Are We Providing Older Patients the Care they Deserve? Improving the Quality of Care for Older People

1. Are We Providing Older Patients the Care they Deserve?Improving the Quality of Care for Older People Neil S. Wenger, MD, MPH Division of General Internal Medicine David Geffen School of Medicine at UCLA Maine Medical Center Annual Geriatrics Day 2009

2. The Quality of Health Care • Americans receive 55% of recommended care (439 indicators for 30 conditions and preventive care) • Care for specific conditions varies greatly • Cataract 79%; hip fracture 23% McGlynn EA, et al. NEJM. 2003; 348:2635-45.

3. Health Care Quality for Vulnerable Elders: ACOVE results • Overall, 55% of Quality Indicators passed • Compliance for geriatric conditions was worse than for general medical conditions (31% versus 52%) • Care for specific conditions varies greatly • Stroke 82%; end-of-life care 9% -Ann Int Med 2003

4. Quality of Care for“Geriatric Conditions” -Ann Intern Med. 2003;139:740-7.

5. Care Provided to Vulnerable Elders:Examination After a Fall 6% Blood pressure 25% Vision 7% Gait and balance 28% Neurological exam

6. Care Provided to Vulnerable Elders: Approach to Urinary Incontinence 50% document some history 22% dedicated exam 38% urine test 13% behavioral treatment suggested

7. Quality of Care for Initial Cognitive Impairment Evaluation -Belmin J, et al. Assessment and Management of Patients with Cognitive Impairment and Dementia in Primary Care. Under review.

8. Quality of Care for Prevalent Dementia (N=101) -Belmin J, et al. Assessment and Management of Patients with Cognitive Impairment and Dementia in Primary Care. Under review.

9. Overview of Presentation • What’s the problem? • Approaches to care for the older patient • Does practice redesign work? • ACOVE-2 study • ACOVE – Alzheimer’s Association project • ACOVEprime with the ACP • How can you change your practice?

10. The Problem Physicians are unable to provide high quality of care for conditions affecting older persons within the context of busy primary care practice.

11. Why do we Provide suboptimal care? • Barriers to effective management of geriatric conditions • Inadequate case recognition • Lack of physician knowledge • Poor patient adherence to treatment plan • Inadequate follow-up • Lack of time and resources

12. Cognitive capacity • Too much to know • During 2001, the US National Library of Medicine added more than 12,000 new articles per week to its on-line archives • To maintain current knowledge, a general internist would need to read • 20 articles per day • 365 days per year • Shaneyfelt TM. JAMA 2001; 286:2000-2601

13. Not enough time • Assuming • practice size 2500 patients • age chronic distribution of US population • following guidelines for 10 chronic diseases • Would take 10.6 hours per day • Plus time for management of other problems • Ostbye, Ann Fam Med. 2005; 3:209-14.

14. Improving Medical Care • Higher level of quality cannot be achieved by further stressing current systems of care. • Trying harder will not work. Changing systems of care will. • Institute of Medicine, 2001

15. Physicians’ Opinions on Strategies to Improve Quality of Care % of physicians responding that the factor is “very effective” in improving quality of care Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. 2005

16. Models of Improving Care for Older Patients • Consultation model • Geriatrician, team • Assume care • Care management interventions • Geriatric Resources for Assessment and Care of Elders (GRACE) • Home-based geriatric care management intervention: decreased ED visits and improved general health, vitality, social and mental health. • Disease management by care managers • Improved quality of dementia care, quality and outcomes for depression • Guided care using specially-trained practice-embedded nurses • Decreased utilization, improved health among high utilizing patients, and increased patient ratings of care. • -Callahan CM, et al. JAMA. 2006;295:2148-57. • -Unutzer J, et al. JAMA. 2002; 288:2836-45. • -Counsell SR, et al. JAMA. 2007;298:2623-33. • -Boult C, et al. J Gerontol A Biol Sci Med Sci. 2008;63:321-7.

17. What is Practice Redesign? • Redesign = hybrid between principles of continuous quality improvement and reengineering. • CQI focuses on small cycles of testing changes and observing results at local points of care. • Reengineering focuses on more radical restructuring of basic processes of care, with motivation for change coming from higher managerial levels and affecting larger units of organization.

