ARE WE THERE YET Transforming Through Integration: Experiences from the Field

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ARE WE THERE YET?Transforming
Through Integration Experiences from the Field

• Integrated Health Networks Learning Session II
• Vancouver, BC
• February 7-8, 2008
• Dr. Rob Wedel
• Physician Lead, Chinook Primary Care Network
• Co-Chair, Alberta AIM

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Outline

• Where we have been-
• Taber Health Project 2000
• Lessons Learned
• Where are we going?
• Chinook Primary Care Network 2006
• Lessons being Learned
• Alberta AIM
• Albertas provincial spread initiative

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Taber Health Project

• Four year integrated primary care demonstration
  project initiated in 2000
• Serves a community of 15,000
• Two autonomous entities
• Taber Associate Medical Centre
• 8 physicians in private, free standing clinic
• Chinook Health Region
• 19 bed hospital, inc. ER, surgery, OBS
• 70 bed LTC
• home care, public health, Mental Health, rehab,
  etc.
• All publicly funded

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Healthcare Environment then and now

• Bed closures, shorter hospital stays, long waits
  for specialists, investigations, admissions, and
  procedures
• All resulting in increased pressures on community
  resources,
• family physician offices, public and community
  care nursing, mental health and rehab services,
  and the list goes on.
• Continuing shortages of health human resources
  have made for a pressurized and unsatisfying
  working environment.
• Recruitment and retention remains a major problem
• Worst of all, it just doesnt feel good to
  practice like this ...a general sense of being
  overwhelmed with the volume of work, and the
  mediocre quality of care that resulted.

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Healthcare Environment then and now

• These deficiencies have resulted in
• Long wait times for a 2 minute appointment.
• No time for teams.
• Inadequate community based resources
• Inadequate resources to help patients to self
  manage their own illnesses

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Healthcare Environment then and now

• Calgary Stampede of Chronic Disease
• the management of chronic illness will be the
  greatest health system challenge of the 21st
  century. -WHO 2002
• 50 of the Canadian population over 65 has 5 or
  more chronic conditions.
• 75 of health care spending relates to care for
  chronic conditions.
• Only 3 of us will die in our sleep. The rest
  will have a 1-3 yr period of progressive
  dependency, with 7-9 symptoms related to chronic
  illness.
• The rate of rise in healthcare spending will
  outstrip Canadas GDP by 2020. Increased capacity
  and productivity is essential.
• -Conference Board of Canada

Chronic Care, editorial by Andre Picard in Globe
and Mail, Aug 16, 2007 Morgan,et al. An
Inconvenient Truth A sustainable Healthcare
System Requires Chronic Disease Prevention and
Management Transformation. Healthcare Papers 2007
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The Canadian health system is not healthy!
(Health Council of Canada, Dec 2007)

• Hypertension
• One of four adults has HTN, 1/3 dont know it,
  and lt1/3 are controlled
• Diabetes
• 60 of diabetics have gone gt1yr without an
  examination
• Heart Failure
• 20 of heart failure patients are readmitted lt60
  days
• Asthma
• Third leading cause of presentation to ER
• Screening
• 38 of eligible women in Alberta get Pap
  screening
• lt10 of those with indications for colon
  screening are screened (CMAJ, 2007)

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The Canadian health system is not healthy!
(Health Council of Canada, Dec 2007)

• Delay in seeing a doctor and getting treatment is
  the highest among the seven developed countries.
  
