Disease Management: Proactive vs. Reactive Reengineering for success

1. Disease Management:Proactive vs. Reactive?Reengineering for success Maureen O Padden MD MPH CDR MC USN (FS)

2. The Reality of Healthcare Today: We must move from a health care system that manages already rampant disease�.�to one that is founded in preventing disease to begin with

3. How many of you are aware of Business Planning? Have you been involved? Are they AWARE a business plan exists? Have any of them been involved in the planning? What is their understanding of the business plan and the part that disease management plays in the business plan.Are they AWARE a business plan exists? Have any of them been involved in the planning? What is their understanding of the business plan and the part that disease management plays in the business plan.

4. Setting the Stage BUMED Business Plan mandates implementation of disease management Diabetes performance metrics identified Modest expectations: HEDIS HbA1C, LDL MTF Performance��Whole Goals� Population Health Navigator (PHN) the accepted information source Diabetes Action Team (DAT): Accepted the DOD VHA Diabetes CPG & Toolkit Drive home that BUMED requires each MTF to develop a business plan that has uniform elements such as 1) Improved access 2) Budget neutral (Manage your capitated budget well!) 3) High quality care 4) Internal and external customer satisfaction 5) Highly productive (RVU�s, Value of care, Operating margin) Dec 2004 BUMED Note 6310: Commands must establish disease management programs for diabetes, asthma and breast health care. Must have a champion, identify populations. Goals are to be aware of diabetics with HbA1C > 9.0% and when our patients go to the ER. Note can be found at: https://dataquality.med.navy.mil/community/default.aspx Drive home that BUMED requires each MTF to develop a business plan that has uniform elements such as 1) Improved access 2) Budget neutral (Manage your capitated budget well!) 3) High quality care 4) Internal and external customer satisfaction 5) Highly productive (RVU�s, Value of care, Operating margin) Dec 2004 BUMED Note 6310: Commands must establish disease management programs for diabetes, asthma and breast health care. Must have a champion, identify populations. Goals are to be aware of diabetics with HbA1C > 9.0% and when our patients go to the ER. Note can be found at: https://dataquality.med.navy.mil/community/default.aspx

5. False Assumptions Simply providing a CPG changes practice MTFs have clinic processes that optimize disease management There is no more work to be done in disease management at our facilities It is easy to implement change in our MTFs The rest of our discussion will be based upon you accepting a few things: Simply putting a CPG in providers mailboxes wont change practice and wont improve patients care. There is more to it than that. Commands must take a critical look at how they do business and reengineer their processes to achieve the outcomes they want. For instance, not waiting until patients decide to come in�rather, contacting them when they have not been seen within a specified period of time and bringing them in for needed and overdue care. The road map is a tool to help you analyze all the various parts of your clinical business processes to recognize areas you may not initially be aware of. It helps you to bring the stakeholders together to the table to figure out the roles of the various team members and how they can work together to achieve improved outcomes especially on the measured metrics. Through originality, some commands may find innovative process improvements that can be shared.The rest of our discussion will be based upon you accepting a few things: Simply putting a CPG in providers mailboxes wont change practice and wont improve patients care. There is more to it than that. Commands must take a critical look at how they do business and reengineer their processes to achieve the outcomes they want. For instance, not waiting until patients decide to come in�rather, contacting them when they have not been seen within a specified period of time and bringing them in for needed and overdue care. The road map is a tool to help you analyze all the various parts of your clinical business processes to recognize areas you may not initially be aware of. It helps you to bring the stakeholders together to the table to figure out the roles of the various team members and how they can work together to achieve improved outcomes especially on the measured metrics. Through originality, some commands may find innovative process improvements that can be shared.

6. Wagner Model Exemplifies how teams can have an impact Framework for examining the disease management process Recognizes that several areas of clinical practice must be optimized for �excellence� Steps beyond the CPG �quick fix� Stresses practice redesign, patient education and expertise of providers Ed Wagner at Group Health in Seattle is probably one of the most knowledgeable researchers where disease management is concerned. He has published a model to examine the disease management process, this model and his work being the foundation for the creation of the road map. This model, and the roadmap recognize that there are discreet areas of clinical practice that must be optimized to achieve excellence in disease management.Ed Wagner at Group Health in Seattle is probably one of the most knowledgeable researchers where disease management is concerned. He has published a model to examine the disease management process, this model and his work being the foundation for the creation of the road map. This model, and the roadmap recognize that there are discreet areas of clinical practice that must be optimized to achieve excellence in disease management.

