Challenges of Sustaining, Scaling, and Spreading Innovations in Cardiovascular Care

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Slide 1

Challenges of Sustaining, Scaling, and Spreading Innovations in Cardiovascular Care

AHRQ Annual Meeting
Session 34, Track C
Sept. 10, 2012

Slide 2

Session Goals

1. To share two heart health innovations from the Health Care Innovations Exchange.
2. To consider how organizations might explore adoption of these and similar innovations.

Slide 3

Heart Health Focus

• National Quality Strategy:
  • Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease.
• Million Hearts™ Campaign:
  • National initiative to prevent 1 million heart attacks and strokes over five years.
  • http://millionhearts.hhs.gov.

Image: An icon of a heart is shown.

Slide 4

Agenda

• Introduction:
  • Judi Consalvo, AHRQ.
• Language Concordant Health Coaches Innovation:
  • Hali Hammer, San Francisco General Hospital. Family Health Center.
• Heart360® Innovation:
  • David Magid, Kaiser Colorado.
• Activity: How Can I Implement This Innovation?
  • Veronica Nieva, Westat.

Slide 5

What Is the Health Care Innovations Exchange?

• Goal:
  • To accelerate sharing of innovations and online tools to improve health care services and reduce health care disparities.
• Components of the Exchange:
  1. The Web site: http://innovations.ahrq.gov.
  2. Learning and Networking Activities.

Image: The logo of the Health Care Innovations Exchange is shown.

Slide 6

What Is the Health Care Innovations Exchange?

• Web site features profiles of successful and attempted innovations and practical tools:
  • Service Delivery.
  • Policy.
• Learning and Networking:
  • Webinars.
  • Meetings to promote spread.
  • Videos.

Image: The logo of the Health Care Innovations Exchange is shown.

Slide 7

The Innovations Exchange

• Visit our Web site: http://innovations.ahrq.gov.
• Follow us on Twitter: #AHRQIX.
• Send us Email: info@innovations.ahrq.gov.

Image: The logo of the Health Care Innovations Exchange is shown.

Slide 8

Health Coaches as Members of the Health Team

Hali Hammer
San Francisco General Hospital,
Family Health Center

Slide 9

San Francisco General Hospital Family Health Center

• Hospital-based full scope family medicine clinic.
• Part of the San Francisco Department of Public Health's primary care network.
• Participating in access and quality improvement initiatives as part of the 1115 California Medicaid Waiver (CMS Incentive Program), which ties federal funding to milestones, including PCMH standards (team-based care, clinical outcomes).
• 10,700 patients served; 1500+ adults with diabetes.
• 50,000+ patient visits per year.
• Teaching clinic: 41 family practice residents and many medical and nursing students.
• Diverse patient population:
  • 42% Latino, 26% Asian, 14% Caucasian, 12% African American.
  • 51% Medicaid, 33% uninsured (almost all enrolled in Healthy San Francisco), 15% Medicare.
  • 31 different languages spoken:
    • 48% English, 30% Spanish, 9% Cantonese/ Mandarin.

Image: A cartoon shows people standing on top of bridges and buildings, holding hands.

Slide 10

Description of health coaching at the SFGH Family Health Center

Health Coaches are members of the health care team who provide self-management support to a stable panel of patients with chronic illness (in our setting, primarily diabetes).

Health Coaches:

• Are language-concordant with all their patients.
• Are trained in motivational interviewing, panel management, diabetes basics, and medication adherence.
• Work collaboratively with a patient's Primary Care Provider, unlike promotoras or community health workers in other settings.
• Are primarily in the job classification "Health Worker," but may also be Medical Assistants, pre-medical students, trained peers.

Slide 11

Description of health coaching at the SFGH Family Health Center

The Health Coach role includes:

• Self management support:
  • Supporting their patients to have the knowledge, skills, and confidence to become active participants in their care.
• Bridge:
  • Clarifying information provided by the provider, pharmacy, or insurance company.
  • Bridging cultural/linguistic gaps.
• Clinical continuity:
  • Following patients who are in their continuity panel, with a goal to maximize continuity between patient and health coach.
• Emotional support:
  • Language- and often cultural-concordance enhances trust and engagement in learning how to self-manage the chronic illness.
• Clinical Navigation:
  • Health Coaches may be more accessible because they are in clinic every day and can be the primary clinic contact person for patients throughout the week.
  • Help with making and keeping appointments, accessing pharmacy and other services.

