Integrating Chronic Care and Business Strategies in the Safety-Net (Text Version)

Slide Presentation from the AHRQ 2008 Annual Conference

On September 9, 2008, Katie Coleman, made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (297 KB).

Slide 1

Integrating Chronic Care & Business Strategies in the Safety-Net

AHRQ Annual Meeting
September 9, 2008.

Slide 2

Chronic Illness in America

• More than 125 million Americans suffer from one or more chronic illnesses and 40 million limited by them.
• Despite annual costs of more than $1 trillion and significant advances in care, one-half or more of patients still don't receive appropriate care.
• Gaps in quality care lead to thousands of avoidable deaths each year.
• Patients and families increasingly recognize the defects in their care.

Slide 3

Chronic Care Model (CCM)

The diagram shows a large, teal oval with two, blue arrows radiating downward and merging into one.

• Community:
  • Resources and Policies.
    • Self-Management.
• Health System:
  • Health Care Organization.
    • Delivery System Design.
    • Decision Support.
    • Clinical Information Systems.
• These lead to Informed, Activated Patients and Prepared, Proactive Practice Teams.
  • Productive Interactions Between the Two.
• Leads to Improved Outcomes.

Slide 4

Experience with Collaboratives

• More than 1,500 different health care organizations and various diseases involved to date.
• Health Resources and Services Administration's (HRSA's) Health Disparities Collaboratives- 600+ community and migrant health centers.
• Academic Medical Centers.
• State, regional, and organization specific.

Slide 5

Evaluation of Chronic Care Collaboratives

RANDHealth

• Practices can change—organizations made average of 48 changes in 5.8/6 CCM areas.
• Process measures may improve—Congestive heart failure (CHF), asthma, diabetes.
• Outcome measures may improve—better glycemic control in Diabetes.

Chin, et al. & Landon, et al.

• May take more than 1 year to see outcome changes.
• Cost-effective.

Slide 6

Lessons Learned from the Teams

• Teams spent considerable time searching for/developing tools.
• Some teams felt intimidated by taking on the whole model—asked for a sequence.
• Collaboratives were time & resource intensive.
• Many changes were made in ways that were not sustainable financially.

Slide 7

Integrating Chronic Care & Business Strategies in the Safety-Net

The diagram shows a large, teal arrow broken into four smaller arrows.

• Reaching beyond early adopters.
• Integrate business & clinical changes.
• Provide high-quality tools.
• Less time-intensive learning.

Slide 8

The Patient-Centered Medical Home (PCMH) and the Chronic Care Model?

A screen shot showing a page with "Content of PPC-PCMH-Wagner CCM." Three rectangles overlap, "Patient Centered Medical Home," "PPC [Physician Practice Connection]," and "Wagner CCM." Surrounding the rectangles: "Delivery System Design," Clinical Information Systems," "Decision Support," "Self-Management Support," "Community Support," "What's Included? (Infrastructure)," "How Much Used? (Extent)," "What Functions? (Implementation)," and "Evidence and Scoring (Verification)."

• Correct
  • The National Committee for Quality Assurance (NCQA) PPC-PCMH view: Much of the PCMH is consistent with the CCM.

A screen shot showing a blank page with "Patient-Centered Medical Home" and a small rectangle with CCM.

• Misperception
  • A Common Misunderstanding: The CCM is only a small component of the PCMH.

Slide 9

The Intervention

The diagram shows two blue rectangles, "Practice Coach/STEP-UP Methodology" and "Toolkit/Business & Clinical Tools," with a "Plus" sign placed in between.

Slide 10

Coaching Outline

• Tasks:
  • Assessment Day.
  • ½ day presentation on CCM & Plan-Do-Study-Act (PDSA) cycle.
  • On-going meetings by phone, E-mail & in-person.
  • Coaching of the leaders & the teams.
• Philosophy:
  • Focus on motivation, consultation & education.
  • Be mindful of the timing of interventions.
  • Fix processes relevant to the task at hand.
  • Well-structured & supported groups benefit most.

Slide 11

Preliminary Reflections

• Six months is short.
• Randomization presents both challenges & opportunities.
• There is a trade-off between customization and collaborative learning, but providing structured learning time is key.
• Clearly define the coaches role & regularly check expectations.

Slide 12

More Preliminary Reflections

• Identify a leader on-site who is accountable, creative, flexible, & empowered. It is the functions of leadership, not the role that matters.
• Coaches can identify major infrastructural barriers to improvement.
• Coaching is one piece within a multi-level system—must seek out alignment between programs.
• Coaching can jump-start spread.

Slide 13

Next Steps

• Complete evaluation.
• Revise toolkit & make available at AHRQ.gov & improvingchroniccare.org.
• Develop companion Coaching Manual.
• Pursue additional research questions
  • What are characteristics of teams that can succeed using this toolkit & coaching intervention?
  • What kinds of micro- and macro- business changes can we expect to see within 6 months or a year implementing the CCM?

Slide 14

Thank you!

www.improvingchroniccare.org

Slide 15

Our Evaluation Uses a Block-Randomized Design with an External Control Group

The diagram shows three, colored arrows all pointing to "Difference in Changes."

Top Arrow: Intervention Arm

• Baseline Measures.
• Tool Kit plus Practice Coaching.
  • Forming Team & Choosing Tools leading to Implementing CCM and Related Business Processes Improve.
• Post Measures.
• Pre-Post Changes.

Middle Arrow: Internal comparison Arm

• Baseline Measures.
• Secular Trends.
• Post Measures.
• Pre-Post Changes.

Bottom Arrow: External Comparison Arm

• Baseline Measures.
• Secular Trends.
• Post Measures.
• Pre-Post Changes.

Slide 16

Measures

• Implementation: pre-post qualitative interviews
  • Organizational context & baseline assessment.
  • Plan for change & organizational support.
  • Improvement strategies & implementation processes.
  • Perceived impact & lessons learned.
• Health process & outcomes: Health Plan Employer Data Set (HEDIS) & utilization.
• Financial measures: ReDeFin
  • No show rate.
  • # of patient care encounters per full-time-equivalent physicians (FTE).
  • Charges per patient encounter.