Martha Rome, RN, MPH Milwaukee, WI February 11, 2009

1. Improving Performance in Practice (IPIP)Change PackageCoaching PracticesImproving Healthcare State by State Martha Rome, RN, MPH Milwaukee, WI February 11, 2009

2. Aims of IPIP • To dramatically improve patient outcomes by transforming the way we deliver primary care, focusing initially on measurable improvement in diabetes and asthma, but rapidly spreading to preventive services and other conditions • To assist different types of practices in using practice redesign strategies to improve efficiency and implement best practices • To align efforts and motivate action at the national, regional, state, practice and patient level

3. National State Network Practice Patient Aligning Across Policy Levels

4. Build will on state level and create state infrastructure • National specialty societies work through state chapters • Specialty Boards provide clear expectations for maintenance of certification • Partner with other organizations in the state • AHEC, QIO, payers, businesses, state government • Aligning state efforts creates the IPIP model • National Team supports states with: • Standard protocols • Decision support tools • Access to other practices who’ve done this work successfully • Access to experts in the field • Data aggregation and reports

5. Model • Improvement networks/collaboratives • Quality Improvement Coaches: Support individual practices and improvement networks • Onsite consulting • Group meetings (in person and phone) • Reporting: monthly submission of performance measures

6. Schematic of IPIP Process QIC Enroll in IPIP Improved outcomes with physicians and practices expert in QI Documentation of knowledge and performance Activated physician Starting point for QI Collaborative practice Using shared data Statewide primary Care practices Knowledge Management

7. Role of Quality Improvement Coaches • Intensive (often) on-site work with the practice team • Provide avenue to network activities and share best practices • Focused approach for implementation starting with key process changes • Move practices faster for basic implementation • Create group momentum with regard to implementation and standardization • Help practices ensure that all IPIP changes are implemented • Assist practices in developing teams & standardized work flow • Provide examples of tools (standing orders) and roles • Assist practices with regular monitoring of implementation to ensure reliability

8. Living with chronic illness is like piloting a small plane

9. To get safely to their destinationpilots need: • Flight instruction • Preventive Maintenance • Safe Flight Plan • Air Traffic ControlSurveillance • Self-Management Support • Effective ClinicalManagement • Treatment Plan • Close Follow-up

10. Usual care works well if your plane is about to crash

11. The IOM Quality Report:Selected Quotes • “The current care systems cannot do the job.” • “Trying harder will not work.” • “Changing care systems will.”

12. Systems are perfectly designed to get the results they achieve The Watchword

13. Evidence-based Clinical Change Concepts System Change Concepts A Recipe for Improving Outcomes System change strategy • Learning • Model

14. Advantages of a General System Change Model • Applicable to most preventive and chronic care issues • Once system changes in place, accommodating new guideline or innovation much easier • Early participants in our collaboratives using it comprehensively

15. Essential Element of Good Chronic Illness Care Prepared Practice Team Informed, Activated Patient Productive Interactions

16. What characterizes a “prepared” practice team? Prepared Practice Team At the time of the visit, they have the patient information, decision support, people, equipment, and time required to deliver evidence-based clinical management and self-management support

17. What characterizes a “informed, activated” patient? Informed, Activated Patient Patient understands the disease process, and realizes his/her role as the daily self manager. Family and caregivers are engaged in the patient’s self-management. The provider is viewed as a guide on the side, not the sage on the stage!

18. How would I recognize a productive interaction? Prepared Practice Team Informed, Activated Patient Productive Interactions • Assessment of self-management skills and confidence as well as clinical status • Tailoring of clinical management by stepped protocol • Collaborative goal-setting and problem-solving resulting in a shared care plan • Active, sustained follow-up

19. Chronic Care Model Community Health System Health Care Organization Resources and Policies ClinicalInformationSystems Self-Management Support DeliverySystem Design Decision Support Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Improved Outcomes

20. ClinicalInformation System • Provide reminders for providers and patients. • Identify relevant patient subpopulations for proactive care. • Facilitateindividual patient care planning. • Share information with providers and patients. • Monitor performance of team and system.

21. Delivery System Design • Define roles and distribute tasks amongst team members. • Use planned interactions to support evidence-based care. • Provide clinical case management services. • Ensure regular follow-up. • Give care that patients understand and that fits their culture

22. Self-management Support • Emphasize the patient's central role. • Use effective self-management support strategies that include assessment, goal-setting, action planning, problem-solving and follow-up. • Organize resources to provide support

23. To Change Outcomes (e.g., HbA1c) Requires Fundamental Practice Change • Interventions focused on guidelines, feedback, and role changes can improve processes • Interventions that address more than one area have more impact • Interventions that are patient-centered change outcomes. Renders et al, Diabetes Care, 2001;24:1821

24. Templates Related to Better Performance and Less Variation (IPIP practices)

25. IPIP Change Package • High-leverage Changes • Implement Registry • Use Template for Planned Care • Use Protocols • Adopt Self-management Support Strategies

26. Implement IPIP Changes in Steps • Use Registry to identify asthmatics/diabetics prior to visit (this requires the work of implementing a registry or “fixing” the EHR) • Use condition-specific decision support tool (e.g., visit planner) • Create customized flow diagram and protocols to standardize the care process • Nursing Standing Orders to increase reliable execution [examples] • Standard Protocol [example] • Specific Care Team roles: who does what in the protocol • Implement a self-management support system Throughout: Frequent monitoring of reliability and investigation of failures for ideas about how to improve standard performance

