Turning on the Care Coordination Switch in Rural Primary Care Practices

Transcription

1 Turning on the Care Coordination Switch in Rural Primary Care Practices

2 AHRQ Master Contract Task Order #5 HHSA I (9/07-11/09) Care Management Plus research at OHSU is supported by funding from the John A. Hartford Foundation and the Agency for Healthcare Research and Quality. Principal investigator David Dorr, MD

3 Why did we do this study? What were the study objectives and design? What did the practices look like? What were the results? What are the prospects for sustainability?

4 Multiple initiatives to transform primary care practices into medical homes Typical primary care clinician coordinates care for their panel of Medicare patients with 229 other physicians in 117 different practices. (Pham, 2009) Nurse based care management + IT = improved coordination of care and outcomes of chronic illness Care Management Plus shown to be clinically and cost effective in a large health system (Dorr, 2006, 2007) Three-fourths of primary care practices in 2006 employed 5 or fewer physicians

5 Need for external incentives and information technology (Casalino, 2003) Two most common facilitators were strong leadership and an organizational culture that places a high value on quality (Bodenheimer, 2004) Barriers: reimbursements unrelated to quality, poor financial position, physician resistance, physician time constraints, lack of agreement about care process changes desired (Bodenheimer, 2004; Hroscikoski, 2006) In primary care settings, coordination of care has been of poor quality with adverse health care outcomes and poor satisfaction among providers and patients. (O Malley, 2009; Schoen, 2007)

6 TransforMed NCQA PPC-PCMH Initiative Joint Principles Statement AAFP, AAP, ACP, AOA Commonwealth Safety Net Medical Home Initiative Medicare Demonstration Project

7 Outcome: Care that is coordinated across the healthcare system and community Processes included in the Joint Principles: patient population registries; information technology; health information exchange Selected processes from operational definitions (NCQA, CMS demonstration, TransforMed): medication reconciliation; referral tracking; care management by nonphysician staff; facilitate information transfer *Friedberg, Lai, Hussey, Schneider. A Guide to the Medical Home as a Practice-Level Intervention. Am J Manag Care 2009;15:S291-S299

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9 Moving from the exam room (individual patient) care to population-based care Moving from physicianbased care to teambased care Using the Shared Decision Making concept to create an informed activated patient

10 Referral - For any condition or need - Focus on certain conditions Care management Care manager - Assess & plan - Catalyst - Structure Technology - Access - Best Practices - Communication Evaluation - Ongoing with feedback - Based on key process and outcome measures

11 Care Managers act as a guide, coordinator, and helper to facilitate patients receiving coordinated, sensitive care. Access Better teamwork = better access Performance Measurement & Quality improvement Help improve both experience and measures Evidence-based practice Collaborative care planning Care managers involved in population review, assessments, and protocols Health Information technology Use IT better Care management system = CMT Planned visits / Followup Care managers help with follow-up Tracking Help create a tracking environment

12 Patients are taught to self-manage and have a guide through the system. Care managers receive special training in Education, motivation/coaching Disease specific protocols (all staff included) Care for seniors / Caregiver support Connection to community resources

13 Majority of daily patient/clinician interactions occur in ambulatory settings Majority of prescriptions for medications written in ambulatory settings While growth of HMOs and large integrated healthcare systems has been dramatic, >50% of Americans still receive primary care services in smaller (3-10 clinician) practices Significant amount of care in these settings flies under radar of most national quality monitoring efforts *David Lanier, Agency for Healthcare Research and Quality

14 Funded by a task order from the AHRQ PBRN Master Contract initiative Task Order #5: Assessing the clinical impact and business care for nurse-based care management Care Management Plus (CMP) is a program with a proven track record, improved clinical and economic outcomes in a large integrated health system Most small practices do not have a systematic approach to coordinated team care Research Question: Will CMP work in small to medium sized independent primary care practices?

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16 Test the feasibility and acceptability of nurse-based care management coupled with information technology in rural settings through implementation and expansion of Care Management Plus; Evaluate the effect of care management in rural settings on clinical outcomes, including hospitalizations, emergency department visits, disease-specific clinical measures, and specialty utilization; Evaluate the economic impact of nurse-based care management at the overall patient expenditure and primary care practice level.

17 Designate a care manager for 17 months (Group 1) with enough FTE to implement the project 3 to 5% of patient panels (>18 years old) with chronic conditions 1.0 FTE manager cares for up to 1000 patients/year For example, 10,000 patient panel requires.4 FTE manager Nurse Care Manager to participate in a 2 day training program in Portland Clinicians and staff to participate in pre- and postintervention surveys Clinicians to complete ACIC pre- and postintervention To provide data from the clinics billing systems

18 Training in care coordination for patients with chronic conditions-- Care management software and support A summary of clinic s own clinical and economic data: de-identified aggregate outcomes for the entire project Payment to offset training time and data collection by the care managers and clinic staff--$6,000/practice

19 Intervention Group Immediate Delayed Specialty Clinic A FM Clinic B PEDS Clinic C FM Clinic D FM Clinic E PEDS Clinic F FM Physicians Other clinicians Patients in the practice 11,312 12,813 12,647 9,936 6,180 6,627 Business Model Not for profit Private Practice Not for profit Private Practice Private Practice Electronic Health Record NextGen Misys Epic Centricity Practice One Not for profit Epic

