Presentation on theme: "Improving Health Outcomes by Linking the Clinic to the Community"— Presentation transcript:
1Improving Health Outcomes by Linking the Clinic to the Community Thomas Sequist, MD MPH
2What you have heard about US health care Poor qualityCostly
3Improving Chronic Care Outcomes AHRQ National Quality Report 2012
4Atrius HealthNon-profit alliance of six leading independent medical groupsGranite MedicalDedham Medical AssociatesHarvard Vanguard Medical AssociatesReliant Medical GroupSouthboro Medical GroupSouth Shore Medical CenterProviding care for ~ 1,000,000 adult and pediatric patients with physicians, 1450 other healthcare professionals across 35 specialties.
5Atrius Health100% on an electronic medical record combined with corporate data warehouse, used for managing quality and cost.Long history with global payments: close to 50% of patients under global risk across Commercial, Medicare and MedicaidWidespread use of rosters in population managementTrack record of quality measurement and reportingAll adult primary care sites accredited as NCQA Level 3 Patient Centered Medical Homes
6Harvard Vanguard Medical Associates Multi-specialty group practice17 ambulatory health centers400,000 adult patients175 primary care physicians
7HVMA Diabetes Care Model Clinical Information SystemsElectronic medical recordComputerized alertsPopulation ManagementCentralized patient mailingsPatient EngagementPrimary care teamsDiabetes dashboardsChronic disease visitsImproved Diabetes Care
9Panel Diversity and Disparities in LDL Control Median = - 8.0%IQR = -6.9% to -9.4%p = 0.84Sequist; Arch Intern Med 2008
10The “Not Me” Phenomenon Do racial disparities in diabetes care exist in….Sequist; JGIM 2008
11Intervention Components Cultural competency training1 to 2 day course (89% team attendance)Monthly educational materialsClinical performance feedbackMonthly distributionRace-stratified (HbA1c<7%, LDL < 100, BP < 130/80)Provider level (benchmarked to practice)
14Impact on Clinician Awareness Do racial disparities in diabetes care exist in….P=0.003P=0.02P=0.04
15Clinician Support for Intervention How effective are these strategies to reduce racial disparities?P=0.01P=0.02
16Clinician Views on Disparities “Even though their diabetes might be under horrendous control, it wasn’t the top thing on life’s list. You know they might have a kid in jail, or they might have been in the midst of an eviction proceeding or others are at risk of losing their jobs. There were a lot of other topics that were higher on their list than their HbA1c of 13”I think that I feel very overwhelmed by this whole kind of concept because in many respects I think that a lot of this is very, very difficult to change because of what happens outside of these four walls.
17Clinician Views on Reports Well it was an initial kind of negative feeling, you know, like I’m failing in these particular situations. But then there was a feeling of, well these are the things that we’ve really got to focus on so we’re just going to have to pull this apart and try and focus on these things.It’s just not useful information. I see very little that I have accessible at my disposal to make any impact on it, and telling me that it's there, it changes or doesn't change, seems to be random and have absolutely nothing to do with what I personally do or can do.
18Views on Cultural Competency Training Feeling that training educated on history of racism, trust, and biasHelped them to explore these concepts in clinical setting“You know I never knew there wasn’t a grocery store [there], I felt so stupid, but now I understand…”
19Where Does this Leave Us? Address social determinantsAddress built environmentSystematic approach?The 15 minute office visit will not be enough
20Quality of Primary Care – Community Interface Toward A Rational ProcessIdeal StateRecognition/ ownership of issuesQuality of Primary Care – Community InterfacePrimary care resourcesIdentifying community resources and partnersPayment modelsCurrent StateIntegration of care plans
21Different Viewpoints Medical Clinic Public Health Advantages: Access to health indicatorsDirect management of servicesDisadvantages:Piecemeal interactionsLack of broader contextFocus on medical managementPublic HealthAdvantages:Focus on communitiesContextual approachDisadvantages:Lack clinical contextNo integration into care plansMultiple constituents
22Our Roadmap Change measurement paradigm Target communities for action Allow clinicians to view communitiesTarget communities for actionHigh disease prevalencePoor qualityHigh penetrationIdentify successful strategiesPositive outliers and trajectoriesResource catalogueClinical integrationClinician liaisonEHR tools
23Our Barriers Traditional performance focus on clinicians Clinician sphere of responsibilitySystematic approach to community partnershipHealth center resources