• 25 of Canadians waited gt6 days to see a doctor
  last time they were sick, compared with
• US 19
• UK 13
• Australia 7
• New Zealand 2

When the Clock Starts Ticking, CFPC,
2006 Editorial, Edmonton Journal, Nov 1, 2007.
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The Problem

• Despite all our best efforts
• Using our traditional medical model, and the
  resources currently available to us, we have been
  singularly ineffective in meeting targets and
  providing guideline level care.
• Wait times at all levels of the system are
  worsening!
• There are few existing tools or models that
  support
• Inter-professional models providing
  multi-dimensional care
• Team based services within a community based
  setting

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CROSSING THE QUALITY CHASMA NEW HEALTH SYSTEM
FOR THE 21TH CENTURY DON BERWICK

• These quality problems occur typically not
  because of failure of good will, knowledge,
  effort or resources directed to health care, but
  because of fundamental shortcomings in the way
  care is organized

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Top Ten Mistakes- Dr. Marco Bonollo, Australia

• Start with a nebulous patient population.
• Use specialists instead of general practitioners
• Take patients over from FPs.
• Concentrate CDM in separate programs and
  institutions
• Separate work by disease entity.
• Forget about self management.
• Assume doctors would follow a good thing.
• Build something new, rather than build on what
  already works.
• Start with no identified Quality Indicators!

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Lessons Learned
More by accident than Design!
Dont Confuse the Means for the End. Dr.
Shortt, Queens University
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OUR PILLARS OF INTEGRATION
Alternative Payment Model
Integrated Electronic Record
Governance through Co Management with the RHA
Community Assessment and Shared Planning
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OUR PILLARS OF INTEGRATION

• Integrated Service Delivery using
  Multidisciplinary Teams

Alternative Payment Model
Integrated Electronic Record
Governance through Co Management with the RHA
Community Assessment and Shared Planning
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Modified Care Model
Health System
Community
Health Care Organization
Resources and Policies
Self-Management Support
ClinicalInformationSystems
DeliverySystem Redesign
Decision Support
Prepared, Proactive Practice Team
Informed, Activated Patient
Productive Interactions
Functional and Clinical Outcomes
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Core Elements of the Care Model

• organizational changes that support the
  integration of regional and community services
  with Family Practice clinics/groups
• Improved capacity and continuity in order to
  improve access
• the establishment of registries supported by
  Information Technology
• and the establishment of teams with individuals
  whose role includes care co-ordination
  (co-ordinating and facilitating - including
  system navigation)
• a greater emphasis on self-management

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Lessons Learned

• More by accident than Design!
• Dont Confuse the Means for the End.
• Upstream changes make the difference.

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Service Delivery Changes
Medical Management
Case Management
Self Management
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Outcomes

• Physician Services
• Progressive decrease in the rate of physician
  visits/pt
• Rates of non-physician services increased
• Absolute number of physician services increased
• Avg return rate 2.1 visits/yr (cf. control
  communities 5.6 visits/yr)
• Utilization
• Taber hospital admissions decreased
• Morbidity index and ALOS increased significantly
• 78 occupancy (cf . control communities gt100
  occupancy)
• Emergency room visits decreased
• Lab utilization decreased

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ER visits for Asthma Taber
Taber Asthma Project
Taber Family Practice Teams
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Lessons Learned

• More by accident than Design!
• Dont Confuse the Means for the End.
• Upstream changes make the difference.
• Teamwork Role Identity is the key followed
  closely by role clarity.

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Professional Identity Under Reconstruction

• Most difficult shift identified was for
  physicians
• From a traditional role, with physicians holding
  the sole responsibility for patient care.
• To shared responsibility, recognizing the
  expanded capacity for high quality care offered
  by a team.
• Other disciplines are also struggling with the
  same issues
• Gradual recognition of the subtle difference
  between substituting other providers and
  supplementing the work with a team made all the
  difference.

Wedel, et al. Turning Vision into Reality
Successful Integration of Primary Healthcare in
Taber, Canada, Healthcare Policy, Aug 2007
Chreim S, et al. Inter-Level Influences on the
Reconstruction of Professional Role Identity.
Academy of Management Journal. Dec 2007.
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Lessons Learned

• More by accident than Design!
• Dont Confuse the Means for the End.
• Upstream changes make the difference.
• Role Identity is the key.
• Quality doesnt just happen because we want it
  to.

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What will it take to achieve the Improvements we
want?

