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Meeting the Needs of the Community: A System for Redesigning Care

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She calls her doctor who cannot see her until the following week. ... is discharged after her first bout of breathlessness with information about CHF, ... – PowerPoint PPT presentation

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Title: Meeting the Needs of the Community: A System for Redesigning Care


1
Meeting 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

2
Overview
  • 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

3
Mrs. 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.

4
Four Biggest Worries About Having A Chronic
Illness (Age 50 )
  1. Losing independence
  2. Being a burden to family or friends
  3. Affording medical care

5
The 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)
6
Differences 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
7
Systems are perfectly designed to get the
results they achieve
The Watchword
8
Problems 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

9
Chronic 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
10
Model 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

11
Essential Element of Good Chronic Illness Care
Informed, Activated Patient
Prepared Practice Team
Productive Interactions
12
What 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

13
Self-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

14
Delivery 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

15
Decision 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

16
Clinical 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

17
Health 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

18
Community 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

19
Advantages 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

20
Research and QI Findings about The Chronic Care
Model
21
The Evidence
  1. Randomized controlled trials (RCTs) of
    interventions to improve chronic care
  2. Studies of the relationship between
    organizational characteristics quality
    improvement
  3. Evaluations of the use of the CCM in Quality
    Improvement
  4. RCTs of CCM-based interventions
  5. Cost-effectiveness studies

22
The 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.

23
The 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.

24
Overview
  • 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

25
For every problem, there is a solution that is
simple, neat, and wrong.
- H.L. Mencken
26
Model 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
27
Repeated 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
28
if only they had done more PDSA cycles...
29
Quality Improvement Efforts
R Grol. JAMA 20012842578-85
30
Interventions and their targets
Ann Intern Med 2002136642
31
Effectiveness of strategies to improve physician
performance
R Grol. JAMA 20012842578-85
32
The 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

33
Clinical 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

34
Educate 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

35
Decision 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

36
Decision 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.
37
Decision 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

38
UMHS 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

39
Leadership Report on Asthma Care Patients age 18
years or younger
lt 18 years old
all patients
40
Delivery System Design
41
Delivery 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

42
Delivery System Design Patients with diabetes
with blood pressurelt135/80
UM average 58
Health Center
43
Delivery 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
44
Activate 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

45
Self-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

46
Reinforce Self-management Goals
47
Self-management goals documented
48
University of Michigan Diabetes Care Improvements
over time, 2004 2007 (n9170)
49
Spreading 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)

50
For 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
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