# Presentation: 011197

## Integrating Chronic Care & Business Strategies in the Safety-Net

- AHRQ Annual Meeting
- September 9, 2008

**Notes:**
Good afternoon! My name is Katie Coleman  and I’m thrilled to be here with you all this afternoon to talk with you about a project that we’ve been working on that uses a toolkit & practice coaching to help teams improve the quality of care. 

I’ll start with a quick overview of how this initiative came to be, 

then walk through some of the details of the project like how we structured our intervention & what the toolkit looks like, 

then I’ll share some preliminary reflections on that work.  

I have to warn you up front that this presentation is kind of a teaser – organized as an RCT & RAND, our partners in evaluating this, are just now analyzing the cost & outcomes data.  This presentation will act as an overview of the project, with a “watch this space” plug for the formal evaluation results.

## Chronic Illness in America

- More than 125 million Americans suffer from one or more chronic illnesses and 40 million limited by them.
- Despite annual costs of more than $1 trillion and significant advances in care, one-half or more of patients still don’t receive appropriate care.
- Gaps in quality care lead to thousands of avoidable deaths each year.
- Patients and families increasingly recognize the defects in their care.

## Slide 3

**Notes:**
Based on those research findings, and others, the MacColl Institute created the Chronic Care Model in the late 1990s.
Our premise is that good outcomes at the bottom of the Model (better health status and patient satisfaction) result from productive interactions. To have productive interactions TWO things need to happen: the practice team must be prepared & proactive, and the patients have to be informed and activated.  Our current healthcare system is based on an acute care model – a patient in injured or sick, they come to the doctor, they get fixed and are on their way.  Now that paradigm makes sense in certain specialties, but does nothing to help those 45% of Americans with on-going, sometimes life-long diseases.  They need proactive medical care that reaches out to them to keep them healthy & out of an acute care situation.  On the other side, patients need to be able to manage their illness on their own.  Even those with multimorbidities spend less than 1% of their time with doctors & they life with their illness, managing it on their own for 99% of the time.  That means patients need to be brought on board & taught how to manage their diabetes, check their blood sugar levels, understand how diet & exercise effects their risk, and learn how to cope with the long-term implications of their illness. 

How can we get there?  We’ll for a practice team to be prepared and proactive it must be redesigned in four areas (shown in the middle): self-management support (how we help patients live with their conditions), delivery system design (who’s on the health care team and in what ways we interact with patients), decision support (what is the best care and how do we make it happen every time), and clinical information systems (how do we capture and use critical information for clinical care). These four aspects of care are at the practice level. 
Some aspects of larger healthcare organizations influence clinical care. The health system itself exists in a larger community. Resources and policies in the community also influence the kind of care that can be delivered. 

The essential element of good chronic illness care is a productive interaction, versus current interactions that tend to be frustrating for both patients and providers. An interaction can be a face-to-face visit, a phone call or an email message. Productive means that the work of evidence-based chronic disease care gets done in a systematic way, and patient needs are met. 

Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B. A survey of leading chronic disease management programs: Are they consistent with the literature? Managed Care Quarterly. 1999; 7(3):56-66. 
Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, Part 2. JAMA 2002 Oct 16; 288(15):1909-14. 
Wagner EH, Austin BT, Davis C, Hindmarsh M, re met. 
Schaefer J, Bonomi A., Improving chronic illness care: translating evidence into action. Health Aff (Millwood). 2001 Nov-Dec; 20(6):64-78. 

## Experience with Collaboratives 

- More than 1,500 different health care organizations and various diseases involved to date
- HRSA’s Health Disparities Collaboratives-600+ community and migrant health centers,
- Academic Medical Centers
- State, regional, and organization specific

**Notes:**
So the impetus for the development of this toolkit & practice coaching intervention was based on the national experience with BTS-style colaborabitves.

How many of you have been a part of a learning collaborative, either sponsored through HRSA or through SEED, IHI or someone else?

IN the 10 years since the Chronic Care Model was developed, BTS-style collaboratives have been the primary way that teams have learned about quality improvement – for those of you unfamiliar with the Chronic Care Model or the structure of breakthrough series collaboratives, there are a few slides at the end that you can review * I’m happy to answer any questions after this webex via email.

Now, there is quite a bit of published data on their effectiveness.  RAND conducted a large evaluation of some of the first collaboratives showing that implementing changes along the lines of the care model is possible & that process & outcome measure do indeed improve., Marshall Chin & Bruce Landon have recently done work on the Health Disaprities collaboratives and there have been several RCTs of other types of CCM-interventions that show similar results.

