A8/B8: Self-Management: Critical to Chronic Care

Transcription

1 A8/B8: Self-Management: Critical to Chronic Care Brian Sandoval, Psy.D. Erin Wnorowski, MPH, PCMH CCE IHI 2015 Summit March 2015 Disclosures Erin Wnorowski is an employee of Arcadia Healthcare Solutions a healthcare analytics and consulting services company. We will by no means be talking about our services; however, we are co-presenting our approach with the community health center client. We have been careful to focus on the work at the CHC and their results (vs. our services). Brian Sandoval is an Associate Consultant of Primarycareshrink.com. 1

2 Objectives 1. Describe the value of embedding evidence-based selfmanagement into a chronic disease management program. 2. Guide the development of a self-management program targeted for specific chronic conditions. 3. Design a plan-do-study-act (PDSA) cycle to iteratively test and improve upon self-management program components. Yakima Valley Farm Workers Clinic 2

3 Yakima Valley Farm Workers Clinic 2013 Report to our Communities Our Patients 3

4 Self-Management Approach Goal: Culture Change 4

5 That s Tough How? Plan-Do-Study-Act 5

6 PLAN Program Design DO Implementation 6

7 STUDY Measure Healthy Behavior Counseling 25% Collaborative Goal-Setting 47% Diabetic Foot Exams 15% PCMH-A Level C Level B Values Vision The health of one person is the health of humanity. Mission Together we are dedicated to lead, with the courage to care, the determination to promote personal growth, and the compassion to champion the cause of those who have no voice. We will 1. Consistently trust one another to work for the common good. 2. Foster integrity by demonstrating ethical behavior and insisting on doing what we say we will do. 3. Demonstrate transparency, by being candid and truthful, no matter the risk. 4. Create partnerships to strengthen ourselves and our community. 5. Fight for just treatment for all individuals. 6. Let joy in. 7. Have the courage to be an agent of change and refuse anything short of excellence. 7

8 Define Self-Management Work Team Model Multi-disciplinary work team to define self-management Define SM, using existing evidence Determine how SM would be documented in care plan Consider how SM performance would be measured Train staff with a broad spectrum of skills and experience Considerations for recruiting: Frontline experience necessary; already attempting goal-setting in some way with patients Stakeholders with specific subject-matter expertise High-degree of cultural competency 8

9 Self-Management Philosophy Self-management is defined as the process by which healthcare team members aid and inspire patients to become informed about their conditions and take an active role in their treatment. Bodenheimer et al., CA Healthcare Foundation (2005) Design Components Transformation of the patientcaregiver relationship into a collaborative partnership Portfolio of techniques and tools Supporting patients in goal setting Determining patient s motivation towards adopting health behaviors, assessing barriers, and counseling 9

10 Tools & Methods Documentation Self-Management Template 4.A.3 Documents SM Plans/Goals Provides SM tools Documents SM Abilities Addresses Barriers to Goals Provides/refers to ed. resources Counsels Pt to adopt healthy behaviors Documents SM Plan/Goals 10

11 Documentation All Templates Brief Format Documents SM Abilities/Barriers Documents SM Goals Counsels Pt to adopt healthy behaviors Provides SM Tools Provides/refers to educational resources Documentation Self-Management Template 4.A.3 Documents SM Plans/Goals Provides SM tools Documents SM Abilities Addresses Barriers to Goals Provides/refers to ed. resources Counsels Pt to adopt healthy behaviors Documents SM Plan/Goals 11

12 Documentation All Templates Brief Format Documents SM Abilities/Barriers Documents SM Goals Counsels Pt to adopt healthy behaviors Provides SM Tools Provides/refers to educational resources Self-Management Training in Context Operationalizes values, founded on evidence-based skills. YVFWC Mission, Vision, Values Person Centered Communication Skills Self- Management Skills Motivational Interviewing 12

13 Training: Design Two Phases: 1. Person Centered Communication Training All care team members who interact with the patient, clinical and non-clinical Foundational skills in patient engagement/mi 2. Self-Management Training Focus on clinical staff Training on documentation / use of templates Integration of SM into patient visit Ask-Provide-Ask (Brief MI for primary care visit) Training: Core Components Temperature Check Skills Assessment Self-Reflection Learning Check and Review Didactic Teaching (PowerPoint, Videos, EMR demo) Large Group Participation Exercises Small Group Skills Practice Humor 13

14 Implementation Implementation: PDSA Cycles The Institute for Health Improvement s model, which centers around the use of Plan-Do-Study-Act (PDSA) cycles allows changes to be tested, evaluated, and improved upon before full implementation. Key Drivers for PDSA Success: 1. Clearly define end-goal and related performance target 2. Keep cycles brief 3. Comprehensive documentation of process and outcome 4. Clearly define tasks and roles 5. Identify how progress will be measured 6. Measure progress and track across cycles 14

