Planning Care for Individual Patients and Whole Populations MODERATOR: Nicole Van Borkulo, MEd, Practice Improvement Specialist, SNMHI, Qualis Health

SPEAKERS:

•Ed Wagner, MD, MPH, Director and Senior Investigator, MacColl Institute for Healthcare Innovation, Group Health Research Institute

•Brian Austin, Associate Director, MacColl Institute for Healthcare Innovation, Group Health Research Institute

•Central City Concern: Krista Collins, Data Analyst

•Idaho State University Department of Family Medicine: John Holmes, PharmD

Organized, Evidence-based Care

Delivering Organized, Evidence-Based Care: The Heart of the

Medical Home

Ed Wagner, MD, MPH, MACP and Brian AustinMacColl Institute for Healthcare Innovation

Group Health Research Institute

Safety Net Medical Home InitiativeJune 7, 2011

Understanding the origins of the Patient-Centered Medical Home

1. Pediatric Medical Home

2. The Centrality of Primary Care

3. Redesigned Systems of Care (aka, the Chronic Care Model)

First-contact Care Responsibility over time Comprehensive Coordination across providers, settings and

conditions

Medical home – Chronic Care ModelDuplicative, Complementary or Antagonistic?

• Both models advocate that every health care experience (visit, referral, admission, etc) connects the patient back to their PCP.

• Both emphasize and support patient role in decision-making and care

• Both the PCMH and CCM rest on the clinical evidence of practice changes that lead to improvements in patient care and outcomes.

• PMH underscores primary care’s responsibility for access, continuity, comprehensiveness, and coordination

• CCM redesigns care delivery for planned, whole person care

Changing demography and practice contentProportion of Office Visits for Chronic Illness Care

by Age - 2005

11%42%Age 65+

10%37%Age 45-64

9%26%Age 25-44

9%30%All patients

Chronic Problem,Flare-up

Chronic Problem,Routine

NAMCS, Advance Data No. 387, 2007

What do Chronically Ill Patients Need to Optimize Outcomes?

• A continuous healing relationship• Clinical therapy that gets them safely to the

therapeutic goals • Effective self/family-management • Services to meet major clinical and other needs, and

coordination of those services• Preventive interventions at recommended time• Evidence-based monitoring and self-monitoring• Follow-up tailored to severity

Patient Needs Practice Roles/Functions

Drug therapy that gets them safely to the therapeutic target

Effective self-management support

Preventive interventions at recommended time

Evidence-based monitoring and follow-up tailored to severity

Coordinated services

Medication Management

Self-managementSupport

Visit Planning/PopulationManagement

Follow-up/Care Management

Care Coordination

Population Management

Population management• Maintain a database (Registry) that includes key

information on important patient groups within a practice population.

• Monitor the database to identify and reach out to those needing service.

Medication Management

• Many chronic conditions treated by stepped care protocols that increase treatment intensity to reach goal.

• Clinical Inertia – Treatment is often not changed in visits with individuals not achieving therapeutic goals.

• Medication Management – Nurses or other care managers initiate and monitor, by telephone or brief visit, medication adjustment in patients not at goal.Requires agreement on and use of evidence-based protocols.

Clinical Inertia

• Patient has not reached treatment goal• Patient is taking medications as prescribed• Therapy (usually limited to drugs) has not been

intensified

First described by Phillips et al., Ann Int Med 2001

Care Management

• The provision of more intensive monitoring, clinical management, and self-management support to high risk patients.

• Usually provided by a nurse or other health professional.

Care Coordination

• Developing linkages and agreements with specialists and community resources

• Helping patients access outside resources• Assuring timely flow of relevant information to

and from referral sources

Three Areas of Emphasis in this Guide

1. Planned Care.2. Decision Support.3. Care Management.

The Importance of Planned Care

• Only half of recommended services are delivered

• Care is often reactive, even though many patient needs are predictable

• Planned Care creates an agenda for the encounter

• Planned Care can be delivered in patient- or provider-initiated visit, or even opportunistically

What is a Planned Visit?

• A Planned Visit is an encounter that uses patient data, team and practice organization, and decision support to assure a productive interaction.

• Can be patient-initiated or practice-initiated• Pre-visit planning (huddle) assures that patient

needs are met; post-visit huddle assures follow-up.