7. Addresses OBJ #1 & #3 Ed Wagner�s ModelAddresses OBJ #1 & #3 Ed Wagner�s Model

8. Disease Management �Best� programs incorporate elements of Wagner model Certain aspects of care are delegated Elements Population management Clinical practice guideline Self-management support Intensive follow up

9. BUMED MTF Road Map for Disease Management Based on the Wagner Model Assists teams to consider how they might redesign their practices to optimize disease management Requires multidisciplinary approach from various stakeholders to be most effective Now used by the MedIG team as well

10. �Clinician Basics� Familiarize providers and team with CPG, BUMED metrics and sources of data Carefully define team member roles as clinical business process is redefined Ensure providers have the knowledge necessary to execute high quality care Timely and regular feedback to providers regarding their performance is paramount Addresses OBJ #1 The accepted CPG for diabetes management in the Navy is the DOD/VHA CPG. This decision was recommended to BUMED by the Diabetes Action Team. When reviewed, it showed better evidence based content than both the ADA standards of care and the American Association of Clinical Endocrinologists (AACE) guidelines. Though many of the recommendations of the CPG are modest, one has to start somewhere and this is the minimum recommendation for care. Of course, providers can always elect to be more stringent in their targets for their patients. BUMED Metrics: Patients with HBA1C > 9.0% Patients with LDL < 100 mg/dl Official data source for the Navy is Population Health Navigator. Show providers where they can get timely and accurate data concerning their diabetics, then give them regular feedback regarding their performance on metrics of concern. Addresses OBJ #1 The accepted CPG for diabetes management in the Navy is the DOD/VHA CPG. This decision was recommended to BUMED by the Diabetes Action Team. When reviewed, it showed better evidence based content than both the ADA standards of care and the American Association of Clinical Endocrinologists (AACE) guidelines. Though many of the recommendations of the CPG are modest, one has to start somewhere and this is the minimum recommendation for care. Of course, providers can always elect to be more stringent in their targets for their patients. BUMED Metrics: Patients with HBA1C > 9.0% Patients with LDL < 100 mg/dl Official data source for the Navy is Population Health Navigator. Show providers where they can get timely and accurate data concerning their diabetics, then give them regular feedback regarding their performance on metrics of concern.

11. Disease Management Models Two different approaches: Carved in model Carved out model Choice of a model should be individualized Practice style of providers Needs / demands of patients Resources available at the MTF Addresses OBJ #2 We will now discuss two distinct models of disease management. Again, choice should be dictated by your patients, your providers, and the resources available. There is no one size fits all remedy.Addresses OBJ #2 We will now discuss two distinct models of disease management. Again, choice should be dictated by your patients, your providers, and the resources available. There is no one size fits all remedy.

12. Carved-in Model Disease management is incorporated into Primary Care Team function Multidisciplinary team attends to various aspects of care Provider is supported with tools to ensure that patients receive high quality care �Right person delivers the right care� in a familiar environment Addresses OBJ #1 & #2 Carved in model builds the program around the primary care provider, with the team supporting the provider in provision of care to diabetics. Each member has a distinct, clarified role. That which requires the providers expertise should be accomplished by him�everything else should be delegated to the member of the team who is most appropriate to accomplish the task. Addresses OBJ #1 & #2 Carved in model builds the program around the primary care provider, with the team supporting the provider in provision of care to diabetics. Each member has a distinct, clarified role. That which requires the providers expertise should be accomplished by him�everything else should be delegated to the member of the team who is most appropriate to accomplish the task.

13. Carved-out Model Disease management is carved out from primary care team Separate disease management �teams� attend to that aspect of care Many HMO�s have favored such models Primary Care Team must maintain contact Specialized team can focus on high risk disease management Addresses OBJ #1 & #2 Carved out model removes responsibility for the care of the patients from the primary care manager to a specialized team designated to provide that aspect of care. For example, a clinic might choose to form a diabetes clinic within or even outside their clinic and refer all patients to that clinic for that segment of their care. Such clinics could be run by nurses, pharmacists or subspecialists and typically are multidisciplinary in nature. Many HMOs have favored such models. One concern is that the PCM often gets no feedback about this segmented care and is left out of the process. Such programs have also been criticized for taking money away from other primary care processes. Addresses OBJ #1 & #2 Carved out model removes responsibility for the care of the patients from the primary care manager to a specialized team designated to provide that aspect of care. For example, a clinic might choose to form a diabetes clinic within or even outside their clinic and refer all patients to that clinic for that segment of their care. Such clinics could be run by nurses, pharmacists or subspecialists and typically are multidisciplinary in nature. Many HMOs have favored such models. One concern is that the PCM often gets no feedback about this segmented care and is left out of the process. Such programs have also been criticized for taking money away from other primary care processes.

