Regional strategies to improve care
for the chronically ill
A chartbook created by the staff of:
Improving Chronic Illness Care
Group Health MacColl Institute
Supported by The Robert Wood Johnson
Foundation
Chronic illness in America
• More than 125 million Americans suffer from one or more
chronic illnesses and 40 million are limited by them
• Despite annual spending of more than $1 trillion and significant
advances in care, one-half or more of patients still don’t receive
appropriate care
• Gaps in the quality of care lead to thousands of avoidable
deaths each year
• Patients and families increasingly recognize the defects in
their care
2
Current chronic illness care
Patients with major chronic illnesses receive recommended
care about half of the time
These deficits are now perceived by patients, physicians
and policymakers
Percent agreement
Public
People with chronic
conditions usually
receive adequate
medical care
48
Physicians Policymakers
45
22
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Chronic illness and medical care
•
Primary care dominated by chronic illness care
•
Clinical and behavioral management increasingly effective and
increasingly complex
•
Inadequate reimbursement and greater demand forcing primary care to
increase throughput—the hamster wheel
•
Unhappy primary care clinicians leaving practice; trainees choosing other
specialties
•
Loss of confidence in primary care by policymakers and funders
•
But there is a growing interest in changing physician payment to
encourage and reward quality
•
The patient-centered medical home is the new hope
4
Greater care complexity and efficacy,
but with lower self-efficacy?
Multiple Medications
Complex Guidelines
Self-management Support
5
I. We have to do better
6
What to do?
• The future of primary care (and our healthcare system) depends
upon its ability to improve the quality and efficiency of its care for
the chronically ill
• It will also require a recommitment of primary care to meet the
needs of patients for timely, patient-centered, continuous and
coordinated care
• That will require a major transformation or redesign of practice, not
just better reimbursement
• But such transformations will be difficult to motivate or sustain
without changes to the larger healthcare environment
7
What’s responsible for the quality
chasm for the chronically ill?
• Practice systems oriented to
acute disease that aren’t
working for patients or
professionals
• Inadequate use of information
technology
• Poorly aligned payment
structure
8
Toward a chronic care oriented system
Reviews of interventions show that practice changes are
similar across conditions
Integrated changes with components directed at:
Use of non-physician team members
Planned encounters
Modern self-management support
Intensification of treatment
Care management for high-risk patients
Electronic registries
9
We have models to improve care; are
they complementary or antagonistic?
Medical Care Home
The Chronic Care Model (CCM)
10
Medical Home and Chronic Care Model
are complementary
Both emphasize and support patient role
in decision-making
MH redefines primary care
CCM redesigns care delivery
responsibility
for planned care
Elements of both are
integrated into the
Patient-Centered Medical
Home
11
What are the key features of a
Patient-Centered Medical Home?
• Personal physician – first contact, continuous care
• Team care – collectively take responsibility
• Whole person orientation – responsible for all patient needs
• Coordinated care – across all elements of the healthcare system
• Quality and safety – by implementation of CCM, continuous quality
improvement (QI) and voluntary recognition process
• Enhanced access – via open scheduling, expanded hours and
expanded communication
• Payment – value of the home recognized, pays for coordination,
electronic communication with patients and IT
12
Can busy practices really change to
improve care? YES!
• Strong results from year-long collaborative improvement efforts
involving multiple delivery systems and faculty
• Chronic Care Model guides system change
• More than 1,000 health care organizations and various diseases
involved to date
• Began with national Breakthrough Series Collaborative but shifted to
regional efforts
• HRSA’s Health Disparities Collaboratives have involved more than
600 community and migrant health centers
13
Lessons learned in chronic illness
care improvement
• Mostly reaching early adopters
• Regional collaboratives less costly, equally effective and enabled
other stakeholders (e.g., health plans) to be involved
• Practice redesign is very difficult in the absence of a larger
supportive “system”, especially for smaller practices
• Perverse payment was an obstacle but didn’t stop motivated
practices
• Lack of registry functionality and limited availability and/or use of
clinical office staff or care managers are major barriers
14
Characteristics of high-performing
healthcare systems
Factors that support high-quality chronic care:
• Leadership and values support long-term investment in managing
chronic diseases
• Well-aligned goals between physicians and managers
• Integration of primary and specialty care
• Investment in information technology systems and other infrastructure
to support chronic care
• Use of performance measures and financial incentives to shape
clinical behavior
• Use of explicit improvement models
– usually the Chronic Care Model
15
Is chronic care improvement possible
across the entire population?
