ICIC Website: http://www.improvingchroniccare.org/

Decision Support: More Than Guidelines

Winston F. Wong, M.D., M.S.The Care Management Institute

Kaiser Permanente

CAPH CCLC November 2, 2004

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

Functional and Clinical Outcomes

DeliverySystemDesign

Decision Support

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community

Health Care Organization

Chronic Care Model

Decision Support Systems

• A process for incorporating guidelines, education, expert advice and practice aids into routine clinical practice

NCQA

Decision Support• Embed evidence-based guidelines which

describe stepped-care into daily clinical practice.

• Integrate specialist expertise and primary care.

• Use proven provider education methods.

• Share evidence-based guidelines and information with patients to encourage their participation.

Knowledge Management…One Approach

What Works & What Doesn’t?

• Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance. A systematic review of the effect of continuing medical education strategies. JAMA. 1995 Sep 6;274(9):700-5.

• Meta-analysis of 99 trials, 160 interventions designed to change physician behavior –

– Effective change strategies

• Provider reminders

• Patient-mediated interventions

• Outreach visits (academic detailing)

• Opinion leaders

• Multifaceted interventions

– Less Effective

• Audit with feedback and educational materials

– Not Effective

• Formal CME conferences or activities, without enabling or practice-reinforcing strategies.

What is evidence-based medicine?

Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.

-David Sacket, BMJ 13 Jan 1996

What is evidence-based medicine?

• Evidence-based medicine is an approach to health care that promotes the collection, interpretation, and integration of valid, important and applicable evidence.

• The best available evidence, moderated by patient circumstances and preferences, is applied to improve the quality of clinical judgments.

McMaster University

What is evidence-based practice?

• Efforts made to base clinical & other healthcare decisions on the best available evidence

• Evidence is critically appraised & synthesized

• The evidence synthesis is adapted to assist providers & patients in making decisions about specific clinical conditions.

Embed evidence-based guidelines

into daily practice

Clinical Practice Guidelines

• Clinical guidelines are systematically developed statements to assist practitioners and patients in choosing appropriate healthcare for specific conditions.

-The Institute of Medicine

Clinical Practice Guidelines

Efforts to distill a large body of medical knowledge into a convenient, readily usable format.

- Eddy. The challenge. JAMA 1990;263:287-290

The purpose of clinical practice guidelines

CurrentPractice

Currentoutcomes

OptimalPractice

OptimalOutcomes

GAP

Health statusSatisfactionCostUtilization

A quality gap persists: “…on average, Americans receive about half of recommended medical care processes.” — McGlynn, et al, NEJM, 6/26/03

IOM: “What is perhaps most disturbing is the absence of real progress toward restructuring health care systems to address both quality and cost concerns, or toward applying advances in information technology…”

Overall care 439 54.9%

Preventive 38 54.9%

Acute 153 53.5%

Chronic 248 56.1%

Screening 41 52.2%

Diagnosis 178 55.7%

Treatment 173 57.5%

Follow-up 47 58.5%

Fu

nc

tio

nT

yp

e o

f C

are

NEJM 348:26, Rand study

# of Indicators

% Recommended Received

QUALITY

Need for Information at the Point of Care

Clinicianscarry

frequently used

informationresources with them

Information systems goal: Empty the lab coat pocket

Evidence-based Practice• Begin with NIH Guidelines

– all team members should be familiar

• Identify thought/opinion leaders

– within your organization and outside

– systematic literature review

– organized learning within organization

Steve Simpson, MD Kansas University

Stickies wereubiquitous

Labels with patient Information and pre-visit summaries are also used as reminders

Evidence-based practice, cont.• Customize guidelines to your setting

• Embed in practice: able to influence real time decision-making

Flow sheets with prompts

Decision rules in EMR

Share with patient

Reminders in registry

Standing orders

• Have data to monitor care

Attributes of Good Guidelines

• Clear definition of condition and population

• Exceptions are described

• Evidence summaries are available with links to key articles

• Clinical actions for stepped-care are clearly stated

• “Nice-to’s” that are not evidence-based are omitted

• Regularly updated to incorporate new data

http://pkc.kp.org

Stepped Care

• Often begins with lifestyle change or adaptation (eliminate triggers, lose weight, exercise more)

• First choice medication

• Either increase dose or add second medication, and so on

• Includes referral guideline

4Overvi ew

Level 3Patients are complex. High intensitymanagement of the patient’s care is required.

