Let’s all work towards

Improving Patient Care

“Indian Health Medical Home”

George J.Ceremuga, DO, FAAFPCDR, USPHSDirector Emergency Department and Inpatient ServicesCheyenne River Sioux Service UnitEagle Butte, SD 57625george.ceremuga@ihs.gov

Acknowledgements:

CAPT Ty Reidhead, MD CAPT Kelly Acton, MD,MPH,FACP Dr Ann Bullock, MD Dr Peter Ziegler, MD LCDR Michelle Jesse, RN,BSN,MPH

Learning Objectives:

Understand the Improving Patient Care (IPC) model (formerly Chronic Care Initiative), past present and future

Discuss implementation challenges and successes at the Service Unit level

Discuss the effectiveness of the IPC model with clinical outcome data

“What must underlie successful epidemics, in the end, is a bedrock belief that change is possible…”

Malcolm Gladwell- The Tipping Point

We are the “Champions”…..

IHS needs to be the care Indian people choose when they have many choices.

Dr. RoubideauxNational Combined Councils Meeting

IHS Priorities

To renew and strengthen the partnership with Tribes and improve the tribal consultation process.

To bring reform to the IHS in the context of national health insurance reform.

To improve the quality of and access to care.

To have everything we do be as transparent, accountable, fair and inclusive as possible.

What matters to patients/families?

“The care they want and need, when they need it”

Timely and effective access to care Reduced waiting times Helpful, specific, relevant information from

their provider Welcoming environment (customer

service) Safety

What matters to the clinician?

Information at the point of care Summaries, Clinical Notes, Consultant Notes Medication lists, Patient Data

EHR working for the patient/provider, not the other way around

Safety Professional Satisfaction->“Customer

Service”?

How Good Are We in the IHS?

Measure

2008 GPRA Results

Diabetes Dyslipidemia Assessment

63%

Cervical Cancer Screening 59%

Colorectal Cancer Screening

29%

Alcohol Screening 47%

Depression Screening 35%

2008 National Summary – Performance Measurement: Improving Healthcare for AI/ANs

Chronic Care Initiative = Improving Patient Care

Process to address chronic care Practical, supportive, population and

evidence based Interactive between informed

patients and health care team Prepared and pro-active

Improving Patient Care (IPC)

Fall 06

IHS/IHIInitial Meeting

3/06

Expert Meeting

1/07

First meeting of Chronic Disease

Workgroup

12/04

IPC Teams Chosen

Kickoff of “Chronic Disease

Management Initiative”

2/06

Chronic Disease

Management Strategic Plan

Finalized

9/05

What Does the Indian Health System Need to Address Chronic Disease?

“Addressing chronic care as a group would pose significant challenges… requiring an entire system redesign”

IHI are… Experts in:

Looking at systems of care Improvement Execution

Advisors

IHI is not… Experts in Indian Health System Directing our work

Innovations in Planned Care (IPC)

Learning and innovation arm of the Improving Patient Care Model

Began in 2006: IHS and Institute of Health Care Initiatives partnership

Transform the IHS system of care Utilize the Chronic Care Model by

the McColl Institute for Health Care Innovations: used internationally

Improving Patient Care

Fall 06

IHS/IHIInitial Meeting

3/06

Expert Meeting

1/07

First meeting of Chronic Disease

Workgroup

12/04

IPC Teams Chosen

Kickoff of “Chronic Disease

Management Initiative”

2/06

Chronic Disease

Management Strategic Plan

Finalized

9/05

IPC2

LS 1Virtual LS 3

Site visit

Virtual LS 4

LS 5

D

S

A

P

10/08 – 3/10

IPC IPC22/07 – 1/09

We are here…

10/08 – 3/10

Virtual LS 5

LS 1Virtual LS 3

Site visit

Virtual LS 4

LS 5

D

S

A

P

Virtual LS 2

Virtual LS 5

LS 4 & Site Visit

Improving Patient Care Transitions

IPC1

Informed,Empowered Patient

and Family

Productive Interactions through effective asset based partnering over time

Prepared,ProactivePractice Team

Improved achievement of patient and community goals

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community

Health Care Organization

Care Model

Patient Driven Coordinated

Timely and Efficient

Evidence-based and Safe

Informed,Empowered Patient

and Family

Productive Interactions through effective asset based partnering over time

Prepared,ProactivePractice Team

Improved achievement of patient and community goals

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community

Health Care Organization

Care Model

Patient Driven Coordinated

Timely and Efficient

Evidence-based and Safe

IPC2

Improving Patient Care

Design to meet interested IPC2 Teams’ needs

Quality and Innovation Learning Network

Begin July 2010

IPC2 Facilities

Foundations SeriesA system-wide forum for web-based sharing of Best Practices

October 2010

Indian Health Medical Home(IPC3 Collaborative)

