Medically Complex Patients (MCP) WebinarTheories of Change

Onil Bhattacharyya, MD, PhDFrigon-Blau Chair in Family Medicine

Research, Women’s College HospitalUniversity of Toronto

Gary Naglie, MDHunt Family Chair in Geriatric

Medicine, Baycrest Health SciencesUniversity of Toronto

October 27, 2014

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1. Recognize the maturity and complexity of your models and how this impacts the key goals for your project

2. Introduce the concept of theory of impact as a starting point for thinking about your models

3. Provide a framework to test key aspects of your model and identify opportunities for improvement

OBJECTIVES

PROJECT MATURITY – SETTING THE RIGHT GOALS

• Developing new program• Major modification to existing

project• Minor modification to existing

project• Scale up/replication

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Kaiser Permanente Innovation Consultancy 4

“If things are fundamentally working in your system, then you are operating in the world of improvement. ”

“If you fundamentally believe that what you have is broken, then you are operating in the world of innovation.” 

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Features Improvement

Typical problem

Improve uptake of hand washing

Goal How to deliver service better

Parameters Clear user and outcome

Strategy Iterative, tests of smaller breadth

Innovation

Improve access for frail elderly

Develop the appropriate service

Tentative solution, user and outcome

Iterative, tests of larger breadth

IMPROVEMENT VS. INNOVATION

Developing a Theory of Impact

Why might your intervention work?

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THEORY OF IMPACT

1. Problem – Something important but also manageable

2. Solution (intervention/mechanism) – A target group, a provider and a mechanism to address problem

3. Outcomes – Key outcomes that can be attributed to solution (shorter- and longer term)

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THEORY OF IMPACT - COPD

1. Problem – COPD is a major cause of readmissions and COPD action plans are rarely used

2. Solution (intervention/mechanism) – Nurse case managers can increase self-management and use of action plans

3. Outcomes - Symptom scores, ED visits and hospitalizations,

THEORY OF IMPACT - ICCT

1. Problem – Growing frail senior population receive fragmented care that is expensive and does not meet their needs

2. Solution (intervention/mechanism) – Integrated primary, community and specialty care outreach service providing intensive case management and coordinated care across transitions

3. Outcomes – Better care experience, smoother transitions, reduced health care utilization

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Original Model:Baycrest Community Outreach Team (COT)

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Frail Older Adult/Caregiver

Referring Community Primary

Care Physicians

• Consultation

Community Outreach Team

New Model:The Integrated Community Care Team (ICCT)

Integration at the Point of Care

Frail Older Adult/Caregiver

Community “Solo” Primary Care Physicians

COT + COE + NP AcuteHospital

CCACIntensive Case

Managers + Pharmacist

• Consultation• Shared Care• Assumed Primary Care

Testing Key Hypotheses About Your Program

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• Most programs have many untested elements related

• May relate to target group, intervention or context

• Articulating assumptions and testing them will help you find and fix problems early on

WHY IS THIS IMPORTANT?

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KEY CHALLENGES FOR CARE INTEGRATION PROJECTS

• Difficulty implementing• Slow recruitment• Poor fit between between

intervention and target population not identified or modified

• Success rate <40% in well-conducted studies

• Variable results when replicated

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INTEGRATION EXISTS ALONG A CONTINUUM

 

2-Way Communication

 

Joint Care Delivery

 

Joint Management Across

Institutions

Engagement 

Communication & Behaviour

 

Culture & Policy

Low Medium High

Common Strategies

Common Challenges

Adapted From: Blank, S. Harvard Business Review, May 2013.

User Discovery

User Validation

Recruitment Program Building

Search Execution

Change user or intervention

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FINDING THE RIGHT PATIENTS, BUILDING THE RIGHT PROGRAM

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TESTING HYPOTHESES AT EACH STEP

• Feasibility of Implementation• Recruitment of patients• Recruitment of providers• Intervention• Outcomes

FEASIBILITY OF IMPLEMENTATION

• Hiring staff – clerical, providers, managers• Organizational support• Data sharing • Divergent institutional processes • Governance

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ICCT EXAMPLE: IMPLEMENTATION CHALLENGES

• Hiring staff

• Data sharing

• Divergent institutional processes

• Governance

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PATIENT RECRUITMENT

• Why would patients join?• Which patients will benefit?• Are there enough patients?• Are referral mechanisms effective?• Will patients show up?• Are the people who are being

referred different than expected?

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PROVIDER RECRUITMENT

• What is the benefit for providers?• Is it easy to join or refer patients?• Consider steps in adoption

Enrollment First use Regular use

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ICCT EXAMPLE: PATIENTS AND PROVIDERS

• Are people referred different than those being targeted? Yes – not all require in-home

assessment • Is it easy to refer patients?

Not from community docs perspective

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INTERVENTION

• Is the intervention doable?• Are the elements of the

intervention working?• If reaching the target group, does

the intervention meet their needs?• Are there any missing

components?

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ICCT EXAMPLE: FEATURES OF INTERVENTION

• Are elements of the intervention working? Consultation stream and shared care

require adjustments in hand-off and communication

• Are there any missing components? Over 50% of referrals from Central LHIN

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• Do the outcomes match the maturity of the model?

• Are the outcomes appropriate given the mechanism of the intervention?

• Are the outcomes appropriate given the target patients?

ICCT EXAMPLE: OUTCOMES

ICCT EXAMPLE: OUTCOMES

• Do the outcomes match the maturity of the model? Premature to focus on health care

utilization Focus on patient and care provider

experience• Are the outcomes appropriate given the

target patients? Add quality end-of-life care

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Use questions to inform yourself about how various parts of your project are working

Systematic review of quality improvement studies found that less than 20% documented changes through iteration or used monthly cycles

ITERATION IS HARD WORK

If you’re worried about your model, you will test it!

BMJ Quality and Safety, Taylor MJ et al 2013

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“The real measure of success is the number of experiments that can be crowded into twenty-four

hours”Thomas Edison

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CONCLUSIONS

1. Models are at varying levels of maturity and levels of complexity

2. Start from a high-level theory of impact

3. Drill down and test all of the aspects of your model to identify opportunities for improvement

4. This will help you find the right patients and build the right program

Questions