1. Cooperative Health Planning Penny Thron-Weber, MD Amy Varble, MD St Anthony Family Medicine, Denver, CO

2. Introduction Introduction How We Thought of This How We Thought of This Background Background Our Project Our Project Health Planning Visits Health Planning Visits Creating a Flow Sheet Creating a Flow Sheet Follow-up Follow-up Improvements Improvements Future Future

3. Introduction We are a two-clinic system with 27 residents and 10 family physicians seeing 32,000 patients a year We are a two-clinic system with 27 residents and 10 family physicians seeing 32,000 patients a year Our payor mix is largely Medicaid (50%), Medicare (18%), and self-pay (22%), although we provide about $250,000 of free care each year; we also have some private payors Our payor mix is largely Medicaid (50%), Medicare (18%), and self-pay (22%), although we provide about $250,000 of free care each year; we also have some private payors Our ethnic mix is mostly Hispanic with 20% of our population only speaking Spanish, although we have some Caucasian, SE Asian, and African American Our ethnic mix is mostly Hispanic with 20% of our population only speaking Spanish, although we have some Caucasian, SE Asian, and African American

4. How We Thought of This We feel overwhelmed by the daily task of providing high-quality care to our volume of patients We feel overwhelmed by the daily task of providing high-quality care to our volume of patients Trying to follow the new Chronic Care Model seems impossibly time-consuming Trying to follow the new Chronic Care Model seems impossibly time-consuming Our patients bring their own challenges unique to their socioeconomic situation: frequent no- shows, frequent address and phone number changes, difficulty getting and keeping medications Our patients bring their own challenges unique to their socioeconomic situation: frequent no- shows, frequent address and phone number changes, difficulty getting and keeping medications

5. How We Thought of This As we moved from a single flow sheet for diabetes mellitus to multiple flow sheets for patients with multiple medical problems, the idea of a single, customized, integrated flow sheet arose As we moved from a single flow sheet for diabetes mellitus to multiple flow sheets for patients with multiple medical problems, the idea of a single, customized, integrated flow sheet arose

6. Robert Wood Johnson Foundation. http://www.improvingchroniccare.org/ch ange/index.html Background The Chronic Care Model was developed to address these deficiencies of current care: The Chronic Care Model was developed to address these deficiencies of current care: “Rushed practitioners not following established practice guidelines “Rushed practitioners not following established practice guidelines Lack of care coordination Lack of care coordination Lack of active follow-up to ensure the best outcomes Lack of active follow-up to ensure the best outcomes Patients inadequately trained to manage their illnesses” Patients inadequately trained to manage their illnesses”

7. Robert Wood Johnson Foundation. http://www.improvingchroniccare.org/ch ange/index.html Background The Chronic Care Model suggests changes in the following categories: The Chronic Care Model suggests changes in the following categories: The Community The Community The Health System The Health System Self-management Support Self-management Support Delivery System Design Delivery System Design Decision Support Decision Support Clinical Information Systems Clinical Information Systems

8. Robert Wood Johnson Foundation. http://www.improvingchroniccare.org/ch ange/index.html Background Our project aims to meet some of these new recommendations, particularly in the area of self-management support: Our project aims to meet some of these new recommendations, particularly in the area of self-management support: “Empower and prepare patients to manage their health and health care “Empower and prepare patients to manage their health and health care Emphasize the patient’s central role in managing their health Emphasize the patient’s central role in managing their health Use effective self-management support strategies that include assessment, goal-setting, action planning, problem- solving and follow-up Use effective self-management support strategies that include assessment, goal-setting, action planning, problem- solving and follow-up Organize internal and community resources to provide ongoing self-management support to patients” Organize internal and community resources to provide ongoing self-management support to patients”

9. Robert Wood Johnson Foundation. http://www.improvingchroniccare.org/ch ange/index.html Background We also hope to work towards the goals of the Community with the use of promotoras and group visits: We also hope to work towards the goals of the Community with the use of promotoras and group visits: “Mobilize community resources to meet needs of patients “Mobilize community resources to meet needs of patients Encourage patients to participate in effective community programs Encourage patients to participate in effective community programs Form partnerships with community organizations to support and develop interventions that fill gaps in needed services Form partnerships with community organizations to support and develop interventions that fill gaps in needed services Advocate for policies to improve patient care (2003 refinement)” Advocate for policies to improve patient care (2003 refinement)”

