integration at all levels - new buzz word talk at sc pca ... at all levels - new buzz word... ·...
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National Center for Primary CareMorehouse School of Medicine
Integration: The N B W dNew Buzz Word
George Rust, MD, MPH, FAAFP, FACPMFather of Dan & Christina, Husband of Cindy,
Professor of Family MedicineDirector, National Center for Primary Care
National Center for Primary Care at Morehouse School of Medicine
Promoting Excellence in Community‐Oriented Primary Health Care and Optimal Health Outcomes for all Americans
WHO
WHO World Health Report 2008 Reaffirms Primary Care 30 years after Alma Ata Declaration of Health for All.
• Primary Care Matters!!!
Best Practice Model:JCAHO‐Accredited,
Patient‐Centered, Open‐Access, Culturally‐Relevant,
Community‐Governed, Quality‐Driven, Quality riven,
Behaviorally‐Enhanced, System‐Integrated,
Primary Care Health Home
• West Orange Farmworker Health Association’s Family Health Centers circa 1989 ‐‐ Apopka, FL
Patient‐Centered Medical Home
Checklists or Transformation?
• Change is hard enough; transformation to a PCMH requires epic whole‐practice re‐imagination and re‐design.
‐‐ Paul Nutting
Nutting PA, Miller WL, Crabtree BF, Jaen CR, Stewart EE, Stange KC. Initial lessons from the first national demonstration project on practice transformation to a patient-centered medical home. Ann Fam Med. 2009 May-Jun;7(3):254-60.
Integration“We need a comprehensive, integrated approach to serviceintegrated approach to service delivery. We need to fight fragmentation.”
‐‐WHO Director‐General, 2007
Five Levels of IntegrationPopulation Outcomes
Community
Healthcare SSystem
Practice
Person
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Integration! Population Outcomes
Community
Healthcare System
Person‐LevelIntegrating
h i l l hPractice
Person
Behavioral Health & Primary Care
• Behavior Change
• Mental Health
• Substance Use
Mental Health Physical Health
“Baseball is 90% mental ‐‐ the other half is physical."
‐‐ Yogi Berra
Cherokee Health Systems “Integrated Care” Model:
Prevalence of Depression in Chronic Disease
Prevalence of Depression in Chronic Disease
51%
42%
23%27%
Why Primary Care?Why Primary Care?
23%17% 16%
12% 11%
Parki
nson's
Cance
r
Diabet
es CVA
CAD MI
HIV
Alzhe
imer's
Clinical Scenarios
• Diabetic patient with depression
• Insomnia patient with nervios
• Schizophrenia patient gains 100 lbs, and develops diabetes
• Bipolar patient on lithium has hypothyroidism and high blood pressure
• CHF patient who self-treats PTSD with alcohol
• Chronic back pain patient develops opioid addiction
Choices Real People Make
Diabetic Patient with Depression
Agree to Accept Referral and then Don’t Go
Accept Referral to Psychiatry Practice
Deal with Mental Health Problem in Primary Care Setting Only
Get Help XAvoid Stigma XGet Optimal Treatment X XCoordinate Medical & Psych Rx
X ?
Behaviorally-Enhanced Primary Care
Gregory E. Simon, MD, MPH; Wayne J. Katon, MD; Elizabeth H. B. Lin, MD, MPH; Carolyn Rutter, PhD; Willard G. Manning, PhD; Michael Von Korff, ScD; Paul Ciechanowski, MD; Evette J. Ludman, PhD; Bessie A. Young, MD, MPH Cost-effectiveness of Systematic Depression Treatment Among People With Diabetes Mellitus. Arch Gen Psychiatry. 2007;64(1):65-72.
Continuum of Integration
Separate Referral Coordinated Collaborative Integrated
Separate Co-Located Common
Coordinated Care
• Tracking & Confirmation of Referrals & Follow‐up
• Sharing of Medical Records
Sh i f P ibi• Sharing of Prescribing Changes & Medication Lists
• Inter‐Operable Electronic Health Records
• Mutual Participation in Effective Health Information Exchange
Collaborative Care• All of the Above plus . . .
– Team‐Based Case Conferences– Frequent Interaction on Therapeutic Strategy– Patient‐Centered, Shared Decision‐Making– Shared Care Management– Joint Decision‐Making on Medication Changes
– Frequent, secure communication by phone, e‐mail, & videoconferencing
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The Power of IntegrationWhat would happen if all the health professionals
Faith Communities
Mental H lth came
together and created a therapeutic community of healers for whole people?