Slide 12

Health outcome measures for a population of patients working with Health Coaches

Slide 13

Costs associated with health coaching

• Health Coach program cost considerations:
  • Salary ($58,000 per year in our setting, which is 44% of an RN).
  • A full time Health Coach can manage a patient panel of 200 patients.
  • Physician or Nurse Practitioner supervision (approximately 5% time).
  • Training costs (6-8 sessions).
  • Must consider how Health Coaches are assigned and interface with other members of the care team (i.e., case managers, social workers)?

Slide 14

Factors to consider in the business case for health coaching

Who provides self-management support and education in a traditional primary care visit? What is the most cost-effective and efficient way to provide this important component of chronic illness care? Health coaching may be the answer.

Image: An oval captioned "Family Community" sits above a square captioned "Patient." A double-headed arrow labeled "Post-visit / Pre-visit" points to/from "Patient" to a square captioned "Health Coach." Between the two squares, above the arrow, is a box containing the following text, "Assessment of medication adherence, education, self-management support, phone follow-up (between-visits)."  A second double-headed arrow labeled "Visit" points to/from "Patient" to a square captioned "Provider." Between "Patient" and "Provider", above the arrow, is a box containing the following text, "Review of symptoms, diagnosis, medications, addressing urgent problems)."  A third double-headed arrow points to/from "Provider" and "Health Coach," forming the third side of a triangle. This third arrow is labeled "Team huddle or other communication" and below it is a box containing the following text, "Communication about medical and psychosocial issues, goals of care, medication problems."

Slide 15

Factors to consider in the business case for health coaching

• The business case for Health Coaching relies on showing that it decreases long-term complications, hospitalizations, and emergency department use.
• Self-management support does improve health outcomes in patients with chronic illness.
• So, the question for health care organizations is: who should provide the self-management support?
• The answer is based on the payer mix for the organization, as well as staffing costs.
• In our organization, Health Coach salaries are approximately 36% of physicians and 44% of registered nurses.
• Health coaching can be done effectively by a non-licensed, trained member of the staff under appropriate supervision.

Slide 16

Lessons learned in scaling and spreading

• Health coach resources should be allocated to patients at highest risk of poor outcomes if they are not able to self-manage their chronic illness. In our setting, we targeted diabetic patients with hgbA1c ≥ 8.
• Highest risk patients may also be most in need of emotional support: Health Coaches must be trained to place limits on patients so that coaching is possible.
• Communication, a patient's perception of access, and self-management education are best provided by trained staff who speak the patient's language.
• Other health coaching models which use RNs include the added roles of medication adjustment by protocol and symptom assessment; we prioritize self-management support and medication adherence education, which can be provided by an unlicensed coach.

Slide 17

Plans for scaling and spreading

Capitation (instead of fee-for-service reimbursement) allows providers to prioritize outcomes and satisfaction. As reimbursement is increasingly tied to improved patient outcomes, team-based approaches to chronic illness care will be feasible for more organizations.

Primary care workforce issues have also shed light on the increasing pressures and low job satisfaction among a decreasing pool of primary care providers. Engaging other members of the team to take on time-consuming, non-medical tasks, such as self-management support, may improve satisfaction and make primary care more sustainable.

With funding incentives through the CMS Incentive Program / Medicaid Waiver, we will be able to expand health coaching if we continue to show improvement in patient care and access.

Slide 18

Heart360®

David J. Magid
Institute for Health Research
Kaiser Permanente Colorado

Slide 19

Rates of Hypertension Control in the U.S. are Low

• Benefits of hypertension therapy:
  • 25% reduction in heart attack.
  • 40% reduction in strokes.
  • 50% reduction in heart failure.
• NHANES (2005-2008):
  • Treatment 70%.
  • Control 46%.

