1. Care by Design ™ at University of Utah: Developing and Implementing Care Management, Engaging Patients, and Assessing Cost of Care Michael K Magill, MD Professor and Chairman Department of Family and Preventive Medicine University of Utah School of Medicine and Community Clinics

2. Primary Care Practice Redesign – Successful Strategies AHRQ Grant #1R18HS020106 Michael K. Magill, MD, Principal Investigator

3. Implementation and Research TeamImplementation and Research Team  Tatiana Allen  Julie Day, MD  Timothy Farrell, MD  Karen Gunning, PharmD  Teresa Hall, PT  JaeWhan Kim, PhD  Michael Magill, MD  Annie Mervis, MSW  Ruth Murdock  Debra Scammon, PhD  Andrada Tomoaia- Cotisel, MPH, MHA  Norman Waitzman, PhD

4.  Visits (FY11):317,000  Active patients: 157,000 11 Community Clinics11 Community Clinics

6. Care by Design TM – Early days Appropriate Access – 2003 Balance visit supply and demand Standardized schedules Care Team – 2004 Expanded MA role Providers and MAs working in teams EMR tools (BPAs, Xfiles) Planned Care – 2006 Protocols, order sets Pre-visit planning, labs Registries

7. Care by Design TM - Moving Forward… Care Management Program for patients with chronic diseases Embed care managers in clinics Facilitate clinical care Coordinate care Promote patient self-efficacy and self-management Transitions management

8. Visit Non Visit Care Managers Clinical Pharm Appointment/ Message Call-Center Compensation System EMR Expanded Team Macro Team Environment Care Team Institutional Priorities

9. Care ManagersCare Managers Multidisciplinary backgrounds Social Work, Nursing, Healthcare Administration, Health Education, Hospice, Chaplain Formal training in care management techniques and motivational interviewing

10. Selection of Patients for Care Management Data driven Patients with diabetes, heart failure, coronary artery disease Age of patient Last appointment Next scheduled appointment Last 3 Hgb A1c Last 3 LDL Last 3 Blood Pressures Provider referral

11. Care Management ProgramCare Management Program Assessment Tools Patient Activation (PAM) Quality of Life (RAND36) Depression Screening (PHQ9) Motivational interviewing Individualized patient self-management goals in EMR Self-monitoring tools via EMR patient portal (“MyChart”) Blood glucose, blood pressure, exercise, weight

12. Patients Participating in Care ManagementPatients Participating in Care Management

13. Transitions ManagementTransitions Management Objective: prevent unnecessary readmissions Focus: Inpatient  outpatient Population: Community Clinics patients recently discharged from University of Utah Hospital Mechanism: Daily electronic registry generated from EMR Care managers call recently discharged patients listed on this registry

14. Key Transitions QuestionsKey Transitions Questions How feeling since discharged? Questions you have that were not answered? Changes to medications (while in ED/hospital)? Who is primary care provider? Follow-up appointment with this provider? Do you know danger signs to indicate you need to return to hospital/call doctor?

15. Patients Parti cipating in Transitions Management

16. “Mr. RR was able to finally admit that he has difficulty with Drs and being able to understand teaching that is provided. He says that Drs use ‘all those big words’ that he does not understand. He expressed an appreciation for me explaining cholesterol, diabetes complications and HgbA1C lab results.” Care Management: Notes From the Field

17. “Ms ZZ seems to deal with her anxiety and stress about her husband’s condition by monitoring all his intake. This causes stress between them. Ms ZZ had a misunderstanding about some things the patient should or should not eat. They were both receptive about going to the Diabetic Nutrition Class.” Care Management: Notes From the Field

18. “Mrs. CCC seems motivated and is ready to go. She reports that she has already made changes in her diet…. After setting a goal and making a return appointment, she said ‘I’m excited.’”

19. Plan: Measures of SuccessPlan: Measures of Success Patient activation score Patient Activation Measure (PAM) Patient outcomes Patient functional status (RAND36), clinical quality, address depression (PHQ9) Patient experience PCMH CAHPS pilot survey Cost ED visits, hospitalizations and readmissions

20. Care Management: Plan to Assess Impact on Utilization and Cost Data - patient level linkage to… Medicare and All-Payer data from 2007-2012 Outcomes - Utilization and Cost Inpatient Care Outpatient, home health, nursing home Prescription Drug

21. Delivery Systems Research: Challenges Clinical Operations vs. Research Relationship-building: care manager role, patient consent Data needs are different Business decisions and environmental events affect implementation IRB, HIPAA Access to PHI Linking PHI to external data