Steps for Planned Care

1. Identify the key clinical tasks associated with evidence-based care

2. Decide who on the team should do the task

3. Review patient data prior to the encounter to identify needed services

4. Structure the encounter so the relevant team members deliver all needed care

Decision Support

• Embed evidence-based guidelines into daily clinical practice.

• Integrate specialist expertise and primary care.

• Use proven provider education methods.• Share guidelines and information with

patients.

Decision Support

• Can be linked to ordering a clinical service or triggered via patient data

• Increasingly built into EMRs, making “the right thing to do the easy thing to do.”

• Meaningful Use core criteria place special emphasis on decision support mechanisms

Will greater sharing of care between primary and specialty care improve care for complex

patients?

• Recent meta-analysis* of interventions to increase collaboration between primary and specialist physicians found consistently positive effects on patient outcomes in mental illness and diabetes.

• Effective interventions include:< interactive communication—telephone, E-mail, videoconference< quality of information—structured information, pathways to improve information quality< Needs assessment—input based on initial and continuing identification and tracking of needs.

• It is not clear how this might work with the multi-problem patient.

* Foy et al. Ann Int Med 2010; 152:247-258

Care Management

• Usually provided by a nurse or other health professional.

• Care management is far more effective when the care manager:< is an integral member of the practice team< can influence medications< is supported by relevant medical specialist(s).

Clinical Care Management

Logistical

Logistical

Logistical Clinical Monitoring

Care Coordination

Clinical Follow-up Care

Medication mgmt

Relationship Between Care Coordination and Care Management Activities in Primary Care

©MacColl Institute for Healthcare Innovation, Group Health Research Institute 2011

Clinical Monitoring

Will care manager interventions be effective for multi-problem patients?

• Nurse and pharmacist care manager interventions improve outcomes in diabetes, depression, bipolar disorder, CHF, etc.

• Care managers in studies usually have experience and expertise in the targeted condition.

• Some care manager interventions now targeting complex patients with evidence of effectiveness—e.g., TeamCare*,Guided Care.

• Integration of the care manager with primary care appears critical.

*Katon et al., NEJM 2010. 363(27): p. 2611-20.

Implementing Care Management

1. Decide which populations are to be managed

2. Choose which services are required3. Develop and use a case identification

strategy4. Identify and train a clinical care manager5. Create a support structure for the

manager

A toolbox for

improving care

systems

What’s in the Kit

• Step by step advice on Implementing the CCM• Over 60 tools hyperlinked• Additional resources cataloged• A companion practice coaching manual is also

available.Find it at:

http://www.improvingchroniccare.org/index.php?p=toolkit&s=244

•www.improvingchroniccare.org

To learn more:

Thanks

•http://www.safetynetmedicalhome.org/

Point-of-Care Reminders in a Paper-Based World

Creating Delivery Systems that Drive Patient Care

Krista Collins, Data Analyst

• FQHC and Safety Net clinic located in Portland, Oregon

• Part of Central City Concern, one of Portland’s largest agencies serving single adults and families impacted by homelessness, poverty and addiction.

• The clinic sees 2,600 patients annually, with over 15,000 visits

• Of those, 40% of patients are uninsured, and the majority are < 100% FPL

• Up until May of 2011, the OTC did not have an EMR system in place for providing patient care

The Old Town Clinic

One Panel Manager created a handwritten form (called a “Health Summary”) to summarize chronic disease prevention measures for each patient on her panel prior to their visit.

The format was later standardized by one of our providers, who added several other crucial health measures to track.

The OTC Operations Team coordinated with our IT dept to create an electronic version of this form.

The “modern day” Health Summary - an electronic form printed before every GM appointment that summarizes a patient’s recent lab results, imaging results and vitals at last visit.

