Practice Support Program Chronic Disease Management Module

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Practice Support ProgramChronic Disease
Management Module
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• Agenda Review

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Objectives for this Evening

• Brief review of the PSP
• Overview of the CDM Module
• Why CDM?
• Provincial Goals
• Timeline and Payment
• Introduce the Toolkit
• Develop a clear plan for creating a pt registry

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Review of the Practice Support Program (PSP)
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What is the PSP?

• Provincial program coordinated by the BCMA and
  supported by the Society of GPs, the Ministry of
  Health, and the HAs.
• Program funded via the 2006 Working Agreement
  between the BCMA and the MoH for change
  management
• Provide GPs with support and resources to enable
  them to learn and test new ways of working

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What is the PSP continued.

• Consists of multiple modules
• Modules delivered over an extended period of time
• Each Learning Session (LS) has been approved for
  3.5 M-1 Mainpro credits

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Overall Goals of the PSP

• To offer GPs the opportunity to enhance the
  organizational structure and clinical
  effectiveness of their practice
• Improve pt access and care
• Improve the quality of work life for GPs and
  their staff

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Overview of the CDM Module
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CDM Module Overview

• Purpose
• Overall Goals Measures
• Key Strategies
• Timeline
• Payment Details

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Purpose of the CDM Module

• To work and learn together to enhance clinical
  practice for optimal CDM
• Provide the ability to measure the results via
  the Toolkit
• To improve pt outcomes
• To improve job satisfaction

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Overall (stretch) Goal of the CDM Module

• GP practices will be supported so that 70 - 80
  of their patients will be receiving
  evidence-based CDM
• You will be setting your own goals later tonight

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Measures for the CDM Module

• You will be able to measure
• of pts with the selected condition on the
  registry (goal is 100)
• of pts receiving recommended care based on
  pre-determined indicators
• of pts who are at target for indicators

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Goals and Measures(diabetes as an example)
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Key Strategies for Optimal CDM

• Use of a patient registry
• Use of the Toolkit to manage a patient registry
• Use of Planned Recall

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CDM Module Timeline
LS Learning Session AP Action Period
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Payment for the CDM Module

• 3.5 hr Learning Sessions (LS)
• Action Periods (AP)
• Toolkit Incentive Bonus

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1 Payment for the LSs

• Funding for a maximum of 8 LSs
• Each LS is invoiced as follows
• GPs at 384.31
• MOAs at 80.00
• Not sure if we need all 8

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2 Payment for the APs

• AP1 -Develop a registry
• -Toolkit (apply, digital
• cert, baseline data)
  1647.00
• AP2 -Toolkit (data entry)
• -Recall report
  1647.00
• AP3 -Refine processes
• -Embed changes
  576.47
• AP4 -Refine processes
• -Embed changes
  576.47
• AP5-8 - ??
• Potential Total 4446.94

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3 Toolkit Incentive Bonus Payment

• Eligible if
• GP
• Enter 50 pts into the Toolkit
• Have entered the baseline data (at least 3
  indicators)
• Never received this payment before
• Amount is 500.00

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Payment Summary

• Attend 6 LSs (GP MOA) 2785.80
• Accomplish all AP tasks 4446.94
• Qualify for Toolkit bonus 500.00
• Potential total payment 7732.74

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Toolkit Live Demo
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Chronic Disease Management
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Why employ CDM ?

• Medical staff focus
• Improve office management of a complex patient
• To improve job satisfaction
• Measure the results
• Patient focus
• Improve patient care ie guideline
  standard/systematic approach
• Improve patient outcome

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What impact does CDM - Planned Care have on
billing?

• Its much easier to bill the CDM incentive fees
• 14050 - Diabetes
• 14051 - CHF
• 14052 - Hypertension
• The Business Case
• The average GP currently only bills CDM incentive
  fees for 30-40 of their eligible CDM patients
• Complex Care Fees
• Knowing who your complex patients are will help
  you to develop Complex Care Plans so you can bill
• CDM - Planned Care module participation
• Talk to your Practice Support Team about whats
  involved and how you can be compensated to learn
  and test changes in your practice

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Guidelines Decision Support
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BC Diabetes Flowsheet
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(No Transcript)
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A System of Care for Chronic Disease
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Chronic Disease Management

• Growing body of evidence shows
• SIGNIFICANT GAP between
• RECOMMENDED CARE
• ACTUAL CARE for those at risk or are living
  with Chronic Illness

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THE CARE GAPQUALITY CHASM

• Translates to
• INCREASED MORBIDITY MORTALITY
• LENGTHEN WAIT TIMES FOR HEALTH CARE SERVICES
• ESCALATING HEALTH CARE COSTS