10. Robert Wood Johnson Foundation. http://www.improvingchroniccare.org/ch ange/index.html Background Delivery System Design recommendations are addressed as well: Delivery System Design recommendations are addressed as well: “Assure the delivery of effective, efficient clinical care and self-management support “Assure the delivery of effective, efficient clinical care and self-management support Define roles and distribute tasks among team members Define roles and distribute tasks among team members Use planned interactions to support evidence-based care Use planned interactions to support evidence-based care Provide clinical case management services for complex patients (2003 refinement) Provide clinical case management services for complex patients (2003 refinement) Ensure regular follow-up by the care team Ensure regular follow-up by the care team Give care that patients understand and that fits with their cultural background (2003 refinement)” Give care that patients understand and that fits with their cultural background (2003 refinement)”

11. Robert Wood Johnson Foundation. http://www.improvingchroniccare.org/ch ange/index.html Background With additional resources, clinical information systems goals could be met as well: With additional resources, clinical information systems goals could be met as well: “Organize patient and population data to facilitate efficient and effective care “Organize patient and population data to facilitate efficient and effective care Provide timely reminders for providers and patients Provide timely reminders for providers and patients Identify relevant subpopulations for proactive care Identify relevant subpopulations for proactive care Facilitate individual patient care planning Facilitate individual patient care planning Share information with patients and providers to coordinate care (2003 refinement) Share information with patients and providers to coordinate care (2003 refinement) Monitor performance of practice team and care system” Monitor performance of practice team and care system”

12. National Healthcare Disparities Report. http://www.ahrq.gov/qual/nhdr03/nhdrsu m03.htm Healthcare Disparities Healthy People 2010 calls for a elimination of healthcare disparities, an issue for our largely Hispanic and low socioeconomic group clinic Healthy People 2010 calls for a elimination of healthcare disparities, an issue for our largely Hispanic and low socioeconomic group clinic “Opportunities to provide preventive healthcare are often missed “Opportunities to provide preventive healthcare are often missed Knowledge of why disparities exist is limited” Knowledge of why disparities exist is limited” This project tries to address more preventive and chronic disease care This project tries to address more preventive and chronic disease care Documenting compliance and barriers to compliance towards national guidelines may help to elucidate why disparities exist Documenting compliance and barriers to compliance towards national guidelines may help to elucidate why disparities exist

13. Institute of Medicine. Crossing the Quality Chasm. http://www.iom.edu/Object.File/Master/2 7/184/Chasm-8pager.pdf IOM: Crossing the Quality Chasm We are addressing some of the elements of the Institute of Medicine’s Crossing the Quality Chasm We are addressing some of the elements of the Institute of Medicine’s Crossing the Quality Chasm “2 Effective—providing services based on scientific knowledge to all who could benefit and refraining from providing services that will not likely benefit them “2 Effective—providing services based on scientific knowledge to all who could benefit and refraining from providing services that will not likely benefit them 3 Patient-centered—providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions 3 Patient-centered—providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions 6 Equitable—providing care that does not vary in quality because of personal characteristics, such as gender, race, ethnicity, geographic location, and socioeconomic status” 6 Equitable—providing care that does not vary in quality because of personal characteristics, such as gender, race, ethnicity, geographic location, and socioeconomic status”

14. Background Collaboration and Cultural Competency Collaboration and Cultural Competency Our system is modifiable to meet the needs of changing populations Our system is modifiable to meet the needs of changing populations We are interested in creating a plan that allows our patients to meet the standards while respecting their social needs and cultural norms We are interested in creating a plan that allows our patients to meet the standards while respecting their social needs and cultural norms Clinicians can make the time to explore patient’s stance against some recommended care practices Clinicians can make the time to explore patient’s stance against some recommended care practices

15. Our Project We created a laminated menu of preventive healthcare and chronic disease management services, with one topic per card We created a laminated menu of preventive healthcare and chronic disease management services, with one topic per card Health Maintenance COPD Diabetes Mellitus Hypertension Hyperlipidemia Coronary Artery Disease Congestive Heart Failure

