Organization of Health Care and Delivery System Design Alan Glaseroff MD CMO, Humboldt IPA IHI...

Organization of Health Care and Delivery System Design

Alan Glaseroff MDCMO, Humboldt IPAIHI National Forum 2007

Orlando, Florida12/10/07

[email protected]

Redesigning Chronic Illness Care: Evidence, Experiences, and Stakeholders

IHI National Forum December 10, 2007

Health of Populations and Individuals

• Delivery system exists within communities

• Many other stakeholders with interests

– Patients, employers, public health/government, community groups, educational system, payers

• Chronic disease affects certain populations disproportionately

• Collaboration needed (spectrum of relationships) to improve outcomes and reduce disparities

• Collective accountability/responsibility the only answer

• “If not us, who? If not now, when?”

60

65

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1981

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1995

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1999

2001

Ye

ars

Overall White

Overall Black

without Homicides White

without Homicides Black

without AIDS White

without AIDS Black

without Both White

without Both Black

Disparities: Life Expectancy at Birth

Tony Iton MD, Alameda County Public Health Director

Alameda County

50

55

60

65

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90

95

100

0% 10% 20% 30% 40% 50% 60%

Poverty Rate

Lif

e E

xp

ectan

cy (

Years)

Life Expectancy by Census Tract


Causes of Differences in Health Outcomes By Race

• Genetics* 10-15%

• Access to health care 10-15%

15% + 15% = only 30%

What causes the other 70%???*genes ≠ race


-Bay Area Regional Health Inequities Initiative

Medical ModelSocio-Ecological

HE

AL

TH

CA

RE

A

CC

ES

S

Expanded Model

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

Functional and Clinical Outcomes

DeliverySystemDesign

Decision Support

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community

Health Care Organization

Chronic Care Model


• Quality as core strategy

• Visibly support improvement at all levels, starting with senior leaders.

• Promote effective improvement strategies aimed at comprehensive system change.

• Encourage open and systematic handling of problems.

• Provide incentives based on quality of care.

• Develop agreements for care coordination.



Prepared,ProactivePractice Team

Functional and Clinical Outcomes

DeliveryDeliverySystemSystemDesignDesign

Decision Support

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community


Chronic Care Model

Delivery System Design

• Multiple levels

– Regional/National: macrosystem

– Integrated Medical Care Organization: mesosystem

– Practice level: microsystem

• Alignment required for breakthrough improvement in community health

Delivery System Design

• Define population of patients

• Define roles and distribute tasks amongst team members.

• Use planned interactions to support evidence-based care.

• Provide clinical care management services.

• Ensure regular follow-up.

• Give care that patients understand and that fits their culture

Mesosystem: Practice Environment in Humboldt

• 29 primary care practices in various sizes, types and stages of transformation (all in the Humboldt IPA)

– 5 community health centers

– Many 1-3 clinician practices in private practices (one 17 MD Internal Medicine practice)

– No large integrated multispecialty group

– Managed care covering 5% of population

• How to rapidly improve chronic disease care in the community?

Humboldt Diabetes Project• CHCF-funded research project started 11/02

• County-wide effort coordinated by IPA (>95% of all clinicians in the county, including MDs, advanced-practice clinicians, behavioral health providers) but…

• IPA manages only 10% of lives in Humboldt County

…but systems must apply to most patients in a practice

• Problem:

– Lack of access to most administrative data

• Solution:

– Information must come from clinical setting

Getting Started

• “Burning Platform” to capture hearts and minds (disease focus vs. abstract “redesign”)

• Grant support for concept

• Clinical champion presenting own data making it safe for others

• “Inviting the implementers into the planning process”

• Piloting systems

• Kick-off conference (including patient voices)

• Site champion network supervised by ½-time FNP

• Feedback on practice-level and individual performance

ClinicianEducation

PatientEducation

Registryand Flow

Sheet

Promptsand

Reminders

CaseManage-

ment

Build and Maintain aChronic Care

Infrastructure

Connect Offices

to the Internet for

Clinical

Information and

Communication

Get Payers

and Hospitals

to Play

NextChronic

Disease

PatientsInvolved InSelf-Care

Integreted

Decision

Support

Humboldt Diabetes Project

Pt. enrolled in diabetic study

Data entered in registry

Services delivered?

Registry note returned?

yes

yes

no

Staged Diabetes Management

Guideline

Monthly audit of data in registry

Prompts and reminders

Feedback to clinicians

Pharmacy data

Lab data

PACES, CHCF chart audits

BASICS Case management

Office visit: scheduled,

random

Data from office visit

Patient visit

sheet

DIABETIC PROJECT

FLOW DIAGRAM

Risk stratificationA1c > 9

Data analysis

To improve outcomes in chronic illness…

• Patients must be prescribed and taking proven therapies

• Patients must be managing their illness well

Microsystem: Frustration• Patients are frustrated by waits and

discontinuities, often don’t receive proven services and often feel they are not heard.

