organizational policy and systems change

Organizational Policy and Systems Change

Agenda

Welcome (Belinda Nelson)

Overview and Examples of Organizational Policy and Systems Change (Martha Quinn)

Systems Change in Dallas: Community Health Workers (James Walton)

Systems Change in Chicago: Clinic Redesign (Monica Peek and Marshall Chin)

Q & A (Darla Williams)

Presenters

Martha Quinn

University of Michigan, Center for Managing Chronic Disease

Alliance Grantees

Camden, New Jersey

Memphis, Tennessee

Dallas, Texas

Chicago, Illinois

Wind River Indian ReservationFort Washakie, Wyoming

Objectives

Develop a shared understanding of what we mean by “policy and systems change”

Highlight current examples of policy and systems change efforts

Facilitate discussion and peer-to-peer learning

Why is this important?

An overarching goal of the Alliance is to CHANGE the SYSTEMS and POLICIES that have negative impact on people with diabetes and introduce new policies that will have a positive impact

So that, the work of the Alliance will outlive the funding and be sustained over the long-term

www.alliancefordiabetes.org

Policy and Policy Change

What is policy?

Public policy Organizational policy

Public policy

A set of agreements about how government will address societal needs and spend public funds. These agreements are:

articulated by leaders in all three branches of government, and embedded in many different policy instruments

(for example, laws and regulations).

Organizational policy

A set of written rules and policies that govern behavior and practice within an organization, agency or business

Custom and Practice

Routine practices, cultural norms, customs, and unwritten agreements about behavior are not policy, but can influence and be influenced by policy

What is organizational policy change?

The creation of new written policies or rules, or a change in the current written policies or rules of an organization


Systems and Systems Change

What is a system?

A group of independent but interrelated and interacting elements (individuals, institutions and infrastructure) that form a unified whole

For example:health care delivery system

What is systems change?

Systems change occurs when one or several elements in a system change, altering their relationship to one another and the overall structure of the system itself

What drives systems change?

Changes in existing policies or creation of new policies

Organizational practices Social or cultural norms Changes to infrastructure

What is the relationship between policy and systems change?

Policy change is an important way to achieve systems change


Examples of Organizational Policy and Systems Change

Health Care Team Approach

CareSouth Carolina


Care manager Behavioral health counselor Nurse Physician

Change: Health Care Team Approach includes


Related Policy Changes: Written job descriptions Board of Director’s approval Funding allocated

Change: Care managers (new position)


Change: Nurses have expanded role

Related Policy Changes: Creation of “standing orders” Chief Medical Officer approval Clinical Manual of

policies/procedures


Change: Behavioral health counselors integrated into regular care

Related Policy Changes: Implement 45/15 rule Changes in written job description Clinical Manual of policies/procedures CEO approval


Overall lower HbA1c levels Reduction in diabetes disparities

Impact: Health outcomes

Medical Office Visits

Providence St. Peter Family Medicine Clinic in Olympia, Washington


Change: patients have a choice to participate in three different types of non-traditional office visits:

Planned visits Mini-group medical visits Open office group visits


Change: Planned visits

Related Policy Changes: Creation of “standing orders” New job descriptions for MAs Curriculum for training formally

adopted by the clinic Clinic Manual of policies/procedures


Change: Mini-group visits

Related Policy Changes: Patient Confidentiality Forms required HIPAA compliance required Clinical Manual of policies/procedures


Change: Open office group visits

Related Policy Changes: Changes in physician job

descriptions Creation and adoption of training curriculum Clinical Manual of policies/procedures Chief Medical Officer approval


St. Peter’s Approach: policy change came after showing positive outcomes from small pilot

First small pilot project Rapid cycle improvements Showed positive outcomes Changed clinic-wide policies

and practices


Clinic policies and procedures approved by:

Medical Director Organizational Operations Committee (OOC)


Impact: Planned and Group medical visits Results of survey data:

Patients: “..felt well cared for, better supported and more successful and confident”

Medical Assistants: “...gained knowledge and confidence in diabetes and self management, and were more satisfied with their jobs.”

Physician: “…modest improvements in comfort with, and perceived effectiveness in providing self management support.”


