Improving Health Outcomes by Linking the Clinic to the Community

1. Improving Health Outcomes by Linking the Clinic to the Community Thomas Sequist, MD MPH

2. What you have heard about US health care • Poor quality • Costly

3. Improving Chronic Care Outcomes AHRQ National Quality Report 2012

4. Atrius Health • Non-profit alliance of six leading independent medical groups • Granite Medical • Dedham Medical Associates • Harvard Vanguard Medical Associates • Reliant Medical Group • Southboro Medical Group • South Shore Medical Center • Providing care for ~ 1,000,000 adult and pediatric patients with 1000 physicians, 1450 other healthcare professionals across 35 specialties .

5. Atrius Health • 100% on an electronic medical record combined with corporate data warehouse, used for managing quality and cost. • Long history with global payments: close to 50% of patients under global risk across Commercial, Medicare and Medicaid • Widespread use of rosters in population management • Track record of quality measurement and reporting • All adult primary care sites accredited as NCQA Level 3 Patient Centered Medical Homes

6. Harvard Vanguard Medical Associates • Multi-specialty group practice • 17 ambulatory health centers • 400,000 adult patients • 175 primary care physicians

7. HVMA Diabetes Care Model • Clinical Information Systems • Electronic medical record • Computerized alerts • Population Management • Centralized patient mailings • Patient Engagement • Primary care teams • Diabetes dashboards • Chronic disease visits Improved Diabetes Care

8. Baseline Racial Disparities

9. Panel Diversity and Disparities in LDL Control Median = - 8.0% IQR = -6.9% to -9.4% p = 0.84 Sequist; Arch Intern Med 2008

10. The “Not Me” Phenomenon Do racial disparities in diabetes care exist in…. Sequist; JGIM 2008

11. Intervention Components • Cultural competency training • 1 to 2 day course (89% team attendance) • Monthly educational materials • Clinical performance feedback • Monthly distribution • Race-stratified (HbA1c<7%, LDL < 100, BP < 130/80) • Provider level (benchmarked to practice)

12. Sample Performance Report

13. Patient Survey Feedback

14. Impact on Clinician Awareness Do racial disparities in diabetes care exist in…. P=0.003 P=0.02 P=0.04

15. Clinician Support for Intervention How effective are these strategies to reduce racial disparities? P=0.01 P=0.02

16. Clinician Views on Disparities “Even though their diabetes might be under horrendous control, it wasn’t the top thing on life’s list. You know they might have a kid in jail, or they might have been in the midst of an eviction proceeding or others are at risk of losing their jobs. There were a lot of other topics that were higher on their list than their HbA1c of 13” I think that I feel very overwhelmed by this whole kind of concept because in many respects I think that a lot of this is very, very difficult to change because of what happens outside of these four walls.

17. Clinician Views on Reports Well it was an initial kind of negative feeling, you know, like I’m failing in these particular situations. But then there was a feeling of, well these are the things that we’ve really got to focus on so we’re just going to have to pull this apart and try and focus on these things. It’s just not useful information. I see very little that I have accessible at my disposal to make any impact on it, and telling me that it's there, it changes or doesn't change, seems to be random and have absolutely nothing to do with what I personally do or can do.

18. Views on Cultural Competency Training • Feeling that training educated on history of racism, trust, and bias • Helped them to explore these concepts in clinical setting “You know I never knew there wasn’t a grocery store [there], I felt so stupid, but now I understand…”

19. Where Does this Leave Us? • Address social determinants • Address built environment • Systematic approach? The 15 minute office visit will not be enough

20. Toward A Rational Process Ideal State Recognition/ ownership of issues Quality of Primary Care – Community Interface Primary care resources Identifying community resources and partners Payment models Current State Integration of care plans

21. Different Viewpoints Medical Clinic Advantages: Access to health indicators Direct management of services Disadvantages: Piecemeal interactions Lack of broader context Focus on medical management Public Health Advantages: Focus on communities Contextual approach Disadvantages: Lack clinical context No integration into care plans Multiple constituents

22. Our Roadmap • Change measurement paradigm • Allow clinicians to view communities • Target communities for action • High disease prevalence • Poor quality • High penetration • Identify successful strategies • Positive outliers and trajectories • Resource catalogue • Clinical integration • Clinician liaison • EHR tools

23. Our Barriers • Traditional performance focus on clinicians • Clinician sphere of responsibility • Systematic approach to community partnership • Health center resources

24. Community Base Performance Measurement