14. Carved-in versus Carved-out Which do you think is better? The answer lies in which is a better fit for the culture of your MTF and patient population. Which is better, r/t your MTF culture, capability, etcWhich is better, r/t your MTF culture, capability, etc

15. Patient Compliance �The extent to which a person�s behavior coincides with medical or health advice� Addresses OBJ #3 Need to reframe the patient compliance issue and understand what we are really talking about. Addresses OBJ #3 Need to reframe the patient compliance issue and understand what we are really talking about.

16. The problem with compliance... Gives no credence to the patient�s role Implies patients simply follow directions Adherence is a better term Characterizes patients as intelligent, independent Encourages active and voluntary role Patients help to define and pursue goals Adherence assumes patients to be equal partners Addresses OBJ #3 Elicit audience participation (so we can say �Good point/example!) Addresses OBJ #3 Elicit audience participation (so we can say �Good point/example!)

17. Successful Disease Management Partnership between provider and patient Self-regulation changes patients behavior and improves health status Patient should be their own Primary Care Manager (PCM) Provider assists in establishing the best therapeutic plan for the individual patient The team adjuncts their support Addresses OBJ #3 We can add to the last bullet, that the provider establishes the best plan for the individual patient and the TEAM then adjuncts their support�.. Addresses OBJ #3 We can add to the last bullet, that the provider establishes the best plan for the individual patient and the TEAM then adjuncts their support�..

18. The Highly Trained PCM Team Highly trained PCM teams are powerful: Reduce unnecessary and costly ER visits Limit specialty consultation to those cases needing their expertise Learn how to provide the care they have overlooked, deferred or referred in the past Improve health outcomes for their patients Seek information from important liaisons such as Tricare to continually improve care Addresses OBJ #1 I would also add the highly trained team should find out who the TRICARE Contract liasion is and request data be provided r/t ER useage, and other relevant reports, like �cost of care data� (they either can access this or point to who in the MTF can, per contract MOU) Addresses OBJ #1 I would also add the highly trained team should find out who the TRICARE Contract liasion is and request data be provided r/t ER useage, and other relevant reports, like �cost of care data� (they either can access this or point to who in the MTF can, per contract MOU)

19. Disease Management Chronic Diseases such as Diabetes consume a large fraction of healthcare $ Early management and prevention of costly complications is ideal How do you manage patients with chronic diseases such as Diabetes, Asthma and Heart Disease? Are you proactive or reactive?

20. If You Could Set Up the Ideal Disease Management Process�What Would It Look Like? A Case Study in Diabetes

21. Regular visits Prevention of complications of chronic disease requires regular visits How do patients access care in your facility? Do you wait for them to call for an appointment on their own? Consider developing a mechanism to contact patients with high cost medical issues to ensure they come in regularly

22. Clerk Calls Patient Due Care

23. Clerk has standing orders

24. Patient arrives for appointment Checks in at front desk Insurance and address verified in computer system Team member sees that the patient�s appointment is for �diabetes follow up� Clerk has standing orders: Patients following up for diabetes complete standard questionnaires

25. Corpsman or Nursing Staff Places patient in exam room Takes vital signs Reviews medication list Inquires regarding tobacco and alcohol use / desire to quit Patient removes shoes. Nurses are trained to do the foot exam Inquires regarding Influenza, Pneumovacc, daily aspirin and other prevention strategies Takes an initial history to see how the patient has been doing

26. Time with the Provider Reviews already resulted labs Focuses discussion on achieving: Glycemic control Lipid control Blood pressure control Use of daily aspirin Recommends course of action / change in medications to achieve these goals Addresses primary care concerns The other team members contributions allow him to focus on those areas that require his expertise

27. No missed opportunities Nurse returns prior to patient departure and provides immunization if the patient is due for: Pneumovax Influenza Tetanus

28. Check Out With Clerk Patient directed to check out with clerk before leaving the clinic Follow up appointment made for next visit in 1-3 months Any needed consults per provider are entered Patient directed to lab if additional blood work is needed

29. Clinic Appointment Cards(Front)

30. Appointment Card(Back)

31. Lab and Pharmacy Pt picks up any new medications or refills Any additional blood work is drawn by the lab Pt is notified prior to going home that blood work for next visit is already ordered and she can come in a week before her appointment to have it drawn

32. Informed Patient on the Team Knows what is expected Has his targets Has an appointment More likely to engage

33. If Patient Doesn�t Show Up? Process Starts Over Jim notes that patient missed the appointment Calls patient to reschedule

34. Keys to Successful Disease Management Prepared, Proactive Team Clear Standing Orders for Team Members Multidisciplinary Approach to care Reminders built into the system Aware, Responsive Patient Periodic assessment and reengineering of clinical business processes

35. Questions