Title: Meeting the Needs of the Community: A System for Redesigning Care
1Meeting the Needs of the Community A System
for Redesigning Care
- Mike Hindmarsh
- Hindsight Healthcare Strategies
- Steven J. Bernstein
- University of Michigan
- Ann Arbor VAMC
- Winslow Lecture
- Battle Creek, MI
- 9 October 2007
2Overview
- Mike Hindmarsh
- Burden of chronic illness
- Chronic care model
- Research findings
- Steven J. Bernstein
- Model for Improvement
- Quality improvement approaches
- Application of the chronic care model
3Mrs. C We all know one
- Ms. C is a 68yo woman with cough and shortness of
breath and risk factors for Type II diabetes.
She calls her doctor who cannot see her until the
following week. - Two days later she is hospitalized with shortness
of breath. She is diagnosed with CHF,
discharged on captopril and a no added salt
diet with encouragement to see her MD in three
weeks - When she sees her MD, he does not have
information about the hospitalization - PE reveals rales, S3 gallop, edema and possible
depression - Ms. C is told she has a little heart failure,
encouraged not to add salt, and Captopril is
increased. Her depression is not addressed. - She is told to call back if she is no better
- Two weeks later Ms. C calls 911 because of severe
breathlessness and is admitted. - Fuller history in the hospital reveals that she
has been taking the Captopril "as needed"
because it seems strong, and she has never
added salt to her diet, so her diet hasnt
changed. - Further tests reveal elevated blood glucose. She
is warned of impending diabetes. - She is discharged feeling ill and frightened.
4Four Biggest Worries About Having A Chronic
Illness (Age 50 )
- Losing independence
- Being a burden to family or friends
- Affording medical care
5The Increasing Burden of Chronic Illness
For example Patients with diabetes have
Additional Medical Problems 45
Functional Limitations 50
gt 2 Symptoms 35
Poor Health Habits 30
Arthritis (34), obesity (28), hypertension
(23),cardiovascular (20), lung (17)
Physical (31), pain (28), emotional (16),
daily activities (16) Eating/weight (39),
joint pain (32), sleep (25), dizzy/fatigue
(23), foot (21), backache (20)
6Differences between acute and chronic conditions
(Holman et al, 2000)
Acute disease Chronic Illness
Onset Abrupt Generally gradual and insidious
Duration Limited Lengthy and indefinite
Cause Usually single Usually multiple and changes over time
Diagnosis prognosis Usually accurate Often uncertain
Intervention Usually effective Often indecisive adverse effects common
Outcome Cure possible No cure
Uncertainty Minimal Pervasive
Knowledge Prof.s - knowledgeable Patients - inexperienced Prof.s and patients have comple-mentary knowledge and experience
7Systems are perfectly designed to get the
results they achieve
The Watchword
8Problems with Current Disease Management Efforts
- Emphasis on physician, not system, behavior
- Lack of integration across care settings
hindering quality care - Characteristics of successful interventions
werent being categorized usefully - Commonalities across chronic conditions
unappreciated
9Chronic 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
Improved Outcomes
10Model Development 1993 --
- Initial experience at GHC
- Literature review
- RWJF Chronic Illness Meeting -- Seattle
- Review and revision by advisory committee of 40
members (32 active participants) - Interviews with 72 nominated best practices,
site visits to selected group - Model applied with diabetes, depression, asthma,
CHF, CVD, arthritis, and geriatrics
11Essential Element of Good Chronic Illness Care
Informed, Activated Patient
Prepared Practice Team
Productive Interactions
12What is a productive interaction?
