1. CMOs and Implementation Science Researchers: A productive partnership for clinical improvement Sponsored by CMOG and ROCC Andreas Theodorou, M.D. Russell Howerton, M.D. Laura Peterson, M.D. Hosted by Alexander Ommaya, D.Sc. and David Longnecker, M.D.

2. Russell Howerton, M.D.,F.A.C.S., CMO of Wake Forest University Medical Center Andreas Theodorou, M.D., CMO of the University of Arizona Medical Center Laura A. Petersen, M.D., M.P.H., F.A.C.P., Associate Chief of Staff for Research, Houston VA Medical Center, Director VA HSR&D Center of Excellence, and Professor of Department of Medicine, Baylor College of Medicine Guest Speakers

3. During the presentation, your telephone line will be muted To submit questions for the speakers, please use the chat box on the lower right side of your screen Q& A Communication

4. Agenda 12:30 Introduction David Longnecker, MD Alexander Ommaya, D.Sc. 12:35 Russell Howerton, MD 12:45 Questions 12:50 Andy Theodorou, MD 1:00 Questions 1:05 Laura Petersen, MD, MPH 1:15 Questions 1:20 Next Steps 1:30 Adjourn

5. AAMC Implementation Science/CMO Webinar Monday March 25 th, 2013

6. Observation Unit Stress Imaging to Manage Patients with Intermediate to High Risk Acute Chest Pain

7. Wake Forest Baptist Health Objective To reorganize existing resources to deliver care in a way that reduces hospital readmissions among patients with intermediate to high-risk chest pain.

8. Wake Forest Baptist Health Vashi et al. JAMA 2013

9. Wake Forest Baptist Health A possible solution: Observation Unit – Stress Imaging Care Pathway Highly efficient units driven by care algorithms, staffed by midlevel providers −Efficient and cost effective in low risk patients ACC/AHA: Class I recommendation endorses OU care ACC / AHA NSTE ACS guidelines: Anderson et al. Circulation 2007; Institute of Medicine: “…clinical decision units reduce boarding and diversion, avoid expensive hospitalization, and appear to contribute to improved management...”

10. Very low risk Low risk High risk Intermediate risk Lower complexity: Care easily integrated into care algorithm Proven efficacy of OU care: Low event rates High patient satisfaction Widely adopted Higher complexity = higher readmission rate 25-40% with pre-existing CAD (1-3) Perceived complexity inhibits development of care algorithms Is OU care an alternative to inpatient care? Cost? Event rates after discharge? Readmission rates? Higher risk = high complexity 1. Tatum et al. Ann Emerg Med, 1997 2. Stowers et al. Ann Emerg Med 2000 3. Gomberg-Maitland et al. AHJ 2005

11. Wake Forest Baptist Health Methods Design for 2 RCTs conducted at Wake Forest Patients at intermediate to high-probability for ACS ED eval Randomize Observation unit Inpatient care Stress imaging Serial biomarkers Care per individual providers Follow up through 1 year

12. Wake Forest Baptist Health Cost of OU care versus Inpatient care (Miller et al. Ann Emerg Med 2010) (Miller et al. JACC:Imaging 2011) Analyses based on intent to treat

13. Wake Forest Baptist Health 38% vs 13%, P=0.004 OU CareInpatientP Composite 7 (13%)20 (38%).004 Revascularization 1 ( 2%) 8 (15%).031 Hospital readmission 4 ( 8%)12 (23%).033 Recurrent cardiac testing 2 ( 4%) 9 (17%).028 Inpatient OU Care Trial 2 Primary outcome: Composite Readmit, Revasc, Recurrent testing

14. Wake Forest Baptist Health Combined events, Trials 1 and 2 Observation UnitInpatient Adverse Events Death1/104 (1.0%)0/110 (0%) MI (after randomization)6/104 (5.8%)5/110 (4.6%)

15. Wake Forest Baptist Health Summary OU care with perfusion imaging at Wake Forest: −reduces cost, readmissions, and revascularization procedures Death and MI −Very low rates with either strategy Leverages and reorganizes existing resources to achieve these benefits

16. Wake Forest Baptist Health Future directions and opportunities Implementation: −Can benefits observed in single center trials be achieved in a multi-center setting? Implementation study with outcome surveillance −Are results dependent on using cardiac MRI as the imaging modality? How can we remove barriers so we can organize EMRs to automate data capture and outcome surveillance across medical centers?

17. Wake Forest Baptist Health Musculoskeletal Emergency Center Development of an integrated practice unit (IPU). Replace physician-centric processes with patient-centric ones Decrease the distance between patient and final decision-maker. Prospective database to monitor clinical outcomes. “Maximize Value. Optimize Education.”

