Implementing the Chronic Care Model Evolution of the Medical Home

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Implementing the Chronic Care Model Evolution of
the Medical Home

• Population Health Disease Management Colloquium
  
• Gary Piefer,MD,MS,FACPE,FAAFP
• Chief Medical Officer-WellMed
• March 3, 2009
• 1015 a.m.

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Implementing the Chronic Care ModelAgenda

• Introductions / Background
• Quality current state
• Why the Chronic Care Model
• Change Management in medical practice
• Physician Education
• What-Why-Who-When
• Project Overview
• Outcomes
• Questions

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• Corporate Office San Antonio
• 25 clinics in Texas, 7 in Florida
• 51 affiliated physicians offices and 119
  physicians in Greater San Antonio
• Multiple offices with 60 independent physicians
  in Greater Orlando
• 1,100 Employees
• Approximately 40,000 full risk Medicare patients
  in San Antonio

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• Serve 80,000 patients
• Affiliated Companies
• HealthRight Disease Management
• Comfort Care Transportation
• WellMed Clinical Research
• Bexar Imaging
• DataRap
• Physicians Health Choice

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Quality

• Current State

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Quality
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Quality

• American Society for Quality Source
  http//www.asq.org/glossary/q.html.
• "a subjective term for which each person has his
  or her own definition. In technical usage,
  quality can have two meanings
• 1. the characteristics of a product or service
  that bear on its ability to satisfy stated or
  implied needs.
• 2. a product or service free of
  deficiencies."

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Quality Score Card

• National Score Card on U.S. Health System
  Performance, 2006
• Commonwealth Fund http//www.commonwealthfund.org/
  topics/topics_list.htm?attrib_id15311

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Scores Dimensions of a High Performance Health
System
Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
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Mortality Amenable to Health Care
LONG, HEALTHY PRODUCTIVE LIVES
Mortality from causes considered amenable to
health care is deaths before age 75 that are
potentially preventable with timely and
appropriate medical care
Deaths per 100,000 population
State variation,2002
Percentiles
Countries age-standardized death rates, ages
074 includes ischemic heart disease. See
Technical Appendix for list of conditions
considered amenable to health care in the
analysis. Data International estimatesWorld
Health Organization, WHO mortality database
(Nolte and McKee 2003) State estimatesK.
Hempstead, Rutgers University using Nolte and
McKee methodology.
Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
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Quality Score Card

• Quality includes indicators organized into four
  groups
• The right care
• Coordinated care
• Safe care
• Patient-centered, timely care
• The Scorecard scores each group of indicators
  separately, and then averages the four scores to
  create the overall score for Quality.

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The Right Care

• Scored Indicators
• Adults received recommended screening and
  preventive care
• Children received recommended immunizations and
  preventive care
• Received all recommended doses of five key
  vaccines
• Received both medical and dental preventive care
  visits
• Needed mental health care and received treatment
• Adults
• Children
• Chronic disease under control
• Adults with diabetes whose HbA1c level lt9
• Adults with hypertension whose blood pressure
  lt140/90 mmHg
• Hospitalized patients receive recommended care
  for AMI, CHF,and pneumonia

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Receipt of Recommended Screening and Preventive
Care for Adults,by Family Income and Insurance
Status, 2002
QUALITY THE RIGHT CARE
Percent of adults (ages 18) who received all
recommended screening and preventive care within
a specific time frame given their age and sex
Recommended care includes seven key screening
and preventive services blood pressure, cholester
ol, Pap, mammogram, fecal occult blood test or
sigmoidoscopy/colonoscopy, and flu shot. Data B.
Mahato, Columbia University analysis of 2002
Medical Expenditure Panel Survey.
Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
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Coordinated Care
QUALITY COORDINATED CARE

• Scored Indicators
• Adults under 65 with an accessible primary care
  provider
• Children with a medical home
• Care coordination at hospital discharge
• Hospitalized patients with new Rx Medications
  were reviewedat discharge
• Heart failure patients received written
  instructions at discharge
• Follow-up within 30 days after hospitalization
  for mental health disorder
• Nursing homes hospital admissions and
  readmissions among residents
• Home health hospital admissions

Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
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Having an Accessible Primary Care Provider, by
Age Group,Family Income, and Insurance Status,
2002
QUALITY COORDINATED CARE
Percent of adults with a usual source of care who
provides preventive care, care for new and
ongoing health problems, and referrals, and who
is easy to get to
Elderly adults
Nonelderly adults
Data B. Mahato, Columbia University analysis of
2002 Medical Expenditure Panel Survey.
Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
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Medications Reviewed When Discharged from the
Hospital,Among Sicker Adults in Six Countries,
2005
QUALITY COORDINATED CARE
Percent of hospitalized patients with new
prescription who reported prior medications were
reviewed at discharge
GERGermany AUSAustralia UKUnited Kingdom
CANCanada NZNew Zealand USUnited
States. Data 2005 Commonwealth Fund
International Health Policy Survey of Sicker
Adults (Schoen et al. 2005a).
Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
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Heart Failure Patients Given Written Instructions
or Educational Materials When Discharged, by
Hospitals and States, 2004
QUALITY COORDINATED CARE
Percent of heart failure patients discharged home
with written instructions or educational material
Hospitals
States
Discharge instructions must address all of the
following activity level, diet, discharge
medications, follow-up appointment, weight
monitoring, and what to do if symptoms
worsen. Data National and hospital estimatesA.
Jha and A. Epstein, Harvard University analysis
of data from Hospital Quality Alliance national
reporting system State estimatesRetrieved from
Hospital Compare database at http//www.hospitalco
mpare.hhs.gov.
Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
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Safe Care
QUALITY SAFE CARE

• Scored Indicators
• Patients reported medical, medication, or lab
  test error
• Unsafe drug use
• Ambulatory care visits for treating adverse drug
  effects
• Children prescribed antibiotics for throat
  infection withouta strep test
• Elderly used 1 of 33 inappropriate drugs
• Nursing home residents with pressure sores
• Hospital-standardized mortality ratios
• Other Indicators
• Nosocomial infections in intensive care unit
  patients
• AHRQ indicators for patient safety in hospitals
  trends

Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
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Medical, Medication, and Lab Errors Among Sicker
Adults, 2005
QUALITY SAFE CARE
Percent reporting medical mistake, medication
error, or lab error in past two years
International comparison
United States, by race/ethnicity,income, and
insurance status
UKUnited Kingdom GERGermany NZNew Zealand
AUSAustralia CANCanada USUnited
States. Data Analysis of 2005 Commonwealth Fund
International Health Policy Survey of Sicker
Adults Schoen et al. 2005a.
Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
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Medical, Medication, and Lab Errors Among Sicker
Adults, 2005
QUALITY SAFE CARE
Percent reporting medical mistake, medication
error, or lab error in past two years
United States, by race/ethnicity,income, and
insurance status
International comparison
UKUnited Kingdom GERGermany NZNew Zealand
AUSAustralia CANCanada USUnited
States. Data Analysis of 2005 Commonwealth Fund
International Health Policy Survey of Sicker
Adults Schoen et al. 2005a.
Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
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Inappropriate Use of Medications by Elderly,
19962002
QUALITY SAFE CARE
Percent of community-dwelling elderly adults
(ages 65) who reported taking at least 1 or more
of 33 drugs that are potentially inappropriate
for the elderly
Annual averages
By gender, race, and region, 2002
Data Medical Expenditure Panel Survey (AHRQ
2005a).
Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
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Patient-Centered, Timely Care
QUALITY PATIENT-CENTERED, TIMELY CARE

• Scored Indicators
• Ability to see doctor on same/next day when sick
  or needed medical attention
• Very/somewhat easy to get care after hours
  without going to the emergency room
• Doctorpatient communication always listened,
  explained, showed respect, spent enough time
• Adults with chronic conditions given
  self-management plan
• Patient-centered hospital care
• Other Indicator
• Physical restraints in nursing homes

Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
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QUALITY PATIENT-CENTERED, TIMELY CARE
Waiting Time to See Doctor When Sick or Need
Medical Attention, Sicker Adults in Six
Countries, 2005
Last time you were sick or needed medical
attention, how quickly could you get an
appointment to see a doctor?
Percent of adults
NZNew Zealand GERGermany AUSAustralia
UKUnited Kingdom USUnited States
CANCanada. Data 2005 Commonwealth Fund
International Health Policy Survey of Sicker
Adults (Schoen et al. 2005a).
Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
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Why the Chronic Care Model
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Crossing the Quality Chasm
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American Healthcare A Broken System

• The IOM Quality Report Crossing the Quality
  Chasm
• The current care systems (models) can not do the
  job.
• Trying harder will not work
• Changing care systems (models) will

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Healthcare An Unreliable System

• Errors in Healthcare A Leading Cause of Death
  and Injury
• Proportion of Hospital Admissions experiencing an
  adverse event/injury (2.9-3.7)
• Proportion of adverse events attributable to
  errors 58.
• 50 90 thousand potentially avoidable deaths
  annually
• The IOM Quality report A New Health System for
  the 21st Century

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A Major Study of Reliability in American Health
Care

• The Defect Rate in the technical quality of
  American healthcare is approximately 45
• McGlynn, et al The quality of health care
  delivered to adults in the United States. NEJM
  2003 348 2635-2645 (June 26, 2003)