But there are some limitations to the collaborative methodology that we’ve learned from our experience with teams – what are some of the limitations to collaboratives that you all have experienced?

## Evaluation of Chronic Care Collaboratives

- RANDHealth
- Practices can change - organizations made average of 48 changes in 5.8/6 CCM areas
- Process measures may improve – CHF, asthma, diabetes
- Outcome measures may improve – better glycemic control in Diabetes
- Chin, et al. & Landon, et al.
- May take more than 1 year to see outcome changes
- Cost-effective

**Notes:**
And they found that...

## Lessons Learned from the Teams

- Teams spent considerable time searching for/developing tools
- Some teams felt intimidated by taking on the whole model – asked for a sequence
- Collaboratives were time & resource intensive
- Many changes were made in ways that were not sustainable financially

**Notes:**
So in our experience with the collaboratives, we have learned quite a bit about teams.  For example, we know that
Teams who present at collaboratives are often early adopters.  They are people who are willing and able to shut down their clinics for 8 days a year and send a group of doctors and nurses offsite to learn, which can be expensive & often limits the numbers of individuals from a certain site who are able to participate.
We also know that collaboratives can be incredibly powerful experiences as the new evidence by Marshall Chin & RAND shows, teams are willing and able to make changes in all elements & those changes lead to improved process & outcome measures.  Powerful in another way...creating a community of like-minded people with similar practice challenges, normalizing the unsettling feelings that come with trying to change & sharing ideas & tools like action planning documents for self management support and standing orders for nurses around diabetes.
We also learned that teams made great strides doing work during the collaborative year, but some f the changes they made weren’t really able to be sustained.  For example, to get a registry up and running in practice, many groups had an MA print out face sheets from the registry, but had the doctor complete that form AND another, and then have the MA manually enter both sets of data into two different practice management software.  Any time this type of double data entry took place, we knew it wouldn’t last forever. 

Remain convinced of the effectiveness of collaboratives

## Integrating Chronic Care & Business Strategies in the Safety-Net

- Reaching beyond early adopters

- Less time-  intensive learning

- Integrate business & clinical changes

- Provide high- quality tools

**Notes:**
So in 2006 the Agency for Healthcare Research and Quality issued a contract asking: can we develop a way of teaching the CCM that addresses some of these challenges?  That

Reaches beyond the early adopters
-integrates business changes & thinks about sustainability up front
Provides high quality tools so that teams don’t continue to have to remake them
And provides a less time intensive & resourse intenseive way of learning?

With partners RAND, and the California Healthcare Safety Net institute, we thought, SURE!

So in the last year & a half we have worked together with two public hospital systems in California to develop, implement, test & evaluate this toolkit & coaching intervention

## The Patient-Centered Medical Home and the Chronic Care Model?

**Correct**

**Misperception**

## The Intervention

**PLUS**

-    Practice Coach
- _________________
- STEP-UP Methodology

- Toolkit
- ______________
- Business & Clinical
- Tools

**Notes:**
So what does this intervention look like specifically?

Two parts  - practice coaching based on a deliberately time-limited model called the STEP UP Model.  Created by Kurt Stange and colleagues at Case Western, this behavioral approach to coaching has been tested & demonstrated to improve preventive care in practice.  We added a bit more structure using tools from other successful interventions like Dartmouth’s Clinical Microsystems & others to fill it out & apply it to broader primary care redesign.  We’ll talk more about the specific coaching details in a minute. 
The second part of the intervention was the toolkit, which acts a the curriculum for the intervention.

## Coaching Outline 	

_**Tasks**_
- Assessment Day
- 1⁄2 day presentation on CCM & PDSA
- On-going meetings by phone, email & in-person
- Coaching of the leaders & the teams

_**Philosophy**_
- Focus on motivation, consultation & education
- Be mindful of the timing of interventions
- Fix processes relevant to the task at hand
- Well-structured & supported groups benefit most

