Are We Providing Older Patients the Care they Deserve? Improving the Quality of Care for Older People

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Are We Providing Older Patients the Care they
Deserve?Improving the Quality of Care for Older
People

• Neil S. Wenger, MD, MPH
• Division of General Internal Medicine
• David Geffen School of Medicine at UCLA
• Maine Medical Center Annual Geriatrics Day 2009

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The Quality of Health Care

• Americans receive 55 of recommended care (439
  indicators for 30 conditions and preventive care)
• Care for specific conditions varies greatly
• Cataract 79 hip fracture 23
• McGlynn EA, et al. NEJM. 2003 3482635-45.

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Health Care Quality for Vulnerable Elders ACOVE
results

• Overall, 55 of Quality Indicators passed
• Compliance for geriatric conditions was worse
  than for general medical conditions (31 versus
  52)
• Care for specific conditions varies greatly
• Stroke 82 end-of-life care 9
• -Ann Int Med 2003

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Quality of Care forGeriatric Conditions
Condition Recommended Care Process Provided
Falls and mobility 34
Under-nutrition 47
Pressure ulcers 41
Urinary Incontinence 29
Cognitive impairment 35
-Ann Intern Med. 2003139740-7.
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Care Provided to Vulnerable EldersExamination
After a Fall
6 Blood pressure
25 Vision
7 Gait and balance
28 Neurological exam
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Care Provided to Vulnerable Elders Approach to
Urinary Incontinence
50 document some history
22 dedicated exam
38 urine test
13 behavioral treatment suggested
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Quality of Care for Initial Cognitive Impairment
Evaluation
Care Process Recommended Care Process Provided
New cognitive impairment (N34) Cognitive evaluation Evaluation for depression 50 41
New dementia diagnosis (N27) Neurological examination Cause of dementia sought Dementia severity assessed 15 37 11
-Belmin J, et al. Assessment and Management of
Patients with Cognitive Impairment and Dementia
in Primary Care. Under review.
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Quality of Care for Prevalent Dementia (N101)
Care Process Recommended Care Process Provided
Education about dementia 11
Patient safety counseling 19
Counseling about driving 21
Advance care planning, any 50
-Belmin J, et al. Assessment and Management of
Patients with Cognitive Impairment and Dementia
in Primary Care. Under review.
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Overview of Presentation

• Whats the problem?
• Approaches to care for the older patient
• Does practice redesign work?
• ACOVE-2 study
• ACOVE Alzheimers Association project
• ACOVEprime with the ACP
• How can you change your practice?

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The Problem

• Physicians are unable to provide high quality of
  care for conditions affecting older persons
  within the context of busy primary care practice.

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Why do we Provide suboptimal care?

• Barriers to effective management of geriatric
  conditions
• Inadequate case recognition
• Lack of physician knowledge
• Poor patient adherence to treatment plan
• Inadequate follow-up
• Lack of time and resources

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Cognitive capacity

• Too much to know
• During 2001, the US National Library of Medicine
  added more than 12,000 new articles per week to
  its on-line archives
• To maintain current knowledge, a general
  internist would need to read
• 20 articles per day
• 365 days per year
• Shaneyfelt TM. JAMA 2001 2862000-2601

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Not enough time

• Assuming
• practice size 2500 patients
• age chronic distribution of US population
• following guidelines for 10 chronic diseases
• Would take 10.6 hours per day
• Plus time for management of other problems
• Ostbye, Ann Fam Med. 2005 3209-14.

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Improving Medical Care

• Higher level of quality cannot be achieved by
  further stressing current systems of care.
• Trying harder will not work. Changing systems of
  care will.
• Institute of Medicine, 2001

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Physicians Opinions on Strategies to Improve
Quality of Care
of physicians responding that the factor is
very effective in improving quality of care
Source The Commonwealth Fund National Survey of
Physicians and Quality of Care. 2005
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Models of Improving Care for Older Patients

• Consultation model
• Geriatrician, team
• Assume care
• Care management interventions
• Geriatric Resources for Assessment and Care of
  Elders (GRACE)
• Home-based geriatric care management
  intervention decreased ED visits and improved
  general health, vitality, social and mental
  health.
• Disease management by care managers
• Improved quality of dementia care, quality and
  outcomes for depression
• Guided care using specially-trained
  practice-embedded nurses
• Decreased utilization, improved health among high
  utilizing patients, and increased patient ratings
  of care.