Slide 20

Focus Groups Kaiser Colorado Clinics

• Controlling my BP is critical.
• Office visits are inconvenient and time-consuming.
• Using a home BP cuff is appealing.

Image: A photograph shows a focus group of patients sitting in chairs that form a rough circle.

Slide 21

Provider Meetings Kaiser Colorado Clinics

Providers

Supportive

Image: A photograph shows a primary care provider meeting gathered around a table for a discussion.

Slide 22

Home BP Monitoring supported by Pharmacists and Heart360®

Image: A photograph shows a young black woman, smiling.

Slide 23

Research Question

For patients with hypertension, is a clinical pharmacy specialist-led Heart360® home BP monitoring program (HBPM) more effective than usual office-based care?

Slide 24

Study Setting

Image: A map of the Denver Metro Area shows the locations of the 10 Kaiser Colorado Facilities that participated in the study.

Slide 25

Study Population

Image: A chart shows the following procedures followed for the two groups in the study population:

1. Uncontrolled HTN → Usual Care → Initial Visit → Referral to PCP → six month follow-up visit.
2. Uncontrolled HTN → HBPM-Heart360® → Initial Visit → Home BP monitoring → six month follow-up visit.

Slide 26

Monitoring Protocol

Images: Photographs show a computer with keyboard, monitor, and mouse, a smiling woman working at a laptop computer, and an older woman monitoring her blood pressure at home. Arrows point from one image to the next.

Slide 27

Results

Image: A photograph shows footprints in the sand.

Slide 28

HBPM Patients Had .Superior 6-month BP Control

Image: A bar graph compares Usual Care, 37%, and HBPM, 57%. (RR = 1.5 (1.2-1.9); p <0.001.)

Slide 29

Heart360® HBPM Group Had a Greater Drop in Systolic BP

Image: A bar graph compares Usual Care, -8, and HBPM, -21. (p <0.001.)

Slide 30

Heart360® HBPM Patients Reported. Greater Satisfaction with Care

Image: A bar graph compares Usual Care, 61%, and HBPM, 90%.(p <0.001.)

Slide 31

What are the cost implications for Heart360® HBPM?

• Intervention Costs.
• CV Events Prevented.
• Cost of Events Prevented.

Image: A photograph shows a complicated locking hatch.

Slide 32

Cost Benefit over 10 Years

Image: A line graph compares millions invested and saved for a ten-year period. The total invested over 10 years =  11 million. Total return over 10 years = 31 million.

Slide 33

Implementation Barriers

• Cost of BP cuffs.
• Need for computer and internet.
• Capitation vs. Fee for Service.

Slide 34

Translation to Routine Practice: A Tale of Two Regions

Kaiser Colorado

Kaiser Southern California

Images: Photographs of a skier skiing downhill and a surfer riding a curving wave are shown.

Slide 35

KP Colorado

• Enthusiastic response to presentations to health plan leaders and stakeholders.
• Initially little movement towards adoption in routine clinical practice:
  • Turnover in clinical champion.
  • Change in organizational priorities.
  • Limited bandwidth.
  • Lack of sponsorship.
• Director of Pharmacy Department stepped forward to sponsor rollout:
  • Currently working toward broader implementation.

Slide 36

KP Southern California

• Enthusiastic response to presentations to health plan leaders and stakeholders.
• Movement towards adoption:
  • Stable clinical champion— > 20 years.
  • Organizational priority—improve efficiency.
  • Sponsorship by Associate Medical Director.
• Current Plans:
  • Pilot at 2 medical centers.
  • Subsidize cost of cuff, consider BP cuff library.
  • Existing infrastructure to support rollout.

Slide 37

Lessons Learned

• Clinical champion.
• Sponsorship.
• Organizational priorities.
• Bandwidth.

Slide 38

Q&A

Images: A question mark and two cartoon figures scratching their heads in puzzlement are shown.

Slide 39

Activity

How Can I Implement This Innovation in My Organization?

Images: A cartoon image shows three people working together to move an enormous stack of papers and file folders.