Care Coordination and Interoperable Health IT Systems

1. Care Coordination and Interoperable Health IT Systems Unit 2: Team-based Approach to Patient Care Lecture c – Evidence-based Clinical Practice This material (Comp 22 Unit 2) was developed by The University of Texas Health Science Center at Houston, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0006. This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-sa/4.0/.

2. Team-based Approach to Patient CareLearning Objectives • Objective 1: Identify best-practice types of team-based interventions (Lecture a) • Objective 2: Describe key elements for transforming to team-based care (Lecture a) • Objective 3: Plan for transformation to team-based care (Lecture b) • Objective 4: Identify evidence-based clinical practice guidelines resources (Lecture c)

3. A Change Plan for Team-based Care Transformation • No one, proscriptive approach • General guidance needs to be applied to your context • Plan phases of assessment and reassessment through transformation to a collaborative team-based care model

4. A Change Plan for Team-based Care Transformation (Cont’d – 1) • Phases should include: • Opportunities for gap analysis • Milestones measurement • Examination from baseline to current milestones progress, monitored and tracked for optimum adaptation during the transformational change process • Refer to Component 18, Unit 10 for more information on Change Management

5. A Change Plan: Assessment Phase • Assesses collaborative team leadership and team roles and responsibilities • Establishes a baseline related to: • Team-based care key elements • Standards and criteria defined in the patient-centered medical home team-based care models

6. A Change Plan: Assessment Phase (Cont’d – 1) • Assessment allows leadership to aim and prioritize: • Where to most easily begin transformation that will yield the highest results • How to gain early momentum and team experience satisfaction

7. A Change Plan: Measurements & Gap Analysis • Planned measurement and gap analyses reveals when, where, and how to analyze and adapt plans to efficiently move towards establishing high-functioning, team-based care

8. Considering Health IT Systems • Systems technology provides: • Opportunities for identification and prioritization of managing clinical conditions • An emphasis on managing population health, wellness promotion, disease prevention, chronic disease management, and patient activation and engagement

9. Opportunities for Health IT Systems • Properly designed health information technology systems improve opportunities for: • Predictive modeling • Risk assessment • Patient population stratification

10. Health IT and High-risk Populations • Analyzing data can identify and prioritize the patient population or provider panel with the highest stratification of most needs and most increasing needs for health care utilization

11. Parameters for High-risk Patients • Patients have: • Three or more chronic diseases • Poorly controlled chronic diseases • Demonstrated difficulty with care recommendations and compliance • Three or more hospitalizations and / or emergency department visits in the past year • Identified high health care cost and services utilization according to health plan or payer historical data • Risks associated to social determinants of health (SDOH)

12. Interventions Targeting Chronic Disease • The most common chronic diseases worldwide are: • Heart disease • Stroke • Diabetes • Asthma • Cancer • Chronic obstructive pulmonary disease (COPD)

13. Interventions Targeting Chronic Disease (Cont’d – 1) • Common, modifiable risk factors that can benefit from team-based intervention: • Unhealthy diet • Physical inactivity • Tobacco use • Refer to Component 21 for more information on Population Health and Health IT Systems

14. Utilization of Clinical Care Pathways or Evidence-based Clinical Practice Guidelines • Using evidence-based clinical guidelines, primary care providers can: • Experience degrees of apprehension related to evidence-based guidelines (EBG), creating a “cookbook approach” to clinical care • Discuss, agree upon, and choose their own evidence-based guidelines and measures

15. Primary Care Physicians (PCPs) • PCPs use evidence-based guidelines: • Embedded in electronic health record systems • Establish standardization of care • Support individualized interaction with patients • Create time for PCPs for individual clinicals • Rest of team attends to the more minimal standards of care

16. Primary Care Physicians (Cont’d – 1) • Develop protocols and guidelines to delegate authority and responsibility to teams • Integrate decision-support mechanisms • Reduce fragmentation, improve safety and quality outcomes • Use data-driven measurement for decision-making and management

