# Presentation: 090135

## Care Model Applicability and Evidence for Planned, Proactive Care for All 

- Pat Lundgren
- Innovations in Planned Care - IHS
- Cindy Hupke
- Institute for Healthcare Improvement

## Objectives

- Define the three elements; Will, Ideas, and Execution, that are needed to achieve remarkable breakthrough improvement.
- Describe evolutionary changes made to the Chronic Care Model over the past five years and recent refinements made to the Care Model for the IPC-IHS
- Identify the population that we are collectively trying to reach and the similarities to IHS Diabetes Programs already in place
- List high leverage system wide changes applicable across all conditions and prevention
- Summarize the Challenges and Successes experienced by the participating Pilot sites in the IPC-IHS.

**Notes:**
First bullet:  The focus in this segment will be on “ideas”, with an overview of the changes and sequencing of such that are currently being tested and implemented in each of the pilot organizations. 

## Elements needed for “breakthrough” improvement?

- Will
- Ideas
- Execution

**Notes:**
Breakthrough improvement:  large scale, sustainable

## Elements needed for “breakthrough” improvement?

- Will
**Ideas**
- Execution

## Chronic Care Model

**Informed,**
**Activated**
**Patient**

**Productive**
**Interactions**

**Prepared,**
**Proactive**
**Practice Team**

**Improved Outcomes**

**Delivery****System**
**Design**

**Decision**
**Support **

** ****Clinical****Information****Systems**

**Self-****Management ****Support**

**Health System**

**Resources and Policies**

**Community **

**Health Care Organization**

**Chronic Care Model**

- ICIC is a national program supported by The Robert Wood Johnson Foundation with direction and technical assistance provided by Group Health Cooperative's MacColl Institute for Healthcare Innovation".

## The expanded model:  The Care Model

- The Institute of Medicine report, “Crossing the Quality Chasm”
- Redesigning care processes and improving coordination across conditions, services, and settings includes **more than simply achieving more productive interactions for chronic illness or preventive care**. It also means _greater office efficiency, better access, more assured patient safety, and the other features of high quality care outlined in the “Quality Chasm" report_.
- The Care Model (2003) differs from the Chronic Care Model in two important ways:
- inclusion of the six aims from the Quality Chasm report as criteria for high quality services; and
- addition of change concepts addressing staff development, cultural competence, care coordination and patient safety.

## Care Model

**Informed,**
**Empowered Patient and Family**

**Productive Interactions**

**Prepared,**
**Proactive**
**Practice Team**

**Improved Outcomes**

**Delivery****System**
**Design**

**Decision**
**Support **

** ****Clinical****Information****Systems**

**Self-****Management ****Support**

**Health System**

**Resources and Policies**

**Community **

**Health Care Organization**

**Care Model**

- ICIC is a national program supported by The Robert Wood Johnson Foundation with direction and technical assistance provided by Group Health Cooperative's MacColl Institute for Healthcare Innovation".

- Patient Centered

- Coordinated

- Timely and Efficient

- Evidence-based and Safe

- Define roles and distribute tasks among team members
- Use planned interactions to support evidence-based care
**Provide clinical case management services for complex patients**
- Ensure regular follow up by the care team
**Give care that patients understand and that fits with their cultural background**

**Delivery System Design**

## Care Model:  IPC-IHS

- Informed,
- Empowered Patient and Family

**Productive Interactions through effective asset based partnering over time**

- Prepared,
- Proactive
- Practice Team

**Improved achievement of patient and community goals**

- Patient Driven

- Coordinated

- Timely and Efficient

- Evidence-based and Safe

- Productive Interactions

- Improved Outcomes

## Care Model

- Informed,
- Empowered Patient and Family

- Productive Interactions through effective asset based partnering over time

- Prepared,
- Proactive
- Practice Team

- Improved achievement of patient and community goals

- DeliverySystem
- Design

- Decision
- Support

-  ClinicalInformationSystems

- Self-Management Support

- Health System

- Resources and Policies

- Community

- Health Care Organization

- Patient Driven

- Coordinated

- Timely and Efficient

- Evidence-based and Safe

- Developed by the MacColl Institute and adpated by IHS for the CCI

- Wagner EH. _[Chronic disease management: What will it take to improve care for chronic illness?](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?orig_db=PubMed&db=PubMed&cmd=Search&defaultField=Title+Word&term=Improving+chronic+illness+care+translating+)__ _Effective Clinical Practice. 1998;1:2-4

- Patient Centeredness
- Assessment of Practice
- Leadership and Sponsor Development and Responsibility
- Process Mapping for Efficiency
- Care Team
- Optimizing the Care Team
- Continuity

