1. Organization of Health Care and Delivery System Design Alan Glaseroff MD CMO, Humboldt IPA IHI National Forum 2007 Orlando, Florida 12/10/07 alang@hdnfmc.com Redesigning Chronic Illness Care: Evidence, Experiences, and Stakeholders IHI National Forum December 10, 2007

2. 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?

3. Disparities: Life Expectancy at Birth Tony Iton MD, Alameda County Public Health Director

4. Life Expectancy by Census Tract Tony Iton MD, Alameda County Public Health Director

5. 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 Tony Iton MD, Alameda County Public Health Director

6. -Bay Area Regional Health Inequities Initiative Medical ModelSocio-Ecological HEALTH CARE ACCESS

7. Expanded Model

8. Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Functional and Clinical Outcomes Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Chronic Care Model

9. Health Care Organization 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.

10. Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Functional and Clinical Outcomes Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Chronic Care Model

11. Delivery System Design Multiple levels –Regional/National: macrosystem –Integrated Medical Care Organization: mesosystem –Practice level: microsystem Alignment required for breakthrough improvement in community health

12. 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

13. 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?

14. 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

15. 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

16. Humboldt Diabetes Project

18. To improve outcomes in chronic illness… Patients must be prescribed and taking proven therapies Patients must be managing their illness well

19. Microsystem: Frustration Patients are frustrated by waits and discontinuities, often dont 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.

20. 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

21. 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

22. 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 Informed, Activated Patient Productive Interactions Prepared Practice Team How would I recognize a productive interaction?

23. Microsystem: Defining roles and tasks across team to achieve productive interactions

24. 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

25. Team Meetings Regular intervals All members of care team (groups of < 10) Agenda: –Old business –New Business –What isnt working? –Opportunities for excellence?

26. Defining Tasks

27. Example of task distribution Microalbuminuria 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

28. Use planned interactions to support evidence-based care One-on-one, group, telephone, email, outreach….the possibilities are endless

29. 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)

30. 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.

31. How do you do a Planned Visit? You Plan It!

32. 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

33. 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)

34. 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

37. Ask patient open-ended questions –Hows your health? Any issues you want to discuss? Review patients 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

38. Group Visits: Introduction Fun and efficient Patients can receive: Self-management support training Social support Specialty service as needed/available One-on-one with medical provider Medication 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

39. In general, would you say your health is: (check one box) ExcellentVery GoodGoodFairPoor B4%19%37%30%10% F5%27%42%22%4% : How effective do you believe your health care provider is in managing your diabetes? Not effective at all Not very effective Somewhat effective EffectiveVery effective B1%3%18%45%34% F<1%1%13%44%41% Patient Survey: Less Frustrated?

40. How effective do you believe you are in caring for your diabetic patients? Not effective at all Not very effective Somewhat effective EffectiveVery 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 Somewhat less effective Same Somewhat more 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?

41. What is care management? Many different things to different people Resource coordination Utilization management Follow-up Patient education Clinical management

42. 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

44. Ensure regular follow-up by the primary care team The trick is noticing when it isnt happening Can be accomplished in many different ways

45. Humboldt Diabetes Project Data October, 2003October, 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 <140/9062%59% Patients with BP <130/8032%33% Patients with LDL<13060%73% Patients with LDL <10032%44% January, 2007 Results (n=4330) 5.2% 59% 67% 37% 78% 49%

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47. New Methods for Teaching the Chronic Care Model IHI National Forum December 10, 2007

48. Select Topic Planning Group Identify Change Concepts Participants Prework LS 1 P S AD P S AD LS 3 LS 2 Action Period Supports E-mailVisits Web-site PhoneAssessments Senior Leader Reports Event AD P S (12 months time frame) Breakthrough Series Collaborative

49. 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 HRSAs 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

50. 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

51. Challenges Remaining Reaching beyond early adopters Try less time- intensive learning Create supportive systems Target small practices

52. Trying New Ideas Virtual Collaboratives On Wheels Coaching Combos

53. Integrating Chronic Care and Business Strategies in the Safety Net

54. The Intervention PLUS Practice Coach _________________ STEP-UP Methodology Toolkit ______________ Business & Clinical Tools

55. 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 Organize Your Care Team Clearly Define Patient Panels Create Infrastructure To Support Patients Plan Care Organize Your Care Team Clearly Define Patient Panels Create Infrastructure To Support Patients Support Self-Management Plan Care Organize Your Care Team Clearly Define Patient Panels Create Infrastructure Support Pts Reexamine Outcomes & Adjust Capture Incentives Redesign Care and Business Systems Integrated CCM & Business Changes Organized into four phases

56. The Toolkit & The Business Case The Toolkit & the Business Case

58. Thank you! Katie Coleman, MSPH coleman.cf@ghc.org www.improvingchroniccare.org

59. 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

60. Redesigning Chronic Illness Care: Taking Improvement to Scale Ed Wagner, MD, MPH MacColl Institute for Healthcare Innovation Center for Health Studies Group Health Cooperative Improving Chronic Illness Care A national program of the Robert Wood Johnson Foundation IHI National Forum December 10, 2007

61. 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).

62. Challenges Remaining Early Adopters Try less time- intensive learning Create supportive systems Target small practices

63. 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.

64. 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

65. Whats 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

66. Care will not improve unless we change the systems of care The goal is to transform health care delivery across a region

67. Someone needs to take and then assure leadership Major stakeholders need to be involved and committed to improvement Leadership

68. Need outcome and patient experience data as 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

69. Need strategies and infrastructure to help ALL practices change their delivery systems Strategies – QI methods, Provider networks InfrastructureIT, guide- lines, care managers

70. More activated and informed consumers may help push improvement Public disclosure of performance data may spur improvement

71. Create incentives for providers to make the investments needed to improve chronic care Create benefit plans that reward consumers for making cost- effective choices

72. Leadership A Framework for Regional Quality Improvement

73. Is geographic improvement possible? State efforts

74. 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

75. 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

76. Is geographic improvement possible? Washington State Diabetes Surveillance Regional Collaboratives Laid groundwork for PSHA

77. Is geographic improvement possible? Pennsylvania Governor brought disparate interests together All the major players at the table Timeline & ?budget to make it happen

78. Lessons Learned IndianaMake your effort bipartisan & protect it from political winds. North Carolina Reach out! Provider networks can engage small practices in quality improvement Rhode IslandBring all the ps to the table: providers, purchasers, payers, patients, policy-makers ColoradoConnect 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

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