17. Evidence-based Clinical Practice Guidelines Resources • Institute for Clinical Systems Improvement • Michigan Quality Improvement Consortium • American College of Physicians (ACP) • US Preventive Taskforce • NQF Diabetes • American Diabetes Association (ADA) • American Association of Clinical Endocrinologists (AACE)

18. Evidence-based Clinical Practice Guidelines Resources (Cont’d – 1) • Centers for Disease Control and Prevention • Canadian Task Force on Protective • National Heart, Lung and Blood Institute (NHLBI) • American College of Cardiology (ACC) • Agency for Healthcare Research and Quality (AHRQ) U.S. Department of Health and Human Services National Guideline Clearinghouse • Agency for Healthcare Research and Quality (AHRQ) U.S. Department of Health and Human Services Innovations Exchange

19. Unit 2: Team-based Approach to Patient CareSummary – Lecture c – Evidence-based Clinical Practice • A change plan for team-based care transformation requires planning phases of assessment and reassessment • Properly designed health IT systems hold potential • The primary care physicians (PCPs) can utilize evidence-based clinical practice guidelines • There are variety of evidence-based clinical practice guidelines resources available

20. Unit 2 Summary: Team-based Approach to Patient Care • Team-based care is a proven, preferred model • Foundational elements for successful transformation to team-based care are leadership, communication, and teamwork • There are various recognized resources for evidence-based guidelines

21. Unit 2: Team-based Approach to Patient CareReferences – Lecture c References 508. (n.d.). Retrieved April 12, 2016, from http://www.qualityforum.org/Measures_List.aspx#k=diabetes Canadian Task Force. Retrieved March 08, 2016, from http://canadiantaskforce.ca/ Centers for Disease Control. (2015, January). Overview of Chronic Disease Indicators. Retrieved March 08, 2016, from http://www.cdc.gov/cdi/overview.html AHRQ Health Care Innovations Exchange. Retrieved March 08, 2016, from http://www.innovations.ahrq.gov/index.aspx Archived: Diabetes Mellitus (Type 2) in Adults: Screening. (n.d.). Retrieved March 08, 2016, from http://www.uspreventiveservicestaskforce.org/uspstf/uspsdiab.htm Guidelines. (n.d.). Retrieved March 08, 2016, from https://www.acponline.org/clinical_information/guidelines/guidelines/ Guidelines - American College of Cardiology. (n.d.). Retrieved March 08, 2016, from http://www.cardiosource.org/science-and-quality/practice-guidelines-and-quality-standards.aspx Guidelines & More. (n.d.). Retrieved April 12, 2016, from http://www.icsi.org/guidelines__more/ Handelsman, Y., Bloomgarden, Z. T., & Grunberger, G. (2015). American College of Endocrinology—clinical practice guidelines for developing a diabetes mellitus comprehensive care plan—2015. EndocrPract, 21(Suppl 1), 1-87

22. Unit 2: Team-based Approach to Patient CareReferences – Lecture c (Cont’d – 1) References MQIC Guidelines. (n.d.). Retrieved March 08, 2016, from http://www.mqic.org/guidelines.htm NGC is a public resource for evidence-based clinical practice guidelines. (n.d.). Retrieved March 08, 2016, from http://www.guideline.gov/ Standards of Care. (n.d.). Retrieved March 08, 2016, from http://professional.diabetes.org/content/clinical-practice-recommendations Systematic Evidence Reviews and Clinical Practice Guidelines. (n.d.). Retrieved March 08, 2016, from http://www.nhlbi.nih.gov/guidelines/index.htm

23. Unit 2: Team-based Approach to Care Coordination Lecture c – Evidence-based Clinical Practice This material was developed by The University of Texas Health Science Center at Houston, funded by the Department of Health and Human Services, Office of the National Coordinator for Health Information Technology under Award Number 90WT0006.