**High Leverage Early Changes**

## Indian Health Diabetes Best Practices

| Wt. Mgt | Depression | Case Mgt. | CVD | DSME | Systems of Care |
| --- | --- | --- | --- | --- | --- |
| Assessing overweight and obesity | Obtaining education ... | Identifying eligible patients for case mgt.  | Assessing smoking status.... | Assessing the educational needs ... | Forming a multidisciplinary  DM team |
| Using lifestyle approaches to treat overweight and obesity | Screening for depression among patients with diabetes | Develop, implement, and monitor individual care plans. | Assessing, controlling, and treating high blood pressure  | Assessing the resources available for quality DSME | Identifying people at risk for diabetes and implem. intervention |
| Recognizing exclusions from weight loss therapy. | Providing depression care and treatment | Assessing the patient’s needs
 | Measuring, evaluating, and treating lipids.
 | Providing diabetes education for pts. with DM | Managing people ...using a systems approach. |
|  | Recognizing when to refer ... | Monitoring outcomes.
 | Using data systems to monitor and evaluate CVD | Evaluating DSME activities | Monitoring and evaluating patient outcomes |

**Notes:**
This slide has the title fly in on the second click:  the reason being to review the key changes in the grid as something that one could glance at and consider changes for almost any condition.  Identify that these are not new to any of the organizations within IHS across the nation...second click:  they are from the “Diabetes best practice” documents and all sites are well versed in their language and message.  The next slide highlights the similarities between these changes and those recommended within the IPC-IHS initiative.

## Indian Health Diabetes Best Practices and IPC-IHS

| Wt. Mgt | Depression | Case Mgt. | CVD | DSME | Systems of Care |
| --- | --- | --- | --- | --- | --- |
| Assessing overweight and obesity | Obtaining education ... | Identifying eligible patients for case mgt.  | Assessing smoking status.... | Assessing the educational needs ... | Forming a multidisciplinary  DM team |
| Using lifestyle approaches to treat overweight and obesity | Screening for depression among patients with diabetes | Develop, implement, and monitor individual care plans. | Assessing, controlling, and treating high blood pressure  | Assessing the resources available for quality DSME | Identifying people at risk for diabetes and implem. intervention |
| Recognizing exclusions from weight loss therapy. | Providing depression care and treatment | Assessing the patient’s needs
 | Measuring, evaluating, and treating lipids.
 | Providing diabetes education for pts. with DM | Managing people ...using a systems approach. |
|  | Recognizing when to refer ... | Monitoring outcomes.
 | Using data systems to monitor and evaluate CVD | Evaluating DSME activities | Monitoring and evaluating patient outcomes |

**Notes:**
Same slide, with the elements relating solely to DM faded and those for IPC-IHS in bold.  It is clear that there is a direct link between the two, with an easy transition to the concepts for planned care for all.  I would point out specific examples that they might relate to....the CVD column might be one, or the case management column....actually any one of them!

## DV/IPV:  8 Steps

**Create a multi-disciplinary team**** **which may include physician, nurse, soc. worker, BH providers, and local DV advocate
- Complete an **assessment of your practice** (response to DV, P&P, GPRA scores, etc.)
**Develop screening process**
**Develop and/or revise policies and procedures**** **so that the process is easily understood and reliable moving forward.
**Train your staff to build capacity within your organization**
**Get the message out to the community**** **about the importance of the problem and approaches
- Support employees who have experienced DV/IPV
**Use data to drive improvement**.  Collect data on measures, plan and do the changes, study the results, and make subsequent changes.

**Notes:**
These are the 8 steps that the DV/IPV program have described as essential to any organization approaching DV/IPV.  The bold areas in each show the relationship and crossover with IPC-IHS.  This simply points out the similarities that might not be evident otherwise and accentuates the fact that the IPC-IHS is not reinventing anything....it is augmenting each of the valuable and well-thought through programs and initiatives that IHS already has in place and in development.  The fundamental elements are the same:  team, assessment, screening processes, P&P, staff training and capacity building, community messaging, collecting and using the data to drive improvement (not just for accountability)

## Others include...	

- Behavioral health
- Tobacco screening and programs to quit
- Cardiovascular programs and approaches
- Cancer
- Prevention
- Public Health and CHRs

**Notes:**
Examples of how other IHS programs and initiatives are easily woven into the fundamental concepts of planned care for all:
You can probably think of better examples than I can, but here are some:
BH:  depression screening, integration of BH into the care team, group visits
Tobacco:  part of the intake bundle, followed up by the wonderful approaches that IHS Tob. Programs have developed for cessation
CVD:  part of intake bundle, working on outcome measure for lipids, our only outcome measure at this time is related to CVD (BP control)
Cancer:  CA screening bundle, speakers from IHS at Learning sessions
Prevention:  Lots of screening and preventive activities
PHN and CHR

## Patients with Diabetes

**Patients with Diabetes and Preventive Services Needs**

**Patients with Diabetes and other Chronic Conditions**

**Patients at Risk:  **Obesity, Sedentary, Family History of Chronic Conditions, Environment, Etc.

- Patients Needing Safe, Timely, Effective,
- Efficient, Equitable, and Patient Centered Care

**Notes:**
Most of focus on patients scheduling appts.
Proactive management is imperative for great planned care
Reach out to all patients in the microsystem, with plans developed on how to reach the total population!