• Providers feel they have little control over their work life, are stressed by demands for productivity despite older, sicker clientele and the reduced variability in their clinical day.

Is There Time for Management of Patients With Chronic Diseases in Primary Care?

• METHODS

– Applied guideline recommendations for 10 common chronic diseases to a panel of 2,500 primary care patients with an age-sex distribution and chronic disease prevalence similar to those of the general population, estimated the minimum physician time required to deliver high-quality care for these conditions.

• RESULTS

– Top 10 chronic diseases (STABLE) 828 hours per year, or 3.5 hours a day

– Top 10 chronic diseases (Poor Control) 2,484 hours, or 10.6 hours a day.

• CONCLUSION?

Ann Fam Med 2005;3:209-214.

Duke University Dept. of Community and Family Medicine

What we know about primary care visits

• 50-70% are largely informational or informative (including check-backs for chronic illness care) yet they are organized like acute visits

• US average is 16.3 minutes

• Patients are given an average of 20 seconds to tell their story before they are interrupted

•Assessment of self-management skills and confidence as well as clinical status•Tailoring of clinical management by stepped protocol•Collaborative goal-setting and problem-solving resulting in a shared care plan•Active, sustained follow-up



PreparedPractice Team

How would I recognize aproductive interaction?

Microsystem: Defining roles and tasks across team to achieve

productive interactions

“It is naïve to bring together a highly diverse group of people and expect that, by calling them a team, they will in fact behave as a team. It is ironic indeed to realize that a football team spends 40 hours a week practicing teamwork for the two hours on Sunday afternoon when their them work really counts. Teams in organizations seldom spend two hours per year practicing when their ability to function as team counts 40 hours per week."

Harold Wise, Making Health Teams Work

Team Meetings

• Regular intervals

• All members of care team (groups of < 10)

• Agenda:

– Old business

– New Business

– What isn’t working?

– Opportunities for excellence?

Defining Tasks

Example of task distributionMicroalbuminuria testing

• Receptionist recognizes patient has diabetes, attaches requisition to chart

• MA collects specimen

• RN reviews slip, recognizes out-of-range tests, orders confirmatory test, discusses possible need for ACE inhibitor

• MD discusses and prescribes ACE inhibitor

• RN calls pt. to check on med. adherence and side effects

Use planned interactions to support evidence-based care

One-on-one, group, telephone, email, outreach….the possibilities are endless

What is a Planned Visit?

• A Planned Visit is an encounter with the patient initiated by the practice to focus on aspects of care that typically are not delivered during an acute care visit.

• Planned care elements can be inserted into acute visits if needed (small practices, patients refusing to come in for planned care, etc.)

• All visits contain elements of both (patient agenda/clinician agenda)

• The more planned care functions done by other members of the team, the more time for the patient agenda in the exam room (improves clinician-patient relationship, higher patient satisfaction)

What does a Planned Visit look like?

• The provider team proactively calls in patients for a longer visit (individual or group) to systematically review care priorities.

• Visits occur at regular intervals as determined by provider and patient.

• Team members have clear roles and tasks.

• Delivery of clinical management and patient self-management support are the key aspects of care.

How do you do a Planned Visit?

You Plan It!

Example: Diabetes

• Choose a patient sub-population, e.g., all patients with diabetes not seen in 6 months with A1c > 7

• Identify patients from registry

• MD reviews list for patients at highest risk (via evidence-based guidelines): BP>130/80; LDL>100, etc and prioritizes visits

Patient Outreach

• Have receptionist or provider call patient and explain the need for planned visit using script explaining different nature of visit

• Personal appeal by clinician works best

• Ask patient to bring in bag of all medications they are taking (including OTCs and herbals)

• “Team Huddle” at start of clinic session

• RN/LPN/MA prints any relevant patient summaries from registries and attaches to front of chart

• MD reviews medications/labs prior to visit

Preparing for the Visit

Planned Visit

Walk-in Visit

Registry Patient?

Prep chart

Pull chart

Download most recent

Progress Note

Place PN on front of chart

Medical Assistant tells patient: “Take off your shoes”

Progress Note employed in visit

Progress Note returned to office staff

Progress Note faxed to IPA

IPA updates registry

Patient Info sheet sent to patient

Updated Progress Note faxed to office

and placed on Registry web-site

yes

no

Chart visit in normal fashion

REGISTRY FLOW

OFFICE-VISITS

• Ask patient open-ended questions

– “How’s your health? Any issues you want to discuss?