20 Feedback to participants Final assessment / maintenance Implementation Assessment (mid) Readiness Assessment (pre) Introduction Implementation Randomize Selected Clinics Group 1 Group 2 CMP Training IT Assessment / Implementation Care manager available IT Available Continue Care Manager Continue IT CMP Training IT Assessment / Implementation Month

21 Practice C (FM) Practice B (Peds) Total # patients seen # patient encounters # of Encounter Types Telephone MD Office CM Visit Non-encounter related Home *12 months of activity for Practice C and 10 months for Practice B

22 Practice B (FM ) Practice C (Peds ) Total # of Encounter Reasons Status Check New Patient Resource Management Unknown DM Follow-up Med Assistance Med Management

23 Diabetes 180 Tobacco use 92 Hypertension 90 Depression 59 Chronic pain 41 COPD 36 Alcohol Dependence 33 Lupus 31 PKU 29 Pregnancy 29 Developmental Delay 93 IEP 74 GERD 68 Social Service Intervention 68 ADHD 65 Autism 63 Asthma 55 IFSP 54 Apnea 51 Cerebral Palsy 49 Practice C Family Medicine Practice B--Pediatrics

24 Chronic conditions Medications Preventive care summary Pertinent labs Pertinent exams Passive recommendations Organized by illness

25 Measure Family Medicine Clinic A C D F Diabetics will have HbA1C measured in the last 6 months X X X X Diabetics will have LDL cholesterol in the last 12 months X X X Diabetics will have a target HbA1c level of <7.0% X Diabetics will have BP measures in the last 6 months X Diabetics will have a depression screen with a PHQ9 in the last 12 months X Patients, ages 5 to 40, with mild, moderate or severe persistent asthma will be prescribed a long-term control medication Patients with CAD will be prescribed aspirin or clopidogrel X X

26 Pediatric Clinic B (ages 0 to 21) Patients with Pervasive Developmental Disorder evaluated with clinic version of Childhood Autism Rating Scale (CARS) Type 1 DM patients will have HbA1C measured in the last 3 months Patients with Anxiety Dx will be evaluated every 6 months with Screen of Child Anxiety Related Disorders (SCARED) Pediatric Clinic E (ages 0 to 18) Diabetic patients will have a HbA1C level measured in the last 3 months Newly-diagnosed depression patients ages will have a PHQ 9 administered at each monthly visit Asthma patients who are on preventive medication will have a current action plan in place

27 Semi-structured interviews Cohorts: clinician champions, clinician partners, practice-administrators, nurse care managers Pre ideal outcomes, current barriers to chronic illness care Post barriers to implementation, facilitators, and sustainability

28 Cohort Pre-Intervention Post-Intervention Clinician Champion 6 6 Clinician Partners Physician a NP or PA 8 6 b Practice Administrator 6 6 Nurse Care Manager 11 8 c Total a Four physicians left the practices or retired during the study b Two non-physician clinicians were unavailable for post-intervention interviews c Three NCMs did not participate in the post-intervention interviews. Two RNs were trained but never served as NCMs in their practices. One NCM left practice prior to the post-intervention interview

29 Barriers to Chronic Disease Management in Current Practice Patient Factors Behavioral barriers Lack of patient resources Clinic Factors Access to care Time: payment structure and 15-minute office visits No patient registries and reminders Barriers to Practice Change (Implementing Nurse Care Management) Resistance to change in procedures, provider interactions Clarifying role definitions Resources: time and money Resistance to practice change IT implementation challenges Support from clinic/health system administration

30 Pre-Implementation Interviews Ideal Outcomes Care coordination and patient follow-up Improved patient outcomes/quality of care Increased clinic efficiency Post-Implementation Interviews Post-Implementation Successes NCM incorporated into routine care Systematic way to track care and communicate outcomes Improved patient care and clinical/ community services Facilitators of Success NCM is the the right person for the job Leadership across cohorts Developing a teambased care approach Challenges to Success Finding the right person for the NCM role Limited clinic resources (i.e. time, financing, personnel) Lack of support from clinic administration/ management Practice facilitation Integration of role takes time Resistance to change Technical barriers Limited patient resources

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32 Ongoing engagement is vital Frequent face-to-face visits, the Practice Enhancement Research Coordinators (PERCs) are key Developing a learning community among the intervention practices to learn from each other. Identify the decision makers in the practice, it is not always the clinician champion To implement an effective care management program the practices need resources beyond a model and software. Translation: $$$ are needed as well as ongoing facilitation Change across an entire practice is difficult Practice change fatigue is real Listen and be responsive to the care managers and clinicians

33 Clarity of task, direction from leadership, organization of the team and empowerment of the staff were critical to implementation success. (Clinician) If administration doesn t support it, it won t happen. (Lead clinician) The [use of NCM] increased once the clinicians had a good experience with the process providers need to develop a better mind-set that thy have another team member to rely upon. (Care Manager) It s nice to know there is something else to offer these patients other than another office visit. (Clinician)

34 Before During After Clinic A, FM Clinic B, PEDS Clinic C, FM Clinic D, FM Clinic E, Peds Clinic F, FM Total *At clinics A, B, C, & D, NCMs may fill this role part-time, so staffing should not be equated with 1 FTE

35 A proven care coordination program Adequate staffing for care coordination Buy-in at all levels leadership, clinicians, and staff Time for change Functional health information technology Measurement Practice facilitation