Lessons learned from IPC2 to lay the foundation for the Indian Health Home

Foundational Work

I/T/U Facilities

February 2012

Indian Health Medical Home Access and Continuity

Every patient has a relationship with a provider and care team, and has consistent and reliable access to that provider and care team.

Care Centered on the Patient and Family Health programs design their services to put the patient and family at the

center of care, to provide great customer service and to support them as they strive toward wellness.

Care Team Everyone works in a coordinated way as members of highly functioning

teams meeting the needs of the patient. Community Focus

Renew and strengthen partnerships with Tribes and community-based services, and the culture or cultures of the Tribe(s) are integrated into the organization & delivery of care.

Quality and Transparency Everyone in the system has the skills and tools for making improvement,

and uses measurement and data to build better care.

Patient

Care Team

FamilyCommunity

IPC changes compared with other models of care referred to as a “Medical Home”

Improving Patient Care NCQA Patient Centered

Medical Home AHRQ Transforming

Primary Care

Access and Continuity Access and Communication (1) Continuous Access

Care Team

Patient Tracking and Registry Functions (2)

Care Management (3) Test Tracking (6) Referral Tracking (7)

Care Coordination Team-Based Care

Centered on the Patient and Family

Patient Self-Management Support (4) Whole Person Orientation

Quality and Transparency Performance Reporting and

Improvement (8) System-Based Commitment

to Quality and Safety

Community Focused Not addressed Not addressed Meaningful use of the IHS

Clinical Information System or similar capabilities is essential for making the changes of IPC.

Electronic Prescribing (5) Advanced Electronic

Communications (9)

Collection/exchange of information is critical, with health IT an essential tool for achieving these principles

Improving Patient CarePilot Sites (IPC1)

• Gallup Indian Medical Center • Albuquerque Service Unit • Warm Springs Service Unit • Chinle Comprehensive Health Care

Center

• Wind River Service Unit • Sells Service Unit • Whiteriver Service Unit • Rapid City Service Unit

Eight Federal sites:

• Indian Health Council, Inc.• Cherokee Nation Health Services • The Choctaw Health Center• Eastern Aleutian Tribe  • Forest County Potawatomi Health &

Wellness Center

Five Tribal sites:

• The Gerald L. Ignace Indian Health Center 

Urban program:

Improving Patient CareAdditional Sites (IPC2)

• Clinton Indian Health Center• Colville Indian Health Center• Fort Defiance Service Unit• Fort Peck Service Unit• Fort Yuma Health Center• Kayenta Health Center• Northern Cheyenne Service Unit

• Phoenix Indian Medical Center• Red Lake Hospital• Ute Mountain Ute Health Center• Wagner IHS Healthcare Facility• Wewoka Service Unit• White Earth Health Center• Yakama Indian Health Service

Federal sites: (14)

Tribal sites: (8)

Urban programs: (2)

• Chickasaw Nation Health System• Chief Andrew Isaac Health Center • Chugachmiut• Fort Mojave Indian Health Center

• Oklahoma City Indian Clinic

• Oneida Indian Health Service• South East Alaska Regional Health Center• Swinomish Health Clinic• Cherokee Indian Hospital (Eastern)

• South Dakota Indian Health Center

What are we trying to

accomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

Act Plan

Study Do

Plan Do Study Act

Aim: Goal to achieve

Decrease turn around time for pts lab reports to provider at time of visit

Plan: Registration clerks give lab order numbers to pts Prediction: decrease bottle neck and wait time for

patients

Do: Nursing staff report increase wait time bottle neck moved from Lobby to hallway Increased pt confusion

Plan Do Study Act

Study: bottle neck did not improve test not successful

Act: modify plan nurse prepare pt lab orders in advance and clerk to give to pt and instruct to go to lab

Let’s work together towards

Improving Patient Care

The Wewoka Service Unit Experience

Phase 1 Phase 2 Phase 3

LEADERSHIP ENGAGEMENTEngage leadership; Identify sponsor who embraces their role

THE CARE TEAMIdentify and develop the care team, optimizing the roles of the care team , patients and families, and community programs