• Quality doesnt just happen.
• Working harder helps, but is not sustainable.
• We need to work smarter.
• We needed to
• Improve access to family practices.
• Improve efficiency in order to increase our
  capacity and productivity.
• Improve quality and clinical outcomes.
• Show leadership focused on Clinical Excellence.
• The people that do the work must change the
  work.
• Visibly support improvement efforts in CDM and
  prevention

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Modified Care Model
Health System
Community
Health Care Organization
Resources and Policies
Self-Management Support
ClinicalInformationSystems
DeliverySystem Redesign
Decision Support
Prepared, Proactive Practice Team
Informed, Activated Patient
Productive Interactions
Functional and Clinical Outcomes
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Alberta Primary Care Networks 2006

• One of 26 PCNs so far in Alberta
• 1495 family doctors, 51 of the Alberta FP
  population
• 1.2 million rostered patients
• Chinook Primary Care Network
• Joint Venture Agreement between the RHA and
  physicians
• 23 independent clinic sites, both rural and urban
• patient population of 184,000/ 110 FPs
• Focus on office/community based Family Practice
  Teams
• Alberta AIM
• 12 Collaboratives, including FP Clinics and
  Regional Specialty Programs
• Improvement Process supported by Mark Murray and
  Assoc

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Access and Capacity

• The most effective systems (clinical outcomes),
• and the most efficient systems (cost-revenue),
• with the most satisfying systems for patients
  and providers
• function with as little delay as possible.
• Institute Healthcare Improvement

Mark Murray and Don Berwick, Advanced Access
Reducing Waiting and Delays in Primary Care. JAMA
Feb 2003 Bodenheimer et al. Improving Timely
Access to Primary Care Case Studies of Advanced
Access JAMA 2006 Ohara et al. The Outcome of
Open-Access Scheduling Family Practice
Management, Feb 2004
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Improvement Principles

• Improved Access and Efficiency to improve
  Capacity
• Continuity and Comprehensiveness
• Improved Quality of Care
• Reliability and Patient Safety

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PRINCIPLES FOR CAPACITY IMPROVEMENT

• Know your own patients.
• See your own patients.
• Dont make them wait.

Moore, Escaping the Tyranny of the Urgent by
Delivering Planned Care. Family Practice
Management. May 2006 Brousseau, et al.
Association Between Infant Continuity of Care and
Pediatric Emergency Department Utilization
Pediatrics Apr 2004 Saultz et al. Interpersonal
Continuity of Care and Care Outcomes A Critical
Review Annals of Family Medicine. Vol 25. Sept
2004
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• Without access there is no quality.
• Dr. Jonathan Perlin, MD,
• Under Secretary for Health

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Why this Delay?
Moore, Escaping the Tyranny of the Urgent by
Delivering Planned Care. Family Practice
Management. May 2006
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Why Focus on Access and Delay?

• Delays lead to
• patient dissatisfaction
• staff dissatisfaction
• provider dissatisfaction
• Delays
• cost money
• Reduce our efficiency and capacity
• Delays adversely effect clinical outcomes
• The perception is that delay lack of resources
• Eliminating delays is the foundation for improved
  clinical care

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High Level Overview

• Build the foundation within the clinic
• Improvement Steps to build Access and Capacity
• Know your practice and your patients
  (Measurements)
• Look at HOW we do our work to improve efficiency
  and capacity.
• Dont make them wait.

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TIME TO NEXT 3RD APPT.
OPERATIONAL TEAMS DEVELOPED
SUPPLY DEMAND /-
CLINICAL TEAMS IMPLEMENTED
BACKLOG REDUCTION
PANELS IMPLEMENTED
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Taber Mental Health Program Wait Times
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High Level Overview

• Build the foundation within the clinic
• Improvement Steps to build Access and Capacity
• Know your practice and your patients
  (Measurements)
• Look at HOW we do our work to improve efficiency
  and capacity
• Improvement Steps to improve Clinical Care
• Look at WHAT work we do
• What care does our patient population need?
• What protocols and guidelines do our clinical
  teams need?