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THE BURDEN OF CHRONIC DISEASE

• gt50 of North Americans have chronic illness
• 2/3 of hospital admissions are due to
  exacerbation of chronic disease
• 80 primary care visits
• 2/3 medical cost are related to chronic disease
• Rapoport et al 2004

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Six country performance on diabetes
careCommonwealth Fund International Health
Policy Survery (Schoen et al.2006)
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CHRONIC CARE MODEL

• Adopting best practices to provide comprehensive,
  coordinated supportive, evidence-based care
  delivery that are population-based and
  patient-centric
• 32/39 studies of use in diabetes show improved
  patient outcomes
• 18/27 studies showed reduced costs
• www.improvingchroniccare.org

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EXPANDED CHRONIC DISEASE MODEL

• INTRODUCED IN BRITISH COLUMBIA IN 2003
• CONGESTIVE HEART FAILURE
• DIABETES
• HYPERTENSION
• COPD
• FRAIL ELDERLY
• www.health.gov.bc.ca/cdm

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Solid evidence of improvement for Diabetes
Diabetes patients receiving 2 A1C tests
lt41 41 to 48 gt48

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and CHF
CHF patients on an ACE-I or ARB
lt41 41 to 49 gt49

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Fixing the System

• Its time to stop running faster and fix health
  care
• A broken system is breaking us.
• Trying harder wont work changing systems will

Smith R. Hamster Health. BMJ 2000 3211541-1542
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What does primary care need?

• Reimbursement is not enough
• Major changes to practice organization
• Major changes in delivery systems

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What do patients with chronic illness need?

• Primary care provider and continuity of care
• A practice system and a clinical team who can
  help meet their needs
• Effective treatment
• Information and support for self-management
• Systematic follow-up and assessment tailored to
  meet the clinical severity
• Coordination of care across the continuum

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(No Transcript)
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Essential Element of Good Chronic Illness Care
Prepared Proactive Community Partners
Productive Interactions
Activated community
Informed, Activated Patient
Prepared Practice Team
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What characterizes a prepared practice team?
Prepared Practice Team

• Patient information (i.e. lab data) is organized
  and readily available to the team.
• The team utilizes evidence-based guidelines to
  manage care and prevent illness.
• The team has time to teach the patient , provide
  self-management support, and follow-up on
  outcomes.

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What characterizes a informed, activated
patient?
Informed, Activated Patient

• Patient understands the disease process, and
  realizes his/her role as the daily self manager.
• Family and caregivers are engaged in the
  patients self-management.
• The patient manages his own care according to
  guidelines.
• The provider is viewed as a mentor and guide.

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Cornerstones in the CDM Module

• Evidence-based using clinical foundations
• System change strategy
• Performance improvement model from IHI, PDSAs
• Evidence based system change concepts
• The Care Model which has been successfully
  trialed for both practice redesign and system
  redesign
• Learning Model
• Breakthrough Series Structured Learning
  Collaboratives

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Dinner!

• Random selection for order
• Tables 7 and 2
• Tables 5 and 8
• Tables 9 and 4
• Tables 1 and 3
• And 6!

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Integrated Health Networks
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Integrated Health Networks

• Practice Support Program is funded through BCMA
• Whereas,
• Integrated Health Networks are the Ministry of
  Health and the Health Authorities coming to the
  table to support family practice physicians.

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What is an integrated health network?

• A model to improve the linkage and alignment of
  IH community and chronic disease programs and
  services to better support family physicians and
  the needs of their patients.

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Volunteer Process

• The creation of a network starts with a group
  of family physicians and the patients to whom
  they provide care. It will specifically target
  additional support for your patients in the
  community with complex medical problems.

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What will that support be?

• That has not been determined. We need to have
  the discussion with you as to how best to use the
  additional funding to provide the resources you
  need
• --Nurse?
• --Mental Health support?
• --Dietician?
• --Professional that just helps navigate the
  system.

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What will I have to do?

• Sessional funding is available but we need to
  have some time to understand what additional
  support will best meet your needs.
• If another health care practitioner will be
  supporting you and your practice they will need
  to understand what care you would like them to
  provide

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Evaluate

• The Health Authority will need to know if
  providing additional support helps in patient
  careand will want some aggregate data. (not
  patient specific)
• If it appears that additional support is valuable
  they will commit to ongoing funding of the
  program.
• If interested in further discussion sign up sheet
  available.

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Developing a Patient Registry
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What is a Patient Registry?

• A list of all patients with a particular
  condition
• ie diabetes mellitus or hypertension
• Contains health status information tracked on
  flow sheets

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Why Use a Pt Registry?