• Review patient’s data

• Identify interventions, labs, referrals and self-management needs

• Problem solve adherence/other issues with patient

• Create an patient action plan (if indicated)

• Schedule follow-up

The Visit

Group Visits: Introduction

• Fun and efficient• Patients can receive:

Self-management support trainingSocial supportSpecialty service as needed/availableOne-on-one with medical providerMedication counseling

• Multiple models for Group Visit agendas: open-ended vs. curriculum-based; single disease vs. multiple; newly diagnosed vs. range of experience; professional vs. peer-led

In general, would you say your health is: (check one box)

Excellent Very Good Good Fair Poor

B 4% 19% 37% 30% 10%

F 5% 27% 42% 22% 4%

:

How effective do you believe your health care provider is in managing your diabetes?

Not effective at

allNot very effective

Somewhat effective

Effective Very effective

B 1% 3% 18% 45% 34%

F <1% 1% 13% 44% 41%

Patient Survey: Less Frustrated?

How effective do you believe you are in caring for your diabetic patients?

Not effective at all

Not very effective Somewhat

effectiveEffective Very

effective

Baseline - 3% 32% 57% 8%

F/U - - 27% 56% 17%

Compared to a year ago, how effective are you in caring for your diabetic patients?

Less effective

Somewhatless effective

Same

Somewhatmore effective

More effective

F/U - - 27% 41% 33%

Note: The sum of the categories may not add to 100% due to rounding.

Clinician Survey: Less Overwhelmed?

What is care management?

Many different things to different people

• Resource coordination

• Utilization management

• Follow-up

• Patient education

• Clinical management

Features of effective care management

• Regularly assess disease control, adherence, and self-management status

• Either adjust treatment (best practice) or communicate need to physician immediately (less effective)

• Provide self-management support• Provide more intense follow-up • Assist with navigation through the health

care process

Effect of Group SMS on HbA1cGroup SMS (Basics) vs. Control and Sustainability

6.80

7.00

7.20

7.40

7.60

7.80

Basics Oct 05Grads(n=135)

non Basics(n=3400+)

Ensure regular follow-up by the primary care team

•The trick is noticing when it isn’t happening

•Can be accomplished in many different ways

Humboldt Diabetes Project Data

October, 2003 October, 2004

Measure

Results

(n=802)

Results

(n=778)

HbA1c control: >9% (poor control) 7.7% 6.9%

HbA1c control: <7% (good control) 52% 55%

Patients with BP <140/90 62% 59%

Patients with BP <130/80 32% 33%

Patients with LDL<130 60% 73%

Patients with LDL <100 32% 44%

January, 2007

Results

(n=4330)

5.2%

59%

67%

37%

78%

49%

•www.improvingchroniccare.org

Contact us:

New Methods for Teaching the Chronic Care Model


Select Topic

Planning Group

Identify Change

Concepts

Participants

Prework

LS 1

P

S

A D

P

S

A D

LS 3LS 2

Action Period Supports

E-mail Visits Web-site

Phone Assessments

Senior Leader Reports

Event

A D

P

S

(12 months time frame)

Breakthrough Series Collaborative

Experience with Collaboratives

• More than 1,000 different health care organizations and various diseases involved to date

• Began with national BTS, now regional, state-based & facility specific

• HRSA’s Health Disparities Collaboratives-600+ community and migrant health centers, now academic medical centers & small practices

• External evaluations of early efforts by Chin et al., RAND

Lessons Learned from the Teams

• Teams spent considerable time searching for/developing tools

• Some teams felt intimidated by taking on the whole model – asked for a sequence

• Collaboratives were time & resource intensive

• Many changes were made in ways that were not sustainable financially

Challenges Remaining

Reaching beyond early adopters

Try less time- intensive learning

Create supportive systems

Target small practices

Trying New Ideas

• Virtual

• Collaboratives On Wheels

• Coaching

• Combos

Integrating Chronic Care and Business Strategies in the

Safety Net

The Intervention

PLUS

Practice Coach_________________

STEP-UP Methodology

Toolkit______________

Business & ClinicalTools

Getting Started

Assess Data & Set Priorities

Improve & Sustain Changes

Organize Your Improvement Team

Familiarize Team With Strategies

Use Data To Set Priorities

Select Performance Measures

Build Measurement Capacity

Organize Your Care Team

Clearly Define Patient Panels

Create Infrastructure To Support Patients

Plan Care

Assure Support For Self-Management

Reexamine Outcomes & Make Adjustments

The Toolkit Sequence




Plan Care




Support Self-Management

Plan Care



Create Infrastructure Support Pts

Reexamine Outcomes & Adjust

Capture Incentives

Redesign Care and Business Systems

• Integrated CCM & Business Changes

• Organized into four phases

The Toolkit & The Business CaseThe Toolkit & the Business Case

Thank you!

