New Health Partnerships: Improving Care by Engaging Patients

1. New Health Partnerships: Improving Care by Engaging Patients Doriane C. Miller, MD Director, Center for Community Health and Vitality University of Chicago Medical Center Judith Schaefer, MPH Research Associate MacColl Institute, Group Health Research Institute PCPCC Multi-Stakeholder Demonstrations May 4, 2010

2. Provide an operational definition of CSMS Show the evidence for efficacy Demonstrate its context in patient centered care Promote its role as a quality improvement strategy Give examples of its influence on system redesign, patient outcomes and the business case for chronic care Provide tools for you to try in your practice Objectives

3. Collaborative goal setting and shared decision making Regular follow-up, monitor and assess progress towards goals, relating plans to patient’s social and cultural environment Tracking and ensuring implementation, including linking support programs to the individual’s regular source of medical care and monitoring their effects on a patient’s health Collaborative Self-Management Support: Operational Definition

4. CDSMP - Six Week Program Heterogeneous groups of patients with CHF, arthritis, chronic lung disease and stroke Improvements in cognitive symptom management, health distress, communication with provider Fewer hospitalizations and days in the hospital Follow up Longitudinal study Patients able to maintain gains of reduced ED and hospitalizations, Improved quality of life Lorig KR, et al. Med Care 1999; 37(1):5-14. and Med Care 2001; 39(11):1217-23. Evidence Base for Self-Management Support

5. 19 out of 20 interventions with improved processes or outcomes of care included self-management support Bodenheimer JAMA, 10/2002.

6. Gaps in Practice Provider lack of awareness/skills Provider doubt about effectiveness Rushed practitioners not following established practice guidelines Lack of care coordination Lack of active follow-up to ensure the best outcomes Patients inadequately supported to manage their illnesses

7. Delivery system redesign: assure delivery of effective and efficient clinical care and self-mgt Decision support: promote SMS consistent with scientific evidence and patient preferences Clinical information systems: organize pt and population data to facilitate SMS Health care organization: create a culture, organization and mechanisms that promote SMS Community: mobilize community resources to promote SMS Self-Management Support and The Planned Care Model

8. 7-11 months 26 teams: rural/urban, ethnic mix, condition-specific and cross-cutting projects, safety net and FFS Core competencies, system redesign, IT, community linkages Business Case Patient and/or family involvement Learning Collaboratives 1 & 2

9. Goal setting (patient support measure) System for documenting self-management support services (organizational support measure) Integration of SMS into primary care (organizational support measure) Quality Allies Learning CommunityPrimary Care Resources and Supports Survey3 Measures with Greatest Change -- Baseline to Follow-up

10. Quality Allies Learning CommunityPrimary Care Resources and Supports SurveySupport Score Totals Across All Sites* • n=20 sites at baseline; n=18 sites at follow-up • All pre/post changes significant at p<.01

11. Robust practice models for adoption/replication in varied settings Business case for safety net and fee-for-service Patient and family involvement Content Results

12. Hamster Care

13. ASSESS : Beliefs, Behavior & Knowledge ARRANGE : Specify plan for follow-up (e.g., visits, phone calls, mailed reminders ADVISE : Provide specific Information about health risks and benefits of change Personal Action Plan 1. List specific goals in behavioral terms 2. List barriers and strategies to address barriers 3. Specify Follow-up Plan 4. Share plan with practice team and patient’s social support ASSIST : Identify personal barriers, strategies, problem-solving techniques and social/environmental support AGREE: Collaboratively set goals based on patient’s interest and confidence in their ability to change the behavior Self-Management in office practice Glasgow RE, et al (2002) Ann Beh Med 24(2):80-87

14. If you have DIABETES, here are some things you can talk about with your health care provider • Choose to talk about changing any of these and add other concerns in the blank circles. Blood glucose monitoring Taking medications to help control blood sugar Skin care Taking insulin Diet Depression  Losing weight Daily foot care Smoking (RI Dept of Health Chronic Care Collaborative)

15. 1. Goals: Something you WANT to do 2. Describe How Where What Frequency When 3. Barriers 4. Plans to overcome barriers 5. Conviction and Confidence ratings (1-10) 6. Follow-Up: Action Plan

