new health partnerships: improving care by engaging patients
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New Health Partnerships: Improving Care by Engaging Patients. Doriane C. Miller, MD Director, Center for Community Health and Vitality University of Chicago Medical Center Judith Schaefer, MPH Research Associate MacColl Institute, Group Health Research Institute - PowerPoint PPT PresentationTRANSCRIPT
New Health Partnerships: Improving Care by Engaging Patients
Doriane C. Miller, MDDirector, Center for Community Health and Vitality
University of Chicago Medical Center
Judith Schaefer, MPHResearch Associate
MacColl Institute, Group Health Research Institute
PCPCC Multi-Stakeholder Demonstrations May 4, 2010
• Provide an operational definition of CSMS• Show the evidence for efficacy• Demonstrate its context in patient centered care• Promote its role as a quality improvement strategy• Give examples of its influence on system redesign,
patient outcomes and the business case for chronic care
• Provide tools for you to try in your practice
Objectives
Collaborative Self-Management Support: Operational Definition
• Collaborative goal setting and shared decision making
• Regular follow-up, monitor and assess progress towards goals, relating plans to patient’s social and cultural environment
• Tracking and ensuring implementation, including linking support programs to the individual’s regular source of medical care and monitoring their effects on a patient’s health
Evidence Base for Self-Management Support
CDSMP - Six Week Program
Heterogeneous groups of patients with CHF, arthritis, chronic lung disease and stroke
• Improvements in cognitive symptom management, health distress, communication with provider
• Fewer hospitalizations and days in the hospital
Follow up Longitudinal study • Patients able to maintain gains of reduced ED and
hospitalizations, Improved quality of life
– Lorig KR, et al. Med Care 1999; 37(1):5-14. and Med Care 2001; 39(11):1217-23.
Informed,ActivatedPatient
ProductiveInteractions
Prepared,ProactivePractice Team
DeliverySystemDesign
DecisionSupport
ClinicalInformation
Systems
Self-Management
Support
Health System
Resources and Policies
Community
Health Care Organization
Chronic Care Model
Improved Outcomes
19 out of 20 interventions with improved processes or outcomes of care included self-management support
Bodenheimer JAMA, 10/2002.
Gaps in Practice
• Provider lack of awareness/skills • Provider doubt about effectiveness• Rushed practitioners not following established
practice guidelines • Lack of care coordination • Lack of active follow-up to ensure the best outcomes • Patients inadequately supported to manage their
illnesses
Self-Management Support and The Planned Care Model
• Delivery system redesign: assure delivery of effective and efficient clinical care and self-mgt
• Decision support: promote SMS consistent with scientific evidence and patient preferences
• Clinical information systems: organize pt and population data to facilitate SMS
• Health care organization: create a culture, organization and mechanisms that promote SMS
• Community: mobilize community resources to promote SMS
Learning Collaboratives 1 & 2
• 7-11 months
• 26 teams: rural/urban, ethnic mix, condition-specific and cross-cutting projects, safety net and FFS
• Core competencies, system redesign, IT, community linkages
• Business Case
• Patient and/or family involvement
• Goal setting (patient support measure)• System for documenting self-management support services
(organizational support measure)• Integration of SMS into primary care (organizational support
measure)
Quality Allies Learning CommunityPrimary Care Resources and Supports Survey
3 Measures with Greatest Change -- Baseline to Follow-up
0 10 20 30 40 50 60 70 80
Patient Support Score
Organizational SupportScore
Follow-up
Baseline
Quality Allies Learning CommunityPrimary Care Resources and Supports Survey
Support Score Totals Across All Sites*
•n=20 sites at baseline; n=18 sites at follow-up•All pre/post changes significant at p<.01
Content Results
• Robust practice models for adoption/replication in varied settings
• Business case for safety net and fee-for-service
• Patient and family involvement
Hamster CareHamster Care
Self-Management in office practice
Glasgow RE, et al (2002) Ann Beh Med 24(2):80-87
Personal Action Plan1. List specific goals in behavioral terms2. List barriers and strategies to address barriers3. Specify Follow-up Plan4. Share plan with practice team and patient’s social
support
ASSESS :Beliefs, Behavior & Knowledge
ADVISE :Provide specific
Information abouthealth risks and
benefits of change
AGREE:Collaboratively set
goals based on patient’s interest and confidence in their ability to change
the behavior
ASSIST :Identify personal
barriers, strategies, problem-solving
techniques and social/environmental
support
ARRANGE :Specify plan for
follow-up (e.g., visits,phone calls, mailed
reminders
If you have DIABETES, here are some things you can talk about with your health care provider
Choose to talk about changing any of these and add other concerns in the blank circles.
