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Patient-Centered Primary Care in Prison

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  1. Patient-Centered Primary Care in Prison Renee Kanan, MD, MPH, FACP rjkanan@comcast.net (916) 201-4531

  2. Discussion Outline • Purpose of the Presentation • Overview of CDCR/CPHCS • Case Study: PCPC in a Prison • Conclusion • Questions

  3. Purpose of the Presentation • Share experience establishing a care management system in a correctional setting founded on: • Patient-Centered Medical Home • Care Model • Model for Improvement • Demonstrate that “best practices” can occur anywhere including behind bars

  4. Overview-1 • 170,000 inmates (11% Women) • 60% recidivism rate (3 years) • 70,000 employees (7,000 health care staff) • 470 physicians & midlevel practitioners • 3,700 nursing staff • 33 prisons (3 women’s prisons; 7 major RC prisons)

  5. Overview-2 • $10 billion operating budget (7% General Fund) • $2 billion operating budget for health care (HC) • 100% increase in HC budget since 2006 • 70% budget for salary & benefits • $48,500 annual cost per inmate • $16,000 annual health care cost per inmate

  6. Overview-3 • 170,000 inmates • 25% > 40 years old; 15% > 50 years old • 50% inmates have chronic conditions • HTN, DM, Asthma, COPD, CAD • HCV, ESLD • Mental illness, chronic pain, substance abuse

  7. Overview-4 • Courts oversight all aspects of healthcare • Require board certification in primary care (2004-) • Require proof of competence in primary care (2004-) • > 30% turnover physician staff (~2004-2006) • Significant provider vacancies (2005-) • Federal Receiver over medical program (2006) • Significant provider salary increases (2007)

  8. Overview-5 • Partial paneling of patients with PCP (2006-2007) • “Officially” adopted primary care model (2008-2009) • Annualized death rate 291 inmates per 100,000 (2006) to 203 inmates per 100,000 (2008) • Reduction in preventable deaths noted

  9. Overview-6* • Written policies for access & communication • Patient grievance system; no survey of experiences • Stand alone legacy patient scheduling & tracking system • No enterprise wide EMR or clinical registry • Many charting forms & documentation mandates * NCQA PPC PCMH tool

  10. Overview-7* • Physicians’ & non-physicians’ roles evolving • Primary care team huddles • Track referrals, tests, f/u (paper-based & electronically) • Limited patient self management support * NCQA PPC PCMH tool

  11. Overview-8* • Disease management guidelines & decision support • InterQual for specialty referrals & hospitalizations • Electronic pharmacy & medication system • Centralized clinical data repository in progress * NCQA PPC PCMH tool

  12. Overview-9* • Review of RAND performance metrics in progress • Court-driven and cost-driven data • Limited standardized reports at institution & PCP level • Some benchmarking and adjusted comparison data • Limited tracking of evidence-based clinical outcomes * NCQA PPC PCMH tool

  13. Case Study: PCPC in a Prison Motivating Change

  14. Welcome to Folsom’sGated Community

  15. Planned Primary Care Planned Primary Care COMMUNITY HOSPITALIZATION COMMUNITY ED CARE Reception Clinical Needs Assessment & Classification TTA CARE Discharge Discharge “SICK CALL” Case /Care Management Prevention SPECIALTY CARE

  16. Case Study-1 • Paneled every patient with consistent PCP • Reorganized into consistent primary care teams • Each team included RN, PCP, LVN(s), OT • Collective goals, objectives and strategies to improve outcomes based on PCMH, CCM and MFI (Aims & PDSA)

  17. There is no in Team • Common Purpose • Defined AIMS • Defined Roles • Mutual Accountability

  18. Case Study-2 • Created decision support & self management tools • Created clinical data repository & e-registry • Created reports to use at the point of care • Created reports for performance monitoring & improvement at team and population levels

  19. Case Study-3 • Disseminated baseline and monthly performance information at team level • Conducted lots of training using adult-based learning methods focused on evidence-based practice and QI • Established/leveraged forums to discuss & act upon clinical/performance data over time

  20. Model for Improvement

  21. DIABETES CAREQuality Improvement Project 2009 • Goal: Improve processes of care and clinical outcomes for the patient population with Diabetes as evidenced through the following Aims:

  22. Diabetes Care: MAJOR AIMS • By June 30, 2009 > 75% of diabetic patients at FSP will have a HgbA1C < 7.5 and LDL < 100 and SBP/DBP <130/<80. • By June 30, 2009 >95% of diabetic patients at FSP will have had an annual monofilament foot exam and annual eye exam and annual urine microalbumin.

