.pdf
• Institute of Medicine (2012). Primary Care and Public Health: Exploring Integration to Improve Population Health. Retrieved on 11/12/12 from http://www.iom.edu/~/media/Files/Report%20Files/2012/Primary-Care-and-Public-Health/Primary%20Care%20and%20Public%20Health_Revised%20RB_FINAL.pdf
• National Committee for Quality Assurance (2011). Standards for Patient-Centered Medical Home (PCMH). Retrieved on 10/20/12 from http://www.iafp.com/pcmh/ncqa2011.pdf
• Patient-Centered Primary Care Collaborative (2010). Transforming Patient Engagement: Health IT in the Patient Centered Medical Home. Retrieved on 11/12/12 from http://www.pcpcc.net/files/pep-report.pdf
• Robert Graham Center (2007). The Patient Centered Medical Home: History, Seven Core Features, Evidence and Transformational Change. Retrieved on 11/10/12 from http://www.aafp.org/online/etc/medialib/aafp_org/documents/about/pcmh.Par.0001.File.dat/PCMH.pdf
45
HPSJMeeting Significant Healthcare Needs
With Limited Resources
HPSJ Goals
Easy AccessHigh Quality of CareCoordinated Care to Achieve
1. Individual Health Improvement
2. Population Health Improvement
3. Cost Savings
47
Integrated Patient Centered Medical Home
• Patients• Hospitalists• PCPs• Residentialists• Nurse Case Managers• Social Service Case Managers• MH/BH Counselors• MA Health Navigators• Peer Educators/DM• Wellness Educators• 24/7 Advice Nurse• IHSS Workers
48
Transitional Care
• Visiting Home Family Nurse Practitioner
• Physician Home Visits (“Residentialists”)• Home Behavioral Health/Mental Health
Counselors
• Home Monitoring Technology– Glucometers – Blood Pressure Monitors– Scales for congestive heart failure– Oximeters for chronic obstructive pulmonary
disease–Medication Dispensing
49
50
Fora Care Conversion from TrueTrack
• 51
Technology to Achieve Goals
Home Biometrics Devices Telemedicine Consults Advice Nurse Coordination Ambulance CM/ER Integration Pocket Device with 360 Care Plans Social/Electronic Media DM & ED Programs
52
Presentation Slides
• Can be found here: http://www.thecmafoundation.org/projects/aped/
53
Next Presentation
Promoting Patient Self-Management and Medication Adherence
Wednesday, January 23rd 12:15 - 1:15 pm
Learn how to help your patients take charge of their health, with a guest speaker from the California Diabetes Program sharing lessons learned from 25 years of on-the-ground improvement work.
Dial-in Info: 1-800-615-2820, Passcode 415-615-6376; Webinar link: pbgh.adobeconnect.com/webinar4/
Please RSVP at: www.caldiabetes.org/events_display.cfm?eventsID=896
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