Prepared Practice Team
Informed, Activated Patient
Productive Interactions
- Assessment of self-management skills and
confidence as well as clinical status - Tailoring of clinical management by stepped
protocol - Collaborative goal-setting and problem-solving
resulting in a shared care plan - Active, sustained follow-up
13Self-Management Support
- Emphasize the patient's central role
- Use effective self-management support strategies
that include assessment, goal-setting, action
planning, problem-solving, and follow-up - Organize resources to provide support
-
14Delivery System Design
- Define roles and distribute tasks amongst team
members - Use planned interactions to support
evidence-based care - Provide clinical case management services
- Ensure regular follow-up
- Give care that patients understand and that fits
their culture
15Decision Support
- Embed evidence-based guidelines into daily
clinical practice - Integrate specialist expertise and primary care
- Use proven provider education methods
- Share guidelines and information with patients
16Clinical Information System
- Provide reminders for providers and patients
- Identify relevant patient subpopulations for
proactive care - Facilitate individual patient care planning
- Share information with providers and patients
- Monitor performance of team and system
17Health Care Organization
- Visibly support improvement at all levels,
starting with senior leaders - Promote effective improvement strategies aimed at
comprehensive system change - Encourage open and systematic handling of
problems - Provide incentives based on quality of care
- Develop agreements for care coordination
18Community Resources and Policies
- Encourage patients to participate in effective
programs - Form partnerships with community organizations to
support or develop programs - Advocate for policies to improve care
19Advantages of a General System Change Model
- Applicable to primary and secondary preventive
issues, prenatal and pediatric, mental health and
other age-related chronic care issues - Once system changes in place, accommodating new
guideline or innovation much easier - Fits well with other redesign initiatives such
as improved access - Approach is being used comprehensively in
multiple care settings and countries
20Research and QI Findings about The Chronic Care
Model
21The Evidence
- Randomized controlled trials (RCTs) of
interventions to improve chronic care - Studies of the relationship between
organizational characteristics quality
improvement - Evaluations of the use of the CCM in Quality
Improvement - RCTs of CCM-based interventions
- Cost-effectiveness studies
22The IHP Chronic Care Collaborative
- 15 participating practice teams
- 6 months into process
- Process measures moving clinical outcomes close
behind - Broad acceptance of QI process among team members
- Spreading successful change is next step.
23The Mrs. C We Want to Know
- Mrs. C is discharged after her first bout of
breathlessness with information about CHF, risk
factors for diabetes, and assurance of rapid PCP
follow-up - The discharge nurse notes Mrs. Cs conditions and
care in the EHR and then sends an email to PCPs
office about her recent hospitalization. - The PCP's nurse ensures the physician sees the
information calls Mrs. C to schedule a follow-up
within 48 hours and adds her to the care teams
registry which prompts team to her future care
needs. - Mrs. C is scheduled for 30 minutes 15 minutes
with her physician and 15 minutes with the nurse.
The physician explains CHF and diabetes to her.
He orders the appropriate tests for diabetes and
assures her that all will be fine recognizing her
fear. He closes the loop with her to make sure
she understood his recommendations and then
briefly explained the concept of self-management
support. - Mrs. C then visits with the nurse who steps her
through a collaborative goal setting and action
planning process. While Mrs. C is a bit
overwhelmed, she is assured that her care team
will follow-up in the next couple of days by
phone to make sure she understands her clinical
and self-management care plan and to report on
the results of diabetes test. - The nurse calls within 48 hours and informs Mrs.
C that she should be able to manageher blood
sugar by better diet and exercise. She reviews
the CHF medications with Mrs. C and adjust
dosage since it seems to be bothering her. - She is scheduled for a follow-up visit in one
week to discuss her blood glucose in moredepth
and encouraged to call her team with any concerns
or symptoms in the meantime. - Mrs. C understands the hard work she needs to do
to manage her conditions but is thankful for
such a caring team.
24Overview
- Mike Hindmarsh
- Burden of chronic illness
- Chronic care model
- Research findings
- Steven J. Bernstein
- Model for Improvement
- Quality Improvement Approaches
- Application of the chronic care model
25For every problem, there is a solution that is
simple, neat, and wrong.
- H.L. Mencken
26Model for Improvement
What are we trying toaccomplish?
How will we know that achange is an improvement?
What change can we make thatwill result in
improvement?
Act
Plan
Study
Do
From Associates in Process Improvement
27Repeated Use of the PDSA Cycle
Changes that result in improvement
Implementationof Change
Wide-Scale Tests of Change
Follow-up Tests
Hunches Theories, Ideas
Very Small Scale Test
From Associates in Process Improvement
28if only they had done more PDSA cycles...
