Challenges of Sustaining, Scaling, and Spreading Innovations in Cardiovascular Care

1. Challenges of Sustaining, Scaling, and Spreading Innovations in Cardiovascular Care AHRQ Annual Meeting Session 34, Track C Sept. 10, 2012

2. Session Goals • To share two heart health innovations from the Health Care Innovations Exchange • To consider how organizations might explore adoption of these and similar innovations

3. Heart Health Focus • National Quality Strategy • Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease • Million HeartsTM Campaign • National initiative to prevent 1 million heart attacks and strokes over five years. • millionhearts.hhs.gov

4. Agenda • Introduction • Judi Consalvo, AHRQ • Language Concordant Health Coaches Innovation • Hali Hammer, San Francisco General HospitalFamily Health Center • Heart360® Innovation • David Magid, Kaiser Colorado • Activity: How Can I Implement This Innovation? • Veronica Nieva, Westat

5. What Is the Health Care Innovations Exchange? Goal: To accelerate sharing of innovations and online tools to improve health care services and reduce health care disparities. Components of the Exchange: The Web site: innovations.ahrq.gov Learning and Networking Activities

6. What Is the Health Care Innovations Exchange? Web site features profiles of successful and attempted innovations and practical tools Service Delivery Policy Learning and Networking Webinars Meetings to promote spread Videos

7. The Innovations Exchange • Visit our Web site: innovations.ahrq.gov/ • Follow us on Twitter: #AHRQIX • Send us email: info@innovations.ahrq.gov

8. Health Coachesas Members of the Health Team Hali Hammer San Francisco General Hospital, Family Health Center

9. San Francisco General HospitalFamily Health Center Hospital-based full scope family medicine clinic Part of the San Francisco Department of Public Health’s primary care network Participating in access and quality improvement initiatives as part of the 1115 California Medicaid Waiver (CMS Incentive Program), which ties federal funding to milestones, including PCMH standards (team-based care, clinical outcomes) 10,700 patients served; 1500+ adults with diabetes 50,000+ patient visits per year Teaching clinic: 41 family practice residents and many medical and nursing students Diverse patient population 42% Latino, 26% Asian, 14% Caucasian, 12% African American 51% Medicaid, 33% uninsured (almost all enrolled in Healthy San Francisco), 15% Medicare 31 different languages spoken 48% English, 30% Spanish, 9% Cantonese/ Mandarin

10. Description of health coaching at the SFGH Family Health Center Health Coaches are members of the health care team who provide self-management support to a stable panel of patients with chronic illness (in our setting, primarily diabetes). Health Coaches: • are language-concordant with all their patients • are trained in motivational interviewing, panel management, diabetes basics, and medication adherence • work collaboratively with a patient’s Primary Care Provider, unlike promotoras or community health workers in other settings • are primarily in the job classification “Health Worker,” but may also be Medical Assistants, pre-medical students, trained peers.

11. Description of health coaching at the SFGH Family Health Center The Health Coach role includes: Self management support supporting their patients to have the knowledge, skills, and confidence to become active participants in their care Bridge clarifying information provided by the provider, pharmacy, or insurance company bridging cultural/ linguistic gaps Clinical continuity following patients who are in their continuity panel, with a goal to maximize continuity between patient and health coach Emotional support language- and often cultural-concordance enhances trust and engagement in learning how to self-manage the chronic illness Clinical Navigation Health Coaches may be more accessible because they are in clinic every day and can be the primary clinic contact person for patients throughout the week help with making and keeping appointments, accessing pharmacy and other services

12. Health outcome measures for a population of patients working with Health Coaches

13. Costs associated with health coaching Health Coach program cost considerations Salary ($58,000 per year in our setting, which is 44% of an RN) A full time Health Coach can manage a patient panel of 200 patients Physician or Nurse Practitioner supervision (approximately 5% time) Training costs (6-8 sessions) Must consider how Health Coaches are assigned and interface with other members of the care team (i.e. case managers, social workers)?