15 Examples of Care Team Approach A care team is a small group of clinical and non-clinical staff who, together with a provider, are responsible for the health and well-being of a panel of patients. Safety Net Medical Home Initiative Clinical Support Identifies patients with upcoming appointments from registries & hands-off list to Medical Assistant. Medical Assistant During pre-visit prep, Medical Assistant identifies patients in need of annual selfmanagement assessment Dietitian/ Behavioral Health Rd / BHC joins daily huddle to plan who will provide selfmanagement assessment Nurse RN makes follow-up calls to patients who did not receive selfmanagement assessment during their visit. Asthma Case Study Registry Evidence-based guidelines Non-clinical personnel runs registry Self- Management Registry list handed-off to MA Huddle used to ID team member for conversation Follow-Up Nurse follows up with patients who were missed Asthma Outreach Worker does interim home visits 15

16 Evaluation Reports and Evaluation Daily Using registries and pre-visit prep which individual patients need SM? Weekly Custom report, shared at clinic-level, displaying performance against measures for each care team Monthly Scorecard dashboard, shared across organization, displaying performance over time Overall Program Need for ongoing steering committee to re-evaluate training, process, and tools 16

17 Sustainability Corporate guidelines, adapted at clinic level Empowered clinics to own the process and tools Hired additional Behavioral Health Consultants and Registered Dietitians Incorporated self-management measures into monthly clinic scorecard Process of sharing data, at both the clinic and leadership levels, laid foundation for accountability Quality Department staff and committee structure dedicated to PCMH and related initiatives Custom Self-Management Report 17

18 Monthly Performance Scorecard Self-Management Trend 18

19 Training Challenges Motivational Interviewing Self-Management Needed to balance leadership s desire for MI training with immediate, clinically relevant goals for NCQA recognition Training coordination and cadence Who? How often? How would it be evaluated? Large geographic area and limited training resources 16 clinics, 2 states, 6 hours of drive time Broad spectrum of experience with MI/SM Clinical Skills Documentation Technology Challenges EMR not conducive to SM documentation and workflows Care plans organized in separate templates each visit Reliance on manual updates to trigger process workflows Major technology dependencies Training/implementation depended on template build Template build depended on timing for multiple high-priority projects for IT team Reporting process complex Many reports combined related factors/initiatives Complexity limited ability to delegate tedious tasks 19

20 Team Challenges Diverse workgroups with various stakeholders Clinical abilities and engagement differed inter- and intradiscipline Evidence-based guidelines built on medical perspective only Behavioral health component / evidence-based selfmanagement tools not considered from the outset Resource variability across centers BHC, RD, Dental, Pharmacy, and Program Staff Different levels of teamwork and trust Provider-MA relationship crucial Lack of engagement of patient in design and approach Impact & Goals 20

21 Impact of Self-Management Program Meaningful PCMH transformation vs. checking the boxes Higher-quality teamwork MAs understand how to best support providers Care team expanded to non-traditional clinical roles Provider engagement Providers collaborate with patient to set agenda Providers want more training Increased patient engagement Focus on patient education and collaboration breaks down barriers for patients Future Goals of Self-Management Program Expansion of Current SM Practice New disease states Enhanced care-management Training of New Clinical Skills Comprehensive MI training Movement towards shared decision-making workflows Enhanced Evaluation Preceptorship Link self-management process to change in patient satisfaction and/or health outcomes 21

22 The YVFWC Team Tim Bender, Document Management Yvonne Ebbelaar, RN PI Angela Gonzalez, Regional Administrator Carmen Gonzalez-Camargo, EMR Advisor Aaron Grigg, MD Kelly Evans, Arcadia Coach Minami Furuya, Quality Kevin Heidrick, PA-C Casey Holmes, Arcadia Coach LuAnn Kimker, Arcadia Coach, Lead Shweta Kulkarni, PM Robert Leslie, Arcadia Coach Terry Long, IT Erin Moller, Manager Catherine Murphy-Thomas, Operations Mary O Brien, BHS Dave Perkins, IT Ryan Rubino, Arcadia Brian Sandoval, Psy.D Aaron Schneider, Arcadia PM Duncan Stephens, Arcadia Coach David Sullivan, MD Derek Valdez, Project Coordinator Kevin Walsh, MD Erin Wnorowski, Arcadia Coach Michael Young, Clinic Administrator Executive Sponsorship Glen Davis, COO Mark Koday, CDO Ross Ronish, CMO Stella Vasquez, CPO Thank You! Questions? 22