healthy hearts: transforming communities through the integration of public health … ·...

Sandy Anton & Julia Howland March 6, 2013

Illinois Rural Public Health Institute

Healthy Hearts: Transforming Communities through the Integration of Public Health and

Primary Care

Outline Background and burden of cardiovascular disease Healthy Hearts project overview Healthy Hearts technology Healthy Hearts outcomes Evaluation Implementation strategies Quality improvement strategies Community integration Conclusion

Cardiovascular disease in the United States Leading cause of death in the US 815,000 deaths due to cardiovascular disease More than 2 million heart attacks and strokes each year $444 billion in healthcare and productivity costs each year

Cardiovascular disease in Illinois

Leading cause of death 32,000 deaths in 2009 Mortality rate of 351.0 per 100,000 – down from 505.1

in 2000 330,000 heart attacks each year, or 3.5% of adult

population 158,000 years of potential life lost each year

Coronary heart disease prevalence of 5.9 per 100,000 -- equivalent to national prevalence

Risk factors Clinical risk factors:

Uncontrolled hypertension Uncontrolled cholesterol (LDL-C) Current smoking

49.7% of American adults have at least one clinical risk factor; 21.3% had two

Demographic: Men Blacks and American Indians Low educational attainment

CDC MMWR, 2011

Quality care works! Hypertension:

40.7% PAF for CVD deaths For every 10% increase in HTN treatment, 14,000 deaths

prevented annually

Smoking cessation: 13.7% PAF 5% increase in smoking cessation would save 7000 lives annually

Yang et al, 2012

Outline Background and burden of cardiovascular disease Healthy Hearts project overview Healthy Hearts technology Healthy Hearts outcomes Evaluation Implementation strategies Quality improvement strategies Community integration Conclusion

Healthy Hearts Project Overview Part of Illinois' Community Transformation Grant (CTG)

Five year project, funded through CDC

Separate from We Choose Health

Engage Rural Health Clinics, FQHCs and Health Departments in

non-metropolitan Illinois

Overview Focus on cardiac prevention and care in the clinic and in the

community

Engage clinics and communities to design and implement interventions for both the patient and the community

Use nationally accepted best practices in cardiac care

How will this work? Receive EHR data from participant clinics

Translate data into a dashboard of clinical indicators

Use the dashboard to identify provider and clinic

opportunities for improvement

Collaborate with Health Departments and Community Partners to implement interventions to improve cardiac health

Pilot clinics Shawnee Health Services, Marion

Logan Primary Care, West Frankfort

Community Health Improvement Center, Decatur

Heartland Community Health Center, Peoria

Franklin-Williamson County Health Department

Macon County Health Department

Peoria County Health Department

Scale up to 30 clinics by 9/2016

Project Goals

Improve the System for cardiac and preventive healthcare services

Increase access to and demand for high impact quality prevention services through community wide partnerships

Many principles at play Community Oriented Primary Care National EHR and care delivery initiatives Quality Improvement Data driven Clinical improvements Strategic implementation Culture change

Integrating Primary Care and Community Health 1. Take responsibility for the health of a defined population: clinic

and community

2. Combine epidemiologic studies and social interventions with the care of individual patients

3. Primary care > Community medicine

4. Patient and the community become the foci for diagnosis, treatment, surveillance

Supports national initiatives Meaningful Use:

Data will be aggregated through popHealth

Certified MU reference implementation tool Complies with MU requirements for clinical quality

measure reporting

Supports national initiatives Stage 2 Meaningful Use Measure PCMH Standard Healthy Hearts

More than 80% of all unique patients seen by the EP have blood pressure (for patients age 3 and over only) and height and weight (for all ages) recorded as structured data

2B: BP with the date of update for 50% of patients

Data aggregation and reporting through popHealth enables the tracking and trending of patient vital signs at both the provider and clinic level to ensure the 80% measure is met.

More than 80% of all unique patients 13 years old or older seen by the EP have smoking status recorded as structured data

2B: Tobacco use status for 50% of patients >13y/o

Data aggregation and reporting through popHealth enables the tracking and trending of patient smoking status and cessation counseling.

Use clinical decision support to improve performance on high-priority health conditions

6: Measure and improve performance: Measure and report preventive, chronic and acute care Use and monitor effectiveness of QI process

Reports from popHealth can guide clinical decisions for compliance with national guidelines on HTN, smoking cessation, BMI monitoring

Outline Background and burden of cardiovascular disease Healthy Hearts project overview Healthy Hearts technology Healthy Hearts outcomes Evaluation Implementation strategies Quality improvement strategies Community integration Conclusion

Measures HH priority

area MU Stage 2

measure Definition

Obesity CMS69v1 Percentage of patients aged 18 years and older with an encounter during the reporting period with a documented calculated BMI during the encounter or during the previous six months AND when the BMI is outside of normal parameters, follow-up plan is documented during the encounter or during the previous 6 months of the encounter with the BMI outside of normal parameters.

