Regional strategies to improve care for the chronically ill

1. Regional strategies to improve care for the chronically ill A chartbook created by the staff of: Improving Chronic Illness Care Group Health MacColl Institute Supported by The Robert Wood Johnson Foundation

2. Chronic illness in America • More than 125 million Americans suffer from one or more chronic illnesses and 40 million are limited by them • Despite annual spending of more than $1 trillion and significant advances in care, one-half or more of patients still don’t receive appropriate care • Gaps in the quality of care lead to thousands of avoidable deaths each year • Patients and families increasingly recognize the defects in their care

3. Public Physicians Policymakers People with chronic conditions usually receive adequate medical care 48 45 22 Current chronic illness care Patients with major chronic illnesses receive recommended care about half of the time These deficits are now perceived by patients, physicians and policymakers Percent agreement

4. Chronic illness and medical care • Primary care dominated by chronic illness care • Clinical and behavioral management increasingly effective and increasingly complex • Inadequate reimbursement and greater demand forcing primary care to increase throughput—the hamster wheel • Unhappy primary care clinicians leaving practice; trainees choosing other specialties • Loss of confidence in primary care by policymakers and funders • But there is a growing interest in changing physician payment to encourage and reward quality • The patient-centered medical home is the new hope

5. Greater care complexity and efficacy,but with lower self-efficacy? Multiple Medications Complex Guidelines Self-management Support

6. I. We have to do better

7. The future of primary care (and our healthcare system) depends upon its ability to improve the quality and efficiency of its care for the chronically ill It will also require a recommitment of primary care to meet the needs of patients for timely, patient-centered, continuous and coordinated care That will require a major transformation or redesign of practice, not just better reimbursement But such transformations will be difficult to motivate or sustain without changes to the larger healthcare environment What to do?

8. What’s responsible for the quality chasm for the chronically ill? • Practice systems oriented to acute disease that aren’t working for patients or professionals • Inadequate use of information technology • Poorly aligned payment structure

9. Toward a chronic care oriented system Reviews of interventions show that practice changes are similar across conditions Integrated changes with components directed at: • Use of non-physician team members • Planned encounters • Modern self-management support • Intensification of treatment • Care management for high-risk patients • Electronic registries

10. We have models to improve care; are they complementary or antagonistic? Medical Care Home The Chronic Care Model (CCM)

11. Medical Home and Chronic Care Model are complementary Both emphasize and support patient role in decision-making MH redefines primary care responsibility CCM redesigns care delivery for planned care Elements of both are integrated into the Patient-Centered Medical Home

12. What are the key features of a Patient-Centered Medical Home? • Personal physician – first contact, continuous care • Team care – collectively take responsibility • Whole person orientation – responsible for all patient needs • Coordinated care – across all elements of the healthcare system • Quality and safety – by implementation of CCM, continuous quality improvement (QI) and voluntary recognition process • Enhanced access – via open scheduling, expanded hours and expanded communication • Payment – value of the home recognized, pays for coordination, electronic communication with patients and IT

13. Can busy practices really change to improve care? YES! • Strong results from year-long collaborative improvement efforts involving multiple delivery systems and faculty • Chronic Care Model guides system change • More than 1,000 health care organizations and various diseases involved to date • Began with national Breakthrough Series Collaborative but shifted to regional efforts • HRSA’s Health Disparities Collaboratives have involved more than 600 community and migrant health centers

14. Lessons learned in chronic illness care improvement • Mostly reaching early adopters • Regional collaboratives less costly, equally effective and enabled other stakeholders (e.g., health plans) to be involved • Practice redesign is very difficult in the absence of a larger supportive “system”, especially for smaller practices • Perverse payment was an obstacle but didn’t stop motivated practices • Lack of registry functionality and limited availability and/or use of clinical office staff or care managers are major barriers

