Learning Lab Objectives. Introduce evidence showing team-based primary care leads to better patient health outcomes.

Transcription

1 Washington, DC L11: Team-Based Care: Effective Innovations in Practice Dr. Ed Wagner, MD, MPH Director Emeritus & Senior Investigator MacColl Center for Health Care Innovation, Group Health Research Institute & The Robert Wood Johnson Foundation Emerging Leaders IHI Summit March 10, 2014 Learning Lab Objectives Introduce evidence showing team-based primary care leads to better patient health outcomes. Highlight creative & effective strategies for using primary care team members differently. Offer real-world examples of innovative team roles by including medical assistant, nurse and physician presenters from high-performing primary care practices. 1

2 Why Primary Care Teams? 3 Current State of Primary Care ½ Of patients with major chronic illnesses receive recommended care. Of people leave the doctor s office without understanding what their physician said. Of doctors perceive people with chronic conditions usually receive adequate medical care. The quality of health care delivered to adults in the United States. McGlynn, E.A., Asch, S.M., Adams, J., et al. N Engl J Med June 26; 348: & Studies of doctor-patient interaction. Roter, D.L., Hall, J.A. Annu Rev Public Health. 1989;10: & Closing the loop: physician communication with diabetic patients who have low health literacy. Schillinger, D., Piette, J., Grumbach, K., et al. Arch Intern Med Jan. 13.; 163(1): & Physician, Public and Policy-Maker Perspectives on Chronic Disease Conditions. Anderson, G.F. Archives of Internal Medicine. Feb. 24, 2003: 163(4);

3 Meta-analysis of Interventions to Improve Diabetes Care Shojania, K. G. et al. JAMA 2006;296: Shojania, K. G. et al. JAMA 2006;296: Greater Care Complexity Preventive Care 7.4 hours + Evidence-based Care 10.6 hours Primary Care: Is There Enough Time for Prevention? Kimberly S. H. Yarnall, Kathryn I. Pollak, Truls Østbye, et al. Am J Public Health April; 93(4): & Is there time for management of patients with chronic diseases in primary care? Østbye, T., Yarnall K.S., Krause, K.M.et al. Ann Fam Med May-June; 3(3):

4 Using teams to save physician time 7 Type of care Percent of physician s time in traditional practice Estimated percent of physician s work that can be reallocated to nonclinicians Estimated percent of physician s time saved Preventive Chronic Acute Total Thomas S. Bodenheimer and Mark D. Smith: Primary Care: Proposed Solutions To The Physician Shortage Without Training More Physicians, Health Affairs, 32, no.11 (2013): The LEAP Project 8 Identify innovative primary care practices that can serve as models for improving efficiency and quality of the healthcare workforce. Identify up to 30 exemplar sites Collect data on innovations and change processes, best practices Create a learning community among exemplar sites Develop a toolkit for broad dissemination 4

5 31 LEAP Sites 9 Major Findings from Site Visits 10 Sites have well-developed core teams surrounded by An extended team with care mgrs., pharmacists, behavioral health, etc. Sites perform planned care, population management, care management, and medication management well.. Lay-persons and flow staff play key patient care roles In most practices.. 5

6 RWJF Emerging Leaders 11 Fishbowl #1: Care Team Roles 12 Who is on the care team and what are their roles? Facilitator: Amy Hardy Medical Assistants Jessica Waunch Patti Swierbinkski Amanda Marquez Registered Nurses Kathy Bragdon Sarah Hamilton Brittany Lourens Front Desk Anita Johnson Patricia Alves Jeremie Robenolt 6

7 13 Effective Chronic Illness Care What do Patients with Chronic Illness Need to Optimize Outcomes? Drug or other treatment that gets them safely to their therapeutic goals Effective self-management support Preventive interventions at recommended time (planned interactions) Evidence-based monitoring and self-monitoring Follow-up tailored to severity (proactive follow-up) Effective care coordination and shared/collaborative care 7

8 What does the nation need to reduce health care costs? Take better care of the complex chronically ill. Reduce avoidable hospital admissions and readmissions. Reduce avoidable emergency room visits. Reduce the rampant fragmentation of care. 15 Toward a planned care oriented system Reviews of interventions in multiple conditions show that effective practice changes are similar across conditions i Greater use of non-physician team members, iplannedencounters and follow-up, i modern self-management support, i more systematic medication management i care management for high risk patients ipopulation or panel management using registry functionality Renders CM, Valk GD, Franse LV, Schellevis FG, van Eijk JT, van der Wal G. Long-term effectiveness of a quality improvement program for patients with type 2 diabetes in general practice. Diabetes Care Aug;24(8):

9 Chronic Care Model Community Resources and Policies Self- Management Support Health System Health Care Organization Delivery System Design Decision Support Clinical Information Systems Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes 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): & 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): & Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A., Improving chronic illness care: translating evidence into action. Health Aff (Millwood) Nov- Dec;20(6): Meta-analysis of Interventions to Improve Diabetes Care Shojania, K. G. et al. JAMA 2006;296: Shojania, K. G. et al. JAMA 2006;296:

10 Evidence on the Effectiveness of the CCM 1. Randomized controlled trials (RCTs) of interventions to improve chronic care. 2. Studies of the relationship between organizational characteristics and quality improvement. 3. Evaluations of the use of the CCM in Quality Improvement. 4. RCTs of CCM-based interventions. 5. Cost-effectiveness studies. Coleman et al. Health Affairs Jan-Feb;28(1): Stellefson et al. Prev Chronic Dis. 2013;10:E26. Miller et al. Med Care ;51: To implement the CCM, most organizations must: Change when, how, and by whom care is provided. Ask physicians and other staff to take on new roles and change how they deliver care and relate to each other. Invest time and money on new processes or staff. Increase stress by uprooting established routines

11 What have successful organizations done to create effective teams? Hire bright, energetic folks with good interpersonal skills. Define key roles and tasks and distribute them among the team members. Train staff to perform tasks and monitor performance. Use protocols and standing orders to enable staff to operate independently. Give teams time to meet. Fishbowl #2: Chronic Illness Care 22 How do you deploy a team in caring for patients with common chronic illnesses? How do the team members work together to provide great patient care? Monica Guillen Gina Lamanna Liss Ieong Lainey Trahan Rachel Gardner Facilitator: Andy Tremblay 11

12 Thank You! 23 Find us at: maccollcenter.org/ and improvingchroniccare.org/ 12