Organization of Health Care and Delivery System Design

1. Organization of Health Care and Delivery System Design Alan Glaseroff MD CMO, Humboldt IPA IHI National Forum 2007 Orlando, Florida 12/10/07 alang@hdnfmc.com Redesigning Chronic Illness Care: Evidence, Experiences, and Stakeholders IHI National Forum December 10, 2007

2. Health of Populations and Individuals • Delivery system exists within communities • Many other stakeholders with interests • Patients, employers, public health/government, community groups, educational system, payers • Chronic disease affects certain populations disproportionately • Collaboration needed (spectrum of relationships) to improve outcomes and reduce disparities • Collective accountability/responsibility the only answer • “If not us, who? If not now, when?”

3. Disparities: Life Expectancy at Birth Tony Iton MD, Alameda County Public Health Director

4. Life Expectancy by Census Tract Tony Iton MD, Alameda County Public Health Director

5. Causes of Differences in Health Outcomes By Race • Genetics* 10-15% • Access to health care 10-15% 15% + 15% = only 30% What causes the other 70%??? *genes ≠ race Tony Iton MD, Alameda County Public Health Director

6. Socio-Ecological Medical Model HEALTHCARE ACCESS -Bay Area Regional Health Inequities Initiative

7. Expanded Model

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

9. Health Care Organization • Quality ascore strategy • 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.

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

11. Delivery System Design • Multiple levels • Regional/National: macrosystem • Integrated Medical Care Organization: mesosystem • Practice level: microsystem • Alignment required for breakthrough improvement in community health

12. Delivery System Design • Define population of patients • Define roles and distribute tasks amongst team members. • Use planned interactions to support evidence-based care. • Provide clinical care management services. • Ensure regular follow-up. • Give care that patients understand and that fits their culture

13. Mesosystem:Practice Environment in Humboldt • 29 primary care practices in various sizes, types and stages of transformation (all in the Humboldt IPA) • 5 community health centers • Many 1-3 clinician practices in private practices (one 17 MD Internal Medicine practice) • No large integrated multispecialty group • Managed care covering 5% of population • How to rapidly improve chronic disease care in the community?

14. Humboldt Diabetes Project • CHCF-funded research project started 11/02 • County-wide effort coordinated by IPA (>95% of all clinicians in the county, including MDs, advanced-practice clinicians, behavioral health providers) but… • IPA manages only 10% of lives in Humboldt County …but systems must apply to most patients in a practice • Problem: • Lack of access to most administrative data • Solution: • Information must come from clinical setting

15. Getting Started • “Burning Platform” to capture hearts and minds (disease focus vs. abstract “redesign”) • Grant support for concept • Clinical champion presenting own data making it safe for others • “Inviting the implementers into the planning process” • Piloting systems • Kick-off conference (including patient voices) • Site champion network supervised by ½-time FNP • Feedback on practice-level and individual performance

16. Humboldt Diabetes Project

18. To improve outcomes in chronic illness… • Patients must be prescribed and taking proven therapies • Patients must be managing their illness well

19. Microsystem: Frustration • Patients are frustrated by waits and discontinuities, often don’t receive proven services and often feel they are not heard. • Providers feel they have little control over their work life, are stressed by demands for productivity despite older, sicker clientele and the reduced variability in their clinical day.

20. Is There Time for Management of Patients With Chronic Diseases in Primary Care? • METHODS • Applied guideline recommendations for 10 common chronic diseases to a panel of 2,500 primary care patients with an age-sex distribution and chronic disease prevalence similar to those of the general population, estimated the minimum physician time required to deliver high-quality care for these conditions. • RESULTS • Top 10 chronic diseases (STABLE) 828 hours per year, or 3.5 hours a day • Top 10 chronic diseases (Poor Control) 2,484 hours, or 10.6 hours a day. • CONCLUSION? Ann Fam Med 2005;3:209-214. Duke University Dept. of Community and Family Medicine

21. What we know about primary care visits • 50-70% are largely informational or informative (including check-backs for chronic illness care) yet they are organized like acute visits • US average is 16.3 minutes • Patients are given an average of 20 seconds to tell their story before they are interrupted

22. How would I recognize 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

23. Microsystem: Defining roles and tasks across team to achieve productive interactions

24. “It is naïve to bring together a highly diverse group of people and expect that, by calling them a team, they will in fact behave as a team. It is ironic indeed to realize that a football team spends 40 hours a week practicing teamwork for the two hours on Sunday afternoon when their them work really counts. Teams in organizations seldom spend two hours per year practicing when their ability to function as team counts 40 hours per week."  Harold Wise, Making Health Teams Work

25. Team Meetings • Regular intervals • All members of care team (groups of < 10) • Agenda: • Old business • New Business • What isn’t working? • Opportunities for excellence?

