1. Improving Health Outcomes by Linking the Clinic to the Community
Thomas Sequist, MD MPH

2. What you have heard about US health care
Poor quality
Costly

3. Improving Chronic Care Outcomes
AHRQ National Quality Report 2012

4. Atrius Health
Non-profit alliance of six leading independent medical groups
Granite Medical
Dedham Medical Associates
Harvard Vanguard Medical Associates
Reliant Medical Group
Southboro Medical Group
South Shore Medical Center
Providing care for ~ 1,000,000 adult and pediatric patients with physicians, 1450 other healthcare professionals across 35 specialties .

5. Atrius Health
100% 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 Medicaid
Widespread use of rosters in population management
Track record of quality measurement and reporting
All adult primary care sites accredited as NCQA Level 3 Patient Centered Medical Homes

6. Harvard Vanguard Medical Associates
Multi-specialty group practice
17 ambulatory health centers
400,000 adult patients
175 primary care physicians

7. HVMA Diabetes Care Model
Clinical Information Systems
Electronic medical record
Computerized alerts
Population Management
Centralized patient mailings
Patient Engagement
Primary care teams
Diabetes dashboards
Chronic disease visits
Improved Diabetes Care

8. Baseline Racial Disparities
White
(n=4,858)
Black
(n=2,699)
p value
Process measures, %
Annual HbA1c test
Annual LDL test
Outcomes measures, %
HbA1c < 7%
LDL < 100 mg/dL
BP < 130/80 mmHg 87 83 46 55 32 89 40 43 24
0.14
0.99
<0.001

9. Panel Diversity and Disparities in LDL Control
Median = - 8.0%
IQR = -6.9% to -9.4%
p = 0.84
Sequist; Arch Intern Med 2008

10. The “Not Me” Phenomenon
Do racial disparities in diabetes care exist in….
Sequist; JGIM 2008

11. Intervention Components
Cultural competency training
1 to 2 day course (89% team attendance)
Monthly educational materials
Clinical performance feedback
Monthly distribution
Race-stratified (HbA1c<7%, LDL < 100, BP < 130/80)
Provider level (benchmarked to practice)

12. Sample Performance Report

13. Patient Survey Feedback

14. Impact on Clinician Awareness
Do racial disparities in diabetes care exist in….
P=0.003
P=0.02
P=0.04

15. Clinician Support for Intervention
How effective are these strategies to reduce racial disparities?
P=0.01
P=0.02

16. Clinician 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.

17. Clinician 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.

18. Views on Cultural Competency Training
Feeling that training educated on history of racism, trust, and bias
Helped 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…”

19. Where Does this Leave Us?
Address social determinants
Address built environment
Systematic approach?
The 15 minute office visit will not be enough

20. Quality of Primary Care – Community Interface
Toward A Rational Process
Ideal State
Recognition/ ownership of issues
Quality of Primary Care – Community Interface
Primary care resources
Identifying community resources and partners
Payment models
Current State
Integration of care plans

21. Different Viewpoints Medical Clinic Public Health Advantages:
Access to health indicators
Direct management of services
Disadvantages:
Piecemeal interactions
Lack of broader context
Focus on medical management
Public Health
Advantages:
Focus on communities
Contextual approach
Disadvantages:
Lack clinical context
No integration into care plans
Multiple constituents

22. Our Roadmap Change measurement paradigm Target communities for action
Allow clinicians to view communities
Target communities for action
High disease prevalence
Poor quality
High penetration
Identify successful strategies
Positive outliers and trajectories
Resource catalogue
Clinical integration
Clinician liaison
EHR tools

23. Our Barriers Traditional performance focus on clinicians
Clinician sphere of responsibility
Systematic approach to community partnership
Health center resources

24. Community Base Performance Measurement