Without an EMR, we had to be creative …And one very creative idea lead to an entirely new innovative process

• Focuses on population-specific needs for OTC pts

• Lists last test date / last results

• Testing criteria displayed for reference

• Highlights pay for performance measures

• Printed prior to every GM visit

Health Summary Highlights

The Health Summary– From Start to Finish (Healthcare Organization)

Health Assistant -“Team Assistant” – enters data into CCCER (labs imported automatically); prints Health Summary before each session

Panel Managers -“Patient Care Coordinators” – Coordinates care of panels and supports the PCP in clinical care assessment (huddles)

Providers - The patient’s PCP; oversees all clinical care with each patient and signs off on referrals /orders

Medical Records – Identifies records (mammograms, DEXA scans) and routes them from fax directly to Health Assistant

Medical Assistants – facilitates communication with patient about needed tests, place orders schedules tests after visit

Health Assistant

prints HS form & attaches it to the chart

PM reviews during huddle

prep and highlights next

steps for provider

Provider coordinates w MA to order tests / exams prior to appt

MA talks w pt during check-in

and arranges tests / orders if patient agrees

HS is placed in chart and

discarded only when a new form

is printed

The Health Summary – Who Makes it Happen? (Designed Delivery System)

HBA1C Tests Performed

65% 64% 67% 71% 73% 71% 70%

0%

20%

40%

60%

80%

100%

Q3 2009 Q4 2009 Q1 2010 Q2 2010 Q3 2010 Q4 2010 Q1 2011

If reminding providers is “All that we need to do”, then why wasn‘t there more of an improvement?

The Result– Quick and Efficient Patient Data that Drives Patient Care

Important Lessons LearnedPoint of care reminders, while very helpful, for us only created a modest improvement in our measures

– POC Reminders don’t reach patients that do not visit the clinic on a regular basis– “Tyranny of the urgent” during appointments is still is an issue

Every visit to the clinic-especially a medical home-is “not created equal” due to the variety of services offered

– Patients were visiting the clinic, but not necessarily for a PCP appt but for mental health, “specialty” visits (LAOC, OT, etc), thus bypassing the Health Summary process

– Definitions need to be established as to who can act on point-of-care reminders (e.g. if a MH clinician notices a pt needs an HBA1c, what do they do?)

Patients with complex conditions often require more time for appointments– Huddles are extremely vital in mitigating this issue, and organizing labs

prior to the appt is essential. – Entire team needs to commit to attending and acting on huddle this is

now one of our team “in process” measures

The next steps for the OTC on improving patient-centered care:

• Proactive and Organized Outreach • Accurate Panels / regimented cleaning

process • Data - Recording in-process measures that

drive patient care and improvement• Adapting our Health Summary to our new EMR

– we miss it!“It is not enough to do your best; you must know what to do, and then do your best.” –Dr. W. Edwards Deming

ORGANIZED EVIDENCE-BASEDCARE – DIABETES EMR TEMPLATE

John Holmes, PharmDIdaho State University Department of Family Medicine

CLINIC AND PATIENT DEMOGRAPHICS

Family Medicine Residency Currently a 5-7-5 residency 6-7 new resident providers every year

Patients Mostly Caucasian About 30% have private health insurance About 35% have Medicare and 25% have Medicaid About 10% uninsured

Pocatello, Idaho About 80,000 people in the greater Pocatello area Serve many patients from rural areas around

Pocatello

OTHER CUSTOMIZED TEMPLATES

Depression Congestive heart

failure Asthma Back pain Osteoporosis Dyspepsia Headache Smoking Cessation

Hypertension Dyslipidemia Obesity Metabolic syndrome Menopause Diabetes Preventive care

BENEFITS OF EMR TEMPLATES

Standardized entry of data into the EMR Easily searchable data for QI initiatives

diabetes eye exams, foot exams, etc.

Patient-centered clinical decision support Aid providers in appropriately assessing, evaluating,

and treating patients Significant role in FM residency program (training

tool) Easily accessible provider and patient education

materials Customization of templates Improved efficiency and quality of care

% OF ADULT PATIENTS WITH DIABETES ATGOAL HBA1C LEVELS

0%10%20%30%40%50%60%70%80%90%

100%

2006-07 2007-08 2008-09 2009-10 2010-11

≥9%≥7 - <9%<7%

% OF DM PATIENTS WITH DOCUMENTEDDIABETIC EYE AND FOOT EXAM

0%10%20%30%40%50%60%70%80%90%

Eye ExamFoot Exam

BARRIERS TO TEMPLATES

Universal use Discuss new templates at department/resident

meetings 1 EMR noon conference/month EMR committee

Individual meetings with staff/providers if necessary Work flow issues Time intensive training Need to update templates frequently

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