Impact: Health Outcomes

Patients participating in group visits were more likely to have lower A1C levels than other patients and greater A1C reductions

Significant reductions in LDL cholesterol for patients participating in planned visits

Presenters

Dr. James Walton

Baylor Health Care System in Dallas, Texas

Grantee Efforts Underway - Dallas

• Establishment of Community Care Coordination

– Baylor Health Care System’s Office of Health Equity established a dedicated “new” workforce, providing specialized culturally-sensitive care coordination and self-management training for historically underserved populations with chronic illnesses (i.e. Diabetes)


• Components of Systems Change:– Creation and adoption of the Community Health Worker

(CHW) role within BHCS’ human resources structure– Development of strategies that allow providers to confer

“authority” to CHWs, extending the reach of the health care team

– Establishment of accountability and outcomes measurement systems


Creation & adoption of CHW role•Embed Community Health Worker (CHW) job code within BHCS’ Human Resources structure

– Designed job description and compensation of Diabetes Health Promoter (CHW)• Utilized CoDE™ Medical Assistant qualifications to serve as minimum job requirements• Required market research on CHW/MA salaries

– Required BHCS Human Resources and Compensation formal review and approval•Determine training and continuing education necessary for job role

– Developed training curriculum for CHWs functioning as Diabetes Health Promoters in outpatient setting• Includes training manual, practicum (traditional DSME classes, skills certification, AADE Healthcare

Technician training)• Training/continuing education funded annually as a distinct budget line item

– Integrated state certification as CHW into curriculum•Build career progression for CHW’s

– Developing promotional levels within job code• Differentiation “case” being developed between medical assistants and CHWs (for HR approval

process)– Working to define CHW career path within health system

Develop strategies that allow providers to confer “authority” to CHWs–Protocol, policies and procedures developed

• Protocol Handbook (including educational materials, forms) approved by Physician Vice-President, Office of Health Equity and consulting endocrinologist

• Policies and procedure handbook utilized evidence-based resources (existing BHCS policies, US Department of Health and Human Services, manufacturer procedures for use of equipment)

• Formal PCP Communication Guidelines developed by consulting endocrinologist and Physician Vice-President, Office of Health Equity

– Reviewed by primary care practices referring to the Diabetes Equity Project–Consulting endocrinologist and RN manager–Developing new care model utilizing Nurse Practitioner and CHW as “case management” team (with physician oversight) for “Hot Spot” patients

• In sixth month of pilot currently• Comprehensive Patient Assessment tools developed (assessing self-management behaviors, social

barriers)• Utilizes DiaWEB™ registry and clinic EMR for data tracking• Preliminary data analysis will take place July 2011


– Establish accountability and outcomes measurement systems • DiaWEB™ diabetes registry with reporting capability

– Web-based design with customized Diabetes Health Promotion assessments

– Produces both individual and aggregate data reports• Patient experience satisfaction tool for real-time evaluation of CHW

service quality• Chart audits

– Annual chart audits (random sample) are conducted by RN Manager– Audit analysis completed by BHCS statisticians– Utilize clinical trial standard of <5% error rate


Grantee Efforts Underway – Dallas

• Specific strategies & tactics to change the system:– Deployed BHCS employees (CHWs) into community aligned

with collaborating safety net clinics• Five sites serve as “community hubs” for care coordination• Established operational foundation

– For first 6 months, received referrals only from five sites to build competencies and fine tune processes

» Solicited regular feedback from stakeholders » Slower patient ramp up

– Built team culture» Diabetes Health Promoter team meetings bi-monthly» Monthly meetings with site clinic staff» Strong support from leadership to increase likelihood of employee

engagement and successful implementation

Specific strategies & tactics to change the system (continued)

– Marketed new CHW-led disease management training & care coordination service (referrals to community and health care based resources) to broad network of safety net providers

• Identified provider “targets”– Utilized existing safety net organization’s (Project Access Dallas) administration‘s

endorsement, data on practices with high prevalence of diabetics, and insights into practice partners to identify targets

• Marketing tactics– Diabetes Health Promoter and Manager scheduled individual meetings with target practice

leadership– Presentation including preliminary outcome data, referral process overview (and forms),

patient criteria, patient brochure, and administrative overview– Utilized Project Access Dallas marketing department to build awareness (Dallas Medical