29Quality Improvement Efforts
R Grol. JAMA 20012842578-85
30Interventions and their targets
Ann Intern Med 2002136642
31Effectiveness of strategies to improve physician
performance
R Grol. JAMA 20012842578-85
32The University of Michigan experience with the
model for improvement
- Chronic disease management is a priority
- Establish multi-specialty/department steering
committee - Develop multi-payor chronic disease registries
- Asthma, CAD, CHF and Diabetes
- Collect relevant clinical information
- Report information to provider patient
- Identify a responsible provider
- Modify delivery system to improve care
33Clinical Information Systems Report to provider
their patients data (diabetes)
- Prioritize report and highlight items needing
attention - Decide whether to use color or black white
() - Focus on information that can be easily obtained
and that has clinical relevance
34Educate providers and staff on improving clinical
documentation
- Click on
- Diabetes eye exam
- Click on
- Foot exam visual, sensory, pulses
- Click on
- Self-management goal
- Then enter the goal in
- Additional information
35Decision Support
- Report detailed clinical data to the
provider at patient's visit via an auto-
mated system - Identify items that need attention
provide detailed action steps
36Decision Support Identify registry patients for
automated reminders
Dear John Smith, At the East Ann Arbor Health
Center, we want you to have the best diabetes
care. To improve our care and to keep our
medical record up-to-date, we are sending this
letter with information regarding
diabetes-related tests and exams. After
reviewing your medical record, we have the
following recommendations ? Please take the
enclosed slip to the lab for a blood test to
check your average sugar control (A1c) blood test
to check your cholesterol levels urine test to
check your kidneys You do not have to fast for
this test. We will contact you about the results
and suggest follow-up if needed.
37Decision SupportReporting
- Reports
- Monthly high priority patient reports sent to
nursing and pharmacists for case management - Semi-annual physician, health center comparative,
and leadership reports - Discussed at health center and department
leadership meetings to determine resource
allocation, educational needs - Incorporated into physician annual performance
evaluation
38UMHS Diabetes Report by Provider at one Health
Center
Physician Name
- - - - -
- J. Smith
- - - - -
- - - - -
- - - - -
- - - - -
74
39
50
- Be willing to show all their data to a provider
- Do not single out an individual provider to
other providers
39Leadership Report on Asthma Care Patients age 18
years or younger
lt 18 years old
all patients
40Delivery System Design
41Delivery System Design PDSA
- Use PDSA cycles at pilot sites to determine if an
intervention is both feasible and effective - For example, improving hypertension control
- Medical assistants at East Ann Arbor Health
Center trained to add bright green sticker to
patient encounter form if blood pressure gt than
target goal - Sticker prompts MD to note elevated BP and act
- Sticker also prompts clerk to automatically
schedule 2-4 week follow up with MD or pharmacist
42Delivery System Design Patients with diabetes
with blood pressurelt135/80
UM average 58
Health Center
43Delivery System Design Identify Achievable
Benchmarks
90tile for BP lt 130/80 across 25 academic teams
participating in an Asso. American Medical
CollegesChronic Care Collaborative is 56
Population studied by each academic team
44Activate Patients
- Activate and educate patients by providing
them with information on how they are doing
at the time of their visit - Insert patient data onto a take-home
educational sheet
45Self-management support
- Handout is given to patient when put in the exam
room - MA asks patient to think about a goal
- MD supports goal
- MA documents in medical record
- MA calls patient in 2 weeks
46Reinforce Self-management Goals
47Self-management goals documented
48University of Michigan Diabetes Care Improvements
over time, 2004 2007 (n9170)
49Spreading Success
- Horizontal from pilot clinics to the remaining
fourteen primary care health centers - 131 PCPs, 157 residents
- Standardize practice at the health centers
- Vertical from the primary care clinics to
geriatric and endocrine specialty clinics - Involvement of the multi-specialty team members
assist in implementation - Across conditions from diabetes to other chronic
conditions with registries (asthma, CAD, CHF)
50For more information regarding the chronic care
model and its application, please see
www.improvingchroniccare.org
or contact Mike
Hindmarsh hindmarsh.m_at_ghc.org Steven J.
Bernstein.. sbernste_at_umich.edu
Thank you