16. Assess Conviction/Importance “How convinced are you that it is important to monitor your blood sugars?” Totally convinced Not at allconvinced 0 1 2 3 4 5 6 7 8 9 10 “What makes you say 4?” “What leads you to say 4 and not zero?” “What would it take (or have to happen) to move it to a 6?” (From Keller and White, 1997; Rollnick, Mason and Butler, 1999)

18. “U.S.” SMS Toolkit for Clinicians High Impact Changes before, during and after the visit Big Picture Cycle of SMS proactive care delivery process Brief descriptions and links to tools

19. Three System Change Strategies Create a Team Shared Care Plan Follow up Care and Community Links

21. We will know who you are and we will be ready for you. Borgess Ambulatory Care, Kalamazoo, MI

22. At the center of patient care are face-to-face healing relationships. Nurse: Physician Patient: Nurse Patient: Physician Nurse: Nurse

23. “Teamlet” Model Primary Care Physician 1-2 Medical Assistants Lay “coaches” Action Planning and follow up by MA’s MA’s may accompany patients in doctor visit Bodenheimer, 2008

24. The Medical Assistant The Patient The Provider Leaves with scripts, referrals, and instructions

25. Other Activated Patients Integrated plan Medical & SMG The Patient The Provider The Medical Assistant

26. First key service: MA planned visits Planning and preparation: Do goal setting on patient determined goal Assure all information is up to date in chart

27. The Provider – Integrated medical plan and self management goals B B S W A R ACKGROUND ARRIERS UCCESSES ILLINGNESS… CTION PLAN EMEMBER NON-DIRECTIVE COUNSELLING

28. And our Group Visits… Patients helping Patients… The MINI-group visit The Open-Office Group visit Stressors, depressed mood, barriers, difficulty coping ALWAYS covered Coping strategies develop Both involve goal setting

29. Population Management Work Flow Start • Program Assistant : • Prints structured worksheets containing CV risk factor information including: • Labs • Medications • Blood pressure • Immunizations • Allergies • PCP visit info • Care Management or classes • MD: • reviews worksheets, identifies appropriate interventions, and checks off instructions for Program Assistant to communicate to the patient, including: • Lab studies • Medication adjustment • Referrals • F/U appointments • Requires approx. 15 min per 10 worksheets • Program Assistant: • Contacts patient in doctor’s name and communicates interventions and/or referrals, collects other information (i.e. Aspirin use) as indicated by the physician on the worksheet • Faxes or calls Rx to Pharmacy • Sends Lab requisition Books classes/ TAVs/appointments • Enters data • Confirms patient allergies and current medications • Requires 10-20 min/pt Program Assistant : enters information regarding follow-up interval into a tracking system. And places worksheet in outpatient chart.

30. Mercy Clinics, Inc. • Des Moines, IA & suburbs • 27 Clinics,140 Physicians • 70% Primary Care • 793,000 patient visits in FY06 • 100% Fee-for-Service • Virtual Private Practice • All revenue & expenses are tracked to individual doctors • The difference is the doctors’ salary

31. RN background Health Behavior Change Shared medical appt Medication adherence Plan Do Study Act Diabetes mgt Health Literacy Depression Screening Disease Registry Pre-visit chart review/labs Self-management support Care coordination Quality improvement Mercy Clinics: Population Health Coach

34. Financial Case

35. 2006 North Clinic Health Coach Financial Summary Revenue Comments EM visit & lab differential $76,879 Level 1 visits (1801 * $25) $45,025 1801 visits @ $25 net Offset Dr. & Nurse work $15,183 estimate is probably low P4P - 2006 actually paid $114,000 Total Revenue $251,087 Expenses Health Coach Salary - RN-II $36,728 0.7 time salary & benefits Health Coach Salary - LPN $36,434 0.9 time salary & benefits Differential Microalbumin cost $ 9,932 $6.29 for 1579 tests Differential HgA1cost $ 4,763 $7.50 for 635 tests Total Expenses $87,856 Contribution to Overhead $163,231

36. Shared Care Plan

37. Truly Shared Care Plan Shared Data HbA1c and walking club experience Shared Team Specialists and Aunt Margaret Shared Goals Reducing BP and marimba classes

38. Whatcom County and Beyond PatientPowered.org Web platform Health 2.0 http://www.patientslikeme.com/

39. www.NewHealthPartnerships.org www.improvingchroniccare.org www.familycenteredcare.org Resources