Care by Design ™ at University of Utah: Developing and Implementing Care Management, Engaging Patients, and Assessing

1. Care by Design™ at University of Utah: Developing and Implementing Care Management, Engaging Patients, and Assessing Cost of Care Michael K Magill, MD Professor and ChairmanDepartment of Family and Preventive Medicine University of UtahSchool of Medicine and Community Clinics

2. Primary Care Practice Redesign – Successful Strategies AHRQ Grant #1R18HS020106 Michael K. Magill, MD, Principal Investigator

3. Implementation and Research Team Michael Magill, MD Annie Mervis, MSW Ruth Murdock Debra Scammon, PhD Andrada Tomoaia-Cotisel, MPH, MHA Norman Waitzman, PhD • Tatiana Allen • Julie Day, MD • Timothy Farrell, MD • Karen Gunning, PharmD • Teresa Hall, PT • JaeWhan Kim, PhD

4. 11 Community Clinics • Visits (FY11): 317,000 • Active patients: 157,000

6. Care by DesignTM– Early days • Appropriate Access – 2003 • Balance visit supply and demand • Standardized schedules • Care Team – 2004 • Expanded MA role • Providers and MAs working in teams EMR tools (BPAs, Xfiles) • Planned Care – 2006 • Protocols, order sets • Pre-visit planning, labs • Registries

7. Care by DesignTM - Moving Forward… • Care Management Program for patients with chronic diseases • Embed care managers in clinics • Facilitate clinical care • Coordinate care • Promote patient self-efficacyand self-management • Transitions management

8. Appointment/ Message Call-Center Compensation System Care Managers Visit NonVisit Clinical Pharm EMR Care Team Institutional Priorities Expanded Team Macro Team Environment

9. Care Managers • Multidisciplinary backgrounds • Social Work, Nursing, Healthcare Administration, Health Education, Hospice, Chaplain • Formal training in care management techniques and motivational interviewing

10. Selection of Patients for Care Management • Data driven • Patients with diabetes, heart failure, coronary artery disease • Age of patient • Last appointment • Next scheduled appointment • Last 3 Hgb A1c • Last 3 LDL • Last 3 Blood Pressures • Provider referral

11. Care Management Program • Assessment Tools • Patient Activation (PAM) • Quality of Life (RAND36) • Depression Screening (PHQ9) • Motivational interviewing • Individualized patient self-management goals in EMR • Self-monitoring tools via EMR patient portal (“MyChart”) • Blood glucose, blood pressure, exercise, weight

12. Patients Participating in Care Management

13. Transitions Management • Objective: prevent unnecessary readmissions • Focus: Inpatientoutpatient • Population: Community Clinics patients recently discharged from University of Utah Hospital • Mechanism: • Daily electronic registry generated from EMR • Care managers call recently discharged patients listed on this registry

14. Key Transitions Questions • How feeling since discharged? • Questions you have that were not answered? • Changes to medications (while in ED/hospital)? • Who is primary care provider? • Follow-up appointment with this provider?   • Do you know danger signs to indicate you need to return to hospital/call doctor?

15. Patients Participating in Transitions Management

16. Care Management: Notes From the Field • “Mr. RR was able to finally admit that he has difficulty with Drs and being able to understand teaching that is provided. He says that Drs use ‘all those big words’ that he does not understand. He expressed an appreciation for me explaining cholesterol, diabetes complications and HgbA1C lab results.”

17. Care Management: Notes From the Field • “Ms ZZ seems to deal with her anxiety and stress about her husband’s condition by monitoring all his intake. This causes stress between them. Ms ZZ had a misunderstanding about some things the patient should or should not eat. They were both receptive about going to the Diabetic Nutrition Class.”

18. Care Management: Notes From the Field • “Mrs. CCC seems motivated and is ready to go. She reports that she has already made changes in her diet…. After setting a goal and making a return appointment, she said ‘I’m excited.’”

19. Plan: Measures of Success • Patient activation score • Patient Activation Measure (PAM) • Patient outcomes • Patient functional status (RAND36), clinical quality, address depression (PHQ9) • Patient experience • PCMH CAHPS pilot survey • Cost • ED visits, hospitalizations and readmissions

20. Care Management:Plan to Assess Impact on Utilization and Cost • Data - patient level linkage to… • Medicare and All-Payer data from 2007-2012 • Outcomes - Utilization and Cost • Inpatient Care • Outpatient, home health, nursing home • Prescription Drug

21. Delivery Systems Research: Challenges • Clinical Operations vs. Research • Relationship-building: care manager role, patient consent • Data needs are different • Business decisions and environmental events affect implementation • IRB, HIPAA • Access to PHI • Linking PHI to external data