Using Research in the Real World:
Influencing National Health Policy
Chad Boult, MD, MPH, MBA
Professor of Public Health, Medicine and Nursing
Johns Hopkins University
AcademyHealth
Annual Research Meeting
June 29, 2009
Goal: To use science to help
transform chronic care
Objectives:
– Design an evidence-based model of chronic
care that is feasible to adopt everywhere
– Conduct rigorous tests of the model
– Communicate the results to policy-makers
and other stakeholders in chronic care
– Assist organizations in adopting the model
Diffusability Factors
• Relative advantage over current practice
• Compatibility with current culture and
practice
• Simplicity
• Observability
• Trialability
• Timing of ROI
Everett Rogers, The Diffusion of Innovations
Guided Care
Specially trained RNs based in primary
physicians’ offices
GCNs collaborate with physicians in caring
for 50-60 high-risk older patients with
chronic conditions and complex health
care needs
Nurse/physician team
Assesses needs and preferences
Creates an evidence-based “care guide”
and a patient-friendly “action plan”
Monitors the patient proactively
Supports chronic disease self-management
Smoothes transitions between care sites
Communicates with providers in EDs,
hospitals, specialty clinics, rehab
facilities, home care agencies, hospice
programs, and social service agencies in
the community
Educates and supports caregivers
Facilitates access to community services
Who is Eligible?
25%
High-Risk
All
Patients
Age 65+
Review previous
year’s claims data
with PM software
75%
Low-Risk
Study Design
13,534 Patients of 14 teams/49 physicians
3,383 (25% highest-risk)
904 = Consenting Patients
(Baseline Evaluation)
485 in seven
Guided Care
teams
Random
Allocation
419 in seven
Control teams
Effects on Quality of Care
PACIC scales:
GC
UC
aOR*
95% CI
P
Goal setting
24.6
11.6
2.4
1.5-3.7
<0.001
Coordination
14.2
7.1
2.3
1.3-4.0
0.005
Decision support
42.7
33.1
1.5
1.1-2.1
0.014
Problem solving
33.4
24.7
1.4
1.0-1.9
0.096
Patient activation
26.6
23.0
1.1
0.7-1.5
0.763
17.4
8.5
2.0
1.2-3.4
0.006
Aggregate
* Adjusted for baseline socio-demographics, health, function, PACIC scores, site
Effects on Caregiver Strain
Effects on Physician Satisfaction
Communicating
with patients
Communicating
with caregivers
Educating
caregivers
Motivating
patients
Know all pt’s
meds
Guided Care
(n=18)
Usual Care
(n=20)
0.11
-0.42
P
0.047
0.39
-0.11
0.066
0.50
-0.34
0.008
0.39
-0.40
0.006
0.29
-0.18
0.034
Very satisfied
6
Satisfied
Somewhat satisfied
5
Somewhat dissatisfied
3
Dissatisfied
2
Very dissatisfied
1
GCNs' Satisfaction with Clinical
Activities
4
1
2
3
4
5
6
Satisfaction Items
Satisfaction Items
1= Familiarity with patients
2= Stability of patient relationships
3= Comm. w/ patients; availability of clinical info; continuity of care for patients
4= Efficiency of office visits; access to evidence based guidelines
5= Monitoring patients; communicating w/ caregivers; efficiency of primary care team
6= Coordinating care; referring to community resources; educating caregivers
7= Motivating patients for self management
7
Effects on Net Costs of Care
(per caseload, 55 patients)
GC – UC
Difference
Average
Expenditure
Cost
Differenc
e
Hospital days
-76.1
$1,519/day
-115.6
SNF days
-99.1
$305/day
-30.2
Home health
episodes
-20.1
$1331/episode
-26.8
Physician visits
40.0
$41/visit
1.7
Gross savings
-----
-----
-170.9
Cost of GCN
NET SAVINGS
95.9
-----
-----
-75.0
Early Results
• Guided Care improves the quality of
chronic care.
• Guided Care appears to reduce insurers’
net expenditures for health care.
• Guided Care appears to be feasible to
implement and popular with physicians,
nurses, patients and caregivers.
Stakeholders
Design of the model and the study
Reporting of outcomes in journals and at meetings:
Quality of care, quality of life, caregiver strain, nurses’/physicians’ job
satisfaction, practice environment, use/cost of health care
Beneficiaries
AARP
Physicians
ACP
AAFP
AOA
AGS
Policy Makers
Practice
Organizations
MGMA
AMGA
IHI
Case
Managers
CMSA
Nursing
IJHN
NGNA
ANA/ANCC
Insurers
CMS
KP
Tricare
United
Senate
HR
NHPF
Communicating with Policy Makers
• Identify relevant policy makers’ health LAs
• Meet in person
– Describe research briefly
– Describe its relevance to public policy
• Ask for specific legislative actions
– List who would support legislation
• Follow up
Replication
Will practices adopt the model?
Will practices change the model?
Will the model produce similar results in
non-research settings?
Technical Assistance
•
•
•
•
•
Guided Care implementation manual
On-line course for Guided Care nurses
On-line course for physicians
Guidance in selecting EHRs
Regional weekend “Learning
Collaboratives”
• “Learning communities”
• Consultation
Using Science to Transform Care
• Design the innovation for diffusion
• Conduct rigorous tests of the model
• Communicate relevant results to policy
makers and other stakeholders
• Distribute technical support: books, courses,
certificates, facilitation
• Maximize potential for replicability of results
• Align with secular trends
Grant Support
John A. Hartford Foundation
Agency for Healthcare Research and Quality
National Institute on Aging
Jacob and Valeria Langeloth Foundation