Blood glucose monitoring
Taking medications to help control blood sugar
Losing weight
Daily foot care
Depression
Smoking
Skin careTaking insulin
Diet
(RI Dept of Health Chronic Care Collaborative)
Action Plan
1. Goals: Something you WANT to do
2. Describe
How Where
What Frequency
When
3. Barriers
4. Plans to overcome barriers
5. Conviction and Confidence ratings (1-10)
6. Follow-Up:
“How convinced are you that it is important to monitor your blood sugars?”
Not at all convinced
Totallyconvinced
0 1 2 3 4 5 6 7 8 9 100 1 2 3 4 5 6 7 8 9 10
Assess Conviction/Importance
“What makes you say 4?”
“What leads you to say 4 and not zero?”
“What would it take (or have to happen) to move it to a 6?”
(From Keller and White, 1997; Rollnick, Mason and Butler, 1999)
“U.S.” SMS Toolkit for Clinicians
• High Impact Changes – before, during and after the visit
• Big Picture Cycle of SMS – proactive care delivery process
• Brief descriptions and links to tools
Three System Change Strategies
• Create a Team
• Shared Care Plan
• Follow up Care and Community Links
We will know who you are and we will be ready for you.
Borgess Ambulatory Care, Kalamazoo, MIBorgess Ambulatory Care, Kalamazoo, MI
At the center of patient care are face-to-face healing relationships.
Patient: NursePatient: Nurse
Nurse: PhysicianNurse: Physician
Nurse: NurseNurse: Nurse
Patient: PhysicianPatient: Physician
“Teamlet” Model
• Primary Care Physician • 1-2 Medical Assistants
– Lay “coaches”
• Action Planning and follow up by MA’s• MA’s may accompany patients in doctor visit
• Bodenheimer, 2008
The Patient The Medical Assistant
The Provider
Leaves with scripts, referrals, and instructions
Integrated planMedical
&SMG
The Patient
The Medical Assistant
The Provider
Other Activated Patients
First key service: MA planned visits
Planning and preparation:
Do goal setting on
patient determined goal
Assure all information
is up to date in chart
The Provider – Integrated medical plan and self management goals
BBSWAR
ACKGROUNDARRIERSUCCESSES ILLINGNESS…CTION PLANEMEMBER
NON-DIRECTIVE COUNSELLING
And our Group Visits…
Patients helpingPatients…
The MINI-group visitThe Open-Office Group visitStressors, depressed mood,
barriers, difficulty coping ALWAYS covered
Coping strategies developBoth involve goal setting
Population Management Work Flow
MD:reviews worksheets, identifies appropriate interventions, and checks off instructions for Program Assistant to communicate to the patient, including:
• Lab studies• Medication
adjustment• Referrals• F/U
appointments
Requires approx. 15 min per 10 worksheets
Program Assistant: • Contacts patient in
doctor’s name and communicates interventions and/or referrals, collects other information (i.e. Aspirin use) as indicated by the physician on the worksheet
• Faxes or calls Rx to Pharmacy
• Sends Lab requisition Books classes/ TAVs/appointments
• Enters data• Confirms patient
allergies and current medications
Requires 10-20 min/pt
Program Assistant :enters information regarding follow-up interval into a tracking system. And places worksheet in outpatient chart.
Program Assistant :Prints structured worksheets containing CV risk factor information including:
• Labs• Medications• Blood pressure• Immunizations• Allergies• PCP visit info• Care
Management or classes
StartStart
Mercy Clinics, Inc.• Des Moines, IA & suburbs
• 27 Clinics,140 Physicians─ 70% Primary Care
• 793,000 patient visits in FY06
• 100% Fee-for-Service
• Virtual Private Practice─ All revenue & expenses are tracked to
individual doctors─ The difference is the doctors’ salary
Mercy Clinics: Population Health Coach
• RN background• Health Behavior
Change• Shared medical appt• Medication adherence• Plan Do Study Act• Diabetes mgt• Health Literacy• Depression Screening
• Disease Registry• Pre-visit chart
review/labs• Self-management
support• Care coordination• Quality improvement
Patient Name: ______________________ Date: ___________
Self-Management Support – 5A’s
Agree To an agenda - what does the patient want to work on?