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Power of Panel Data (Know your own patients.)
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Why Continuity? (See your own patients)

• When patients see their own physician
• Visit length is shorter and compliance is
  better.
• Chance of re-visit goes down
• Patient, physician, and staff satisfaction rise,
• costs go down, revenue rises,
• Earlier detection of serious illness
• and clinical care and outcomes improve.
• Increased sense of ownership by provider, patient
  and team.
• if a patient is given the choice, continuity
  usually trumps convenience.

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Advantages of a panel

• Patients know their Family Doctor
• Doctor knows which patients are mine
• Both feel accountable to each other.
• The team is in a position to supplement the
  doctor- patient dyad in order for it to be
  successful
• The screening and chronic disease care needs of
  the patient population can be clearly identified,
  as well as urgent care needs
• Appropriate incentives can be developed and
  aligned for access and quality
• Panel serves as a measurement yardstick,
  encourages accountability
• Shift away from episodic visits by individual
  patients to management of a specific and defined
  patient population.

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KNOWING OUR PANEL TELLS US

• How many support staff are needed in our
  practice/program?
• How many will improve productivity?
• How many will improve outcomes?
• What professional types of person is best?
• Do we need another doctor?
• NP/RN/LPN/MA/Other?
• Social worker, case manager, other?
• What work do we need to do to meet the needs of
  my specific panel?
• What protocols and guidelines do we need?

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High Level Overview

• Build the foundation within the clinic
• Improvement Steps to build Access and Capacity
• Know your practice and your patients
  (Measurements)
• Look at HOW we do our work to improve efficiency
  and capacity
• Improvement Steps to improve Clinical Care
• Look at WHAT work we do
• What care does our patient population need?
• What protocols and guidelines do our clinical
  teams need?
• Improvement Steps to improve Reliability and
  Safety
• Pull it all together so that the right things
  happen every time

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Modified Care Model
Health System
Community
Health Care Organization
Resources and Policies
Self-Management Support
ClinicalInformationSystems
DeliverySystem Design
Decision Support
Prepared, Proactive Practice Team
Informed, Activated Patient
Productive Interactions
Functional and Clinical Outcomes
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• Quality clinical care is not doctor work,
• it is team work.
• The best clinical care is not delivered by
  physician visits alone

Murray, et al. Can Health Care Teams Improve
Primary Care Practice. JAMA March 10,
2004. Shojama, et al. Effects of Quality
Improvement Strategies for Type 2 Diabetes on
glycemic control A Meta-Regression Analysis.
JAMA July 26, 2006
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Do Patients Notice Good Teams?
From John H. Wasson MD - Dartmouth
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WHAT CHARACTERIZES A PREPARED, PROACTIVE
PRACTICE TEAM?
Prepared, Proactive Practice Team

• Goal is to create productive patient interactions
  that maximize the capacity and access to the
  practice, and improve health outcomes
• Move from the physician being the sole agent of
  success or failure --to a team structure where
  everyone understands the goal and their role
• Optimize the utilization of teams organized
  around a physicians specific patient population
• Optimize the system around broader population
  management

• Batalden, Nelson, et al. Continually improving
  the health and value of health care for a
  population of patients the panel management
  process. Quality Management in Health Care,
  1997, 5 (3). 41-51

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PRINCIPLES FOR CLINICAL IMPROVEMENT

• Standardize and support team based care by
  aligning teams with the most responsible
  provider, along with clear accountability and
  leadership.
• Embed clinical protocols and guidelines in daily
  routines to assist the team, and to reduce
  variations in practice.
• Develop specific, measurable performance
  indicators to evaluate success.