-Callahan CM, et al. JAMA. 20062952148-57. -Unut
zer J, et al. JAMA. 2002 2882836-45. -Counsell
SR, et al. JAMA. 20072982623-33. -Boult C, et
al. J Gerontol A Biol Sci Med Sci. 200863321-7.
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What is Practice Redesign?

• Redesign hybrid between principles of
  continuous quality improvement and reengineering.
• CQI focuses on small cycles of testing changes
  and observing results at local points of care.
• Reengineering focuses on more radical
  restructuring of basic processes of care, with
  motivation for change coming from higher
  managerial levels and affecting larger units of
  organization.

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What is Practice Redesign? - 2

• Redesign aims to implement the best of both
  approaches, combining the gradualism of CQI with
  the fundamental restructuring seen in
  reengineering.
• Practice redesign may be one approach to
  overcoming remaining barriers to evidence-based
  practice.

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Practice Redesign Principles

• To improve care, change often focuses at three
  key levels
• patient
• provider
• practice
• Does not need to be expensive
• Chronic Care Model

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Model Assumptions

• Follow-up visit cannot take more than 20 minutes
• General medical care cannot be compromised
• No electronic medical record
• Office staff can provide some help

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Out-of-Office Preparation
Office Visit

1. Reduce time but increase effectiveness/efficiency
   of the inner circle

1. Always push to outermost possible circle whenever
   possible

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Delegation to Patients

• Pre-visit questionnaire
• Initial
• Follow-up
• Lists
• Diaries

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Delegation to Office Staff

• Screening/Case identification
• History gathering
• Following up on triggers
• Medications/allergies
• Enhanced vital signs/physical exam
• Orthostatic blood pressure readings
• Visual acuity testing
• Patient education

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Obstacles to Delegatingto Office Staff

• Cost
• Training
• Capability of acting on results

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The ACOVE-2 Intervention Improving the
Quality of Care for Falls, Incontinence and
Dementia
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ACOVE-2 Quality Improvement Model

• Case finding
• Delegation of data collection
• Structured visit notes to guide appropriate care
  processes
• Physician and patient education
• Linkage to community resources

-Reuben et al. J Am Geriatr Soc. 2003511787-93.
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Case Finding

• Several options
• Telephone call prior to visit
• Staff prior to placing patient in room
• Pre-visit questionnaire in waiting room
• Brief questions to identify target conditions
• Responses are given to provider at clinic
  appointment

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Structured Visit Note

• Leads physician through appropriate data
  collection and care processes
• History items and simple procedures
• (completed by intake office staff)
• More detailed history and exam, ordering
  diagnostic tests
• (completed by physician)
• Impression and plan
• (completed by physician)

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Patient educational materials

• Assembled for each condition
• Readily available to the clinician during care to
  facilitate treatment
• Community resources
• Follow-up visit form

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Decision Support-Physician Education

• Small group educational sessions aimed at
  practical approaches to each condition within the
  context of a busy practice

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ACOVE-2 Study Design
Intervention Period
Control Clinics
287 patients
Patients ? 75 yo with PCP appointment
Screen for D / F / U
Follow-up Quality of Care Survey
Collect Medical Records
357 patients
Intervention Clinics
Intervention Materials
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Participating Medical Groups
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Patient Characteristics
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ACOVE-2Quality of Care after Intervention
Intervention Group Control Group
Dementia 44 43
Falls 44 23
Incontinence 37 22
Overall 41 25
plt0.001 for difference between I and C groups
-A Practice-based Intervention to Improve Primary
Care for Falls, Urinary Incontinence and
Dementia. J Am Geriatr Soc. 200957547-55.
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Physician PerceptionsRelevance, Confidence and
Frustration
5-point scales, 1Not at all, 5Extremely.
plt0.05 comparing difference between I and C.
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Costs of this Practice Change

• Start-up (3,330 per 10 physician practice)
• establishing a screening mechanism
• customizing forms
• identifying condition-specific local
  community-based resources
• training physicians and office staff
• installing clinic materials

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Why wasnt ACOVE-2more effective?

• Failure to delegate data collection?
• Inadequate recognition and correction of
  suboptimal or absent care practices?
• Lack of resources for patient / caregiver action
  and activation?

