Chronic Care Learning Communities Initiative Collaborative

1. Chronic Care Learning Communities Initiative Collaborative Final Outcomes CongressDecember 9, 2005 Santa Clara Valley Medical Center

2. SCVMC: Stroke Prevention • Location: Northern California - Tertiary Regional Medical Center - Silicon Valley Administered by County of Santa Clara. • Size: Metropolitan Area of Santa Clara County Has a Population of 1.7 Million Residents; 50% Live in the City of San Jose, the County Seat; identified 250 patients with multiple risk factors from 9,000 patients in diabetes registry • Population Served: 44% European American; 26% Asian American; 24% Hispanic/Latino; 3% African American; <1% Native American. Over 34% Residents “Foreign Born”; Over 50% Speak Language Other Than English; Over 10% Speak No English.

3. CHRONIC CARE MODEL Community Health System Resources and Policies Organization of Health Care DeliverySystem Design Decision Support ClinicalInformationSystems Self-Management Support • interventions • care-planning & problem solving • Relationship building • Assessing needs, expectations and values • Information sharing • Goal setting • Action planning • Problem solving • Registry • Care reminder • Subgroups • Care-planning • Data mining • Team roles & tasks • planned visits • continuity • follow-up • Team building • Guidelines • specialtyinteraction • provider education • guidelinesfor patients

4. Chronic Care Model Community Health System • Goals: create business plan for CCM • Coordinate care delivery efforts among providers • Introduce and discuss provider incentives • Senior leaders created framework to study CCM Organization of Health Care Resources and Policies • TCOYD • Kaiser, SNI, Diabetes Coalition • Establish liaison with industry Informed, Activated Patient Prepared, Proactive Practice Team Productive Interactions Functional and Clinical Outcomes

5. Risk factor intervention for Cardiovascular complications Informed, Activated Patient Prepared Practice Team Productive Interactions • Key intervention: • Assessment of patients at high risk for cardiovascular event • Design and delivery of educational module for stroke self-management SAVED (sensation, ache, vision, expression, dizziness) • Protocols published and care managers certified • Collaborative Plan formulated with each participant, based on PCP input and participant’s readiness is in role out phase • Self-Management support was emphasized • Proactive follow-up for one year

6. Clinical Information Systems • Registry • Filemaker workgroup based design • Process flow from encounter to remote entry • Care reminders • Outlier reporting to identify patients in need of test • Emails and IVR produced from registry • Patient subgroups • MDs receive lists of patients with hgba1c > 8.0% • Care-planning • Lists generated for those with missing labs

7. Decision Support • Guidelines • Provider agreement to adopt guidelines HEDIS, ADA • Published on the intranet/extranet • Registry programmed to alert clinician • Specialty interaction • Design and pilot a referral form • Transmit retinal scans to ophthalmology • Provider education • Meet with primary care monthly • Educational seminars, TCOYD • Guidelines for patients • Wallet cards with meds printed on back

8. Delivery System Design • Team roles & tasks • Nurses/PA-C/PharmD use medication adjustment protocols • MD refers to educator who records patients goals • Care manager offers education and/or management • Planned visits • Registry printout shows current lab • Alert PCP and patient labs before appointment • Continuity • Prompts for specialty MD contact from referral form • Follow-up • CDE calls patients regularly

9. Self Management Support • Emphasize patient role • Multiple providers send this message to patient • Assessment • Downloaded assessment from website • CDE assesses patient at planned visit • Interventions • CDE trained through chronic disease self-management program • Care-planning & problem solving • Use of motivational interviewing techniques

10. Community Resources • Effective programs • Identified community resources at Diabetes Coalition • Co-sponsored TCOYD conference • Partnerships • Kaiser community benefits program • Outreach to SCC medical society and physician IPA • Coordination • Recognize Diabetes Society as an educational resource

11. Organization of Health Care • Teams • Link care managers to PCP’s within geographic area • Benefits • Partner with division of primary care quality programs for shared goals and processes • Provider incentives • Introduce BP surveillance and goals • Senior leaders • Approved involvement in CCM pilots and spread teams on tracking and reporting on collaborative measures • Sanctioned a study comparing traditional care to care delivered via the chronic care model

12. Functional and Clinical Outcomes Baseline STUDY Hba1c Q 3-4 04 Q1 v Q2 05 • Pre intervention 8.5 8.0 • Post intervention 7.5 7.5

13. BarriersCollaboration Not Dictation • Difficulty with centralized department sending “delinquent” lab monitoring notices to the PCP • Send reminders not delinquent notices • Create a team of care manager and 3 PCP’s • Introduce the possibility of pay for performance

14. Stroke Reduction Education Referral

15. A1c Test

16. Detail of Hba1c Testing Hba1c % <7 • Q1 62 • Q2 57 • Q3 46 • Q4 47

17. Detail of Hba1c Testing Hba1c % <7 # tested • Q1 62 86 • Q2 57 121 • Q3 46 89 • Q4 47 214

18. Detail of Hba1c TestingScalability Hba1c % <7 # tested #<7 • Q1 62 86 54 • Q2 57 121 69 • Q3 46 89 41 • Q4 47 214 100

19. Spreading Chronic Care Improvements • Complete buy-in. • To study of the proof of concept. • Support a trial comparing outcomes traditional ambulatory care the chronic care model. • Compare total expenditures and resource utilization (hospitalization, emergency and urgent care utilization and laboratory/ancillary care costs) within a closed system.

20. A Patient Voice