27. Detailed Changes: Registry • Select and install a registry tool • Determine staff workflow to support registry use • Populate registry with patient data • Routinely maintain registry data • Use registry to manage patient care and support population management

28. Detailed Changes: Templates • Select template tool from registry or create a flow sheet • Determine staff workflow to support use of template • Use template with all patients • Ensure registry updated each time template used • Monitor use of template

29. Detailed Changes: Protocols Step 3: Use Protocols a. Select and customize evidence-based protocols to office b. Determine staff workflow to support protocols, including standing orders c. Use protocols with all patients d. Monitor use of protocols

30. Protocols: Asthma-specific • Assess and document asthma severity and control • Prescribe appropriate asthma medications and monitor overuse of beta agonists • Use Asthma Management plans • Establish visit frequency protocol • Assess and treat co-morbidities • Assess, counsel, and prevent exposure to environmental triggers

31. Protocols: Diabetes • Check and treat BP <130/80 • Check and treat cholesterol • Check A1C and treat hyperglycemia • Assess aspirin and prescribe if not using • Assess need for eye exam and make referral if needed • Assess nephropathy risk • Perform foot exam • Provide appropriate vaccines

32. Self-management Support • Obtain patient education materials (e.g., asthma action plans) • Determine staff workflow to support SMS • Provide training to staff in SMS techniques • Set patient goals collaboratively • Document and monitor patient progress toward goals • Link with community resources (schools, service organizations)

34. Cincinnati Children’s Hospital PHO • 44 geographically dispersed, sites • Individual models and styles of practice • “First Wins” • Early adoption of registry • Concurrent data collection: written parent symptom review and clinical interview

35. BMF Included PHO practices achieve > 80% reliability (“perfect care”)

36. Relationship between changing process and changing outcome 80% of Patients Receive “Perfect Care”

37. Impact of PHO Asthma Initiative

38. UNITE HERE Health Center • Founded 1914 by ILGWU • Union mergers over the years, now UNITE HERE • Comprehensive Primary and Specialty Care • Serves predominantly UNITE HERE members, their families and retirees and SEIU 32BJ members • 1000 office visits/week • 12 PCP’s, 40 specialists, all staff bilingual • On Site Physical Therapy, Radiology and Pharmacy

39. Primary Care Teams • High functioning multidisciplinary teams with 2 hours protected meeting time every other week • Huddles • Led by MA who does chart reviews day before • First 20 minute appointment blocked • Identify patients for health coach interventions • Cell phones and walkie-talkies • Protocols developed & incorporated into EMR templates

40. Teamwork • PCAs trained in monofilament testing, glucose diaries and ABC cards • Standing orders for Pneumovax and ophthalmology appointments • Pharmacy gets A1C lists for medication review • Health Coaches for DM education, self management goal setting, BP checks and blood glucose checks

41. Transforming Medical Assistants into Health Coaches • Curriculum developed for in-house training • Didactic and observational testing • Promotion to “Health Coach” after competency evaluation • Supervision by Nurse Practitioner and RN coordinator

42. Evidence Based Care • All providers use the DM template • Review and discussion of data at provider meetings • DM always on the agenda • Provider educational seminars • Provider chart reviews

43. Challenges

44. Focus on Hypertension • Reinforced use of BP check visit – patient sees RN or Health Coach • New protocol and training for MA to recheck BP if high prior to seeing PCP • BP Loan Program • Chart Reviews • Discussion with PCPs at monthly meeting

45. CHART REVIEW FOR UNCONTROLLED HYPERTENSION IN PEOPLE WITH DIABETES Number of patients: 122 BP at last PCP visit: <140/90  72 (59%) >140/90  50 (41%) Was BP rechecked after first reading: Yes 37 (30%) No 86 (70%) Number of medications for HTN: 0- 14 (11%) 1- 28 (23%) 2- 34 (28%) 3- 26 (21%) 4- 13 (11%) >4- 6 (5%) 2 or fewer 76 (62%) 3 or fewer 102 (84%) Was uncontrolled HTN identified as a problem: Yes 82 (67%) No 40 (33%) Took medications for HTN on day of visit: Yes 33 (27%) No 24 (20%) Not in note 51 ( 42%)N/A 8 (7%)

46. PCP Discussions • Monthly PCP meetings • Results of chart reviews drive PCP discussion • Discuss clinical management of HTN • Ask PCP with best results – what do you do? • Share best practices - start with combination drugs

47. PCP Discussions • Identifies common misconceptions – “uncontrolled patients are already on maximal doses of medications” • Identifies target for improvement – importance of rechecking BP if uncontrolled and asking if patients took their medications on the day of the visit

48. The Multidisciplinary Team: The key to successful planned diabetes care and quality improvement in our practice Robb Malone, PharmD UNC General Internal Medicine January 20, 2009

49. Water cooler discussions Change is scary Change is hard Change is complicated Change is necessary Change requires leadership Change is an opportunityto improve Successful change requires a well designed, active team

50. We assessed root causes and actions