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ACOVE - Alzheimers Association Project

• 2 Sites (Seattle and San Jose)
• Partnership with local chapters of AA
• National AA involvement
• Focus groups guided intervention
• Modified ACOVE-2 intervention
• Evaluation by medical record audit

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Physician Focus Group Findings

• Unmet need for education and support groups for
  patients/families
• Home care and home safety services
• Driving issues, behavioral problems, day
  programs, nursing home placement
• Little knowledge or experience with AA

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ACOVE - Alzheimers Association Intervention

• Cognitive screening by office staff
• Physician performs evaluation using SVN
• Small group educational sessions
• Fax referral to Alzheimers Association
• AA assessment in person or by phone
• AA feedback faxed back to MD

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Evaluation Quality Indicators

• For patient with new memory problem
• Cognitive evaluation, testing gt2 cognitive
  domains
• Review medications
• For patient with newly diagnosed dementia
• Neurological examination
• Laboratory testing
• Depression screening

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Evaluation Quality Indicators for Patients with
Dementia

• Counsel caregiver
• Dementia diagnosis, prognosis, behavioral
  symptoms
• Home safety
• Community resources
• Annual screen behavioral/psychological symptoms
• Assess functional status
• Document behavioral symptoms, try behavioral
  interventions first
• Offer cholinesterase inhibitor therapy
• Reassess antipsychotic therapy
• Counsel about driving
• Advance care planning with surrogate specification

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ACOVE - Alz Assoc Project ResultsReferral and
Overall Quality of Care
Pre-Intervention (N47 patients) Post-Intervention (N90 patients)
Referral to Alzheimers Assoc. chapter 0 17
Recommended care received 38 (N294 QIs) 46 (N463 QIs)
plt0.05 for post v. pre comparison
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ACOVE - Alz Assoc Project ResultsNew
presentation
Pre-Intervention Post-Intervention
New memory problem -cognitive assess -med review (N13) 69 69 (N34) 53 65
New Dementia -neurological exam -depression screen -lab testing (N8) 63 50 0 (N12) 54 92 15
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ACOVE - Alz Assoc Project ResultsDementia
Management
Pre-Intervention (N41) Post-Intervention (N55)
Management of dementia -functional status -cholinesterase inhibitor -screen for behavioral sx -behavioral treatment -reassess antipsychotic -counsel about driving -counsel caregiver -surrogate specified 20 75 54 5 32 13 2 63 51 68 58 12 100 20 30 49
plt0.05 for pre v. post comparison
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The ACOVEprime Intervention Collaboration
with the ACPto promote Practice Redesign
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ACOVEprime

• 5 small to medium practices
• Each with Intervention and Control sites
• Falls and Incontinence intervention
• ACP collaboration
• CQI MD self audit, feedback, repeat
• Practices chose implementation
• Part IV MOC credit
• QI implementation model

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Site Variation in Intervention Implementation
Site Screen Delegate to nurses Timing Pt Ed Materials Follow up EHR
A PSR Nurse Yes Follow up Condition Yes No
B Nurse Yes Screen visit On line Yes Full
C PSR Nurse No Follow up Single No No
D PSR No Screen visit Condition No No
E PSR Nurse No Screen visit Condition No Partial
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Screening for Falls and Incontinence
Site Screened Positive Screen for Falls/Fear of Falling Positive Screen for Incontinence
A 2437 1023 (55) 301 (54)
B 1166 127 (29) 258 (35)
C 992 212 (31) 162 (52)
D 809 295 (53) 146 (58)
E 736 135 (41) 225 (56)
Total 6140 1792 (46) 1092 (48)
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Preliminary Intervention Effect on Care Quality
for Falls and Incontinence (N212)
Site Intervention (N101) Control (N111)
A 38 27
B 75 36
C 58 28
D 51 24
E --- ---
Total 58 29
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Summary

• Practice redesign with low tech interventions can
  improve care for falls, incontinence and
  cognitive impairment in the context of usual
  care.
• Some effects are modest and need intensification.
• Takes a product champion, commitment to change
  (including false starts), and a bit of work.
• In the end, its the older patients who stand to
  benefit.

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Study Team

• David Reuben
• David Ganz
• Carol Roth
• Mayde Rosen
• Patty Smith
• Lillian Min
• William Hall