Health
Substance Abuse
Treatment Primary Care
Integration! Population Outcomes
Community
Healthcare SystemPractice‐Level
Practice
Person
Panel‐based, Team‐Driven Care & Outcomes Management
Primary Caring‐‐ Healing with our “Radical Human Presence”
• Listening• Touching• Affirming• Comforting• Diagnosing• Treating• Grieving• Supporting• Healing
Radical Human Presence is a phrase used in a presentation called “How the Heart Learns” by Landon Saunders; AAMFT, 2004 annual mtg.
20th Century Primary Care NCQA / HEDIS Quality Measures for Comprehensive Diabetes Care
Quality Indicator
Performance (Medicaid)
Performance (Medicare)
Performance (Commercial)
A. Good HbA1c Control (< 7) 30.9% 45.9% 41.8%B. Partial BP Control (<140/90) 57.3% 57.8% 61.4%B. Good BP Control (<130/80) 30.4% 30.2% 29.9%C. Cholesterol Control (LDL <100)
30.6% 46.9% 43.0%
Primary Care is Relational Care
Personalismoy Confianza
Teamwork! • Community Health Workers (Promotoras)
• Medical Assistants• Nurses / Nurse Practitioners• Pharmacists• Social Workers • Health Educators• Oral Health Professionals• Physical Therapists• Primary Care Practitioners• Psychologists • Behaviorists• Sub‐Specialty Physicians• Administrators
Nurse Care Managers• Impact of a diabetes resource nurse (DRN) case manager in a suburban 12‐physician
7.2%6.6%
8.9%
6.8%
5.0%6.0%7.0%8.0%9.0%
B fp y
family practice on quality care and outcomes
Proc (Bayl Univ Med Cent). 2003 Jul;16(3):336-40. Clinical outcomes in patients with type 2 diabetes managed by a diabetes resource nurse in a primary care practice. Couch C, Sheffield P, Gerthoffer T, Ries A, Hollander P. Family Medical Center, HealthTexas Provider Network, Baylor Health Care System, Garland, Texas, USA. [email protected]
0.0%1.0%2.0%3.0%4.0%
Geriatric Non-Geriatric
BeforeAfter
Teamwork: LPN’s & Medical Assistants (every team member working up to the level of his/her license)
77%
72%74%76%78%
BeforeAfter
• Example: Empower More Clinical Staff to Initiate Preventive
68%66%
67%
60%62%64%66%68%70%72%
Intervention Control
• McCarthy BD, Yood MU, Bolton MB, Boohaker EA, MacWilliam CH, Young MJ. Redesigning primary care processes to improve the offering of mammography. The use of clinic protocols by nonphysicians.Gen Intern Med 1997 Jun;12(6):357‐63
to Initiate Preventive Services
• Medical assistants and Licensed Practical Nurses offer mammography as a routine part of the clinic encounter
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Five Preventive Services Could Save over 100,00 Lives*
• Aspirin advice 45,000 lives
• Smoking advice 42,000 lives
• Colorectal CA screening• Colorectal CA screening14,000 lives
• Flu shots 12,000 lives
• Breast CA screening 3,700 lives
116,700 lives
* If we increased from current levels of performance to 90%.
Teamwork! Enhanced Asthma Education via Community Pharmacists
– Symptom scores 50%
– PEFR values 11%
– Beta‐Agonist Use 50%
– Days off school / work 0.6 days/month
– ED Visits 75%
– Medical Office Visits 75%
– Quality of Life Scores 19%
McLean W, Gillis J, Waller R. The BC Community Pharmacy Asthma Study: A study of clinical, economic and holistic outcomes influenced by an asthma care protocol provided by specially trained community pharmacists in British Columbia. Can Respir J. 2003 May-Jun;10(4):195-202.
Staffing Models:(8,000 patientpanel)
• 5 MD’s’
• 2.5 MD’s
• 3 PA’s
• 1 NP/Care Mgr
• 1 LCSW or Psychol/Behav• 2 PA’s
• 1 RPH
Psychol/Behav
• 1 DDS + hygienist
• 1 Pharm D (+ pharm tech)
• 3 Promotoras
Hamster Care Health Outcomes
Nutting PA, Crabtree BF, Miller WL, Stange KC, Stewart E, Jaén C. Transforming physician practices to patient-centered medical homes: lessons from the national demonstration project. Health Aff (Millwood). 2011 Mar;30(3):439-45.