Level 2Patients are in poor metabolic control andmay benef it from participation in a shortterm care management program where theylearn self care skills

Level 1Patients can be supported by routineAPC team care but may need selfmanagement basic educa tion

Prevention & Wellness

Patients with diabetes canbe segmented into threecare levels based on needs.

IntensiveManagement

• Care Mgmt Programs:

– Group Visits– one-on-one F/U

Assisted Care

• Diabetes: The Basics• Living Well with Diabetes

• SMBG

Self Management

Prevention and wellness arethe foundation of basic care.

Population Management Concept

Adult Asthma Presentati on 7

Outreach & triage

•Prior itize CV r isk factors :

•HTN, Dy slipidemia (LDL>100)

Treatment accor ding to protocols

•Behavior change/motivation

•Reinfor ce self-m anagem ent ski lls

•Patient r etur ns to Level 1

Outreach & triage

•Prior itize CV r isk factors :

•HTN, Dy slipidemia (LDL>100)

Treatment accor ding to protocols

•Behavior change/motivation

•Reinfor ce self-m anagem ent ski lls

•Patient r etur ns to Level 1

Diabetes Population Management

Week 2

Group Appt.Assessment

Care ManagerBehaviorist

Dieti tian

Mon ths 2-6

TelephoneFollow- up

Visit s(1:1 Of fice V isi t as

needed )

Mon thly

Group Appt Monthly

Clinical /behaviora lin terventions

Care ManagerBehavioristDieti tian

Week 1

Intake V isit

One-to-OneOffice Visit

Risk reductionGoal setting

Endocrinologist/DiabetologistConf irms diagnosis

Ident ifies co-m orbidit ies

Optim izes m edi cati on regim en

Mentors Case & Care Managers

Endocrinologist/DiabetologistConf irms diagnosis

Ident ifies co-m orbidit ies

Optim izes m edi cati on regim en

Mentors Case & Care Managers

Diabetes Population Management Program 2003

Level 3 Intensive Care

Level 2 Care Management

Level 1 Self Care Primary Care Team

Reviews, adjustsmedications

Regular screening tests

Reinforcesself-management

Primary Care Team

Reviews, adjustsmedications

Regular screening tests

Reinforcesself-management

• Complex medical issues

• Psycho-social barriers t oself-management

• ED visits

• Hospitalization

• HgA1c > 8.5%

• Microalbumin > 30

Any of above WITH

• HTN,/ Dyslipidemia

• Diabet es is well controlled

• Member practices effectiveself-care

Living W ell withDiabet es

Class and others

Living W ell withDiabet es

Class and others

As needed

EducationalResourcesHeal thwise Handbook,KP Onli ne

EducationalResourcesHeal thwise Handbook,KP Onli ne

Case ManagerCoaches members in crisis

Manages access

to specialty and ED care

Coordinates care across continuum

Case ManagerCoaches members in crisis

Manages access

to specialty and ED care

Coordinates care across continuum

DM care path 2003

Yes We Can Stratification Model

Self-Management Support by Primary Care

Basic Case Management by Yes We Can Asthma team

Moderate Case Managementby Yes We Can Asthma team

IntensiveCase

Management

LEVEL 4LEVEL 4 Intensive Case ManagementChild with poor asthma control andFamily in need of self-management skills andHighly complex and unstable social/psychosocial criteria