Society Journal)– Expanded intervention to private practice physicians caring for vulnerable

patients experiencing disease control disparities• 500 physician BHCS organization’s Disease Management Council approved twelve month pilot at

four practices beginning summer 2011• Tracking clinical outcomes via clinic EMR data• Will report results to Disease Management Council in 2012


• Impacts Intended & Accomplished– Use a CHW intervention to produce documented improvement in diabetes control

and reduction of racial/ethnic disparities• Statistically significant increase in percent of vulnerable patients enrolled in the

intervention with “superior” diabetes disease control (HgbA1c < 7%)• No significant differences noted between minority and non-minority patient sub-

populations– Building awareness of CHW scope/role within a health system

• Human Resources – career paths• Added 2 FTE CHW in transitional care role• Received funding for 3 additional CHWs (Diabetes Health Promoter and Transitional Care)• 2 other BHCS departments adding CHWs into their workforce

– Develop funding sources for long term sustainability • Baylor Community Care incorporates Community Care Coordination as a core operating

component with a dedicated budget for CHW roles (Community Health Education, Community Care Transitions, Specialty Care Transitions)

• Planning has started for enlisting community organization funds for non-Baylor owned clinic

Presenters

Dr. Monica Peek Dr. Marshall Chin

University of Chicago, Pritzker School of Medicine

Abby Wilkes, MPH

University of Chicago

Improving Diabetes Care and Outcomes on the Improving Diabetes Care and Outcomes on the South Side of ChicagoSouth Side of Chicago

South Side of Chicago

• Challenges:– Poverty– Social challenges – Food deserts– Unsafe recreation– Mistrust of healthcare– Weakened hospital safety net

• Strengths– Historical social, political and

cultural traditions– Community resources and

institutions– Healthcare institutions

Intervention Components

Six health centers

1) Patient activation trainin2) Provider communication training3) Community connections4) Systems Change: CLINIC REDESIGN

Health System ChangeHealth System Change

• Clinic redesignClinic redesign• QI teams/coachesQI teams/coaches• Collaborative mtgsCollaborative mtgs• PDSA cyclesPDSA cycles

Health System Change: Care ManagementHealth System Change: Care Management

• Nurse care managementNurse care management

– Context: MD-led internal medicine Context: MD-led internal medicine practicepractice

– Intervention: Nurse Practitioner Intervention: Nurse Practitioner Care ManagementCare Management

• Diabetes educationDiabetes education• Insulin initiation/titrationInsulin initiation/titration• Care coordinationCare coordination• Telephone counseling/managementTelephone counseling/management• Involvement in community outreachInvolvement in community outreach

– Incorporate other systems changesIncorporate other systems changes• Improve frequency and Improve frequency and

appropriateness of physician/staff appropriateness of physician/staff referral to nutritionreferral to nutrition

• Increase referrals to NP from each Increase referrals to NP from each provider’s rosters of patientsprovider’s rosters of patients

Health System Change: Care ManagementHealth System Change: Care Management

• Nurse care Nurse care management: Lessonsmanagement: Lessons

• Nurse is crucial member of clinic Nurse is crucial member of clinic redesign teamredesign team

• Nurse cannot do it all - Now have Nurse cannot do it all - Now have staff to support outreach phone callsstaff to support outreach phone calls

• Need to measure process measures Need to measure process measures as well as usual clinical measures – as well as usual clinical measures – e.g. no-show rate and # of patients e.g. no-show rate and # of patients who are contacted to reschedulewho are contacted to reschedule

• Clinic redesign uncovers system Clinic redesign uncovers system capacity challenges - Limited number capacity challenges - Limited number of appointments available for MDs, of appointments available for MDs, NP, and nutritionistNP, and nutritionist

Health System Change: Group VisitsHealth System Change: Group Visits

• Diabetes group visitsDiabetes group visits

– Context: 2 federally-qualified health Context: 2 federally-qualified health centerscenters

– Intervention: Shared medical apptsIntervention: Shared medical appts• Diabetes educationDiabetes education• Medication titration/clinical careMedication titration/clinical care• Support groupSupport group

