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

AHRQ Annual MeetingSession 34, Track C

Sept. 10, 2012

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

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 HeartsTM Campaign– National initiative to prevent 1 million heart

attacks and strokes over five years.– millionhearts.hhs.gov

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

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: innovations.ahrq.gov2. Learning and Networking Activities

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

The Innovations Exchange

Visit our Web site: innovations.ahrq.gov/

Follow us on Twitter: #AHRQIX

Send us email: info@innovations.ahrq.gov

Health Coaches as Members of the Health Team

Hali HammerSan Francisco General Hospital,

Family Health Center

San Francisco General HospitalFamily 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

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.

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

Bridgeclarifying information provided by the provider, pharmacy, or insurance companybridging cultural/ linguistic gaps

Clinical continuityfollowing patients who are in their continuity panel, with a goal to maximize continuity between patient and health coach

Emotional supportlanguage- and often cultural-concordance enhances trust and engagement in learning how to self-manage the chronic illness

Clinical NavigationHealth Coaches may be more accessible because they are in clinic every day and can be the primary clinic contact person for patients throughout the weekhelp with making and keeping appointments, accessing pharmacy and other services

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

MeasuresBaseline

Dec. 2009(n=281)

June 2010

(n=268)

Jun. 2011 (n=265)

Dec. 2011 (n=261)

HbA1c at goal (<8) 43% 43% 40% 50%

HbA1c up to date (2 in last year— > 90 days apart) 36% 73% 77% 66%

LDL cholesterol at goal (<100) 51% 51% 64% 63%

LDL up to date 91% 83% 81% 80%

Self-management goal documented

3% 21% 50% no recent data

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)?

Factors to consider in the business case for health coaching

Review of symptoms, diagnosis, medications, addressing urgent problems

Family Community

Patient

Assessment of medication adherence, education, self-management support, phone follow-up (between-visits)

Provider HealthCoach

Communication about medical and psychosocial issues, goals of care, medication problems

VisitPost-visit Pre-visit

Team huddle or other communication

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.

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.

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.

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.

Heart360®

David J. MagidInsitute for Health ResearchKaiser Permanente Colorado

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%

Focus Groups Kaiser Colorado Clinics

Controlling my BP is critical

Office visits are inconvenient and time-consuming

Using a home BP cuff is appealing

Provider Meetings Kaiser Colorado Clinics

Providers

Supportive

Home BP Monitoring supported by Pharmacists and Heart360®

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

Research Question

Study Setting

Study Population

Uncontrolled HTN

HBPM-Heart360®

Initial visit

Usual Care

six month follow-up visit

Initial visit

Referral To PCP

Home BP monitoring

Monitoring Protocol

Results

HBPM Patients Had Superior 6-month BP Control

RR = 1.5 (1.2-1.9); p < 0.001

Usual Care HBPM

37%

57%

P <0.001

-8

-21

Usual Care

Mea

n B

P

dro

p

(mm

Hg

)

Heart360® HBPM Group Had a Greater Drop in Systolic BP

HBPM

Heart360® HBPM Patients Reported Greater Satisfaction with Care

61%

90%

Very to Extremely SatisfiedP <0.001

What are the cost implications for Heart360® HBPM?

Intervention Costs CV Events Prevented Cost of Events Prevented

Cost Benefit over 10 Years

$0

$5

$10

$15

$20

$25

$30

$35

1 2 3 4 5 6 7 8 9 10

Mill

ion

s o

f $

Year

$ Invested

$ Saved

Implementation Barriers

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

Translation to Routine Practice: A Tale of Two Regions

Kaiser Colorado Kaiser Southern California

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

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

Lessons Learned

• Clinical champion• Sponsorship• Organizational priorities• Bandwidth

Q&A

Activity

How Can I Implement This Innovation in My

Organization?