  23. INCREMENTAL AIMS • By 3/26/09, in each Medical Home, >95% of the diabetic patients will have a current LDL level within the last 12 months. • By 3/26/09, in each Medical Home,>95% of diabetic patients will have an average BP of < 130 / < 80 based on at least 3 documented BP checks over the last 3 months. • By 3/26/09, in each Medical Home, >95% of the diabetic patients will have at least one HbgA1C level checked within the last 6 months.

  24. INCREMENTAL AIMS • By 4/23/09, in each Medical Home, >80% of the diabetic patients will have an average fasting glucose (FS) < 130mg/dl based on an average of at least 3 morning fasting checks and no FS <70mg/dl or >180mg/dl.* • By 5/28/09, in each Medical Home, > 80% of the diabetic patients with HgA1c levels still > 7.5 % will have an average 2-hour post-prandial glucose less than 180 mg/dl based on at least 3 checks. • By 6/30/09, in each Medical Home > 95% of diabetic patients will have had an annual monofilament foot exam done and an annual dilated eye exam done and an annual microalbumin level checked. * This incremental aim does not have to be implemented if last HbA1C ≤ 6.5 and last fasting glucose ≤ 130mg/dl and last 2 hour post prandial < 180 and no history of hypoglycemia in at least the last 12 months.

  25. Diabetic Patients with HbA1C Completed in Last 6 months 90% 80% 70% 60% 50% 40% 30% 20% 124 Patients 33 10% Patients 0% Done Not Done Diabetes Care

  26. Diabetic Patients and Degree of Control by HbA1C in Last 6 Months 100% 90% 80% 70% 60% 50% 40% 30% 20% 74 Patients 10% 50 Patients 0% <=7.5 >7.5 Diabetes Care

  27. Diabetes Care

  28. Diabetes Care

  29. Diabetes Care

  30. Diabetes Care

  31. Test #: Describe the Test of Change/Responsible Person/When/Where PLAN: Describe tasks needed for test/Responsible Person/When/Where 1. 2. 3. 4.   What do we want to happen? How will we know if it did? 1. 2. 3. Evaluation Schedule Date: Location: Time: DO: Describe what happened during test STUDY:  Did what we want to happen actually happen?  Yes/No Why/Why Not ACT:  Describe what modifications will be made for next cycle from what was learned. AIM # By _____, >95% of DM pts in _______________

  32. Diabetes Incremental AIMS by Medical Home

  33. DM Outcomes by Medical Home 05-2009

  34. DM Outcomes by Medical Home 05-2009

  35. DM Outcomes by Medical Home 05-2009

  36. DM Outcomes by Medical Home 05-2009

  37. DM Outcomes by Medical Home 05-2009

  38. DM Outcomes by Medical Home 05-2009

  39. Test #: Describe the Test of Change/Responsible Person/When/Where PLAN: Describe tasks needed for test/Responsible Person/When/Where 1. 2. 3. 4.   What do we want to happen? How will we know if it did? 1. 2. 3. Evaluation Schedule Date: Location: Time: DO: Describe what happened during test STUDY:  Did what we want to happen actually happen?  Yes/No Why/Why Not ACT:  Describe what modifications will be made for next cycle from what was learned. AIM # By _____, >95% of DM pts in _______________

  40. Benefits of PCPC-1 • Improved patient outcomes • Better cost-efficiency & utilization • Reduced waste & cost

  41. STATE PRISON HEALTH CARE SERVICES UNSCHEDULED PATIENT TRANSFERS

  42. Benefits of PCPC-2 • Reduced patient grievances • Positive patient experiences • Positive staff experiences

  43. Patient Centered Medical HoodWired for connectivity C M A A S N E A G E M E N T Patients Primary Care Team PCP RN LVN OT CO _____________________ Huddles Patient Care Reports Community Hospitalization/ Emergency Dept. TTA Reception Discharge Unplanned Primary Care: “Sick Call” Specialty Care Care Management System

  44. Conclusion: Keys to Motivating Change • Crisis is Opportunity • Bottom line: it starts at the Top • Begin with the End in Sight • Aim high • Inspire commitment and curiosity not compliance • Cultivate CQI = JOB culture • Create people-centered place of care

  45. Conclusion: Keys to Motivating Change • Plan your Drive • Patient-Centered Medical (Neighbor) Hood • Care Model • Model for Improvement • Drive your Plan • Don’t let the Perfect get in the way of the Good • Don’t let Immediate get in the way of Important • Excellence is a habit not an act • Can’t manage what you don’t measure (& report)

  46. Conclusion: Keys to Motivating Change • Enjoy the Journey because…

  47. Conclusion: Keys to Motivating Change • You never reach your destination because…