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A quick review of the IHI learning lab

A quick review of the IHI learning lab. Moving into the Medical Home. Building the PCMH From the Ground Up. Using the Model to Get Broad Outcome Improvement. Build the proper structure Focus on high leverage processes that by their nature can be effected to achieve the IHI triple aim of:

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A quick review of the IHI learning lab

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  1. A quick review of the IHI learning lab

  2. Moving into the Medical Home

  3. Building the PCMH From the Ground Up

  4. Using the Model to Get Broad Outcome Improvement • Build the proper structure • Focus on high leverage processes that by their nature can be effected to achieve the IHI triple aim of: • Improve the patient experience (satisfaction) • Improve the health of the population • Control or reduce cost • Then measure the outcomes

  5. 7 High Leverage Processes • Identification and management of depression • Management of care transitions • Care coordination • Team-based care • Identification and management of socially frail/ isolated individuals • Pharmacologic management including optimizing medication and dealing with adherence issues • Enhancement of the therapeutic environment

  6. 1. Depression • Why it’s high leverage • Very high prevalence • Under diagnosed • Major gaps in care • Depressed individuals have more somatic complaints • Chronic illness can produce depression • Depression as a comorbidity roughly doubles the cost of the chronic illness

  7. Depression • Using Technology • Identify high risk patients (multiple chronic illnesses, multiple medications, unemployed, on disability…) • Screening built into visits at regular intervals (e.g. PHQ2) • Recall and tracking systems • Medication adherence tracking • Other resources • Community resources • On site integrated behavioral health (e.g. counselors, CNS) • Liaison Psychiatrists and Psychologists

  8. 2. Care Transitions • Why it’s high leverage • High risk situation for both quality and cost outcomes • Patients and families experience considerable anxiety and frustration at care transitions • Improving care transitions reduces the incidence of hospitalizations and rehospitalizations

  9. Care Transitions • Using Technology • On demand medical records access • Hospital portal • ED and hospitalist access to PCP medical record • Automated HIE • All ED notes, H & P’s, consults, op reports, labs, and imaging reports flow to EMR

  10. 3. Imbedded Care Coordination and Case Management • Why it’s high leverage • Community care of North Carolina, Geisinger Health System, Kaiser, Group Health of Puget Sound, and Voice of Detroit Initiative have all reported positive outcomes using imbedded care coordinators • Care coordinators need to be part of the care team with a well defined specific role • Remote third part care coordination and case management has been shown to not work as well

  11. Care Coordination • Using Technology • Patient registries embedded in the EHR able to identify specific populations • With particular diagnoses • With gaps in care • Who are overdue for services • Who are not at goal • With high illness burden • With limited social supports • Measure overall practice or physician performance • Benchmarking

  12. 4. Team Based Care • Why it’s high leverage • MDs cannot provide all the care in the patient centered medical home model • Consistent with the Chronic Care Model • Improved quality and cost outcomes with team based care (Kaiser, Geisinger, Virginia Mason, CareOregon…)

  13. Team Based Care • Key processes • Redefine roles and responsibilities including integrating BH, SW… • The work is done by more people but needs to be coordinated • Internal communication gets more complex • Reframe patient expectations (this can be part of the PCMH) discussion • Technology support • Internal messaging IMs, Texting… • Patient Portals • Shared care plans (ideally web based that can be accessed by the entire care team) • As well as what has become the floor but needs some refinishing CDSS, registries, and tracking systems

  14. 5. Socially Frail Individual • Definition: combination of social isolation and low self esteem • Why it’s a high leverage process • Four times the cost of matched populations • Amenable to low cost interventions (brief intervention with a counselor significantly improves outcomes) • Support groups, case management, plug in to local resources, pets… • Risk equivalent to smoking a pack of cigarettes per day

  15. How to identify the socially frail individual? • Low self esteem- • Question 6 on the PHQ9 are you feeling bad about yourself or that you are a failure or that you let yourself or your family down. • Lubben Social Network Scale – 6 • Family • How many relatives do you here from at least once a month? • How many relatives do you feel at ease with that you can talk about private matters? • How many relatives do you feel close to such that you could call on them for help? • Friendships • How many of your do you see or hear from at least once a month? • How many friends do you feel at ease with that you can talk about private matters? • How many friends do you feel close to such that you could call on them for help?

  16. 6. Medication Management • Why it’s high leverage • High prevalence of polypharmacy in patients with chronic illness • Increased adverse drug events, drug-drug interactions • Issues of non-adherence, affordability, and patient confusion • Studies have shown decreased benefit when patients are taking more than four medication • Significant morbidity, mortality and cost associated with medication mismanagement

  17. Medication Management • Key functions • Identify patients at risk due to polypharmacy and non-adherence • Manage out of pocket costs • Address various contributors to non-adherence • Medication reconciliation • Technology infrastructure • EHR • drug-drug and drug-condition programs • Formulary management programs • Filled prescription information • Portal • HIE • Brainstorming ideas: • Flash drives, medication reminder apps, blister packing

  18. 7. Enhancing the Therapeutic Environment • Why it’s a high leverage process. • Patients highly value the relationship with their provider • Continuity and the duration of the relationship correlate with positive outcomes • Patients want a care team who take the time to listen to them and to know them as individuals • The relationship often helps with patient activation • Key functions • Continuity • Tracking patient preferences • Access (visits, phone, e-mail…) • Outreach • Responsiveness • Caring relationship

  19. Enhancing the Therapeutic Environment • Technologic support • Secure messaging • Patient portal • Web-sites • Recall systems • Patient interaction with EHR • Use the EHR to track specific patient details

  20. Summary • Superior clinical outcomes require investment in sustainable structures and processes • Medical homes can help achieve the goals of improving the patient experience, reducing costs, and improving population health • Focusing on highly leveraged processes and using technology are essential • Using technology thoughtfully is equally important

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