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Planned Family Practice Team Care

• Identify the Clinical Profile of each physicians
  panel of patients
• Identify Patients with Targeted Conditions
• Diabetes, Hypertension, Obesity
• Identify complex situations for case management
• Frequent flyers
• Generate necessary Pre-Visit Signals or Prompts
  and Planned Response for Patient Needs
• Health screening
• Ongoing Monitoring and targeted followup ie.
  HgA1C

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PREPARED FAMILY PRACTICE TEAM CARE

• Plan visits
• Pre-visit
• anticipate patient needs even during unrelated
  visits (ie lab results, consult letters,
  screening, CDM surveillance, BMI, education, etc)
  
• Use the registry to review care and pro-actively
  plan visits
• Visit
• Choreograph the visit to eliminate needless
  delays
• Assign roles, duties and tasks for these planned
  visits to multidisciplinary care teams
• Post Visit
• Designate staff for follow-up after the visit (ie
  telephone calls for results and followup visits,
  regional programs, community social programs,
  etc)

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Prepared Family Practice Team Care

• Pre-Plan the interventions that every patient
  should receive, based on guidelines
• Build the pathway into several points of entry
  (ie ER presentations for asthma)
• Include these interventions in every appropriate
  contact with patient.
• Develop guidelines for patients that are not at
  goal
• Discuss at meetings how the team is doing with
  the guidelines
• Train team members to support their clinical
  roles, communication skills, team functioning

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PROACTIVE FAMILY PRACTICE TEAM CARE

• Establish a routine proactive recall system based
  on the clinical stability of the patient
• Hopefully, problems can be identified and
  addressed before they escalate into an
  urgent/after hours presentation.
• If the patient does not show up- go out and find
  them.
• Review panel list for patients that dont visit
  gt1 yr.
• Do not allow patients to fall through the
  cracks, and show up months later out of control
  again.
• Case manage transitions between home and
  hospital, community services, etc.

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EXAMPLE PLANNED VISITS AROUND HYPERTENSION

• all patients gt18 have bp measured every
  appropriate visit
• Those with an elevated bp get an appt for follow
  up with the nurse (LPN)
• Using the EMR, we generated a list of all our
  known hypertensives
• Patients not at goal were recalled for action
  planning

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EXAMPLE PLANNED VISITS AROUND HYPERTENSION

• Using the Clinical Guides on HTN, protocols were
  developed
• To establish diagnosis
• risk stratification
• non pharmacological interventions and education
• Roles were assigned to various team members as
  per their scopes of practice.
• Patients with established diagnosis were then
  referred back to the FP for individual action
  plans re meds, exercise, etc
• Patients not at target are immediately discussed
  with the patients identified doctor for further
  management

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CHRONIC DISEASE CLINICAL GUIDES
PurposeTo support family practice teams,
regional programs, community partners, and
patients and their families in the prevention and
management of chronic illness
7. References
1. Diagnosis
2. Classification / Type / Staging
6. Referral to Specialist / Specialty Clinic
3. Patient Care Flow Sheet for Health Teams
5. Management Strategies for Patients/Clients
4. Management Strategies for Health Teams
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On-Line Access to Clinical Guides

• Guides available on-line
• www.chinookprimarycarenetwork.ab.ca
• USER ID primarycare
• PASSWORD health2006

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

• Self care tends not to happen independently
• Self Management happens best within a supported ,
  team based environment, and within a relationship
  with a Family Practice
• Self care reduces utilization through a
  negotiated shift of workload

Gibson et al. Limited information only patient
education programs for adults with asthma.
Cochrane Database of Systematic Reviews.
2002 Gibson et al. Self Management education and
regular practitioner review for adults with
asthma. Cochrane Database of Systematic Review
2003
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OPTIONS TO SUPPORT SELF MANAGEMENT
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Example Group Visits

• Complex and frail elderly
• gt65, gt12 visits/year
• Identified 14 patients
• Avg diagnoses 4.8
• Avg age 78.4
• Avg visits in past 12 months 17.9
• One morning/month, 2 hours (usual case load 8)
• Team MOA, RN, MD, Pharmacist , (HC Nurse in Nov)
• MOA Measures bp, updates meds, records
  concerns/problems
• RN leads an educational discussion (topics
  chosen by the group)
• MD Sees every pt alone, every visit
• Pharmacist Reviews meds, answers group questions