• Enables more focused and organized care for each
  condition
• Helps to
• generate flow sheets
• organize Group Visits
• bill for selected patients
• Facilitates individualized goal-setting with
  patients
• Assists with implementing a planned recall system

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5 Easy Steps to Creating a Registry

• Apply for the Toolkit and the Physician Profile
  Analysis
• Decide on a pt population defined by one chronic
  condition
• Identify all pts with this condition and create
  an accurate list
• Put list into the Toolkit and add demographic
  data
• Use flow sheets to maintain the registry

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Step 1 (to creating a registry)

• Apply for the Toolkit and the Physician Profile
  Analysis
• Is there anyone here tonight who has not applied
  for the Toolkit?

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(No Transcript)
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Step 1 continued.

• Is there anyone here tonight who has not applied
  for a Physician Profile Analysis?

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Practice Profile Registration Form
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Step 2 (to creating a registry)

• Decide on a pt population defined by one (or
  more) chronic condition
• Must be one of the following
• DM
• CHF
• HTN
• CKD
• COPD
• Must have a minimum of 20 pts
• 50 entries into the Toolkit to be eligible for
  the incentive reimbursement (500)

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Step 3 (to creating a registry)

• Identify all pts with this condition and create
  an accurate list
• Chart review
• Billing system
• Physician Profile Analysis (DM, CHF, HTN)

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Step 4 (to creating a registry)

• Put list into the Toolkit .
• The Physician Practice Profile Analysis comes
  with a CD which can be uploaded into the Toolkit
  (MSP CDM probabilistic Patient Registers)
• Physicians can then edit their registers online
  rather than starting from scratch
• Saves data entry time
• Saves chart review time

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Step 4 continued.

• .and add demographic data
• Live demo of adding, deleting, and adding
  baseline and new data in the Toolkit coming up

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Step 5 (to creating a registry)

• Use flow sheets to maintain the registry
• Pull all charts (paper)
• Use a blank flow sheet to collect baseline data
• Transfer baseline data to Toolkit
• Print new flow sheet and add to chart
• Over time, add other patients to the registry as
  they come to light.

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Patient Notification

• Its not necessary to get patient consent to put
  them in the registry, but you should tell them
  the next time you talk to them.
• (Post Patient Notification in waiting room)

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Creating a Registry with an Established EMR

• Steps
• Set up your EMRs reporting function to generate
  a list of patients eligible for the registry.
• Capture any additional information you want to
  include on the list, such as contact information,
  birth date, and date last seen.

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Creating a Registry with an Established EMR
continued

• Locate the EMRs blank electronic template to use
  as a flow sheet
• Tip Standard software such as Excel or Access
  can be used to create a registry list

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Creating a Registry with an Established EMR
continued

• EMR Use the software to flag each selected
  patient.
• Over time, add other patients to the registry as
  they come to light.

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Testimonial

• Dr Paul Farrell
• Why the Toolkit?
• How much work?
• What are the benefits?

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Action Period Planning
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Lessons Learned from Previous Experiences

• Establish a team and work together - there is too
  much to do alone.
• Clearly define tasks and responsibilities for all
  team members.
• Keep each other informed, meet frequently
  (weekly?), communicate often.

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Lessons learned continued.

• If you are in a large group, identify one person
  as the point person.
• Do things slowly , small pieces at a time, to
  avoid feeling overwhelmed.

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Lessons learned continued.

• Dedicate time and staff hire if needed. This
  is what the funding is for.
• Use the Plan-Do-Study-Act (PDSA) cycle to guide
  your actions for larger more complex tasks

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The PDSA Cycle

• Is a common-sense method to help guide change
• Use it to help you keep you focused on small
  incremental changes while maintaining a clear
  overall goal
• Use when the change has multiple steps and/or
  will take significant time

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The PDSA Action Plan Worksheet

• PDSA Action Plan Worksheet
• Date_________

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PDSA Cycle Example

• For Action Period 1
• Complex task will be the gathering and entering
  of baseline data into the Toolkit
• Best to break it down into small do-able segments
  using the PDSA cycle

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PDSA Cycle Example
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PDSA Cycle Example
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PDSA Cycle Example
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PDSA Cycle Example
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Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What changes can we make that
will result in improvement?
Institute for Healthcare Improvement
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Action Plan

• Action Plan handout and worksheet
• Review each task/goal
• Some are simple tasks and just need a who and a
  when
• Others will require PDSA
• Aim, Goals Measures handout
• Finalize your own practice goals and measures

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The END!

• Next Learning Session