1. CCLC/SNI/Kaiser Chronic Care Learning Communities Initiative Collaborative Final Outcomes Congress December 9, 2005 Santa Clara Valley Medical Center

2. CCLC/SNI/Kaiser SCVMC: Stroke Prevention Location: Northern California - Tertiary Regional Medical Center - Silicon Valley Administered by County of Santa Clara. Size: Metropolitan Area of Santa Clara County Has a Population of 1.7 Million Residents; 50% Live in the City of San Jose, the County Seat; identified 250 patients with multiple risk factors from 9,000 patients in diabetes registry Population Served: 44% European American; 26% Asian American; 24% Hispanic/Latino; 3% African American; <1% Native American. Over 34% Residents “Foreign Born”; Over 50% Speak Language Other Than English; Over 10% Speak No English.

3. CCLC/SNI/Kaiser Delivery System Design Decision Support Clinical Information Systems Self-Management Support Health System Resources and Policies Community Organization of Health Care Registry Care reminder Subgroups Care-planning Data mining Team roles & tasks planned visits continuity follow-up Team building Guidelines specialty interaction provider education guidelines for patients interventions care-planning & problem solving Relationship building Assessing needs, expectations and values Information sharing Goal setting Action planning Problem solving CHRONIC CARE MODEL

4. CCLC/SNI/Kaiser Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Functional and Clinical Outcomes Goals: create business plan for CCM Coordinate care delivery efforts among providers Introduce and discuss provider incentives Senior leaders created framework to study CCM Health System Resources and Policies Community Organization of Health Care TCOYD Kaiser, SNI, Diabetes Coalition Establish liaison with industry Chronic Care Model

5. CCLC/SNI/Kaiser Key intervention: Assessment of patients at high risk for cardiovascular event Design and delivery of educational module for stroke self- management SAVED (sensation, ache, vision, expression, dizziness) Protocols published and care managers certified Collaborative Plan formulated with each participant, based on PCP input and participant’s readiness is in role out phase Self-Management support was emphasized Proactive follow-up for one year Informed, Activated Patient Productive Interactions Prepared Practice Team Risk factor intervention for Cardiovascular complications

6. CCLC/SNI/Kaiser Clinical Information Systems Registry –Filemaker workgroup based design –Process flow from encounter to remote entry –Care reminders –Outlier reporting to identify patients in need of test –Emails and IVR produced from registry Patient subgroups –MDs receive lists of patients with hgba1c > 8.0% Care-planning –Lists generated for those with missing labs

7. CCLC/SNI/Kaiser Decision Support Guidelines –Provider agreement to adopt guidelines HEDIS, ADA –Published on the intranet/extranet –Registry programmed to alert clinician Specialty interaction –Design and pilot a referral form –Transmit retinal scans to ophthalmology Provider education –Meet with primary care monthly –Educational seminars, TCOYD Guidelines for patients –Wallet cards with meds printed on back

8. CCLC/SNI/Kaiser Delivery System Design Team roles & tasks –Nurses/PA-C/PharmD use medication adjustment protocols –MD refers to educator who records patients goals –Care manager offers education and/or management Planned visits –Registry printout shows current lab –Alert PCP and patient labs before appointment Continuity –Prompts for specialty MD contact from referral form Follow-up –CDE calls patients regularly

9. CCLC/SNI/Kaiser Self Management Support Emphasize patient role –Multiple providers send this message to patient Assessment –Downloaded assessment from website –CDE assesses patient at planned visit Interventions –CDE trained through chronic disease self- management program Care-planning & problem solving –Use of motivational interviewing techniques

10. CCLC/SNI/Kaiser Community Resources Effective programs –Identified community resources at Diabetes Coalition –Co-sponsored TCOYD conference Partnerships –Kaiser community benefits program –Outreach to SCC medical society and physician IPA Coordination –Recognize Diabetes Society as an educational resource

11. CCLC/SNI/Kaiser Organization of Health Care Teams –Link care managers to PCP’s within geographic area Benefits –Partner with division of primary care quality programs for shared goals and processes Provider incentives –Introduce BP surveillance and goals Senior leaders –Approved involvement in CCM pilots and spread teams on tracking and reporting on collaborative measures –Sanctioned a study comparing traditional care to care delivered via the chronic care model

12. CCLC/SNI/Kaiser Functional and Clinical Outcomes BaselineSTUDY Hba1c Q 3-4 04Q1 v Q2 05 –Pre intervention8.58.0 –Post intervention7.5 7.5

13. CCLC/SNI/Kaiser Barriers Collaboration Not Dictation Difficulty with centralized department sending “delinquent” lab monitoring notices to the PCP –Send reminders not delinquent notices –Create a team of care manager and 3 PCP’s –Introduce the possibility of pay for performance

14. CCLC/SNI/Kaiser Stroke Reduction Education Referral

15. CCLC/SNI/Kaiser A1c Test

16. CCLC/SNI/Kaiser Detail of Hba1c Testing Hba1c % <7  Q162  Q257  Q346  Q447

17. CCLC/SNI/Kaiser Detail of Hba1c Testing Hba1c % <7# tested  Q16286  Q257121  Q34689  Q447 214

18. CCLC/SNI/Kaiser Detail of Hba1c Testing Scalability Hba1c % <7# tested#<7  Q1628654  Q25712169  Q3468941  Q447 214100

19. CCLC/SNI/Kaiser Spreading Chronic Care Improvements Complete buy-in. –To study of the proof of concept. –Support a trial comparing outcomes traditional ambulatory care the chronic care model. –Compare total expenditures and resource utilization (hospitalization, emergency and urgent care utilization and laboratory/ancillary care costs) within a closed system.

20. CCLC/SNI/Kaiser A Patient Voice