SPREADDevelop plan for spread

THE VOICE OF THE COMMUNITYInvolve and engage the community

COMMUNICATION PLANDevelop mechanisms to keep the community and staff informed

EFFICIENCYIncrease value added time of all processes

THE MICROSYSTEMIdentify the Microsystem /Target Population

EMPANELMENT FOR IMPROVEMENTEmpanel patients to achieve continuity and improve outcomes

CARE BETWEEN VISITSCare management integrated into care teamASSESSMENT

Assess the microsystem, using the Green Book (revisit intermittently)

CLINICAL INFORMATION SYSTEMOptimize the CIS, using it for reminders, prompts, queries, etc SELF-

MANAGEMENTEmpower the patient and family members by embedding self-management support processes in care

THE AIMDevelop organizational Aim, including some initial plans relating to spread

ACCESS AND CONTINUITYDevelop mechanism to ensure access to care and support continuity

STRATEGIC ALIGNMENTLink IPC aim and goals to the organizational strategic plan

TRANSPARENCY OF IMPROVEMENTMake quality related data available to all (transparency)

THE IMPROVEMENT TEAMID Multidisciplinary Improvement team

THE PRE-VISITPre-visit planning and care delivery (huddles, previsit calls, etc.)

BEHAVIORAL HEALTH INTEGRATIONIntegrate behavioral health

CAPACITY FOR IMPROVEMENTBuild capacity in staff to support improvement

RESOURCES FOR IMPROVEMENTIdentify inefficiencies and eliminate waste,

Phase 1

Phase 1

LEADERSHIP ENGAGEMENTEngage leadership; Identify sponsor who embraces their role

THE VOICE OF THE COMMUNITYInvolve and engage the community

THE MICROSYSTEMIdentify the Microsystem /Target Population

ASSESSMENTAssess the microsystem, using the Green Book (revisit intermittently)

THE AIMDevelop organizational Aim, including some initial plans relating to spread

STRATEGIC ALIGNMENTLink IPC aim and goals to the organizational strategic plan

THE IMPROVEMENT TEAMID Multidisciplinary Improvement team

• Leadership- CEO drew us the “big picture”

• Community forums- Lack of participation

Phase 2 Communication

Tribal Health Board updates

IPC agenda item for ALL events

Medical Home Designated PCP

EHR Screening template

Pre-visit planning DM chart reviews RN case management iCare

Phase 2THE CARE TEAMIdentify and develop the care team, optimizing the roles of the care team , patients and families, and community programs

COMMUNICATION PLANDevelop mechanisms to keep the community and staff informed

EMPANELMENT FOR IMPROVEMENTEmpanel patients to achieve continuity and improve outcomes

CLINICAL INFORMATION SYSTEMOptimize the CIS, using it for reminders, prompts, queries, etc

ACCESS AND CONTINUITYDevelop mechanism to ensure access to care and support continuity

TRANSPARENCY OF IMPROVEMENTMake quality related data available to all (transparency)

THE PRE-VISITPre-visit planning and care delivery (huddles, previsit calls, etc.)

CAPACITY FOR IMPROVEMENTBuild capacity in staff to support improvement

RESOURCES FOR IMPROVEMENTIdentify inefficiencies and eliminate waste,

Phase 3 New employee orientation

FT IPC Coordinator Spread team

Case management

Self-Management Referral to CH programs

Successful SMS Pt’s 36 lb weight loss!!

Behavioral Health integration?

Phase 3SPREADDevelop plan for spread

EFFICIENCYIncrease value added time of all processes

CARE BETWEEN VISITSCare management integrated into care team

SELF-MANAGEMENTEmpower the patient and family members by embedding self-management support processes in care

BEHAVIORAL HEALTH INTEGRATIONIntegrate behavioral health

Where we came from… Extended wait times

Cycle times in excess of 2 hours Numerous trips back & forth to lobby

Unsatisfied patients c/o long wait times

Patients going elsewhere Unnecessary processes Low morale Limited teamwork

Where we want to be…

Satisfied patients Satisfied staff/high morale

Teamwork Patient centered care

Our patients choose to come to us What if they didn’t?