15. Characteristics of high-performing healthcare systems Factors that support high-quality chronic care: • Leadership and values support long-term investment in managing chronicdiseases • Well-aligned goals between physicians and managers • Integration of primary and specialty care • Investment in informationtechnology systems and other infrastructure to support chronic care • Useof performance measures and financial incentives to shape clinical behavior • Use of explicit improvement models– usually the Chronic Care Model

16. Is chronic care improvement possible across the entire population?

17. II. Regional improvement will require a regional system or organization

18. What’s needed to transform care systems across a region? • Leadership committed to quality improvement and primary care • Collaboration among different stakeholders • A population orientation • Measurement (and incentives) • Infrastructure support • Active program of practice change • Provider networking and vertical integration

19. Regional coalitions have been a commonAmerican response to regional problems “Americans are a peculiar people. If in a local community a citizen becomes aware of a human need that is not met…suddenly a committee comes into existence…and a new community function is established. It is like watching a miracle.” Alexis de Tocqueville, 1840 Regional coalitions tackling health issues are not new or uncommon. Lasker et al. identified more than 400 coalitions in 1997 (Medicine and Public Health: the Power of Collaboration).

20. MacColl study of regional quality improvement coalitions • What are the characteristics and strategies of successful regional coalitions? • Data sources were a literature review and interviews with leaders of major coalitions • Developed a regional framework or model that describes their work • Coalition leaders reviewed the regional framework and confirmed its relevance to their work • The regional framework provides a visual summary of what leading coalitions were doing - not yet an evidence-based summary of what works

21. A framework for regional quality improvement

22. Explaining the regional framework: beginning at the outcome To improve the population’s health, the Quality Chasm report makes clear that we must change or transform care systems everywhere healthcare is delivered to the population Transformed Health Care Delivery

23. Who needs to be involved? Major stakeholders need to be involved and committed to improvement Refusal of a stakeholder group to participate is ominous Collaboration among Stakeholders - Payers, Providers, Plans, Patients

24. Coalitions need strong leadership to succeed Someone needs to take and then assure leadership Long-term success seems to depend on three-tiered leadership • Organizational manager and staff • Respected home base for coalition • Stakeholders involved in program development Leadership

25. Everyone agrees that aggregating data is critical, but for what purpose(s)? Two major goals of regional data aggregation are performance measurement and data exchange Data exchange is proving to be difficult to implement and perhaps more difficult to sustain Regional performance measurement is feasible but often relies on claims data, whose validity must be suspect Optimal performance measurement requires clinical information not available from claims; many (smaller) practices will need help if they are to participate Shared Data and Performance Measurement

26. Transforming care delivery requires a strategy and infrastructure The strategy should have the ability to reach the majority of practices and help them change their delivery systems The majority of practices should have access to an infrastructure that enables them to fully implement the CCM Efforts should be made to reduce practice isolation and lack of integration in communities Improving Health Care Delivery

27. Ambulatory care infrastructure Smaller practices often lack the infrastructure to improve care. Coalitions may be able to help practices obtain: IT to create registries and facilitate performance measurement Consensus guidelines and related decision support Clinical care management services for high-risk patients Improving Health Care Delivery • Information technology tools • Consensus guidelines • Care management

28. QI strategies Need to choose one or more strategies tohelp practices change their care delivery Breakthrough Series collaboratives can beeffective, but are expensive for sponsors and participants Some evidence supports practice coaching Collaboratives, practice coaching programsand other QI programs are going on in manyregions. Regional initiatives should try to identify and collaborate with existing programs Improving Health Care Delivery • Quality improvement strategies

29. The isolation of smaller practices limits peer support, access to infrastructure and the ability to participate in QI Greater integration of primary care with specialty and hospital care should lead to better care coordination Creating networks of providers with a goal of QI appears to be a promising approach (e.g., Medicaid provider networks or practice-based research networks) Provider networks Improving Health Care Delivery • Provider Networks

30. Two goals for consumer engagement Influence Consumer Behavior The hope is that consumers will use publically disclosed quality data to select providers, but evidence is scant. Public disclosure does seem to stimulate provider QI Increase patient activation and self-management skills by providing information and support Engaging Customers • Public Disclosure • Consumer Education