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To Change Outcomes Requires Fundamental Practice
Change

• Interventions which have demonstrated positive
  outcomes
• better use of non-physician team members,
• enhancements to information systems,
• planned encounters
• modern self-management support, and
• care management for high risk patients

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Implementing Change - Critical Mistakes

• Not establishing a great enough sense of urgency
• Not creating a powerful enough guiding coalition
• Lacking a Vision (elevator speech)
• Under-communicating the vision by a factor of ten
• Not removing obstacles to the new vision
• Not planning and creating short-term wins
• Declaring victory too soon
• Not anchoring changes in the corporations
  culture
• Leading Change Why Transformation Efforts Fail
  by John P. Kotter , Harvard Business Review
  March-April 1995

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Project Management

• Physician Education
• Physician Buy-in
• Physician amnesia
• Physician Buy-in
• Physician amnesia
• Physician Buy-in

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Chronic Care Model

• Lead Physicians Meeting
• Wednesday May 16, 2007
• 730 900
• One More time Wednesday February 20, 2008

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Physician Education

• Look at Things Differently
• Systems Thinking
• System Failure vs. Personal Failure
• We Can Do Better

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Physician Education Strategy

• Reliability Science
• Process Failure
• Human Factors and Defect Rates
• Need to Change Models
• Data, References
• The MacColl Institute
• www.improvingchroniccare.org

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A Major Study of Reliability in American Health
Care

• The Defect Rate in the technical quality of
  American healthcare is approximately 45
• McGlynn, et al The quality of health care
  delivered to adults in the United States. NEJM
  2003 348 2635-2645 (June 26, 2003)

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Systems / Outcomes

• Every System is perfectly designed to obtain
  the outcomes it is getting
• 
  Don Berwick IHI

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The definition of insanity is doing the same
thing over and over and expecting different
resultsBenjamin Franklin
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The Hard Work

• Project Implementation
• Michelle Henry, MSN, RN

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Primary Care and Patient-Centered Medical Home

• Greater focus on chronic illness such as diabetes
  and heart disease
• Clinic operational approach and appointments
  aligned to ensure better chronic disease
  management

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Key Changes for Clinic Operations

• Longer, planned scheduled visits to address
  chronic disease (3-4 times a year)
• Teams assist and become more involved
• The patient becomes more engaged

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Key Changes for Clinic Operations

• Know your current process (process map)
• Choose what changes will work best for your
  practice
• Clarify roles and responsibilities
• Avoid Big Bang

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Key Changes for Clinic OperationsPlanning the
New Initiative

• Project Management support
• Introduce project management 101
• Project Plan for systematic and consistent
  implementation

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Project Plan
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Key Changes for Clinic OperationsA Team Effort
Implementation

• Inclusive implementation
• Every role provided
• feedback on new process
• Rapid Cycles of Change
• (Plan, Do, Study, Act
• PDSA) principles to make
• process improvements
• Avoid Big Bang

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Rapid Cycles of Change
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Key Changes for Clinic OperationsData and Health
Record Management

• A letter template created in our EMR
• Informed patients of our new visit process
• All medical data (lab, x-ray results) collected
  and ready for PCP to review

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Check List
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Electronic Version Protocol Engine
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A New Health Coach Role in the Clinic

• Transition from DM nurse to health coach
• Manages our disease-state registry
• Provides coaching for self-management support
• Provides focused education for specific chronic
• disease needs
• Identifies additional resources for patients
• (medication assistance, Social Worker)

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It Works!!!!
The team worked collaboratively and all feedback
contributed to the final process. What our
patients are saying No one has ever asked me
what I wanted
before. What took you so long to do this?
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Chronic Care Model Visits (2008 Early Results,
After 8 months)
ACE/ ARB A1C w/in 6-12 mos. LDL A1C 7 LDL 70

Diabetic Patients Diabetic Patients 51 92 89 65 31
Diabetics seen in CCM Diabetics seen in CCM Diabetics seen in CCM 56 97 99 83 45

IHD Patients IHD Patients 89 32
IHD Patients seen in CCM IHD Patients seen in CCM IHD Patients seen in CCM 99 39

CHF Patients CHF Patients 39 86 34
CHF Patients seen in CCM CHF Patients seen in CCM CHF Patients seen in CCM 49 98 49
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Clinic Results - NO Chronic Care Model
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Clinic Results - With Chronic Care Model
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Clinic Results - NO Chronic Care Model
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Clinic Results - With Chronic Care Model
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Clinic Results - NO Chronic Care Model
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Clinic Results - With Chronic Care Model
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Clinic Results - NO Chronic Care Model
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Clinic Results - With Chronic Care Model
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Questions and Discussion