Tobacco CMS 138v1 Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user

Cholesterol CMS61v1 CMS64v1

Percentage of patients aged 20 through 79 years whose risk factors have been assessed and a fasting LDL-C test has been performed. Percentage of patients aged 20 through 79 years who had a fasting LDL-C test performed and whose risk-stratified fasting LDL-C is at or below the recommended LDL-C goal.

Hypertension CMS 22v1 Percentage of patients aged 18 years and older seen during the reporting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated

CMS 165v1 CMS 65v1

Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90mmHg) during the measurement period. Percentage of patients aged 18-85 years of age with a diagnosis of hypertension whose blood pressure improved during the measurement period.

Technology

The Public Health Node Framework for integration between data aggregators and

providers

Transforms and maps data, classifies cases

Used for surveillance, immunization data, electronic lab reporting

Certified for Meaningful Use and HIPPA

popHealth

Clinical quality measure reporting tool Interfaces with electronic health reports to receive

health data using nationally recognized data standards

Produces dashboard reports back in a provider-friendly format for quality improvment

Supports stage 1 and stage 2 Meaningful Use measures

Open source software supported by the Office of the National Coordinator

Individual measure screenshot

Insert slide of provider dashboard

Insert slide of patient list

Multi provider measure screenshot

Multiprovider practice screenshot

Outline Background and burden of cardiovascular disease Healthy Hearts project overview Healthy Hearts technology Healthy Hearts outcomes Evaluation Implementation strategies Quality improvement strategies Community integration Conclusion

Clinical quality goals 30% increase in: Obesity measurement and follow-up plan Tobacco screening and cessation counseling Cholesterol screening; cholesterol below recommended goal Blood pressure screening; blood pressure below recommended goal

Long-term clinical outcomes Quality, accessible primary care lowers hospitalizations and reduces

Medicaid and Medicare costs to states (Bodenheimer, 2006)

Link primary care data from Healthy Hearts with: Medicaid/Medicare charge data Vital statistics Hospital discharge data

Sokol et al, 2005

Sokol et al, 2005

Outline Background and burden of cardiovascular disease Healthy Hearts project overview Healthy Hearts technology Healthy Hearts outcomes Evaluation Implementation strategies Quality improvement strategies Community integration Conclusion

Evaluation UIC School of Public Health Evaluating two major goals: 1. Improve cardiac and preventive healthcare services 2. Heightened integration of community health and primary

care.

Evaluation elements include # of clinics and providers submitting data

% of providers using the dashboard to monitor and improve care

delivery

% of patients receiving care that meets national guidelines

# of community/primary care partnerships focusing on

cardiac/preventive issues

# of community interventions in support of Healthy Hearts guidelines

Challenges Multiple statewide CV efforts produce confusion for providers Resources:

Workload for clinics and LHDs Time and resources are tight Technology

Use of EHRs is fairly new and variable Aggregating data from multiple EHRs

Change!

Strengths Providers are passionate about providing high quality care

Providers are interested in using data to improve their clinical

practice and patient outcomes

Strong community partnerships

Outline Background and burden of cardiovascular disease Healthy Hearts project overview Healthy Hearts technology Healthy Hearts outcomes Evaluation Implementation strategies Quality improvement strategies Community integration Conclusion

Implementation Strategies Large Scale Change McCannon CJ, Schall MW, Perla RJ. Planning for Scale: A Guide for Designing Large-Scale Improvement Initiatives. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2008. (Available on www.IHI.org)

Sustainability and Spread http://www.ihi.org/knowledge/Pages/Tools/HowtoGuideSustainabilitySpread.aspx

Large Scale Change

6 factors to consider when planning large scale improvements:

1.Motivating the participants 2.A strong leadership foundation 3.Well defined aim / goal 4.Clearly define desired change 5.Understand people, politics, and processes where will the change be

implemented 6.Ensure communication and support for the change

1. Engage and Motivate •Why would anyone want to join your initiative? –Clearly define the performance gap or urgent need in local terms.

Data, data, data –WIIFM? •How big is the change? Total system transformation, or best

practice spread? –Clearly state what you expect to achieve: build their support –The knowledge of being involved in something large, important, and

impact-ful

Wagner EH, Austin BT, Von Korff M. Organizing Care for Patients with Chronic Illness. Milbank Q. 74(4)511-44.1996. [Link]

2. Develop Strong Leadership Foundation

•Ensure strong, sound leadership is engaged and effective –Will they publicly represent the change effort? –Gain support from executives, statewide groups, agencies, clinical

experts –Need to commit to advocate for change, remove barriers •Create a compelling statement of the shared problem and a

striking vision –Make a big, audacious statement that will engage the right people at the

highest leadership level –Welcome any participant at any level – build engagement and support

3. Have a Well Defined Goal •Establish a clearly stated, desired outcome –Ambitious, achievable, measurable

•Must have a clear timeframe for action –Clear steps with a sense of progress and pace

•Prepare for other associated outcomes –For example: will practice workflows need to change to ensure EHR

completion? Will LHDs need new data sources to effect and monitor change?