## A Sample of Changes Being Tested, Implemented, and Spread across IPC-IHS Sites

- Empanelling
- Care team
- Use data to drive improvement
- Optimize use of HIT
- Remove waste
- Plan for every pt
- Segment care
- Reminders system
- Move work to appropriate licensure
- Reliable follow-up
- Max packing

- Proactive care across spectrum
- Self-Management
- Huddles
- Integration into community
- BH integrated into PC
- Building QI capacity in workforce
- Transportation for pts
- Integration of traditional medicine
- Guidelines of care
- Advanced access

**A Sample of Changes Being Tested, Implemented, and Spread across IPC-IHS Sites**

## Current Sequencing

_**Phase 1**_

**Current ****Sequencing**

**Emphasize the patient’s central role in **
**managing their health **
**Effective self-management support strategies**
**Ensure regular follow-up by the team**
**Provide timely automated reminders**
**Build the business case**

_**Phase 2**_

_**Phase 3**_

**Assessments-Green Book**
**Leadership engagement and involvement**
**Continuity with Provider and Care team**
**Building improvement capacity in staff **
**Identification and optimization of care team**
**Community engagement**

**Process flow mapping to reduce waste and increase efficiencies**
**Clinical Information System (CIS) development**
**Determining community needs and wants**
**Cultural focus**
**Use of data to drive improvement**

## 10 Steps involved in some early successes(not in any specific sequence, yet)

- Assessments-Green Book
- Leadership engagement and involvement
- Determining community needs and wants
- Building improvement capacity in staff
- Continuity with Provider and Care team
- Identification and optimization of care team
- Process flow mapping to reduce waste and increase efficiencies
- Use of data to drive improvement
- Clinical Information System (CIS) development and use
- Reporting regularly

**Notes:**
Key elements that the organizations in the initiative have confirmed so far that are fundamental to improvement.  Highly performing organizations have addressed all of these and continue to do so.  These align with other improvement communities around the world and with the prediction made by the expert panel last January.

## Challenges

- Access
- Delays and waits
- Continuity with provider
- Lack of “care team”
- Communication
- Distance and transportation
- Tribal, Federal, Urban
- Costs
- Recruitment and retention of staff
- Traditional and Western Medicine
- “We would like to see a system where traditional and western practices work alongside one another”  (Gallup Sundancer and Psychiatrist, Dr. Laughter)

**Notes:**
Access:  Can’t get in for appt for months

Delays and waits:  6-8 hours waiting in urgent care because they cannot get an appt with their provider; eye exam waits for 3-6 months; colonoscopy > 6 months in some areas, etc.

Continuity with provider:  in most pilot sites, continuity was not important; still remains a struggle with current scheduling systems and processes.  Very provider centric model and focused on the provider’s needs and wants rather than the patient and family.

Lack of “care team”:  lack of team approach to care.  This has been addressed by every pilot site in the initiative.  Some are still having struggles because of the current system of scheduling providers to multiple sites, etc.  Most teams are not only developing the care team, but then they are optimizing the role of each person on that team (job satisfaction, efficiencies, effectiveness, satisfaction of patient and staff, etc.)

Communication:  sometimes cannot communicate with the patient due to lack of a signal, lack of phones, language barriers

Distance and transportation:  patients sometimes show up anytime they can get a ride.  Transportation limited.  Contributes to delays and waits and overuse of urgent care and ED.  Contributes to decrease in patient and staff satisfaction and lack of continuity.  Approaching this with advanced access methodologies and group visits (drop in appts.)

Traditional vs. Western Medicine:  when and how to integrate the two.  How to do it, do the patients want it?

## Successes

- Increasing continuity
- Care team development and communication
- Staff working to the highest level of their licensure
- Work force development and capacity building relating to improvement work
- Understanding how to use data to drive improvement daily
- Improved access to care
- Timely management of chronic care and preventive services
- Less dependence on urgent care and emergency visits
- Proactive care for patients
- Reduction in hospitalizations

**Notes:**
Talked about these in the previous slide...anything not covered can be addressed.

These changes reflect multiple domains
Safety
Effectiveness
Efficiency
Equity
Timeliness
Patient centeredness

## Intake Bundle

- Cancer Screening Bundle

- BP in Control

- DM Comprehensive

- Office Visit Cycle Time

- 3rd Next Available

- Goal

- Goal

- Goal

- Goal

- Goal=45

- Goal=3

**Notes:**
One organization’s journey

## Hungry for more!

- Advanced access
- Group visits
- Understanding what the patient and community needs and wants and when they need and want it!
- Efficiencies and waste reduction
- Using the clinical information system and data to drive improvement and practice proactive population management
- The business case for this work

## Under Construction

**Uncharted Territory**

**Sequencing**

**Change Package**

**Under Construction**

**Results **

**Early Stages**

**Status Quo**

## Questions?