Patient‐Centeredness = Patient‐Defined QualityContinuous, Rapid‐Cycle Change
(Faster PDSA Cycles)
• Alliance for Clinical Education – Guidebook for Clerkship Directors, 3rd Edition. Available at http://familymed.uthscsa.edu/ACE/chapter3.htm
In a fast‐changing world, we don’t have time for ready‐aim‐fire any more; it’s fire‐aim, fire‐aim, fire‐aim . . .Tom Peters, Passion for Excellence
Patient Flow
Front‐Desk Check‐In
Medical Records
Waiting Room
Appointment Phone Calls
Nursing – Vital Signs
Clinician Visit
Pharmacy Lab Tests
Cashier / Check‐Out
Workflow Re‐Design
Front‐Desk Check‐In
Medical Records
Waiting Room
Appointment Phone Calls
Nursing – Vital Signs
Clinician Visit
Pharmacy Lab Tests
Cashier / Check‐Out
Integration! Population Outcomes
Community
Health Systems
Healthcare Systems Level:
Practice
Person
•Information Systems
•Delivery Systems (Pharmacy, Specialty Care, Emergency Dept, Hospital, etc.)
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Health Information Systems
• Practice Level: Individual Level: • Average A1c level
in all diabetics
• % of Patients with A1c > 8
• Lists of patients with A1c > 8 for outreach / action
• Flags or triggers to promote compliance at each visit and to decrease missed opportunities
• Evidence‐based guideline alerts
Re‐Set the Default: Make Excellence Automatic
• Measure A1c on
DCA 2000: $8 / test
•CLIA waived
•Reagent-filled cartridges
•6 minutes to test result
•Also does micro-albumin and Creatinine
every diabetic visit
A1c Now: $13 / test
•CLIA waived
•No maintenance - disposable
•8 minutes to test result
•Fingerstick or venipuncture
•FDA cleared for home use Bayer DCA2000
Systems Change: Re‐Designing Processes of Care
Step 1
• Diabetic gets finger‐stick blood glucose; patient may have fasted
Step 2
• Doctor sees patient, and may order Hemoglobin A1c test.
Step 3
• Patient may go to the lab and may wait to get their HbA1c drawn.
Step 4
• Doctor may notice that HbA1c is elevated
Step 5
• Dr. may ask staff to call patient back for follow‐up
Step 6
• Doctor / nurse may be able to reach patient by phone.
Step 7
• Patient may agree to come back, and may actually keep appt.
Step 8
• If patient comes back, doctor may intensify regimen.
Systems Change: Re‐Designing Processes of Care
Step 1• Nurses follow standing order for fingerstick Hgb A1C on every diabetic
•Results on chart when doctor sees patientStep 2
•Results on chart when doctor sees patient;
Step 3• Doctor may intensify regimen
•Avg A1c 8.55 before•Avg A1c 7.84 after
Tele‐Health Home Monitoring
Managing Transitions, Managing Between the Lines
Process for knowing right away when your patient has been to the ER
Able to exchange patient info with the
hospital duringa patient’s
hospitalization
Create A Real System of Caring at the Community‐Level
Mental Health
HospitalsFaith
Communities
Emergency Room
Primary CareBusiness & Community
Leaders
Public Health
Integration! Population Outcomes
Community
Healthcare System
Community‐Level:P ti t t h
Practice
Person
• Patient at home
• Family and culture
• Social Determinants
Doctor‐Centered Medical Home: the Exam Room and the Doctor‐Patient Visit
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Free‐Range Humans
(when patients escape from the exam room!)
Individuals
Family
Neighborhood
Community
Environment
Cultural Relevance / Cultural Ownership
South Central Foundation – Anchorage, Alaska
High Tech High TouchAppropriate Technology
• Framingham Risk Calculator for PDA
Community Health Workers (Promotores de Salud)
Triangulate Interventions
Children
Primary Care & Public Health
Family &Community
SchoolsPsychologists & Behavioral Health
Community as Real Partners on the Team
Healthy Patients, Healthy Communities Healthy Patients Need Healthy Communities
The Continuum of Community Health
Example: Why Do We Need Teamwork to Improve Outcomes in Obesity & Diabetes?
Example: To prevent complications of obesity and diabetes, all you have to do is modify a person’s health beliefs and attitudes, daily habits, eating preferences, daily activities, exercise habits, grocery stores, neighborhood walk-ability, food advertising, self-care, employability, economic empowerment, access to medical care, provider quality, and medication adherence, all in the context of his or her family and social relationships.