18. What is Practice Redesign? - 2 • Redesign aims to implement the best of both approaches, combining the gradualism of CQI with the fundamental restructuring seen in reengineering. • Practice redesign may be one approach to overcoming remaining barriers to evidence-based practice.

19. Practice Redesign Principles • To improve care, change often focuses at three key levels • patient • provider • practice • Does not need to be expensive • Chronic Care Model

21. Model Assumptions • Follow-up visit cannot take more than 20 minutes • General medical care cannot be compromised • No electronic medical record • Office staff can provide some help

22. Physician-Patient Encounter $$$$ Out-of-Office Preparation Office Visit $$ $ • Reduce time but increase effectiveness/efficiency of the inner circle • Always push to outermost possible circle whenever possible

23. Delegation to Patients • Pre-visit questionnaire • Initial • Follow-up • Lists • Diaries

24. Delegation to Office Staff • Screening/Case identification • History gathering • Following up on triggers • Medications/allergies • Enhanced vital signs/physical exam • Orthostatic blood pressure readings • Visual acuity testing • Patient education

25. Obstacles to Delegatingto Office Staff • Cost • Training • Capability of acting on results

26. The ACOVE-2 InterventionImproving the Quality of Care for Falls, Incontinence and Dementia

27. ACOVE-2 Quality Improvement Model • Case finding • Delegation of data collection • Structured visit notes to guide appropriate care processes • Physician and patient education • Linkage to community resources -Reuben et al. J Am Geriatr Soc. 2003;51:1787-93.

28. Case Finding • Several options • Telephone call prior to visit • Staff prior to placing patient in room • Pre-visit questionnaire in waiting room • Brief questions to identify target conditions • Responses are given to provider at clinic appointment

29. Structured Visit Note • Leads physician through appropriate data collection and care processes • History items and simple procedures (completed by intake office staff) • More detailed history and exam, ordering diagnostic tests (completed by physician) • Impression and plan (completed by physician)

36. Patient educational materials • Assembled for each condition • Readily available to the clinician during care to facilitate treatment • Community resources • Follow-up visit form

38. Decision Support-Physician Education • Small group educational sessions aimed at practical approaches to each condition within the context of a busy practice

39. ACOVE-2 Study Design Intervention Period Control Clinics 287 patients Patients  75 yo with PCP appointment Screen for D / F / U Follow-up Quality of Care Survey Collect Medical Records 357 patients Intervention Clinics Intervention Materials

40. Participating Medical Groups

41. Patient Characteristics

42. ACOVE-2:Quality of Care after Intervention * p<0.001 for difference between I and C groups -A Practice-based Intervention to Improve Primary Care for Falls, Urinary Incontinence and Dementia. J Am Geriatr Soc. 2009;57:547-55.

43. Physician Perceptions:Relevance, Confidence and Frustration *5-point scales, 1=Not at all, 5=Extremely. † p<0.05 comparing difference between I and C.

44. Costs of this Practice Change • Start-up ($3,330 per 10 physician practice) • establishing a screening mechanism • customizing forms • identifying condition-specific local community-based resources • training physicians and office staff • installing clinic materials

45. Why wasn’t ACOVE-2more effective? • Failure to delegate data collection? • Inadequate recognition and correction of suboptimal or absent care practices? • Lack of resources for patient / caregiver action and activation?

46. ACOVE - Alzheimer’s Association Project • 2 Sites (Seattle and San Jose) • Partnership with local chapters of AA • National AA involvement • Focus groups guided intervention • Modified ACOVE-2 intervention • Evaluation by medical record audit

47. Physician Focus Group Findings • Unmet need for education and support groups for patients/families • Home care and home safety services • Driving issues, behavioral problems, day programs, nursing home placement • Little knowledge or experience with AA

48. ACOVE - Alzheimer’s Association Intervention • Cognitive screening by office staff • Physician performs evaluation using SVN • Small group educational sessions • Fax referral to Alzheimer’s Association • AA assessment in person or by phone • AA feedback faxed back to MD