18. Wake Forest Baptist Health Areas for Multicenter Collaboration Develop evidence-based clinical practice guidelines Develop competencies and standardized education for the new field of Musculoskeletal Emergency Medicine Enhance understanding of operational efficiency and time- driven activity based costing Multicenter prospective database Create best practices in this field

19. Questions?

20. 3 Amd Healthy Together Care Partnership Healthcare Dream– Implementation Nightmare 20 Andreas A. Theodorou, MD, FAAP, FCCM Chief Medical Officer University of Arizona Medical Center Professor and Associate Chair, Pediatrics

21. UAHN – Quick Overview:  Includes two hospital campuses -The University of Arizona Medical Center (University Campus, including Diamond Children’s) & (South Campus)  40 clinics, a health plan division and practice plan for physicians from the University of Arizona College of Medicine  Only Level 1 Trauma Center in Southern Arizona – (University Campus)  Comprehensive Transplant Program(University Campus)  NCI Designation University & South Campus Patient Statistics 2012-13: 21 University Campus & South Campus Admissions20,489 Emergency Visits74,632 Total Net Revenue533193 Patient beds592

22. COMMON CMO PRIORITY ISSUES Hospital/Healthcare-associated Infections Core Measures Procedural Complications Falls Patient Satisfaction Access to Care Patient Through-Put Safe Medication Use Readmission Rates Hospitalization Avoidance Continuity of Care Dual-Eligible

23. The Healthy Together Care Model Focuses on approximately 345 dual eligible Special Needs Plan members within our University of Arizona Health Network Designed to improve quality of care for this high risk/high cost population living in the home and community 23

24. All UAHN Health Plan Duals (n≈9,000) UAHN Health Plans Dual Eligibles in Pima County (n≈4,000) UAHN Health Plan Duals in Pima County assigned to UAHN primary care provider (n=345) Early data indicate that sub-population health risk and cost profile is representative of all UAHN Health Plans dual-eligible SNP population and the national dual-eligible population HEALTHY TOGETHER POPULATION

25. n=345 15% 5% 30% 50% 48% 37% 14% 1% Within our sub-population, the costliest 5% of enrollees account for 48% of total cost of care, while the costliest 20% account for 85% of total cost* Based on retrospective chart review and analysis of 307 dual eligibles with UAHN Health Plan coverage and assigned to primary care with a UA Health Network provider (Goel, et al, 2011) COST OF CARE

26. THE CARE MODEL USES MULTIPLE EVIDENCE SUPPORTED STRATEGIES Interprofessional team-based care “Home-based Primary Care” for ~ 45 most complex and homebound (with telehealth) Case management and telehealth for rest of cohort, in collaboration with primary care providers Medication Reconciliation Integrated behavioral health/physical health care management Patient Engagement and Shared Decision Making 26

27. HEALTHY TOGETHER CARE PARTNERSHIP –Delivery System/Health Plan Partnership designed to reduce utilization in a high risk/high utilizing population –Targeted utilization reduction in population Decreased ED Utilization Decreased Cost of Admissions Decreased Readmission Rate Decreased Med Cost by Pharmacy Review –Net savings if targets achieved: $1.5 Million

28. Good News Primary goals of the program include cost savings, improved quality and satisfaction with care, blended physical and behavioral health, development of individualized strategies to manage at-risk patients, and development of best practices for dual eligible patients in SNP community care settings. Bad News 18 months later the project had still not started! –Overcoming Academic Medical Center Inertia: Building an Innovative Dual Eligible Service Line Great News! Project now fully launched and first 4 patients enrolled last week! 28

29. REASONS FOR DELAYED IMPLEMENTATION Organizational Complexity Clinical Cost Structures Training Expectations Credentialing and Privileging of NPs Employment/supervision of NPs, SWs and RNs Who Provides Space and Infrastructure Non-integrated Information System Coding and Compliance Issues

30. LONG TERM PLANS 30 Eventual development of a stand-alone product that would provide coverage to the entire population of dual-eligible SNP patients resulting in reduced costs and better outcomes (e.g., lower hospitalization rates, better medication compliance, improved morbidity and mortality) -Year 1: Dual-eligible patients in UAHN care (n=345), starting with highest-cost stratum, and rolling additional services out to remaining patients in lower-cost stratum. -Year 2: Expand to include SNP patients in Pima County -Year 3: Expand to include remainder of SNP Savings realized through better care of high-cost stratum would be the basis of funding novel programs for the entire SNP population Current state Stand-alone product for all UAHN SNP patients Healthy Together Pilot

31. HEALTHY TOGETHER DEVELOPMENT TEAM Jane Mohler, NP-C, MPH, PhD 1,2 ; Nancy Wexler, MPH 1 ; Richard Slaughter 3 ; James Stover 3 ; Patricia Harrison-Monroe, PhD 1 ; Tom Ball, MD 1,2 ; Mindy Fain, MD 1,2 UA, College of Medicine 1 ; Arizona Center on Aging 2 ; UA Health Network, Health Plans 3 31

32. Questions?

33. CMOs and Implementation Science Researchers: A Productive Partnership for Clinical Improvement Laura A. Petersen, MD, MPH, FACP Professor of Medicine and Chief, Section of Health Services Research, Baylor College of Medicine Director, Houston VA HSR&D Center of Excellence, Associate Chief of Staff for Research, Michael E. DeBakey VA Medical Center March 25, 2013 Petersen AAMC Webinar