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Integration! Population Outcomes
Community
Healthcare System
Population Level Outcomes
Practice
Person
• Clinical
• Economic
$ Charges Due to Uninsured Hospital Admissions (All‐Cause & ACS Conditions)
Hospital Admission Hospital admission for ACS Conditionage group Count Rate/100,000 Total Discharge
$$ Charges $$Count rate/100,000 Total Discharge
$$ Charges $$
<1yr infancy 3381 2166.8 13052692 30 19.2 2400851‐4 early childhood 533 89.6 4982660 278 46.7 1882363
5‐12 later childhood 515 44.7 5938480 221 19.2 191493513‐19 adolescence 2179 225.5 38505983 417 43.2 5008118
20‐29 early adulthood 11959 847.1 295608834 2546 180.3 37563398
$
30‐44 young adulthood 21240 1005.7 509586602 4801 227.3 8041016145‐59 middle adulthood 26799 1375.4 779924179 6409 328.9 124391039
60‐74 later adulthood 6130 583.6 212189003 1379 131.3 2883029975+ older adulthood 438 100.4 15137085 74 17.0 1829954
Sum $1,874,925,518 $282,070,352
Table 3. Uninsured patient hospital admission/ hospital admission for ACS condition count and rate per 100,000 population and total hospital discharge by age group among Georgia residents in 2009
Indigent Care Hospital Costs (assuming 35.6% cost to charge ratio) – all‐causes of hospital admission
Indigent Care Hospital Costs (assuming 35.6% cost to charge ratio) –hospital admissions due to ambulatory care sensitive conditions
$667,473,484 $100,417,045
Primary Care Community Health Centers Impact on Uninsured ED Visits
31% Excess
62% Excess
No CHC = 37% Excess ED Visits
Closing the Loop, Accelerating Cycle Times
• Practice‐Level Data• Monthly ED Visit Rate• Hospital Bed‐Days• Preventable Adverse Events
• Person‐Level Feedback• Missed refills• Inadequate Care• ED Visit yesterday!
Focus on Global Health Outcomes for Complex Mental Health & Medical Co‐morbidities
One Diabetic Patient:• Diabetes• Arthritis
COPD
• Pneumonia • Cancer
D i
ip op md ot m2 dg total
$217,657 $7,105 $29,756 $10,498 $3,155 $12,182 $280,353
• COPD• CHF•Stroke
• Depression•Alcohol / substance abuse
* 21 ER Visits * 143 hospital bed-days
Drivers of Health Disparities
Health Potential
WorstPotential
Minority
Average
Majority
Best / Optimal
Disparities = Human Tragedy
•Almost every day in Georgia a baby dies who would not have died if
there was no black‐white difference in infant death rates (331 excess infant deaths
in 2006)
Unequal Benefit –Breast Cancer
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Excess Cost Due to Racial Variation in Hospital Admissions by Disease
(mid‐range estimate)
ExcessHospital Admissions(mid‐range)
Hospital Charges Attributable to Excess Hospital Admissions (mid‐range)
Payer Costs Attributable to Excess Hospital Admissions (mid‐range)
A th 2 044 $28 687 330 $13 339 608 45
$
Asthma 2,044 $28,687,330 $13,339,608.45
Diabetes 3,955 $92,172,057 $42,860,006.51
Heart Disease 5,021 $187,289,234 $87,089,493.81 >Coronary
Artery Disease 1,287 $65,156,724 $30,297,876.66
>Congestive HeartFailure 5,868 $162,561,372 $75,591,037.98
HIV 1,644 $76,784,134 $35,704,622.31
Tying it All Together to Achieve Optimal, Equitable Health Outomes
Community Health
Primary Care
Medical Promotion
Health Outcomes
Medical Home
Accountable Health Care Entities
Transformation
• It may be hard for an egg to turn into a bird: it would be a jolly sight harder for it to learnit would be a jolly sight harder for it to learn to fly while remaining an egg. We are like eggs at present. And you cannot go on indefinitely being just an ordinary, decent egg. We must be hatched or go bad.
‐‐ C.S. Lewis
29 babies saved!!!
Disparities Success Stories!
Decline represents 29 infant deaths prevented (expected vs. actual)
Five Levels of IntegrationPopulation Outcomes
Community
Healthcare SSystem
Practice
Person
Integration means working
seamlessly together!
Humility in Working Together
“We are all as angels,with only one wing;
We can only fly when we embrace each other.
-- Luciano de Crescenzo