Community Clinics Initiative: Home Improvements in California Community Health Centers

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Community Clinics Initiative Home Improvements
in California Community Health Centers

• Kevin Grumbach, MD
• Department of Family
• and Community Medicine
• UCSF

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The Primary Care Home
First Contact
Comprehensive
Longitudinal
Coordinated
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Primary-Care Score vs Outcome Indicators
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?USA
10
?GER
?BEL
8
?AUS
Primary care score ranking
?SWE
?CAN
6
?SP
4
?FIN
DK?
?NTH
2
?UK
1
8
9
6
4
3
2
10
7
5
Lower scores are better
Health System Outcome Indicator Score
Source Starfield. Lancet 19943441129
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Source Baicker Chandra, Health Affairs, April
7, 2004
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Source Baicker Chandra, Health Affairs, April
7, 2004
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(No Transcript)
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Problems in Clinical Performance

• 27 of patients with HTN adequately controlled
• 54 of diabetics have Hgb A1c gt 7.0
• 14 of patients with CHD have LDL levels in
  targeted range
• Half of smokers counseled about smoking cessation
  by their physician

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Long waits to get an appointment with my regular
doctor is a problem (among patients in poor
health)
Source Commonwealth Fund Survey 2002 Blendon,
Health Affairs 22(3), 2003
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Positions
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Across the globe doctors are miserable because
they feel like hamsters on a treadmill. They must
run faster just to stay still. Morrison and
Smith, BMJ, 20001
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Have Sufficient Time with PatientsCalifornia
Primary Care Physicians
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Mean Length of Physician Office Visit in the US
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Growing DemandsChronic Illness
Time Required to Deliver All Highly
Recommended Chronic Care Services 10.6
hours/day Yarnell, Ann Fam Med, 2005
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Growing DemandsPreventive Services
Time Required to Deliver All Highly
Recommended Preventive Services
7.4 Hours per Working Day
Yarnall et al. AJPH, 2003
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Growing DemandsMedicalization
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Institute of Medicine2001
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System ProblemNeeding Systems Solution

• IOM Redesign Imperatives
• Reengineered care process
• Effective use of information technologies
• Knowledge and skills management
• Development of effective teams
• Coordination of care over patient conditions,
  services, sites of care over time

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A 20th Century Model of Primary CareWill Not
Meet the Demands of 21st Century Health Care
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Future of Family Medicine Report, 2004American
College of Physicians Report, 2006 point the
way to a proposed new model of practice for
family medicine

• http//www.annfammed.org/content/vol2/suppl_1/

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New Practice Models Examples of Primary Care
Redesign

• Planned Chronic Care Model
• EHealth
• Teams
• Scheduling

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The Chronic Care ModelEd Wagner, McColl Institute

• Community Resources
• Health Care Organization
• Delivery System Redesign
• Self-management Support
• Clinical Information Systems
• Decision Support

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EHealth and Medical Informatics

• Electronic health record
• Communication
• Knowledge base and decision support

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Key Elements of Team Building

• Defined goals
• Systems
• Clinical
• Administrative
• Division of labor
• Definition of tasks
• Assignment of roles
• Training
• Communication

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Efforts to Enhance Accessibility

• Same day/Open access scheduling
• Email, Web (My Chart)

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Assets and Challenges for Primary Care Redesign
in CHCs

• Organization and systems
• Multidisciplinary
• Critical mass
• Resource constraints and payment issues
• Vulnerable populations

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Case Study SFGH Family Health Center

• FQHC on SFGH campus
• County administered, UCSF staffed
• Teaching site
• 40,000 visits annually
• 60 providers, all part-time
• FM residents
• FM attendings
• NPs, Pharm Ds

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Faculty RetreatYear of the Clinic
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Chronic Condition Prioritized

• Diabetes

• Cardiovascular Disease

• Chronic Pain

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Obtaining a Triplicate Refill in FHC
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The Team Huddle
FHC
FHC
FHC
FHC
FHC
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Swiss Clocks
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How can change be created in complex adaptive
organizations?
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Improvement is Possible!