promoting the “triple aim” - · pdf filegeorge thibault, 2013. ... – np...
TRANSCRIPT
Promoting the “Triple Aim” Aligning Interprofessional Education and Health System Redesign
CAB VI Conference October 3, 2017 Banff, Canada
Malcolm Cox, MD Adjunct Professor
Perelman School of Medicine University of Pennsylvania
2
3
What Actions Should be Taken To More Closely Link Educational and Practice Reform …Educational enterprises and healthcare delivery systems have evolved with different structures, incentives, and cultures. There have been insufficient opportunities for them to work and plan together, and it has not been as clear as it should be that both have the same goals – better patient outcomes and better health for society. George Thibault, 2013.
Agenda
• Defining the Journey – What matters?
• Considering the Context – IPE ecosystems – Leadership – Conceptual models – Evidence – Learning
• Enabling Collaborative Practice – Practice redesign – Education reform
• Reaping the Rewards – Better health &
enhanced value
4
5
6
Per Capita Cost of Healthcare
IPE and the Triple Aim
Number of Aims
Number of Publications
Percentage of
Publications Specific Triple Aim Focus
0 108/133 81.2 None
1 22/133 18.5 Experiences of Care
2 3/133 2.3 Population Health + Experiences of Care
3 0/133 0 Per Capita Cost of Healthcare
7
IPE Ecology
• We’ve tended to focus on the guest (the curriculum and its associated pedagogy) but it is the host (the clinical learning environment and its myriad relationships and interactions) that dominates in determining whether IPE will flourish
• An understanding of Health Delivery and Education Systems is central to the rational use of IPE and the demonstration of its effectiveness
8
Educational Reform
Practice Redesign
Learning
Patient
Caring
MACROSYSTEM
Structure Financing
9
MICROSYSTEM
System Alignment
Without a purposeful and more comprehensive system of engagement between the education and health care delivery systems, evaluating the impact of IPE interventions on health and system outcomes will be difficult.
10
Chaos
Plan and
Control
Zone of
Complexity
11
Professional Agreement
About Outcomes
Low
High Low
Certainty About Outcomes
High
Strategic Lessons
• Redesigning the process of care is about culture change
• Moving educational and delivery systems requires a compelling vision and case statement
• Efforts must be appropriately resourced • Leadership at all levels is essential
12
Cultural Challenges
• Individual inertia – “What’s wrong with the old system? It produced
me and I’m terrific.” • Organizational inertia
– “When you really don’t want to do something, one reason is as good as another.”
• National inertia – “There’s no greater barrier to change than past
success.”
13
Enabling or Interfering Factors Foundational
Education Graduate Education
Continuing Professional
Development
Reaction
Attitudes/perceptions Knowledge/skills
Collaborative behavior Performance in practice
Interprofessional Education
Professional culture Institutional culture
Workforce policy Financing policy
Learning Outcomes Health and System Outcomes
Learning Continuum (Formal and Informal)
Individual health Population/public health
Organizational change System efficiencies Cost effectiveness
Value of Conceptual Models
• Communication & Standardization – Foster adoption of consistent terminology and
standardized frameworks • Contextual Analysis
– Define inputs/outputs and enabling and interfering factors • Evaluation & Assessment
– Guide future studies & promote robust experimental designs
• Creativity & Innovation – Guide programmatic, institutional & system-wide
transformation
15
16
Value of Team Training
17
Reactions
Learning
Transfer
Results
Healthcare Team Training
0.48
0.79
0.33 , 0.73
0.66 , 1.11
0.62
0.33
0.52 , 0.82
0.21 , 0.52
Analysis of Outcome Studies
• Emphasis on “early” learning outcomes – Attitudes, knowledge, clinical skills
• Limited evidence for “higher level” outcomes – Behavior, performance in practice – Patient or population benefits, system outcomes
• Significant methodological weaknesses – Absence of control groups
• Lack of attention to long-term impact
18
Educational Transformation
19
Acting your way into
new thinking
Thinking your way into
new acting
Workplace Learning
• Unscripted: Requires workers to go beyond approaches learned previously in order to resolve novel and poorly defined work challenges
• Collaborative: Requires workers to enhance or replace their collective expertise as changes in technology and work processes necessitate the development of new skills
• Distributive: Requires team leadership to be determined by expertise germane to the question at hand rather than artificial hierarchies
20
RP FI
WP
Learning Domains
each profession’s curriculum
“nested” within
“nested” within clinical site
transformation
within and between professions
IPE Learning Domains
21
Collaborative Practice Strategies
• Hierarchical models – Clinician “extension” models (using support personnel
with more limited qualifications) • Independent models
– “Parallel play” by qualified clinicians (e.g., primary care physicians, nurse practitioners, physician assistants)
• Integrated models – “Series play” organized around existing health issues
and provider expertise and availability
22
Moving to Integrated Models • Explicitly recognize the power of collaboration
– Leadership Is Job One! • Demonstrate a positive value proposition for
interprofessional team-based care – Evidence Is Power!