Katie Coleman, MSPH

[email protected]

www.improvingchroniccare.org

mailto:[email protected]

Coaching Outline

Tasks

Assessment Day

½ day presentation on CCM & PDSA

On-going meetings by phone, email & in-person

Coaching of the leaders & the teams

Philosophy

Focus on motivation, consultation & education

Be mindful of the timing of interventions

Fix processes relevant to the task at hand

Well-structured & supported groups benefit most

Redesigning Chronic Illness Care:Taking Improvement to Scale

Ed Wagner, MD, MPH

MacColl Institute for Healthcare InnovationCenter for Health StudiesGroup Health Cooperative

Improving Chronic Illness CareA national program of the Robert Wood Johnson Foundation


CCM Developments

• Guides several state programs

• Adaptations undertaken by European countries, World Health Organization, and several Canadian provinces.

• Foundation for NCQA and JCAHO certification for chronic disease programs.

• Part of new Patient-centered Medical Home Models of Primary Care proposed by AAFP, ACP, AAP, AOA.

• Several practice assessment tools now available for large and small practices.

• Assessments now used in some pay for performance programs (NCQA).

Challenges Remaining

Early Adopters

Try less time- intensive learning

Create supportive systems

Target small practices

What will it Take to Improve Care for Chronic Illness for the Population?

Three Options When Selecting a Strategy

1. Assume that competition, financial incentives and computers will improve care.

2. Rely on direct to patient disease management.

3. Improve medical care by helping practices change care systems.

What can we learn from successful larger health systems?Organizational factors supportive of high quality chronic

care:

• Strategic values and leadership support long-term investment in managing chronic diseases

• Well-aligned goals between physicians and corporate

managers

• Investment in information technology systems and other infrastructure to support chronic care

• Use of performance measures and financial incentives to shape clinical behavior

• Active programs of Quality Improvement based on explicit models

BMJ 2004;328:223-225

What’s needed to improve chronic illness care for the population?

• Collaboration and Leadership

• Measurement (& incentives)

• Infrastructure

• Active program of practice change

Build a regional healthcare “system”

•Care will not improve unless we change the systems of care

•The goal is to transform health care delivery across a region

•Someone needs to take and thenassure leadership

•Major stakeholders need to be involved and committed to improvement

Leadership

•Need outcome and patient experience dataas well as process data to assess effort, performance, and improvement

•Practices will have to be able to provide valid and complete data on these indicators; claims will not suffice

•Practices should be able to use these data in clinical care, not just periodically send them off

•Smaller practices need info. and technical support to develop such data systems

•Need strategies andinfrastructure to helpALL practices change their delivery systems

•Strategies – QI methods,Provider networks

•Infrastructure—IT, guide-lines, care managers

•More activated and informed consumers may help pushimprovement

•Public disclosure of performancedata may spur improvement

•Create incentives for providers to make the investments needed to improve chronic care

•Create benefit plans that reward consumers for making cost-effective choices

Leadership

A Framework for Regional Quality Improvement

Is geographic improvement possible? State efforts

Is geographic improvement possible?Indiana • Health Commissioner and Medicaid Director to improve care

for 80,000 chronically ill Medicaid recipients

• State leadership and money creating a Medicaid care system

• Statewide Collaborative Program PLUS -call center-community-based nurse care managers linked to practices-statewide Web-based patient registry-registry updated with claims data-considering performance incentives-embedded RCT

• Reported cost-savings to the Governor

Is geographic improvement possible? North Carolina

• State leadership and money has created a visionary Medicaid care system

• Measurement system, Guidelines, Physician networks, Care Managers, Collaboratives

• Financial rewards for participating

• Early results promising

• Plans to extend to include all patients regardless of insurance coverage

Is geographic improvement possible?Washington State

•Diabetes Surveillance

•Regional Collaboratives

•Laid groundwork for PSHA

Is geographic improvement possible? Pennsylvania

•Governor brought disparate interests together

•All the major players at the table

•Timeline & ?budget to make it happen

Lessons LearnedIndiana Make your effort bipartisan & protect it from

political winds.

North Carolina

Reach out! Provider networks can engage small practices in quality improvement

Rhode Island Bring all the “p”s to the table: providers, purchasers, payers, patients, policy-makers

Colorado Connect with local foundations and groups already doing the work

Washington/Penn.

Political leadership involvement can be critical catalyst

Maine/ California

Organizing diffuse efforts is a big but important job

www.improvingchroniccare.org

Contact us at: Contact us at:

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