31. Create financial incentives and remove barriers to quality care Create incentives for providers to make the investments and system changes needed to improve chronic care; little evidence yet of effectiveness Create benefit plans that reward consumers for making cost-effective choices Aligning Benefits/ Financing • Incentives for cost-effective care • Performance measures and rewards

32. Questions about Pay-For-Performance Does the limited evidence of Pay-for-Performance effectiveness to date reflect problems in P4P design? Should P4P more aggressively try to remove payment barriers, not just add bonuses? Aligning Benefits/ Financing • Incentives for cost-effective care • Performance measures and rewards

33. III. Promising signs of regional success

34. Is geographic improvement possible? Indiana • Health commissioner and Medicaid director created a Medicaid chronic care program • Program included a statewide breakthrough series collaborative program supported by: - A call center to inform and risk stratify patients - Community-based nurse care managers linked to practices to support high-risk patients - A statewide Web-based patient registry and technical support • Evaluated by University of Indiana - Reported cost savings to the governor

35. Is geographic improvement possible?North Carolina • State leadership and money have created a visionary Medicaid care system—Community Care of North Carolina • Features include a measurement system, guidelines, creation of physician networks, care managers, active QI programs • Capitated payment on top of usual fee-for-service reimbursement to practices for participating and to the networks • Evaluations have demonstrated significant improvements in care and reductions in costs

36. Community Care of North Carolina’sevaluation findings Asthma Disease Management (2000-2005) • 28 percent increase in flu vaccines • More than 90 percent of staged asthma patients on appropriate preventive medication • Saved $3.5 million from 2000-2002 from lower inpatient admissions and emergency department visits Diabetes Disease Management (2000-2004) • 10 percent increase in referrals for eye exams • 62 percent increase in flu vaccines • Foot exams are at 71 percent, improved 18 percent since baseline • Saved $2.1 million from 2000-2002 Emergency Department Initiative (2001– 2002) • Care management follow-up, outreach and education on all enrollees with three or more visits to the ED in a six-month period of time • 30 percent lower per member per month cost • 13 percent lower ED rate

37. Is geographic improvement possible? Prescription for Pennsylvania • Gov. Edward G. Rendell created the Chronic Care Management, Reimbursement and Cost Containment Commission to improve how Pennsylvanians with chronic disease receive health care in the future • The commission is responsible for developing the process to effectively manage chronic disease across the state • The commission designed the informational, technological and reimbursement infrastructure needed to support implementation of the Chronic Care Model throughout Pennsylvania • Implementation of the Chronic Care Model is through regional collaboratives across the state

38. Lessons learned from around the country • Medicaid can be an important engine of innovation and financial support • But involvement of commercial insurers and self-insured employers is critical for long-term success • Community-wide performance measurement is essential, but public disclosure should follow a deliberative process of data validation, piloting and discussion with medical leaders in the community • Much more needs to be known about regional QI strategies that effectively reach beyond larger, more advanced provider organizations • Helping smaller practices acquire and effectively use IT is critical to their ability to participate in QI • Training in QI methods, self-management support interventions and other elements are critical needs in most communities

39. IV. What the future holds

40. The urgency of improving the quality of care • We all hope for federal action to increase insurance coverage • But will our stressed primary care sector be able to improve the quality of its care while trying to meet the added demand? • Many believe that the frustrations of caring for the chronically ill in poorly organized delivery systems contribute to the primary care crisis

41. Quality improvement will be regional Even if we have federal health insurance reform, the major focus for quality improvement will continue to be regional because: • It requires collaboration among purchasers, plans and clinicians, AND most health insurance plans, major employers, and providers are regional • The quality, organization and patterns of care vary tremendously by region • The resources to support QI vary by region • Regional improvement efforts have improved diabetes and asthma care, reduced central line infections and reduced Medicaid expenditures across entire states or large regions within states

42. Contact us at: www.improvingchroniccare.org