# Presentation: 725851

## The Chronic Care Initiative and 

***The Chronic Care Initiative and ***
***The Readiness Call Series***
- C. Ty Reidhead
*April 23, 2008*

## Prevalence of Diagnosed Diabetes

- Source: IHS Program Statistics and National Diabetes Surveillance System. Age-adjusted to the 2000 US standard population with the exception of 1981–1993 data for AIAN, which was age-adjusted to the 1980 US standard population.

**1980- 2004**

**Prevalence of Diagnosed Diabetes**
**AI/ANs compared to U.S. population**

## Care according to guidelines of 10 chronic diseases:
If everyone in the patient panel was “controlled”
3.5 hours per work day
If add some uncontrolled cases
6.7 hours per work day 
Assuming 1,949 hours/year spent in patient care

- If everyone in the patient panel was “controlled”
- 3.5 hours per work day
- If add some uncontrolled cases
- 6.7 hours per work day
- Assuming 1,949 hours/year spent in patient care

*Ann Fam Med 2005*;3(3):209-214

- Is there time for Management of Pts with Chronic Conditions in primary care?

## Adjust for the prevalence of the chronic conditions in the AI / AN: 
4.5 hours of every day spent on these 10 chronic diseases.
9.4 hours of every day if some of the diseases are uncontrolled.

- 4.5 hours of every day spent on these 10 chronic diseases.
- 9.4 hours of every day if some of the diseases are uncontrolled.

- Is there time for Management of Pts with Chronic Conditions in primary care?

## Geographic Isolation

## Slide 6

## “Every system is perfectly designed to get the results it gets.”

*     **- **Donald Berwick, IHI’s President and CEO*

## The System of the “Past”

## International Comparison of Spending on Health, 1980–2004

- Data: OECD Health Data 2005 and 2006.

- Average spending on healthper capita ($US PPP)

**Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006**

**EFFICIENCY**

**58**

## Slide 10

## The Healthcare System Hope

## Crossing the Quality ChasmExecutive Summary

- “The *American* health care delivery system is in need of fundamental change... care delivered is not, essentially, the care we should receive... frustration levels... have... never been higher... Health care harms... and routinely fails to deliver its potential benefits.”

## 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**

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

**Decision**
**Support **

** ****Clinical****Information****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**

## IOM’s 6th Aim

- Equity –
*Freedom from bias or favoritism*
- Equitable –
*Dealing fairly and equally with all concerned *

- _[www.m-w.com/dictionary](http://www.m-w.com/dictionary)__ _*Merriam-Webster’s Online Dictionary*

## The Healthcare System for

*“**The care I need and want, when I need and want it!”*

*my patients, my family, and for me*

## International Comparison of Spending on Health, 1980–2004

- Data: OECD Health Data 2005 and 2006.

- Average spending on healthper capita ($US PPP)

**Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006**

**EFFICIENCY**

**58**

## Optimism

**&**
** ****Islands of Innovation**

**“****The Energy of Few”**
** ****The Champions**

***“******Past performance is no guarantee of future results”****** ***

## Hope

** ****Ideas****+ Improvement ****Tools****(Execution)**

**“****The Energy of Many”**

**Reliably high ****quality care**
**Every patient, ****every time, ****everywhere**

## IHS Diabetes Care & Outcomes Audit

- Source: IHS National Diabetes
- Program Statistics 1996-2007

**A1C,**

- %

- Mean A1C,
- 1996-2007

- *p<0.0001 comparing mean A1C levels in FY96 and FY07

**year**

## 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**

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

**Decision**
**Support **

** ****Clinical****Information****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**

## Productive Interactions through effective asset based partnering over time

**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**

## Chronic Care Collaborative Pilot Sites

- 	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

- The eight federal pilot sites are:

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

- The five Tribal sites are:

-    The Gerald L. Ignace Indian Health Center

- And the Urban program is:

## Innovations in Planned Care for the Indian Health System Pilot

**LS 1**

**Site visit**

- Harvest

**Virtual LS 4**

**We are here...**

**Virtual LS 3**

**Virtual LS 5**

## IPC Measures (Spring 2008)

| Measurement Domain | Areas of Focus/Coverage |
| --- | --- |
| Clinical Prevention | Keeping current on intake screenings (Cancer, BP, etc.) |
|  | Keeping current on Immunizations |
| Management and Prevention of Chronic Conditions | Control of Blood Pressure (Cardiovascular Disease) |
|  | Control of Lipids (Cardiovascular Disease) |
|  | Diabetes Care |
|  | Obesity (Nutrition & Exercise Education) |
|  | Asthma |
| Costs | Dollars spent outside primary care (Hospitalizations, ER & Urgent Care Visits) |
| Patient Experience | Experience and Efficiency (Office Visit Time) |
|  | Activation (Self-Management Goals, Pt. Confidence) |
|  | Satisfaction (Pt. Recommends Facility) |
|  | Building relationships for care (Continuity of Care) |
|  | Access (3rd Next Available Appointment) |

## Improvement is not easy Intake Bundle (Dep, BMI, BP, IPV, Tob, EtOH)

## Powerful CIS tools for improvement Intake Bundle 

- iCare

## What is a Care Team?

- Everybody who is part of the relationship with patients
- Includes people who are not typical partners
- Relationships within the Care Team are essential.

## What is a Care Team?

- Everybody who is part of the relationship with patients
- Includes people who are not typical partners
- Relationships within the Care Team are essential.

## 
“I’ve worked here for 2 years and this is the first time I feel like I’m part of something...  I’m part of a team, and we’re working to make things better.”
- Information Resource Management 

- “I’ve worked here for 2 years and this is the first time I feel like I’m part of something...  I’m part of a team, and we’re working to make things better.”
*- Information Resource Management*

## #1 Reason for Pilot Sites Reaching their Goals?

*Leadership involvement*
*“**Attention is the currency of leadership”* 						- Ronald A. Heifetz

## Importance of Nurses in Improvement (e.g.’s)

- Leading improvement teams
- Leading huddles in preparation for visits
- Planning for visits
- Patient follow-ups
- Patient self-management
- Group visits

## Importance of Nurses in Improvement DM Comprehensive Care

- Nursing Order Entry of optometry consults when due

- Optometrist staff shortage

## Average visit cycle timePatient experience

## Emergency Room/Urgent Care Visits

## Model for Improvement

- What are we trying to

- accomplish?

- How will we know that a

- change is an improvement?

- What change can we make that

- will result in improvement?

**Model for Improvement**

**Act**

**Plan**

**Study**

**Do**

**Notes:**
I have outlined the will that teams have to change and also some of the ideas that teams are using to improve the care at pilot sites.  The way that these improvements are achieved is that last piece; the execution of the improvement.

The execution of improvement relies heavily on the Model for Improvement, and the motor of that improvement is the PDSA.  In the Indian Health System, I have been accustomed to the PDSA that lasts a year.  Some of our accountability measures have perpetuated that believe.  The Diabetes Audit is typically referred to as the Annual Audit and GPRA is typically run annually.  Fortunately, these systems have the ability to run data on a more frequent basis. 

## 
“Some is not a number, and soon is not a time...”
- Donald Berwick, IHI’s President and CEO

*“**Some is not a number, and soon is not a time...”*
- - Donald Berwick, IHI’s President and CEO

## Testing Changes

**DATA and Learning**

- Very small scale test (Small Cost of failure)

- Adaptation and follow-up Tests

- Wide-scale tests of adaptations

- Implementation of adapted guideline(Large cost of failure)

## IPC-Pilot Sites Geographic Isolation

## Overcoming Isolation Working in a new way

- >30 Webex sessions with all teams on.
- Two virtual (Webex) Learning Sessions
- Last two Open Door Forums with Webex
- CCI Staff
- CCI/IHI Partnership