4. Define the Desired Change •Precisely state the change and expected goals –Simple changes, incrementally applied will be better accepted

•Will it make their lives easier - Or improve the lives of their

patients

•Benchmark with others who have successfully implemented

this change. Use them as a shining example –All teach, all learn: prepare for sharing, questions, and problem solving

5. Know the People, Processes and Politics

•Acknowledge the current workload. –Will this be impacted by the change?

•Know what resources are needed from participants – Can we remove “no resources” as an excuse?

•Explore how to align this project with existing work

•Understand how the project and the change may impact

relationships

6. Communicate! •Prepare a structured process for spreading changes between

organizations •Include this project in existing communication channels •Simple, frequent

•Determine the data needed to measure progress. •How will it be collected? Reported?

•Collect and quickly redistribute learning and best practices from

the front lines

•Celebrate accomplishments and improvements

Sustainability: Key principles 1. Supportive, engaged leadership

2. Structures to foolproof change

3. Robust, Transparent Feedback System

4. Shared Sense of System

5. Culture of Improvement

6. Formal capacity-building programs

Robust Feedback System

Monitor what you want to sustain: Quality data dashboards Share information with everyone Establish accountabilities for monitoring, change

implementation

Shared Sense of System

Partnerships between providers, local health departments, community organizations, business

Relationships with a common goal Changes embedded into daily operations

Create a Culture of Improvement From the organization level: everyone needs to be

clear on the quality improvement activity and can explain their role in it.

Staff must see that quality improvement work is part of their job.

Managers write job descriptions to reflect improvement responsibilities.

Create opportunities for sharing ideas and express concerns.

Outline Background and burden of cardiovascular disease Healthy Hearts project overview Healthy Hearts technology Healthy Hearts outcomes Evaluation Implementation strategies Quality improvement strategies Community integration Conclusion

Applied improvement Improving the commute time to work P

D

S

A

Create an improvement mindset Measure what you want to change Involve all staff/participants in data review Apply PDSA

Learning to analyze and objectively think about the data Be willing to continuously review Commit to changes needed for improvements

Outline Background and burden of cardiovascular disease Healthy Hearts project overview Healthy Hearts technology Healthy Hearts outcomes Evaluation Implementation strategies Quality improvement strategies Community integration Conclusion

Community outcomes Strengthen focused partnerships

Implement community interventions

Engage community members

What would this synergy look like? Health occurs in the community Factors that impact patient health? walking trails Farmers' Markets Schools that emphasize activity Community attention to sodium consumption Access to services Relationships between providers and communities

Benchmark practices: Team Up, Pressure Down Pharamacist-directed care, in collaboration with MDs and

nurses, reduces majod CVD risk factors, including HTN Million Hearts sponsored project Train pharmacists in chronic disease management and patient

engagement Pharmacists work with patients to increase medication adherence

and sustain healthy lifestyle choices Videos, patient education materials, posters, medication and

blood pressure tracking tools available

Benchmark Practices: Chronic Disease Self Management Program Workshops facilitated by peer leaders in chronic disease

management Topics: emotional well-being, medication management, exercise,

communication, evaluating new treatments, decision making, nutrition

Highly participative, supportive, and interactive Participants demonstrated improvement in subject areas,

improved perception of health Participants had fewer hospitalizations, fewer days in the hospital,

fewer outpatient visits Cost savings of 1:4

Benchmark Practices: Sodium reduction in hospital environments Hospitals are the second largest employer in the private sector Serve food to sick and immuno-compromised patients, and to

“captured” staff “Healthy” hospital entrees can have >1450 mg sodium Changes in hospital buying practices may affect food service

offerings broadly IDPH and IHA worked with 9 small and rural hospitals to

implement best practice strategies for sodium reduction in hospital environments

Implemented strategies: advertising healthy options, removing salt shakers, increasing healthy options in vending machines

Outline Background and burden of cardiovascular disease Healthy Hearts project overview Healthy Hearts technology Healthy Hearts outcomes Evaluation Implementation strategies Quality improvement strategies Community integration Conclusion

Clinic expectations

Defined leadership and technical contacts Engage all providers Collaborate: in the clinic and the community Participate in learning calls Apply quality improvement techniques Transmit data as needed Information sharing

Health Department expectations

Defined leadership contact Share data Collaborate: clinic and community Participate in learning calls Optimize community activities in support of national guidelines Information sharing

Integrating Primary Care and Community Health 1. Take responsibility for the health of a defined population: clinic

and community

2. Combine epidemiologic studies and social interventions with the care of individual patients

3. Primary care > Community medicine

4. Patient and the community become the focus for diagnosis, treatment, surveillance

Health has nothing to do with Healthcare Healthcare/hospital Rankings Cook County: 3 of the top 100 hospitals Franklin/Williamson: Acute care within standards Macon: Acute care within standards County Health Rankings (of 102 counties) Cook County: #71 Franklin: #97 Williamson: #93 Macon: #86

Sandy Anton, MS RN NEA Sandy.Anton@Illinois.gov 309-231-6123 Julia Howland, MPH CPH Julia.Howland@Illinois.gov 312-814-1344