Post on 31-Mar-2015
transcript
A quick review of the IHI learning lab
Moving into the Medical Home
Building the PCMH From the Ground Up
Build the proper structure
Focus on high leverage processes that by their nature can be effected to achieve the IHI triple aim of:◦ Improve the patient experience (satisfaction) ◦ Improve the health of the population ◦ Control or reduce cost
Then measure the outcomes
Using the Model to Get Broad Outcome Improvement
Identification and management of depression Management of care transitions Care coordination Team-based care Identification and management of socially
frail/ isolated individuals Pharmacologic management including
optimizing medication and dealing with adherence issues
Enhancement of the therapeutic environment
7 High Leverage Processes
Why it’s high leverage◦ Very high prevalence◦ Under diagnosed◦ Major gaps in care◦ Depressed individuals have more somatic
complaints◦ Chronic illness can produce depression◦ Depression as a comorbidity roughly doubles the
cost of the chronic illness
1. Depression
Using Technology◦ Identify high risk patients (multiple chronic
illnesses, multiple medications, unemployed, on disability…)
◦ Screening built into visits at regular intervals (e.g. PHQ2)
◦ Recall and tracking systems◦ Medication adherence tracking
Other resources◦ Community resources◦ On site integrated behavioral health (e.g.
counselors, CNS)◦ Liaison Psychiatrists and Psychologists
Depression
Why it’s high leverage◦ High risk situation for both quality and cost
outcomes◦ Patients and families experience considerable
anxiety and frustration at care transitions◦ Improving care transitions reduces the incidence
of hospitalizations and rehospitalizations
2. Care Transitions
Using Technology
◦ On demand medical records access Hospital portal ED and hospitalist access to PCP medical record
◦ Automated HIE All ED notes, H & P’s, consults, op reports, labs, and
imaging reports flow to EMR
Care Transitions
Why it’s high leverage
◦ Community care of North Carolina, Geisinger Health System, Kaiser, Group Health of Puget Sound, and Voice of Detroit Initiative have all reported positive outcomes using imbedded care coordinators
Care coordinators need to be part of the care team with a well defined specific role
◦ Remote third part care coordination and case management has been shown to not work as well
3. Imbedded Care Coordination and Case Management
Using Technology◦ Patient registries embedded in the EHR able to
identify specific populations With particular diagnoses With gaps in care Who are overdue for services Who are not at goal With high illness burden With limited social supports
◦ Measure overall practice or physician performance
◦ Benchmarking
Care Coordination
Why it’s high leverage
◦ MDs cannot provide all the care in the patient centered medical home model
◦ Consistent with the Chronic Care Model
◦ Improved quality and cost outcomes with team based care (Kaiser, Geisinger, Virginia Mason, CareOregon…)
4. Team Based Care
Key processes◦ Redefine roles and responsibilities including
integrating BH, SW… The work is done by more people but needs to be
coordinated◦ Internal communication gets more complex◦ Reframe patient expectations (this can be part of the
PCMH) discussion Technology support
◦ Internal messaging IMs, Texting…◦ Patient Portals◦ Shared care plans (ideally web based that can be
accessed by the entire care team)◦ As well as what has become the floor but needs some
refinishing CDSS, registries, and tracking systems
Team Based Care
Definition: combination of social isolation and low self esteem
Why it’s a high leverage process◦ Four times the cost of matched populations◦ Amenable to low cost interventions (brief
intervention with a counselor significantly improves outcomes) Support groups, case management, plug in to local
resources, pets…◦ Risk equivalent to smoking a pack of cigarettes
per day
5. Socially Frail Individual
Low self esteem- ◦ Question 6 on the PHQ9 are you feeling bad about yourself
or that you are a failure or that you let yourself or your family down.
Lubben Social Network Scale – 6◦ Family
How many relatives do you here from at least once a month? How many relatives do you feel at ease with that you can talk
about private matters? How many relatives do you feel close to such that you could
call on them for help?◦ Friendships
How many of your do you see or hear from at least once a month?
How many friends do you feel at ease with that you can talk about private matters?
How many friends do you feel close to such that you could call on them for help?
How to identify the socially frail individual?
Why it’s high leverage
◦ High prevalence of polypharmacy in patients with chronic illness Increased adverse drug events, drug-drug
interactions Issues of non-adherence, affordability, and patient
confusion Studies have shown decreased benefit when patients
are taking more than four medication
◦ Significant morbidity, mortality and cost associated with medication mismanagement
6. Medication Management
Key functions◦ Identify patients at risk due to polypharmacy and non-
adherence Manage out of pocket costs Address various contributors to non-adherence
◦ Medication reconciliation Technology infrastructure
◦ EHR drug-drug and drug-condition programs Formulary management programs Filled prescription information
◦ Portal◦ HIE
Brainstorming ideas:◦ Flash drives, medication reminder apps, blister packing
Medication Management
Why it’s a high leverage process.◦ Patients highly value the relationship with their
provider Continuity and the duration of the relationship correlate
with positive outcomes Patients want a care team who take the time to listen to
them and to know them as individuals The relationship often helps with patient activation
◦ Key functions Continuity Tracking patient preferences Access (visits, phone, e-mail…) Outreach Responsiveness Caring relationship
7. Enhancing the Therapeutic Environment
Technologic support◦ Secure messaging◦ Patient portal◦ Web-sites◦ Recall systems◦ Patient interaction with EHR◦ Use the EHR to track specific patient details
Enhancing the Therapeutic Environment
Superior clinical outcomes require investment in sustainable structures and processes
Medical homes can help achieve the goals of improving the patient experience, reducing costs, and improving population health
Focusing on highly leveraged processes and using technology are essential
Using technology thoughtfully is equally important
Summary