16. Our Project Goals for the cards included making them Goals for the cards included making them Visually inviting Visually inviting In the primary language of the patient In the primary language of the patient At the healthcare literacy level of our patients At the healthcare literacy level of our patients And avoiding overwhelming the patient And avoiding overwhelming the patient

17. Health Planning Visits Ideally, patients would schedule a health planning visit to review these cards, discuss them and ask questions of their doctor, and plan their scheduled healthcare for the rest of the year Ideally, patients would schedule a health planning visit to review these cards, discuss them and ask questions of their doctor, and plan their scheduled healthcare for the rest of the year Another option is to do the menu as part of a regularly scheduled visit, perhaps one card per visit Another option is to do the menu as part of a regularly scheduled visit, perhaps one card per visit

18. Health Planning Visits The physician reviews his or her schedule at the beginning of the day and indicates which patients need to review the menu The physician reviews his or her schedule at the beginning of the day and indicates which patients need to review the menu The nurse then gives the menu and provides the explanation to the patient; the patient marks the cards while waiting for the physician; any questions are addressed with the physician The nurse then gives the menu and provides the explanation to the patient; the patient marks the cards while waiting for the physician; any questions are addressed with the physician

19. Creating a Flow Sheet As the physician reviews the cards with the patient, the physician fills in a blank grid to create a healthcare flow sheet for the upcoming year for the patient As the physician reviews the cards with the patient, the physician fills in a blank grid to create a healthcare flow sheet for the upcoming year for the patient The physician and patient discuss the risks and benefits of items checked and left unchecked, providing education about recommendations The physician and patient discuss the risks and benefits of items checked and left unchecked, providing education about recommendations Together they establish a timeline amenable to both for achieving the agreed-upon items Together they establish a timeline amenable to both for achieving the agreed-upon items The patient receives one copy and one copy goes to the chart The patient receives one copy and one copy goes to the chart

20. Follow-up From the beginning, physician and patient know which items of the Chronic Care Model will not be completed by the patient and why From the beginning, physician and patient know which items of the Chronic Care Model will not be completed by the patient and why The patient has a copy of their schedule and is responsible for initiating additional follow-up The patient has a copy of their schedule and is responsible for initiating additional follow-up Additional follow-up could be provided with mailed reminders and telephone calls Additional follow-up could be provided with mailed reminders and telephone calls

21. Ideas for Improvements We do not yet have our cards in Spanish or Vietnamese, our principal second languages in the clinics We do not yet have our cards in Spanish or Vietnamese, our principal second languages in the clinics We need to improve the literacy of the cards We need to improve the literacy of the cards We would like to add a card to collect the patient’s family history We would like to add a card to collect the patient’s family history

22. Future We have many ideas! We have many ideas! Using a nurse case manager to oversee the program and generate reminders Using a nurse case manager to oversee the program and generate reminders Using home visits with the RN or MD to address patients who have failed to follow-up despite and mail and phone Using home visits with the RN or MD to address patients who have failed to follow-up despite and mail and phone Educating lay people to serve as promotoras to provide community and home education Educating lay people to serve as promotoras to provide community and home education Tying in group meetings to the cards for education and support Tying in group meetings to the cards for education and support

23. Future Computerizing flow-sheets and menus? to decrease time and create a database for tracking and providing performance measures Computerizing flow-sheets and menus? to decrease time and create a database for tracking and providing performance measures Increase educational component, especially for nutrition, smoking, and exercise, via Increase educational component, especially for nutrition, smoking, and exercise, via Written literature Written literature Group meetings Group meetings Home visits with MD/RN/promotora Home visits with MD/RN/promotora

24. Conclusion We created a system for preventive health care and chronic disease management that shares the burden of follow-up with the patient We created a system for preventive health care and chronic disease management that shares the burden of follow-up with the patient We meet goals of the Chronic Care Model, the IOM’s Crossing the Quality Chasm, and Healthy People 2010 We meet goals of the Chronic Care Model, the IOM’s Crossing the Quality Chasm, and Healthy People 2010 We have an educational component which could supplement group visits We have an educational component which could supplement group visits With additional resources such as mailed reminders, telephone calls, and home visits, the traditional challenges for our patients might be overcome, eliminating healthcare disparities With additional resources such as mailed reminders, telephone calls, and home visits, the traditional challenges for our patients might be overcome, eliminating healthcare disparities