– Some evidence re: reduced costs, Some evidence re: reduced costs, hospitalizations, lower blood hospitalizations, lower blood pressure, Improved patient/provider pressure, Improved patient/provider satisfactionsatisfaction

Health System Change: Group VisitsHealth System Change: Group Visits

• Diabetes group visits: Diabetes group visits: LessonsLessons

– Pre-planPre-plan

– Identify schedule changes for staffIdentify schedule changes for staff

– Determine types of providers/staff Determine types of providers/staff neededneeded

– Find out how to billFind out how to bill

– Work out patient co-paysWork out patient co-pays

Health System Change: Health System Change: Diabetes Peer Support GroupDiabetes Peer Support Group

• Diabetes Peer Support Diabetes Peer Support GroupGroup– Context: Diabetes center in Context: Diabetes center in

the section of Endocrinologythe section of Endocrinology– Intervention: Group of Intervention: Group of

patients brought together to patients brought together to try out local fitness/nutrition try out local fitness/nutrition resources and provide peer resources and provide peer supportsupport

– Focus on lifestyle modification Focus on lifestyle modification while connecting to while connecting to communitycommunity

– Evidence for:Evidence for:• Improved knowledgeImproved knowledge• Improved psychosocial Improved psychosocial

functioningfunctioning• Increased physical activity Increased physical activity

self-efficacyself-efficacy

Health System Change: Health System Change: Diabetes Peer Support GroupDiabetes Peer Support Group

• Diabetes Peer Support Group: Diabetes Peer Support Group: LessonsLessons – No attendance at first physical No attendance at first physical

activity event: walking groupactivity event: walking group– Low attendance at grocery store Low attendance at grocery store

tourtour– Despite focus groups and survey Despite focus groups and survey

feedback requesting help re: fitness, feedback requesting help re: fitness, nutrition, and peer support, patients nutrition, and peer support, patients did not show.did not show.

– Changing QI focus to care Changing QI focus to care coordinationcoordination

– Innovative new approaches to Innovative new approaches to interface with patients outside of interface with patients outside of health care systemhealth care system

Lessons Learned from QI Process

• Individualize to clinics– What’s important to clinics vs. more

ambitious change– Crawl, walk, run

• Coaches are vital

• Learn from peer clinics– Collaborative meetings– Support network

Lessons Learned from QI Process

• Address challenges of health centers– Staff turn-over– Leadership buy-in– Project scope and size– Learning curve

• Perseverance pays off

Health Policy RelevanceHealth Policy Relevance

• Integration of Quality and Disparities Integration of Quality and Disparities – Using the tools of QI to reduce disparitiesUsing the tools of QI to reduce disparities– Dept. of Health and Human Services, Centers for Dept. of Health and Human Services, Centers for

Medicare and Medicaid ServicesMedicare and Medicaid Services

• Coordinating careCoordinating care– Organizational structures – Medical Home, ACOs Organizational structures – Medical Home, ACOs – Financing mechanisms – Bundled paymentsFinancing mechanisms – Bundled payments

• Move towards efficiencyMove towards efficiency– Regardless of whether Democrat or RepublicanRegardless of whether Democrat or Republican

Our Project Team

• Marshall Chin• Monica Peek• Abigail Wilkes• Tonya Roberson• Anna Goddu• Kristine Bordenave• Michael Quinn• Doriane Miller• Lisa Vinci• Andrew Davis• Elbert Huang• Jonathan Birnberg• Jonathan Dick

• Mickey Eder• Peggy Hasenauer• Louis Philipson• Marla Solomon• Hui Tang• Robert Nocon• Katie Raffel• Ndang Azang-

Njaah• Gwen Burrows• Braunda Anderson• Marjorie Kerr

• Shantanu Nundy• Seo Young Park• Neha Setha• Emily Lu• Rebecca Lipton• Deborah Burnet• Karen Kim• Dawnavan Davis• Sheila Harmon• Quin Golden• Eric Whitaker• Shelley Scott

Questions?

General Questions: Martha Quinn [email protected]

Questions on Dallas or Chicago Initiatives: Darla Williams [email protected]

Technical Questions: Gillian Mayman [email protected]

Organizational Policy and Systems Changewww.ardd.sph.umich.edu

organizational policy and systems change

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