• Realign institutional resources to support interprofessional team-based care – If You Build It, They Will Come!
• Recognize that practice redesign is a prerequisite for clinical education reform – The Tail Does NOT Wag the Dog!
23
VA as a Vehicle for IPE
• Alignment between education and health delivery system
• Joint planning and investment by academic and practice communities
• Broad-based, multi-professional public financing of health professions education
• Organizational seed support based on potential health and societal benefits
• Infusion of public funds based on documented health and societal benefits
24
FA M I LY
C L I N I C A L A S S O C I AT E
P C P R O V I D E R
C L E R K RN C A R E M A N A G E R
R E S I D E N T
25
PACT Implementation
26
PATIENT-ALIGNED CARE TEAMS (PACTS) National Policy Fully Resourced
ADOPTION & DISSEMINATION
Leadership Support Project Management
EDUCATION & TRAINING Learning Collaboratives
Consultation Teams
Learning Center
IMPLEMENTATION GUIDANCE
PACT Handbook Workload Analysis
Staffing Ratios
COMMUNICATION
IT ENHANCEMENTS PCMM
VISTA/CPRS Registry functionality
ASSESSMENT ACP Medical Home
Builder PACT Certification
DEMONSTRATION LABORATORIES
System Outcomes
COE IN PRIMARY CARE EDUCATION (COE-PCE) Academic Partnerships Demonstration Projects
PACT Implementation Index (PI2) PACT Goals PI2 Domains Data Source
Accessible, continuous and coordinated care
Access VA Corporate Data Warehouse and
CAHPS-PCMH Survey (n=75,101)
Continuity of care
Coordination of care
Team-based care Delegation, staffing, team functioning, working to top of competency
VA PACT Personnel Survey (n= 5,404)
Patient-centered care
Comprehensiveness
CAHPS-PCMH Survey (n=75,101)
Self-management support
Patient-centered care and communication
Shared decision making 27
PACT Domain Correlations
28
• Higher Patient Satisfaction • Lower Staff Burnout • Lower ED Use • Lower Hospitalization Rates • Better Clinical Quality
Sites with
Higher PI2
Score had:
29
Changes in Utilization, 2010-2012 % Change in utilization
due to PACT
Age <65
Age 65+
Total
Hospitalizations for ambulatory care-sensitive conditions
-4.2% -0.2% -1.7%
Outpatient primary care visits -1.2% 3.5% 1.0%
Outpatient specialty mental health visits
-7.8% -5.2% -7.3%
30
Return on Investment, 2010-2012
2010 2011 2012 Total Discounted
Total
Costs avoided $96 $264 $280 $639 $596
PACT investment $258 $279 $285 $822 $774
Net loss -$162 -$15 -$5 -$183 -$178
31
VA COE-PCE
Core Requirements • Innovative approaches • Joint sponsorship
(medicine, nursing, others)
• 30% time commitment • Robust evaluation
Key Features • Shared Decision Making • Sustained Relationships • Interprofessional
Collaboration • Performance
Improvement
32
COE-PCE Inaugural Sites
Co-Directors: C. Scott Smith, MD and Melanie Nash, MSN, ANP
Academic Partners: Gonzaga University School of Nursing
University of Washington School of Medicine Idaho State University Schools of Pharmacy and Nursing
Co-Directors: Joyce Wipf, MD and Kameka Brown, PhD, APN
Academic Partner: University of Washington
Schools of Medicine and Nursing
Co-Directors: Rebecca Brienza, MD, MPH and Susan Zapatka, MSN, APN
Academic Partners: Fairfield University School of Nursing
Quinnipiac University School of Nursing Yale University Schools of Medicine and Nursing
University of Connecticut School of Medicine
Co-Directors: Mimi Singh, MD, MS and Mary Dolansky, PhD, RN
Academic Partners: Case Western Reserve University School of Nursing
Ursuline College School of Nursing Cleveland Clinic Foundation
Co-Directors: Rebecca Shunk, MD and Terry Keane, DNP, APN
Academic Partner: University of California at San Francisco
Schools of Medicine and Nursing
33
Trainee Engagement
34
35
When I first read the five cases, what impressed me was the reflection, the deeper story behind the story. We have the opportunity to learn about context and developmental issues from a national larger-scale complex adaptive systems perspective.