*Patient Goal: ____________________________________________ Assess READINESS to Change Not ready Unsure Ready
IMPORTANCE in relation to other values Low Medium High CONFIDENCE of success Low Medium High Advise What would the patient like to talk about?__________________________________ Information exchanged (elicit-provide-elicit): Assist Patient to develop a personal action plan (if patient is ready).
Emphasize personal choice and control Reassess importance, confidence, readiness Do not confront resistance with force – use reflective listening
1. Options for behavior change (usually there are many possible courses of action)
2. Patients preferred option: ____________________________ 3. Are there barriers the patient needs help with (depression)?
4. Follow up plan - When : ___________ How: Phone___________ Other _________ Educator Signature:_______________________
Arrange: to contact the patient between visits. *Follow-up Contact: Completed on - Date:___________
1. Results of behavior changes 2. Barriers encountered (if any) 3. Preferred option for new plan
4. Follow up plan - When : ___________ How: Phone___________ Other _________ Follow-up Signature:_____________________
*Required to bill Wellmark (Individual visit - S9445
Dealing with resistance
MCI Self-
Management Support
Encounter Form
SECAT Performance ReportsSouth
Jan-07
ALL Diabetes Data: February 1, 2006 - January 31, 2007Provider Agey Borchardt Brightwell Brown Evert Herman McCoy Zachary Zea Goal
Total Patients 95 125 47 148 98 7 127 60 16
Process goals:
HgAlc last 12 mo. 98% 95% 94% 98% 95% 100% 93% 100% 100% 94%
LDL last 12 mo. 94% 96% 91% 97% 89% 100% 93% 98% 100% 94%
SBP last 12 mo. 97% 96% 94% 98% 94% 100% 93% 100% 100% 94%
Microalb last 12 mo. 76% 74% 83% 90% 83% 100% 75% 87% 88% 90%
DRE last 12 mo. 25% 19% 9% 32% 31% 0% 33% 37% 19% 70%
Outcome goals:
% HgAlc < 8.0 89% 93% 88% 90% 81% 71% 87% 90% 75% 75%
% HgAlc < 7.0 64% 73% 65% 71% 56% 57% 67% 58% 62% 50%
% LDL < 130 88% 94% 98% 93% 90% 86% 96% 96% 94% 75%
% LDL < 100 60% 76% 77% 71% 67% 43% 80% 81% 63% 65%
% SBP < 140 95% 84% 95% 92% 89% 86% 94% 85% 100% 70%
% SBP < 130 70% 60% 70% 60% 64% 86% 75% 57% 75% 65%
North Clinic - Diabetes VisitsCoach
Introduced
2003 2004 2005 20062007
annualizedTotal Diabetes Visits 733 824 881 1334 1446Per Cent 99214 47% 62% 58% 62% 67%Weighted average charge / visit $105 $113 $111 $113 $115Total Diabetes EM Charges $76,769 $92,746 $97,546 $150,523 $166,516
Microalbumin 365 479 739 2058 2,083UACR charges $10,950 $14,370 $22,170 $61,740 $62,498
HgA1c 1274 1389 1384 2024 2135HgA1c charges $34,398 $37,503 $37,368 $54,648 $57,642
Total Office DM charges $122,117 $144,619 $157,084 $266,911 $286,656Yearly Gross Differential $22,502 $12,465 $109,827 $19,745
Yearly Net Differential $15,751 $8,726 $76,879 $13,821
10 providers & 1.6 FTE Health CoachesFinancial Case
2006 North Clinic Health Coach Financial Summary
Revenue CommentsEM visit & lab differential $76,879 Level 1 visits (1801 * $25) $45,025 1801 visits @ $25 netOffset Dr. & Nurse work $15,183 estimate is probably lowP4P - 2006 actually paid $114,000 Total Revenue $251,087
ExpensesHealth Coach Salary - RN-II $36,728 0.7 time salary & benefitsHealth Coach Salary - LPN $36,434 0.9 time salary & benefitsDifferential Microalbumin cost $ 9,932 $6.29 for 1579 testsDifferential HgA1cost $ 4,763 $7.50 for 635 testsTotal Expenses $87,856
Contribution to Overhead $163,231
Shared Care Plan
Truly Shared Care Plan
• Shared Data– HbA1c and walking club experience
• Shared Team– Specialists and Aunt Margaret
• Shared Goals– Reducing BP and marimba classes
Whatcom County and Beyond
• PatientPowered.org
• Web platform
• Health 2.0
• http://www.patientslikeme.com/
• www.NewHealthPartnerships.org
• www.improvingchroniccare.org
• www.familycenteredcare.org
Resources