26. Defining Tasks

27. Example of task distribution Microalbuminuria testing • Receptionist recognizes patient has diabetes, attaches requisition to chart • MA collects specimen • RN reviews slip, recognizes out-of-range tests, orders confirmatory test, discusses possible need for ACE inhibitor • MD discusses and prescribes ACE inhibitor • RN calls pt. to check on med. adherence and side effects

28. Use planned interactions to support evidence-based care One-on-one, group, telephone, email, outreach….the possibilities are endless

29. What is a Planned Visit? • A Planned Visit is an encounter with the patient initiated by the practice to focus on aspects of care that typically are not delivered during an acute care visit. • Planned care elements can be inserted into acute visits if needed (small practices, patients refusing to come in for planned care, etc.) • All visits contain elements of both (patient agenda/clinician agenda) • The more planned care functions done by other members of the team, the more time for the patient agenda in the exam room (improves clinician-patient relationship, higher patient satisfaction)

30. What does a Planned Visit look like? • The provider team proactively calls in patients for a longer visit (individual or group) to systematically review care priorities. • Visits occur at regular intervals as determined by provider and patient. • Team members have clear roles and tasks. • Delivery of clinical management and patient self-management support are the key aspects of care.

31. How do you do a Planned Visit? You Plan It!

32. Example: Diabetes • Choose a patient sub-population, e.g., all patients with diabetes not seen in 6 months with A1c > 7 • Identify patients from registry • MD reviews list for patients at highest risk (via evidence-based guidelines): BP>130/80; LDL>100, etc and prioritizes visits

33. Patient Outreach • Have receptionist or provider call patient and explain the need for planned visit using script explaining different nature of visit • Personal appeal by clinician works best • Ask patient to bring in bag of all medications they are taking (including OTCs and herbals)

34. Preparing for the Visit • “Team Huddle” at start of clinic session • RN/LPN/MA prints any relevant patient summaries from registries and attaches to front of chart • MD reviews medications/labs prior to visit

37. The Visit • Ask patient open-ended questions • “How’s your health? Any issues you want to discuss? • Review patient’s data • Identify interventions, labs, referrals and self-management needs • Problem solve adherence/other issues with patient • Create an patient action plan (if indicated) • Schedule follow-up

38. Group Visits:Introduction • Fun and efficient • Patients can receive: Self-management support training Social support Specialty service as needed/available One-on-one with medical provider Medication counseling • Multiple models for Group Visit agendas: open-ended vs. curriculum-based; single disease vs. multiple; newly diagnosed vs. range of experience; professional vs. peer-led

39. Patient Survey: Less Frustrated? In general, would you say your health is: (check one box) : How effective do you believe your health care provider is in managing your diabetes?

40. Clinician Survey: Less Overwhelmed? How effective do you believe you are in caring for your diabetic patients? Compared to a year ago, how effective are you in caring for your diabetic patients? Note: The sum of the categories may not add to 100% due to rounding.

41. What is care management? Many different things to different people • Resource coordination • Utilization management • Follow-up • Patient education • Clinical management

42. Features of effective care management • Regularly assess disease control, adherence, and self-management status • Either adjust treatment (best practice) or communicate need to physician immediately (less effective) • Provide self-management support • Provide more intense follow-up • Assist with navigation through the health care process

44. Ensure regular follow-up by the primary care team The trick is noticing when it isn’t happening Can be accomplished in many different ways

45. Humboldt Diabetes Project Data

46. Contact us: www.improvingchroniccare.org

47. New Methods for Teaching the Chronic Care Model IHI National Forum December 10, 2007

48. Breakthrough Series Collaborative Participants Select Topic Prework P P Identify Change Concepts P A D A D A D S S S Planning Group LS 1 LS 2 LS 3 Event Action Period Supports E-mail Visits Web-site Phone Assessments Senior Leader Reports (12 months time frame)

49. Experience with Collaboratives • More than 1,000 different health care organizations and various diseases involved to date • Began with national BTS, now regional, state-based & facility specific • HRSA’s Health Disparities Collaboratives-600+ community and migrant health centers, now academic medical centers & small practices • External evaluations of early efforts by Chin et al., RAND

50. Lessons Learned from the Teams • Teams spent considerable time searching for/developing tools • Some teams felt intimidated by taking on the whole model – asked for a sequence • Collaboratives were time & resource intensive • Many changes were made in ways that were not sustainable financially