NO delays in care Limited waiting Elimination of unnecessary processes

Improved quality of care Medical home for our People

What we’ve encountered so far…

Staff resistance “This is the way we’ve always done it!” “We can’t do it that way.. We tried it

before and it didn’t work..” “Administration doesn’t understand,

just get through this, we’ll go back to the old way soon.”

Confusion lack of communication

Challenges

Resistance to change “new way” & “old way”

How do we know it is improvement? Working at top of licensure Microsystem change mid-project Empanelment IPC workload/deadlines

Division of duties Reorganization of team June 2009 Dedicated FT IPC Coordinator April 2010

Successes

Universal screening template/dialogue Oklahoma Area wide soon Utilization of our CAC

Administration support Tremendous strides in IPC measures

20 significant measures 55% (11) above goal 40% (8) improving Consistent data reporting

Patient reports of improvement

Lessons Learned

Empanelment Data quality Garbage in/Garbage out

Persistence and communication!! Unconscious PDSA’s Sponsor Support

Benefit for patient care was clear Realized the importance

From the mouths of patients..

“I don’t know what you guys are doing up there, but I was in and out in no time the other day!”

“The changes your making are working, keep up the good work!”

“Quicker than in the past.”

“Nurse & Dr. Fried are very efficient & considerate.”

“I think the system has improved quite a bit.”

“Overall the clinic is improving and we are glad to see this.”

2009 DM Camp

Empowerment Day

IPC Results

Measures

Results

Beginning End

Blood Pressure in Control 56% 67%

Mammogram Rates 50% 55%

Colorectal Cancer Screen 31% 56%

Alcohol Screen (FAS Prev.) 43% 65%

IPV/DV Screening 34% 61%

Depression Screening 41% 60%

Pt Recommending 86% 95%

% of Patients with a Primary Care Provider designated in CIS

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33

Sites

% E

mp

an

elle

d

IPC1 Sites IPC2 Sites36% Empanelled 20% Empanelled

421,800 Patients

“Metabolic Memory”

The term “metabolic memory” is used to describe the phenomenon of cells remembering good control for long periods of time.

This phenomenon is stored early in the course of diabetes, and glycemic control initiated prior to the onset of overt pathology has the most profound long-term impact. The persistence or progression of hyperglycemia-induced microvascular alterations during subsequent periods of normal glucose suggests that previous high or low glucose levels imprint their effects.

.

“Metabolic Memory”

Researchers concluded, “There may be many mechanisms, but whatever it is, the observation is true that a short period of intensive therapy seems to result in this long-term benefit.”

The Legacy Effect: conclusions

“The UKPDS showed the benefits of an intensive strategy to control blood glucose levels in patients with type 2 diabetes sustained up to 10 yrs after cessation of the randomized intervention. Benefits persisted despite the early loss of within-trial differences in A1C levels between the intensive-therapy group and conventional-therapy group – a so-called legacy effect.”

Holman RH et al. NEJM 2008. 359: 1577-1589

Source: 2009 USRDS Atlas

Incidence rates of diabetes-related new ESRD

by race, 1980 - 2007

Improved health and wellness for American Indian and Alaska

Native individuals, families, and communities

Delivery SystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

C ommunity

Health Care Organization

IPC Care Model

Activated Family and Community

Informed Activated Patient

Prepared Proactive

Care Team

Prepared,Proactive

Community PartnersEFFECTIVE RELATIONSHIPS

EfficientSafe EffectiveEquitable

TimelyPatient-Centered

Patient

Care Team

FamilyCommunity

Centered on the Patient and Family Access and Continuity Care Team Approach Community Focus Empowerment for Improvement

IPC “Medical Home”

Patient

Care Team

FamilyCommunity

EHR Meaningful Use

Improve quality, safety, efficiency and reduce disparities Use computerized-provider order entry

Engage patients and families in their health care Provide patients with electronic copy of their health

information Improve care coordination

Exchange key clinical information with other providers

Improve population and public health Submit electronic data to immunization registries

Ensure adequate privacy and security protections for personal health information

Measures

Computerized Provider Order Entry (CPOE)

Measures

Recording Smoking Status Generate lists of patients with

specific conditions Clinical Reminders to patients Clinical Decision Support rules Medication Reconciliation Clinical Quality Measures

How can we know that a change is an improvement?!

Yearly Clinical Measures: 22 GPRA Measures

~21 “Other National Measure” 12 “Transparency Measures” 22 Diabetes Audit Measures 17 CMS Hospital Quality Reporting ?? Meaningful Use Measures