16
II. Regional improvement will
require a regional system or
organization
17
What’s needed to transform care
systems across a region?
• Leadership committed to quality
improvement and primary care
• Collaboration among different
stakeholders
• A population orientation
• Measurement (and incentives)
• Infrastructure support
• Active program of practice change
• Provider networking and vertical
integration
18
Regional coalitions have been a common
American response to regional problems
“Americans are a peculiar people. If in a local community a
citizen becomes aware of a human need that is not met…
suddenly a committee comes into existence…and a new
community function is established. It is like watching a
miracle.”
Alexis de Tocqueville, 1840
Regional coalitions tackling health issues are not new or
uncommon. Lasker et al. identified more than 400 coalitions in
1997 (Medicine and Public Health: the Power of Collaboration).
19
MacColl study of regional quality
improvement coalitions
• What are the characteristics and strategies of successful regional
coalitions?
• Data sources were a literature review and interviews with leaders of
major coalitions
• Developed a regional framework or model that describes their work
• Coalition leaders reviewed the regional framework and confirmed its
relevance to their work
• The regional framework provides a visual summary of what leading
coalitions were doing - not yet an evidence-based summary of
what works
20
A framework for regional quality
improvement
21
Explaining the regional framework:
beginning at the outcome
To improve the population’s health, the Quality
Chasm report makes clear that we must
change or transform care systems everywhere
healthcare is delivered to the population
Transformed Health
Care Delivery
22
Who needs to be involved?
• Major stakeholders need to be involved
and committed to improvement
• Refusal of a stakeholder group to
participate is ominous
Collaboration among
Stakeholders Payers, Providers,
Plans, Patients
23
Coalitions need strong leadership
to succeed
Someone needs to take and then assure
leadership
Long-term success seems to depend on
three-tiered leadership
1.Organizational manager and staff
2.Respected home base for coalition
Leadership
3.Stakeholders involved in program
development
24
Everyone agrees that aggregating data
is critical, but for what purpose(s)?
Two major goals of regional data aggregation
are performance measurement and data
exchange
Data exchange is proving to be difficult to
implement and perhaps more difficult to
sustain
Shared Data and
Performance
Measurement
Regional performance measurement is
feasible but often relies on claims data, whose
validity must be suspect
Optimal performance measurement requires
clinical information not available from claims;
many (smaller) practices will need help if they
are to participate
25
Transforming care delivery requires a
strategy and infrastructure
The strategy should have the ability to reach
the majority of practices and help them change
their delivery systems
The majority of practices should have access
to an infrastructure that enables them to fully
implement the CCM
Improving Health
Care Delivery
Efforts should be made to reduce practice
isolation and lack of integration in communities
26
Ambulatory care infrastructure
Smaller practices often lack the
infrastructure to improve care. Coalitions
may be able to help practices obtain:
IT to create registries and facilitate
performance measurement
Consensus guidelines and related
decision support
Improving Health
Care Delivery
Clinical care management services for
high-risk patients
• Information technology
tools
• Consensus guidelines
• Care management
27
QI strategies
Need to choose one or more strategies to
help practices change their care delivery
Breakthrough Series collaboratives can be
effective, but are expensive for sponsors
and participants
Some evidence supports practice coaching
Improving Health
Care Delivery
• Quality improvement
strategies
Collaboratives, practice coaching programs
and other QI programs are going on in many
regions. Regional initiatives should try to
identify and collaborate with existing programs
28
Provider networks
The isolation of smaller practices limits peer
support, access to infrastructure and the
ability to participate in QI
Greater integration of primary care with
specialty and hospital care should lead to
better care coordination
Improving Health
Care Delivery
Creating networks of providers with a goal of
QI appears to be a promising approach
(e.g., Medicaid provider networks or
practice-based research networks)
• Provider Networks
29
Two goals for consumer engagement
Influence Consumer Behavior
The hope is that consumers will use
publically disclosed quality data to select
providers, but evidence is scant. Public
disclosure does seem to stimulate
provider QI
Engaging
Customers
Increase patient activation and
self-management skills by providing
information and support
• Public Disclosure
• Consumer Education
30
Create financial incentives and
remove barriers to quality care
Create incentives for providers to make the
investments and system changes needed to
improve chronic care; little evidence yet of
effectiveness
Create benefit plans that reward consumers
for making cost-effective choices
Aligning Benefits/
Financing
• Incentives for
cost-effective care
• Performance measures
and rewards
31
Questions about Pay-For-Performance
Does the limited evidence of Pay-forPerformance effectiveness to date reflect
problems in P4P design?
