1. 1 Improving the Quality of Care for Injured Workers in Washington State: The Occupational Health Services Project Thomas Wickizer, Ph.D., M.P.H. University of Washington May 2, 2003

2. 2 IOM Crossing the Quality Chasm Recommendations Design of more effective organizational support for care processes Design of more effective organizational support for care processes Create an infrastructure to support evidence- based practice Create an infrastructure to support evidence- based practice Use information technology more effectively Use information technology more effectively Align payment incentives to support quality Align payment incentives to support quality Improve workforce training Improve workforce training

3. 3 Disability Prevention: Bad News--Good News Workers who remain on disability for longer than 2-3 months have greatly reduced chance of returning to work Workers who remain on disability for longer than 2-3 months have greatly reduced chance of returning to work Effective occupational health care can reduce the likelihood of long-term disability Effective occupational health care can reduce the likelihood of long-term disability Bad News Good News

4. 4 Changes in Disability Status among Injured Workers in WA State 1211109876543210 0 20 40 60 80 100 % Workers Receiving Disability Payments Time Loss Duration (months) Key to disability prevention is to intervene early.

5. 5 Cost per claim WA State MCP: Differences in Medical and Disability Costs (n=2,217) Disability costs were paid in usual way and were not under capitated payment. Fewer workers went on disability (14.7% vs 19.2%) and cost per worker on disability was less ($2,332 versus $3,466). Data based on 9-month follow up.

6. 6 Occupational Health Services (OHS) Project WA State Occupational Health Services (OHS) Project initiated in 1998 to: WA State Occupational Health Services (OHS) Project initiated in 1998 to: Improve quality and outcomes of occupational health care Improve quality and outcomes of occupational health care Enhance patient and employer satisfaction Enhance patient and employer satisfaction OHS is not “managed care” OHS is not “managed care” No restrictions placed on provider choice No restrictions placed on provider choice

7. 7 System Redesign through OHS Quality indicators Quality indicators Financial and nonfinancial incentives Financial and nonfinancial incentives Community-based pilot centers of occupational health and education (COHE): Community-based pilot centers of occupational health and education (COHE): Provide quality improvement activities Provide quality improvement activities Case coordination Case coordination CME, provider mentoring, academic detailing CME, provider mentoring, academic detailing Tracking patient care & feed back data to providers Tracking patient care & feed back data to providers Identify and provide care for high-risk cases Identify and provide care for high-risk cases

8. 8 OHS-COHE Organization Pilot Community COHE Business/Labor Advisory Group Community Physicians Dep’t of Labor & Industries UW Research Team Two COHEs: Seattle and Spokane. Seattle COHE operational June 2002; Spokane COHE operational April 2003.

9. 9 Selected Quality Indicators Submission of report of accident (ROA) Submission of report of accident (ROA) “% claims for with ROA received within 2 business days of first office visit” “% claims for with ROA received within 2 business days of first office visit” Two-way communication with employer Two-way communication with employer “% of claims for which two-way communication between provider and employer about return to work is accomplished at first visit when worker off work or expected to be off work” “% of claims for which two-way communication between provider and employer about return to work is accomplished at first visit when worker off work or expected to be off work” Assessment of impediments to return to work Assessment of impediments to return to work “% of workers on time loss who have received assessment or referral for assessment of impediments to return to work by 4 weeks of work loss” “% of workers on time loss who have received assessment or referral for assessment of impediments to return to work by 4 weeks of work loss” Condition-specific quality indicators Condition-specific quality indicators “nerve conduction studies to corroborate presence/absence of CTS if time loss > 2 weeks or surgery is being considered” “nerve conduction studies to corroborate presence/absence of CTS if time loss > 2 weeks or surgery is being considered”

10. 10 Quality Impediments and OHS Strategies Quality Impediments and OHS Strategies Quality Impediment Quality Impediment Poor quality Poor quality Ineffective disability prevention Ineffective disability prevention Administrative delays Administrative delays Poor communication Poor communication Inadequate reimbursement & misaligned incentives Inadequate reimbursement & misaligned incentives Lack of patient care tracking data Lack of patient care tracking data OHS Strategies Track patient care through quality indicators, CME, provider mentoring Time-linked clinical mgt. action, 4- week in-depth assessment of barriers to RTW, occ-health best practices Decrease time to claim authorization by improving timely submission of ROA and provider documentation of work-relatedness Case coordination, improve provider- employer communication Financial incentives linked to quality indicators Develop information technology to track patients

11. 11 Challenges In Implementing Community- Wide Quality Improvement Initiatives Development of information technology Development of information technology Complex and more costly than often anticipated Complex and more costly than often anticipated Physician recruitment Physician recruitment Small % of physicians treat large portion of workers’ compensation patients Small % of physicians treat large portion of workers’ compensation patients Forging cross-institutional relationships in competitive markets Forging cross-institutional relationships in competitive markets Provider organizations focus on short-term financial interests Provider organizations focus on short-term financial interests

12. 12 Preliminary Data from Process Evaluation Seattle pilot COHE began operation in June 2002. Between June and December 2002: Seattle pilot COHE began operation in June 2002. Between June and December 2002: 88 providers were recruited 88 providers were recruited OHS physicians served as attending doctor for 2,670 injured workers OHS physicians served as attending doctor for 2,670 injured workers 55% of pilot physicians met submission of report of accident 2-day benchmark as compared to 8% the previous year 55% of pilot physicians met submission of report of accident 2-day benchmark as compared to 8% the previous year

13. 13Conclusions Community-wide quality improvement interventions can address important impediments to quality in WC Community-wide quality improvement interventions can address important impediments to quality in WC Key is to develop strategies that: Key is to develop strategies that: Provide effective disability prevention Provide effective disability prevention Identify cases at risk for long-term disability Identify cases at risk for long-term disability Challenges include: Challenges include: Physician recruitment Physician recruitment Development of information technology Development of information technology Forging cross-institutional relationships Forging cross-institutional relationships WC may present strong “business case for quality” WC may present strong “business case for quality” Preventing disability offers immediate financial payback Preventing disability offers immediate financial payback