14. Factors to consider in the business case for health coaching Who provides self-management support and education in a traditional primary care visit? What is the most cost-effective and efficient way to provide this important component of chronic illness care? Health coaching may be the answer. Family Community Assessment of medication adherence, education, self- management support, phone follow-up (between-visits) Review of symptoms, diagnosis, medications, addressing urgent problems Patient Post-visit Visit Pre-visit Provider Health Coach Team huddle or other communication Communication about medical and psychosocial issues, goals of care, medication problems

15. Factors to consider in the business case for health coaching • The business case for Health Coaching relies on showing that it decreases long-term complications, hospitalizations, and emergency department use. • Self-management support does improve health outcomes in patients with chronic illness. • So, the question for health care organizations is: who should provide the self-management support? • The answer is based on the payer mix for the organization, as well as staffing costs. • In our organization, Health Coach salaries are approximately 36% of physicians and 44% of registered nurses. • Health coaching can be done effectively by a non-licensed, trained member of the staff under appropriate supervision.

16. Lessons learned in scaling and spreading • Health coach resources should be allocated to patients at highest risk of poor outcomes if they are not able to self-manage their chronic illness. In our setting, we targeted diabetic patients with hgbA1c > 8. • Highest risk patients may also be most in need of emotional support: Health Coaches must be trained to place limits on patients so that coaching is possible. • Communication, a patient’s perception of access, and self-management education are best provided by trained staff who speak the patient’s language. • Other health coaching models which use RNs include the added roles of medication adjustment by protocol and symptom assessment; we prioritize self-management support and medication adherence education, which can be provided by an unlicensed coach.

17. Plans for scaling and spreading Capitation (instead of fee-for-service reimbursement) allows providers to prioritize outcomes and satisfaction. As reimbursement is increasingly tied to improved patient outcomes, team-based approaches to chronic illness care will be feasible for more organizations. Primary care workforce issues have also shed light on the increasing pressures and low job satisfaction among a decreasing pool of primary care providers. Engaging other members of the team to take on time-consuming, non-medical tasks, such as self-management support, may improve satisfaction and make primary care more sustainable. With funding incentives through the CMS Incentive Program / Medicaid Waiver, we will be able to expand health coaching if we continue to show improvement in patient care and access.

18. Heart360® David J. Magid Insitute for Health Research Kaiser Permanente Colorado

19. Rates of Hypertension Control in the U.S. are Low • Benefits of hypertension therapy • 25% reduction in heart attack • 40% reduction in strokes • 50% reduction in heart failure • NHANES (2005-2008) • Treatment 70% • Control 46%

20. Focus Groups Kaiser Colorado Clinics • Controlling my BP is critical • Office visits are inconvenient and time-consuming • Using a home BP cuff is appealing

21. Provider Meetings Kaiser Colorado Clinics Providers Supportive

22. Home BP Monitoring supported by Pharmacists and Heart360®

23. Research Question For patients with hypertension, is a clinical pharmacy specialist-led Heart360®home BP monitoring program (HBPM) more effective than usual office-based care?

24. Study Setting

25. Study Population Uncontrolled HTN Usual Care HBPM-Heart360® Initial visit Initial visit Referral To PCP Home BP monitoring • six month follow-up visit

26. Monitoring Protocol

27. Results

28. HBPM Patients Had Superior 6-month BP Control 57% 37% Usual Care HBPM RR = 1.5 (1.2-1.9); p < 0.001

29. Heart360® HBPM Group Had a Greater Drop in Systolic BP Usual Care HBPM Mean BP drop (mm Hg) P <0.001

30. Heart360® HBPM Patients Reported Greater Satisfaction with Care Very to Extremely Satisfied P <0.001

31. What are the cost implications for Heart360® HBPM? • Intervention Costs • CV Events Prevented • Cost of Events Prevented

32. Cost Benefit over 10 Years

33. Implementation Barriers • Cost of BP cuffs • Need for computer and internet • Capitation vs. Fee for Service

34. Translation to Routine Practice: A Tale of Two Regions KaiserColorado KaiserSouthernCalifornia

35. KP Colorado • Enthusiastic response to presentations to health plan leaders and stakeholders • Initially little movement towards adoption in routine clinical practice • Turnover in clinical champion • Change in organizational priorities • Limited bandwidth • Lack of sponsorship • Director of Pharmacy Department stepped forward to sponsor rollout • Currently working toward broader implementation

36. KP Southern California • Enthusiastic response to presentations to health plan leaders and stakeholders • Movement towards adoption • Stable clinical champion - > 20 years • Organizational priority – improve efficiency • Sponsorship by Associate Medical Director • Current Plans • Pilot at 2 medical centers • Subsidize cost of cuff, consider BP cuff library • Existing infrastructure to support rollout

37. Lessons Learned • Clinical champion • Sponsorship • Organizational priorities • Bandwidth

38. Q&A

39. Activity How Can I Implement This Innovation in My Organization?