Iowa Healthcare Collaboratives Ambulatory Learning Community

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Iowa Healthcare Collaboratives Ambulatory
Learning Community Making population-based
healthcare a core competency of all Iowa
physicians.
100 E. Grand Ave., Ste. 360 Des Moines, IA
50309-1835 Office 515.283.9330 Fax
515.698.5130 www.ihconline.org
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Overview of IHC
IHC Cornerstones

• Align and Equip Health Care Providers on
  Quality and Value
• Responsible Public Reporting
• Engage the Community for Clinical Improvement
• Raise the Standard of Care in Iowa

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ALC Steering Committee

• Established in 2007
• Developed objectives
• Defined metrics
• Established framework of initiative
• Developed curriculum
• Identified faculty

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ALC Faculty

• Dean Bliss
• Rockwell-Collins internal Lean consultant
• Iowa Health System- PI specialist
• Tom Evans, MD
• Faculty with IHI, UI CPH, DMU
• Past president with IAFP and IMS
• NPSF Board

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ALC Faculty

• Timothy Gutshall, MD
• Family Medicine/Emergency Medicine
• Clinical Coordinator, IFMC
• Don Nelson, MD
• Faculty, Cedar Rapids Family Medicine Res.
• Past member of IMS Board of Directors

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ALC Faculty

• Sarah Pavelka
• Process improvement expert
• Lean consultant
• Mark Purtle, MD
• Vice President Medical Affairs- Iowa Health-DSM
• Faculty, IMMC Internal Medicine residency

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ALC Faculty

• David Swieskowski, MD
• Family Medicine
• VP for Quality at Mercy Clinics
• Board Member, IMS

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Project Overview

• Making population based-healthcare a core
  competency of all Iowa physicians
• Goals
• Create an innovator community
• Prepare for Medical Home
• Prepare for Value-based reimbursement

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Project Overview

• Making population based-healthcare a core
  competency of all Iowa physicians
• Objectives
• Promoted a planned care model
• Engage multidisciplinary office teams
• Develop performance improvement skills
• Promote the use of registries in office
  practices
• Reduce waste and improve clinical performance

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Coming together is a beginning. Keeping together
is progress. Working together is success. -
Henry Ford
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Recruitment
This is hard!

• Partnered with local provider professional
  organizations
• IMS, IMGMA, IAFP, IOMA
• No charge for the ALC
• Offered Continuing Medical Education credits

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Project Structure

• Structure
• Modified IHI Breakthrough Series Model
• 3 Learning Sessions, 2 Action Periods
• Series of conference calls throughout
• Commitment to an all teach/all learn
  environment

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2008 ALC Timeline
March 25, 2008 March 26 June 9
April 8, 2008 May 13, 2008 By June
1, 2008 June 10, 2008 June 11 Sept 22
July 8, 2008 August 12, 2008 Sept
9, 2008 By Sept 15, 2008 September 23, 2008
Learning Session 1 Action Period 1 Conference
Call Conference Call Report Baseline
Data Learning Session 2 Action Period
2 Conference Call Conference Call Conference
Call Report Ongoing Data Learning Session
3 Next year
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Project Description

• What teams were asked to do
• Build a registry
• Critically assess current processes
• Better utilize existing electronic data for
  patient management
• Report clinical data to IHC

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Project Description

• Measure Set- Nationally recognized NQF metrics
• Project Key Measures
• HgA1C
• Microalbumin
• Optional Key Measures
• Blood Pressure
• LDL
• Eye Exams

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Project Description

• Project Key Measures
• 1. Blood sugar (A1c) Testing
• Number of patients with one or more A1c test(s)
• 2. Blood sugar (A1c) Control
• Number of patients with most recent A1c results
  at specified level performed during the
  measurement year
• 3. Microalbumin Testing
• Number of patients with at least one test for
  microalbumin in the measurement year or who had
  evidence of medical attention for existing
  nephropathy

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Project Description

• Optional Key Measures
• 4. LDL Cholesterol Testing
• Number of patients with at least one LDL-C test
  in the measurement year
• 5. LDL Cholesterol Control
• Number of patients with most recent LDL-C
  results at specified level performed during the
  measurement year.
• 6. Eye Exam
• Number of patients who received dilated eye
  exam in the measurement year.
• 7. Blood Pressure Control
• Number of patients with most recent blood
  pressure lt140/80 mmHg during the measurement year.