34. Iraq, March 2003 – Embedded journalist Chip Reid, right, travels through southern Iraq with soldiers from the 3rd Battalion, 5th Marine Regiment. Petersen AAMC Webinar

35. Partnerships Between Researchers and the VA Health Care System Partners include national program offices, regional CMOs and facility leadership, clinical leaders and managers, and individual clinicians Increase impact of research on Veteran health by: – Ensuring appropriate input into research priorities from a variety of VA stakeholders – Encouraging ongoing communication between research and operations – Enabling more timely response from the research community to emerging health system issues – Facilitating effective communication of research results and uptake of research into practice (implementation) Petersen AAMC Webinar

36. Translation/Implementation Highways JAMA. 2007;297(4):403-406. doi:10.1001/jama.297.4.403 From: Practice-Based Research—“Blue Highways” on the NIH Roadmap

37. Hold for cartoon Petersen AAMC Webinar

38. Problems with Linear Translation T1  T2 – 17 years from basic discovery to clear evidence from clinical trials Contopoulos-Ioannidis et al. Science 321:1298-99 T2  T3 – 10 years for widespread guideline implementation Linear approach to translation creates excessive lag in evidence implementation

39. Models for Linking Research to Action Adapted from Lavis et al, 2006 Petersen AAMC Webinar

40. Technical Problems vs. Adaptive Challenges (from Ronald Heifetz and Marty Linsky, “Leadership on the Line”) 1.Easy to identify 2.Often lend themselves to quick and easy (cut-and-dried) solutions 3.Often can be solved by an authority or expert 4.Require change in just one or a few places; often contained within organizational boundaries 5.People are generally receptive to technical solutions 6.Solutions can often be implemented quickly-even by edict Petersen AAMC Webinar 1.Difficult to identify (easy to deny) 2.Require changes in values, beliefs, roles, relationships, & approaches to work 3.People with the problem do the work of solving it 4.Require change in numerous places; usually cross organizational boundaries 5.People often resist even acknowledging adaptive challenges 6.“Solutions” require experiments and new discoveries; they can take a long time to implement and cannot be implemented by edict “The single biggest failure of leadership is to treat adaptive challenges like technical problems” Technical ProblemsAdaptive Challenges

41. Examples from Health Care 1.Implement electronic ordering and dispensing of medications in hospitals to reduce errors and drug interactions 2.Improve availability of hand sanitizer 3.Create workflow and structure to deal with low risk chest pain patients in the ED 4.What are the appropriate peer facilities for quality and efficiency comparisons (Partnership project) Petersen AAMC Webinar 1.Encourage nurses and pharmacists to question and even challenge illegible or incorrect prescriptions by physicians 2.Get health care providers to improve hand washing rates 3.Change primary care team roles to adopt a patient centered medical home model (Partnership project) 4.Design and test new model of provider payment to reward quality (Partnership project) Technical ProblemsAdaptive Challenges

42. Researchers Can Help with Evidence to Overcome Both Technical and Adaptive Challenges What are the social, cognitive, workflow barriers to handwashing? Petersen AAMC Webinar

43. Examples of Partnership Projects at the Houston Health Services Research and Development Center of Excellence Longitudinal measures of quality (Petersen and Woodard, PIs) – 10 publications (Circulation, Medical Care, JAGS, HSR, Diabetes Care) Resource efficiency (Petersen, PI) – 7 publications (HSR, Medical Care) Hospital and community living center peer facilities (Petersen, PI) – 2 publications (HSR, American Journal of Managed Care) Evaluation of primary care re-design (Hysong, PI) RCT of pay for performance (Petersen, PI) – 3 publications Petersen AAMC Webinar

44. Understanding Differences Network Needs: – Value fast turnaround, practical projects rather than publications (implementation/external validity) – HSR&D cheaper, more knowledgeable than external consultants – “It doesn’t really have to be perfect” – Rapidly changing needs, priorities Research Needs: – Academic products – Internal validity focus – Slower pace (IRB, funding cycles, data use agreements, HR, credentialing, contracting) – Business model Contracting HR Credentialing VA Research Petersen AAMC Webinar

45. Challenges to Partnerships Regulations! – Data Use Agreements – Research training for non-researchers Business model Petersen AAMC Webinar

46. Advantages of Partnership Aligning research with specific health system partners to increase the impact on VHA Accelerating the timetable for research in areas critical to the health system Focus upon implementation early in the research process Petersen AAMC Webinar Embedded researchers are cheaper and more knowledgeable about the delivery system May have access to data that other consultants don’t have Diverse skill set to tackle problems For ResearchersFor Partners

47. Building and Maintaining Partnership Need champions within partnering organization Some face to face meetings, especially early on Continued mutual recognition of needs of partnering organization Continued attention to sustainability Appreciation of differences Petersen AAMC Webinar

48. Partnership Research is a Team Sport Doing partnership work requires an excellent team Ability to respond to questions and requests Relationships, relationships, relationships! Petersen AAMC Webinar

50. Questions & Next Steps