## 
“I was thinking that I might retire until this stuff came along.”
							- B.C, MD 

“I have been in Indian Health for 28 years, and this is the first time that I have real hope that things can be better.”
					- C.S., RN

*“**I was thinking that I might retire until this stuff came along.”*
- 							- B.C, MD
*“**I have been in Indian Health for 28 years, and this is the first time that I have real hope that things can be better.”*
- 					- C.S., RN

- Hope

## GPRA: 2006

**Cancer Screening: Colorectal**
- AI/AN patients ages 51-80 who have received appropriate Colorectal Cancer Screening

- Patients who received screening

- Patients who did  **NOT** receive screening

**Notes:**
In a system where we only screen for colorectal cancer in 22% of our patients there is much room for improvement. 

## Colorectal Cancer Screening

**Notes:**
And, our teams are showing that this improvement is possible.  
Who here will not get their colorectal cancer screening done?  Let’s not even get into the argument of which is better, colonoscopy or FOBT and whether we can afford the colonoscopy.  It doesn’t really matter... what about the other 80% of the population?

## 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**

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

**Decision**
**Support **

** ****Clinical****Information****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**

**Notes:**
We can use the Care Model to come up with the ideas to improve colorectal cancer screening. 

## Strategy for Spread

**IPC I**

**IPC II**

**Capacity Building**

**Readiness Curriculum**

**Full Scale**

**Strategy for Spread**

***Intensive work with initial 14 pilot teams***

***Addition of 26 new sites to the IPC:  Includes readiness stage, sequencing and staging changes***

***National collaborative for 200+ sites supported by infrastructure***

***Training of Improvement Support Teams       (6 – 12) to support improvement in the field***

***Training remaining sites (200+) on models, project management and leadership for improvement***

**Mar 07  Fall 07  Apr 08   Oct 08                   2010           2011           **

***Five Million Lives Campaign***

**Second Round of Full Scale**

***For sites not ready the first time around***

**Notes:**
We are going to spread the improvements to all of the Indian Health System over the next few years.

## IPC2 – Important Dates

- Technical Assistance web-based calls:
- April 28, 2008
- May 22, 2008
- May 15, 2008 – Letter of Interest due
- June 19, 2008 – Request for Participation proposal due
- 	August 4, 2008 – Notification of Participation
- Pre-work – October thru December 2008
- January 27, 2009 – First Action Period Call
- Subsequent Action Period calls will be every two weeks

## Readiness CurriculumSchedule – 12:00 Eastern Time

| Date | Topic | Faculty |
| --- | --- | --- |
| May 28 | Assessing Your Practice (The Green Book)  | Margie Godfrey  |
| June 25 | To Be Determined |  |
| July 23 | “The Patient Will See You Now”  Patient Driven Care | Judith Schaeffer, Laurel Simmons |
| August 27 | Learning to See:  Waste Identification and Reduction | Maureen Bisognano  |
| September 24 | Integrating Behavioral Health with Primary Care  | Ann Lewis  |
| October 22 | Measurement for Improvement  | Jerry Langley  |

## Readiness CurriculumSchedule – 12:00 Eastern Time

| Date | Possible Topics | Faculty |
| --- | --- | --- |
|  | RPMS Optimization |  |
|  | Learning to Listen:  Ten Ways to Listen to Your Patients and Community |  |
|  | Aligning Organizational Initiatives and Priorities |  |
|  | Workforce Development |  |
|  | Identifying and Optimizing Your Care Team |  |
|  | Self Management Support |  |

## Slide 48

## Lessons Learned

- Hope
- Improvement is everyone’s business
- Waste
- Improvement work can increase staff and patient satisfaction

## Lessons

- Continuity (*Relationships*) are essential
- With the patient
- Within the care team
- I want to work in an Indian Health System where I don’t have to ask for favors to get the best possible care for my daughter.