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Learning Session 1
March 25th, 2008 Getting Started

• 16 multidisciplinary teams from across the
  state
• Average score at project start 1.8
• 8 clinics reported starting at a 1.0 or 1.5
• How to create and use a diabetes registry
• Panel discussion made up of an administrator,
  physician, office manager, and a nurse health
  coach

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Conference Calls
Engagement and additional assistance

• 730 AM to accommodate clinical schedules
• All team members encouraged to attend
• Operational support and sharing of experiences

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Site Visits

• Key Observations
• Physician engagement is imperative to project
  success
• Community coordination (hospital, physician
  clinic, community health center)
• IT can be an obstacle
• Clinics with multiple electronic systems often
  times dont have systems that talk to each
  other
• Competing projects in the clinic limit time
  available for the ALC

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Learning Session 2
June 10th, 2008 Now what???

• Teams brought completed registries with
  baseline data and opportunity reports
• Clinical process improvement discussed
• Plan, Do, Study, Act
• Average score after LS2 2.75

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It isnt hard to be good from time to time.
Whats tough is being good every day. -
Willie Mays
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Using Data
Build a site registry Report clinical data to IHC

• Online data collection tool
• Report at clinic or physician level
• Quarterly reporting

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Using Data

• 13 clinics
• 59 providers
• 3273 diabetic patients

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Using Data
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Using Data
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Learning Session 3
September 23, 2008 All Teach All Learn

• Each team presented on lessons learned
• Average score after LS3 3.2

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ALC Results

• 16 clinics
• Clinic size ranged from 1 provider to 13
  providers

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ALC Results

• Setting up a registry
• Some Electronic Medical Records/Information
  Systems able to transfer the data
• Some clinics had to enter data by hand
• Some off data reports
• Some by sorting through charts
• Is it really worth the time and effort?

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ALC Results

• No single process was promoted.
• Each clinic proceeded in their own direction
• Multiple networking events to exchange
  information
• Presented an opportunity to develop a data base
  of methods No single process will suffice for
  every office.

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ALC Results

• Goal
• Improve the care of patients with diabetes
• Why this one?
• Pay for performance
• Medical Home concept
• A common disorder with established guidelines
  that could provide skeleton for projects for
  other disorders.

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ALC Results

• Taking control of your destiny
• Transparency
• Control of the data
• Improving patient care, especially for chronic
  disorders leading to significant health spending.
  

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ALC Results

• Management of Chronic disorders
• Historically
• Fragmented
• Periodic visits
• Little evaluation of care of the body of patients
  in a particular clinic

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ALC Results

• Management of Chronic disorders
• Near Future
• Transparency Information about each
  practitioners practice will become available
• Continuous Improvement of the care process
• Involvement of other health professionals in a
  team approach to care
• Improvement of coordination of care
  (Patient-centered Medical Home)

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ALC Results

• Essential elements for success
• Physician Champion
• Committed staff assisting in project
• Reliable and accurate information
• Reports showing success
• Setting realistic targets
• Innovation
• Understanding process vs. outcome goals

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ALC Results

• Lessons learned
• Recognizing that chronic conditions managed best
  in a continuous basis and not episodic basis.
• Using guidelines as just that Not requirements
• Limiting the number of elements working to
  improve at any one time
• For any process improvement, must demonstrate
  outcome improvement results

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ALC Results

• Lessons learned
• Collaboration
• Consider clinic wide measures before individual
  practitioners
• Consider single practitioner first before every
  practitioner to refine process
• Realize that compliance is always an issue-so
  cant expect perfect results
• Make the patient a partner

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ALC Results

• Lessons learned
• Use literature and experience to identify reasons
  for non-compliance and attack
• Benchmarking
• Running out of momentum
• Newspaper article
• Using lab source for data
• Assuring all included

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ALC Results

• Lessons learned
• Creating competition
• Physician attribution
• Small office where the reception/office person
  was the main force
• Using procedures in a residency
• Im not doing as well as I thought!

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Whats Next?
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Contact Information
Kyla Kiester Project Manager kiesterk_at_ihconline.or
g 515-283-9332
Malcolm Findlater, MD Chief Medical
Officer mfindlater_at_marengohospital.org