**Notes:**
The way we’ve organized the coaching is as follows.
In their 2005 article in the Academy of Management Review called “A Theory of Team Coaching” Richard Hackman and Ruth Wageman offer several propositions of successful coaching based on their review of the literature.  The say that
1.) coaching interventions that focus on team effort, strategy, knowledge & skill facilitate team effectiveness more than those that focus on interpersonal relationships and as such should be motivational, consultative, and educational in focus
2.) that each of the coaching functions listed above has the greatest impact at specific times in the life cycle of the project motivational at the beginning, consultative at the mid point and educational after performance have been completed. 
3.) coaches should only engage in trying to correct team performance processes that are salient for a given task & getting involved in ancillary processes is not helpful
4.)  competent coaching interventions are more beneficial for groups that are well-structured & supported & can even be detrimental for teams that are poorly structured and supported b/c they create feelings of frustrations

The second part of the intervention is the toolkit & it does 3 things

## Preliminary Reflections

- Six months is short.
- Randomization presents both challenges & opportunities.
- There is a trade-off between customization and collaborative learning, but providing structured learning time is key.
- Clearly define the coaches role & regularly check expectations.

**Notes:**
6 months is short – for teams with no QI experience & no real team orientation.
Randomization presented challenges & opportunities can provide transparency onto underperformers that wouldn’t ordinarily be included, has the opportunity to really empower staff)
Totally able to customize the intervention to the needs of the team./ what you lose when you lose the collaborative learning from other teams 
since of normalcy, shaming & brainstorming, struggling, support, commaraderie.
Both types of programs provide a  the structure provided time for them to figure out their own issues –making formal is key  to QI if the practice had time to do this work, it would already be done. Create a space for this.
Must clearly Defining the coach role & regularly check expectations (scope creep)
not a consulting company – not coming in with answers about what you should do. Coming in with an idea of the vision – one that has been used and demonstrated to be effective & helping facilitate learning so you can figure out your own solutions – PDSAs is one way we do this.  Share how other teams have done it – can provide resources & tools, but someone in there needs to be leading the effort – gathering the team, convening them, providing an agenda & providing leadership consistent with the local context.
Helped by inside leadership who:
Need accountable leader at the site. Unimaginable number of challenges operationally that could divert attention- need clarity of role, but flexibility in bringing issues up to leadership. – expectation of attending a meeting, visibility, lunch, recognition, resources.
functions, not the roles of leadership matter.
local clinic management’s ability to make changes is key
Coaching is one piece, but must fit within Multi component work:  must  aligned with other efforts. – makes the assessment piece & the leadership conversations really important.  
Can jump-start spread. 

## More Preliminary Reflections

- Identify a leader on-site who is accountable, creative, flexible, & empowered.  It is the functions of leadership, not the role that matters.
- Coaches can identify major infrastructural barriers to improvement.
- Coaching is one piece within a multi-level system – must seek out alignment between programs.
- Coaching can jump-start spread.

## Next Steps

- Complete evaluation
- Revise toolkit & make available at AHRQ.gov & improvingchroniccare.org
- Develop companion Coaching Manual
- Pursue additional research questions
- What are characteristics of teams that can succeed using this toolkit & coaching intervention?
- What kinds of micro- and macro- business changes can we expect to see within 6 months or a year  implementing the CCM?

## Thank you!

- 		www.improvingchroniccare.org

**Notes:**
Thank you all!  I hope this has gotten some ideas flowing about alternative ways to teach & spread the chronic care model in your organization or in the regions where you live or work.  Thanks.

## Our Evaluation Uses A Block-Randomized Design with an External Control Group

**Internal Comparison Arm**

**Baseline Measures**

**Post **
**Measures**

**Intervention**
**Arm**

***Pre-post Changes***

**Secular Trends**

**Baseline Measures**

**Forming Team **
**& Choosing **
**Tools**

**Implementing CCM **
**& related Business**
**Processes Improve.**

**Post **
**Measures**

***Difference ***
***in Changes***

***Pre-post Changes***

**Tool Kit + **
**Practice coaching**

**Baseline Measures**

**Post **
**Measures**

**Secular Trends**

***Pre-post Changes***

**External Comparison Arm**

## Measures

- Implementation:  pre-post qualitative interviews
- Organizational context & baseline assessment
- Plan for change & organizational support
- Improvement strategies & implementation processes
- Perceived impact & lessons learned
- Health process & outcomes: HEDIS & utilization
- Financial measures: ReDeFin
- No show rate
- # of patient care encounters per FTE
- Charges per patient encounter

**Notes:**
2007 article in JAMA “Effectiveness of teaching QI to Clinicians”
6 levels of effectiveness:  
Participation
Attitudes
Knowledge
Skills or behavior
Process
Patients