Should P4P more aggressively try to remove
payment barriers, not just add bonuses?
Aligning Benefits/
Financing
• Incentives for
cost-effective care
• Performance measures
and rewards
32
III. Promising signs of
regional success
33
Is geographic improvement possible?
Indiana
• Health commissioner and Medicaid director created a
Medicaid chronic care program
• Program included a statewide breakthrough series
collaborative program supported by:
- A call center to inform and risk stratify patients
- Community-based nurse care managers linked to practices to
support high-risk patients
- A statewide Web-based patient registry and technical support
• Evaluated by University of Indiana - Reported cost savings to
the governor
34
Is geographic improvement possible?
North Carolina
• State leadership and money have created a visionary
Medicaid care system—Community Care of North Carolina
• Features include a measurement system, guidelines,
creation of physician networks, care managers, active QI
programs
• Capitated payment on top of usual fee-for-service
reimbursement to practices for participating and to the
networks
• Evaluations have demonstrated significant improvements in
care and reductions in costs
35
Community Care of North Carolina’s
evaluation findings
Asthma Disease Management (2000-2005)
•
28 percent increase in flu vaccines
•
More than 90 percent of staged asthma patients on appropriate preventive medication
•
Saved $3.5 million from 2000-2002 from lower inpatient admissions and emergency
department visits
Diabetes Disease Management (2000-2004)
•
10 percent increase in referrals for eye exams
•
62 percent increase in flu vaccines
•
Foot exams are at 71 percent, improved 18 percent since baseline
•
Saved $2.1 million from 2000-2002
Emergency Department Initiative (2001– 2002)
•
Care management follow-up, outreach and education on all enrollees with three or more visits to
the ED in a six-month period of time
•
30 percent lower per member per month cost
•
13 percent lower ED rate
36
Is geographic improvement possible?
Prescription for Pennsylvania
• Gov. Edward G. Rendell created the
Chronic Care Management,
Reimbursement and Cost Containment
Commission to improve how
Pennsylvanians with chronic disease
receive health care in the future
• The commission is responsible for
developing the process to effectively
manage chronic disease across the state
• The commission designed the
informational, technological and
reimbursement infrastructure needed to
support implementation of the Chronic
Care Model throughout Pennsylvania
• Implementation of the Chronic Care
Model is through regional collaboratives
across the state
37
Lessons learned from around
the country
•
Medicaid can be an important engine of innovation and financial support
•
But involvement of commercial insurers and self-insured employers is
critical for long-term success
•
Community-wide performance measurement is essential, but public
disclosure should follow a deliberative process of data validation, piloting
and discussion with medical leaders in the community
•
Much more needs to be known about regional QI strategies that effectively
reach beyond larger, more advanced provider organizations
•
Helping smaller practices acquire and effectively use IT is critical to their
ability to participate in QI
•
Training in QI methods, self-management support interventions and other
elements are critical needs in most communities
38
IV. What the future holds
39
The urgency of improving the
quality of care
• We all hope for federal action to increase insurance coverage
• But will our stressed primary care sector be able to improve the
quality of its care while trying to meet the added demand?
• Many believe that the frustrations of caring for the chronically ill in
poorly organized delivery systems contribute to the primary
care crisis
40
Quality improvement will be regional
Even if we have federal health insurance reform, the major focus for quality
improvement will continue to be regional because:
1.
It requires collaboration among purchasers, plans and clinicians, AND
most health insurance plans, major employers, and providers are regional
2.
The quality, organization and patterns of care vary tremendously by
region
3.
The resources to support QI vary by region
4.
Regional improvement efforts have improved diabetes and asthma care,
reduced central line infections and reduced Medicaid expenditures across
entire states or large regions within states
41
Contact us at:
www.improvingchroniccare.org
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