LEVEL 3LEVEL 3Moderate Case ManagementChild with poor asthma control andFamily in need of self-management skills andModerately complex and unstable social/psychosocial issues

LEVEL 2LEVEL 2 Basic Case ManagementChild with poor asthma controlFamily in need of self-management skillsRelatively stable social/psychosocial issues

LEVEL 1LEVEL 1Self-Management SupportChild with relatively well controlled asthmaFamily has self-management skills Relatively stable social/psychosocial status

Integrating Specialist and Primary Care Expertise

Clarifying roles and working together

Definitions

• Referral: transfer of care

• Consultation: one-time or limited time

• Collaboration: on-going co-management

Effective specialty-primary care interactions

• When to consult

– trouble making a diagnosis

– specialized treatment

– goals of therapy not met

Adapted from material by Steve Simpson, MD Kansas University

Using Consultants EffectivelyMake your consultants partners

– 1st principle of partnership - communication

– communication begins with you

– ask a specific question

– specify type of consult: ongoing (referral), one time only, duration of specific problem

Steve Simpson, MD Kansas University

Communicating

• Telephone or in person

• Letter

• Letter with supporting objective data

• e-mail

• e-mail must be encrypted

Steve Simpson, MD Kansas University

Example of an agreement in place

Primary Care1. State that you are requesting a consultation

2. The reason for the consultation and/or question(s) you would like answered

3. List of any current or past pertinent medications

4. Any work-up and results that has been done so far

5. Your thought process in deciding to request a consult

6. What you would like the Specialist to do

Source: HealthPartners, MN

The agreement in place

Specialty Care

1. State that you are returning the patient to primary care for follow-up in response to their consult request2. What you did for the patient and the results3. Answers to Primary Care Physicians questions in their consult request4. Your thought process in arriving at your answers5. Recommendations for the Primary Care Physician and educational notes as appropriate6. When or under what circumstances the Primary Care Physician should consider sending the patient back to you

Source: HealthPartners, MN

Going beyond referral and consultation: integrating specialist expertise

• Shared care agreements

• Alternating primary-specialty visits

• Joint visits

• Roving expert teams

• On-call specialist

• Via nurse case manager

Use proven provider education methods

Beyond CME…

Effective educational methods

Interactive, sequential opportunities in small groups or individual training

• Academic detailing

• Problem-based learning

• Modeling (joint visits)

Effective educational methods• Build knowledge over time

• Include all clinic staff

• Involve changing practice, not just acquiring knowledge

Result: better diagnosis, continuing care and guideline based care in children with asthma

Evans et al, Pediatrics 1997;99:157

Share evidence-based guidelines and information

with patientsto encourage their participation.

What is shared decision-making?

• Patient and clinician share information with each other (clinician shares medical information, patient shares personal knowledge of illness and values)

• Participate in a decision-making process

• Agree on a course of action

Sheridan et al Am Jrnl Prev Med 2004

Guidelines for patients

• Expectations for care

• Wallet cards

• Web sites

• Workbooks

• Stoplight tools

Example of a successful strategy: Adults with asthma

• Developed a skill-oriented self-help workbook

• Health educator session for 1 hour

• Support group

• Telephone calls

RCT: better inhaler skills and use, decreased symptoms, less ER use.

Bailey et al Arch Inter Med 1990;150:1664

Stoplight tools: patient guidelines

Supporting the Patient Role

What Does Work?

• Interventions that increase use of adult immunization and cancer screening services: a meta-analysis. Ann Intern Med, 2002 May 7; 136(9):641-51. Stone EG, Morton SC, Hulscher ME, Maglione MA, Roth EA, Grimshaw JM, Mittman BS, Rubenstein LV, Rubenstein LZ, Shekelle PG.

Important Web Addresses• PubMed

– http://www4.ncbi.nlm.nih.gov/PubMed/

• Guidelines

– http://www.guidelines.gov

• NIH

- http://www.nih.gov

•www.improvingchroniccare.org

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