Barbara F. Brandt, PhD
Key Outcome Questions
• Does interprofessional team training enhance learning outcomes? – NP residents – IM residents
• Does interprofessional team training influence practice performance? – Patient, staff and trainee satisfaction – Quality of care outcomes – Utilization outcomes
36
Learning Outcomes – NP Residents
Learning Domain
Competency Item
Mentor Assessment Mean (SD)
Month 1 Month 12 Interprofessional Collaboration
Safely transition patients among team 3.0 (1.4) 4.5 (0.56)
Shared Decision Making
Facilitate patient participation in health care decisions 3.1 (1.0) 4.5 (0.94)
Sustained Relationships
Devise, follow, review and adjust longitudinal care plan 3.0 (1.0) 4.6 (0.6)
Performance Improvement
Perform root cause analysis and reflect on critical incidents 1.2 (1.3) 3.2 (1.8)
37
p<0.001 for all items
Placeholder 1
Learning Outcomes – IM Residents For information about this study, please contact:
38
Placeholder 2
Learning Outcomes – IM Residents For information about this study, please contact:
39
Placeholder 3
Qualitative Outcomes – Patient Satisfaction For information about this study, please contact:
40
Placeholder 4
Quality and Utilization Outcomes For information about this study, please contact:
41
Placeholder 5
Quality and Utilization Outcomes For information about this study, please contact:
Placeholder 6
43
Quality and Utilization Outcomes For information about this study, please contact:
Placeholder 7
Quality and Utilization Outcomes For information about this study, please contact:
Burning platform
Pockets of Success
Linked Success
Learning Organization
•Awareness •Education
•Learn •Do
•Connect Success •Engage Value Stream
•Leaders as Teachers •Empowered Teams •Self-sustaining Culture of Improvement
Engagement of People in Re-Designing Work
45
New Rules • Practice redesign is foundational!
– Delivering safe, satisfying, effective and efficient care is the end game
• Alignment of education reform with health system redesign is vital! – Without it resources will be hard to find
• Learning by doing is essential! – Workplace learning trumps formal instruction – Reflection on and in action are critical
• Context matters (a whole lot)! – Evidence-based blueprints are important, but local
modifications are essential for maximum effectiveness and sustainability
46
More New Rules • Outcomes are persuasive (but still largely missing)!
– Even traditionalists will yield to evidence of positive outcomes • Demonstrating a financial and/or social return on
investment is critical! – Health and system outcomes are more meaningful than learning
outcomes alone • Understanding what works (and when and why) is as
important as demonstrating enhanced educational, clinical and system outcomes! – Without such information generalizability is unknowable
• Culture matters most of all! – Leadership, leadership, leadership…
47
48
Give Up Professional Prerogative When It Hurts the Whole
…the romantic image of the totally self sufficient physician [clinician] no longer serves professionals or patients well. The most important question a modern professional can ask is not “What do I do?” but “What am I part of?” Those who prepare young professionals should nurture that redirection from prerogative to citizenship. Don Berwick, 2016.