Breathe Easier: Using Clinical Education and Redesign Techniques to Improve Pediatric Asthma Care

Transcription

1 Breathe Easier: Using Clinical Education and Redesign Techniques to Improve Pediatric Asthma Care Lalit Bajaj,, MD, MPH The Children s s Hospital, Denver Hoke Stapp,, MD, FAAP Colorado Pediatric Partners, LLC Angela Stowe, MS Physician Health Partners, LLC

2 Introductions

3 Objectives Understand how clinical education and disease-specific registries can improve implementation of asthma guidelines Illustrate how the Chronic Care Model and LEAN techniques enhance the redesign of practice office workflow to optimize adherence to evidence based guidelines Apply concepts learned to your health care delivery environment in order to foster collaboration between primary care providers, specialists and hospitals

4 Outline Scope of the Problem Historical Perspective on the Development of the CPP Asthma Quality Improvement Project Program Design Data Lessons Learned Open Discussion

5 What problem are we trying to solve? Asthma prevalence Costs direct, indirect Do we follow published guidelines? Is this a problem that we can solve with the current practice environment?

6 How much does it cost? The direct cost of treating childhood asthma is estimated at $3.2 billion annually. 1 Children with asthma have 3.5 times as many hospitalizations, 3.1 times as many medication prescriptions, and 1.9 times as many physician office visits as do children without asthma. 2 1 Raskin 2003, 2 Raskin 2003

7 Is this all the cost? Each year approximately 10.1 million school days are lost due to asthma. 1 Between 1990 and 2000 the costs associated with the time adults lost from work due to care for a child sick from asthma increased by 88%. 2 And in 1994 alone, the last year for which there is data, children age 5-17 missed 11.8 million school days costing employers $957 million for parents/ caregivers lost work time. 3 1 AON 2001, 2 AAFA 2001, 3 Williams & Powell 2001

8 Do practitioners use the guidelines? delines/asthma/asthgdln.pdf Adherence to published guidelines varies ICS for persistent asthma: 25-50% Influenza vaccine: 25-40% Action plans: 9-40% Barriers: Lack of familiarity Lack of agreement Lack of self-efficacy Lack of time Lack of support staff 440 pages Cabana, 2001

9 Is there a way to fix the problem?

10 Is there a way to fix the problem? Studies all show significant increases in process measures (ICS, action plans, influenza vaccines) More importantly, they are all showing decreases in ED visits and hospitalizations Interventions vary from guideline implementation to more complex interventions utilizing disease registries, case workers, etc. Some study designs utilize CQI analytic techniques, while other utilize chart reviews

11 Background Why invest in quality improvement? Why now? Why asthma? Goals of the program

12 Reimbursement EHR implementation Continuity of care Physician shortages Retail-based clinics Challenges to PCP Volume of clinical information Time Increasing attention to quality

13 Asthma Quality Initiative Collaborative Partnership Colorado Pediatric Partners (CPP) Physician Health Partners (PHP) The Children s Hospital (TCH) Colorado Allergy and Asthma Centers (CAAC) Planning, implementation and evaluation team

14 Target population Population Pediatric primary care practices (CPP) 19 practices, 68 physicians, 140,000 patients Pediatric patients with asthma 7,000 patients (estimated 5% prevalence) Geographic area Front Range

15 Overarching Goals Redesign underlying systems to achieve sustainable improvements Provide consistent and evidence based treatment Empower PCPs/asthma champions/families to take the best care of the patients

16 Process outcomes Severity assessment Controller meds Influenza Action plan Clinical outcomes Measurable Goals ED utilization and hospitalization Missed days of work and school for parents and patients Caregiver confidence

17 Key Components Clinical Education and Access to Specialists Asthma education for providers and staff Guidelines into practice Device training Asthma nurse specialist hotline Asthma consultation or specialist referral Improved communication b/w PCPs and specialists

18 Key Components (continued) Practice Redesign and Improvement Dedicated practice coach Practice assessment Improvement team Chronic Care Model PDSA, Lean

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21 Key Components (continued) Asthma Registry Training and support Registry process Regular reporting Using data to drive improvement

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23 Process Mapping

24 Data

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31 Evaluation/Monitoring Follow-up with practice coach Planning team and board review of IPA and practice-level registry reports Use data to identify gaps in care and drive future educational sessions Collaboration with TCH informatics on data analysis

32 Keys to Success Partnership Keys to Success Planning and implementation infrastructure Curriculum building Registry and tool development Discussions with payers Team members with clearly defined roles IPA commitment Rigorous data evaluation

33 Challenges Hard decisions Buy-in Time commitment Long term investment EMRs Challenges

34 Next Steps Developing IPA-wide educational sessions targeted at improving process outcomes Action plans Asthma Initiative Users Group Better understand practice barriers and how to enhance registry functionality Examine clinical outcomes and patient satisfaction measures

35 Next Steps (continued) Using framework for additional disease states Growth and dissemination Topic of CPP Board discussion Best practice for implementing best practice Integration with other programs Partnership with TCH and CAAC TCH Asthma Clinics IMPACT Network Collaboration with IPIP 30% of CPP practices currently participating Linking information systems

36 How is the office impacted?

37 Scenarios Practice is meeting significant resistance from one of the more senior partners that he is resistant to changing his practice to incorporate the program. My patients get all of the asthma care they need. Same provider, nine months later, with sense of accomplishment on the number of patients he has activated in registry, and noting improvement in patient care

38 Scenarios Mother of persistent asthmatic, having difficulty keeping her child's asthma symptoms under control prior to instituting Asthma Quality Control Program. Unsure what medicines to use when. Since program onset, she now receives updated, written action plan to take home for review when her child s asthma flares. She feels increased sense of competence and confidence in maintaining her child s health.

39 Scenarios Trials of office implementation. Staff concerned about possible increased workload, how will this fit into workflow, does this make a difference for the patient. Establish initiative champions, process development group. Seek input from affected staff, develop processes, continually refine processes. Use Asthma Registry reports to highlight accomplishments of team effort. Meeting or exceeding goals and relationship to improved care.

40 Open Discussion What is the current patient care environment in terms of care for a patient with asthma? Is the care focused on chronic or episodic care? What do the most current guidelines recommend? Severity assessment - do you use a validated tool? Are controllers used appropriately? Flu shots Action plans - are you comfortable with the content?

41 Open Discussion How do you know how you re doing? Do you measure adherence to guidelines? Is there adequate communication with specialist/hospitalist?

42 What tools do we need to improve asthma care? improve asthma care? Clinical education Know who the patients are The right information at the right time A way to measure performance A way to incorporate into practice so we don t die Frequent feedback Some money Partners (can t do it alone)