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Example Group Visits

• Preliminary Learnings
• Reduced individual visits from avg 17.9/yr to
  8/yr
• Nobody has dropped out, virtual perfect
  attendance.
• Highly satisfied, increasing requests from others
  to join
• One person has seen me 5 times additionally
  (Palliative)
• Two people have seen me twice more (Shared mental
  health visits)
• Do not forget the social aspect!
• By moving these patients to a group visit, I
  created an additional 100 clinical
  appointments/yr

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High Level Overview

• Build the foundation within the clinic
• Improvement Steps to build Access and Capacity
• Know your practice and your patients
  (Measurements)
• Look at HOW we do our work to improve efficiency
  and capacity
• Improvement Steps to improve Clinical Care
• Look at WHAT work we do
• What care does our patient population need?
• What protocols and guidelines do our clinical
  teams need?
• Improvement Steps to improve Reliability and
  Safety
• Pull it all together so that the right things
  happen every time
• Insure sustainability through Ongoing Measurement

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Care Model
Health System
Community
Health Care Organization
Resources and Policies
ClinicalInformationSystems
DeliverySystem Design
Self-Management Support
Decision Support
Prepared, Proactive Practice Team
Informed, Activated Patient
Productive Interactions
Functional and Clinical Outcomes
65
Lessons Learned

• More by accident than Design!
• Dont Confuse the Means for the End.
• Integrated Service Delivery is horizontal and
  vertical (ie. includes linkages with both the
  community, and the specialized service programs.)
  
• Upstream changes make the difference.
• Role Identity is the key.
• Quality doesnt just happen because we want it
  to.
• METRICS MATTER!

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Metrics Matter

• Drumbeat of Change
• Routinely measure and compare
• Demonstrate the changes made and effort extended
  actually resulted in improvement
• Some excellent measurement tools are available
• www.clinicalmicrosystems.org
• www.improvingchroniccare.org
• www.howsyourhealth.org

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Our Measurement Team

• Advises on the Improvement/Quality Assurance
• Focus areas include
• Review of best practices/evidence
• Create an atmosphere of transparency
• Development of measurement and evaluation
  frameworks and methodology
• Develop a process to support Measurement, and
  report feedback to the clinics
• Facilitation of spread and momentum of
  improvement

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Outcome Measures Domain of Access

• Measure 1 Delay
•  Measure 2 Demand (Panel Size)
• Measure 3 Supply (Capacity)
•  Measure 4 Continuity
•  Measure 5 Failure to Keep Appt Rate
•  Measure 6 Cycle Time (Time pt in clinic)
• Measure 7 Flow Mapping

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Outcome Measures Domain of Quality

• Measure 1 Cancer
• Breast/Cervical/Colon cancer screening
• Measure 2 Cardiovascular
• Blood Pressure (Process and Outcome)
•  Measure 3 Diabetes Mellitus
• HgbA1c Testing (Process and Outcome)
• Measure 4 Infectious Disease
•  Influenza/Pneumococcal Immunization
• Measure 5 Tobacco Use
• Measure 6 Physician Use of Chronic Disease
  Guidelines 

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People Make the Difference
The people that do the work must change the
work

• Its people willing to work together in
  partnership that build more effective systems

Elizabeth Duke, PhD National Leadership Summit
on Eliminating Racial and Ethnic Disparities Jan.
11, 2006
73

• Take the leap. we will build our own wings on
  the way down.
• Donald Berwick

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References

• Institute of Healthcare Improvement
• www.ihi.org
• Chinook Primary Care Network
• www.chinookprimarycarenetwork.ab.ca
• Professional Login
• User ID primarycare
• Password health2006
• CFPC Primary Care Toolkit
• http//toolkit.cfpc.ca
• Taber Health Project
• www.uleth.ca/man/taberresearch.html