Best Practice in Managing Patients with Multiple Chronic Conditions Learning Collaborative Participating Group Projects Overview: Common Themes
Advocate Medical Group Affinity Medical Group Arch Health Partners Columbia-St. Mary s Medical Group Crystal Run Medical Group Dartmouth-Hitchcock Medical Group Essentia Health Fletcher Allen Health Care Geisinger Health System HealthPartners Medical Group Intermountain Healthcare Mercy Clinics, Inc. Mercy Medical Group Novant Medical Group Primed Physicians Riverside Medical Group Sentara Medical Group Sharp Rees-Stealy Medical Group The Polyclinic ThedaCare University of Pittsburg Medical Group University of Utah Medical Group Wenatchee Valley Medical Group
What Do You Look Like? Populations Served: Small to Large From Rural to Urban Areas Deliver health care to approximately 13.6 million patients across the country
MPMCC Groups by Organization Type 16% Academic Practices 5% IPAs 26% Group Practices 53% Integrated Delivery Systems
MPMCC Groups by Number of Physicians 10% <50 MDs 70% > 150 MDs 20% 51-150 MDs
Proposed Framework for Complex Chronic Care Care Processes Redesign Performance Improvement Care Coordination & Transitions Patient Registries Medication Reconciliation Pre and Post Visit Plan Performance Measurement & Transparency Test Tracking & Reporting Patient Self- Management Support Health Coaching Systematic Improvement Plan Creating and Implementation of Standardized Processes Organizational Infrastructure Leadership Commitment Aligned Incentives Strategic Alliances IT Infrastructure
Group Pre-work Chronic Care Goals and Objectives Chronic Care Intervention and Population Baseline Self Efficacy Improvement Interventions Measures Used Payment Reform Challenges or Obstacles Outcomes and Successes Future Steps Lessons Learned Questions
High Level Common Theme Care Delivery System Changes Mission New scope (24/7/365) Structure (Redesign) Team Composition New Responsibilities New Dependencies Integration of Previously Separate Silos Process New Functions Measurement Best Practice / Standardization New Accountabilities Improvement / Optimization
Delivery System Redesign PCMH IOPC Transitions of Care Special Needs Populations Expanded Venues of Care Common processes Coordination of care Navigators Health Coaches Medication Reconciliation Adherence Mental Health integration Range of Activities
Chronic Care Goals and Objectives Virtually all groups, with varying differences in emphasis of each of the elements, have incorporated the three element of the IHI Triple Aim into their chronic care objectives: Improve the health of the population Enhance the patient experience of care (quality, access, rehabilitation) Reduce or at least control the per capita cost of care
Chronic Care Objectives Population Condition specific outcomes: DM, depression, COPD, CHF public reporting Patient Experience Continuum of care/coordination Reduce errors/defects, EBM Transitions Functional status Cost Reduce ER use, hospitalization Reduce errors/defects
Populations / Conditions Disease based: DM, CFH, HTN, Depression, COPD, CAD, Asthma Special populations: elderly, high needs, Medicare Advantage Special situations: transitions of care
Use of Standards External National (NQF, NCQA) Local (state, regional) Internal
Improvements Intervention Access Registries Chronic Care Model Complex case management for high risk patients (IOPC) AVS Pre-visit planning Group visits Home visits Medication reconciliation Care coordination with specialist Health coaches ARNP in SNF IP case management Post ER / Post IP d/c F/U Multi-disciplinary, teams Referral management Patient education Create new tools Align incentives PDSA cycle LEAN Standard workflows Worksheets (checklists) Lower thresholds for initiation of treatment (Rx) EMR tools Embed care coordinators in primary care practices Add PharmD, ARNP, RN navigators
Challenges Culture Engagement / momentum Resources Conflicting priorities Communication Collaboration across organization Internal alignment External dependencies Standardization Business case (external reimbursement) MD engagement Patient engagement Hiring right people Data
Successes Leadership (local and senior) Support from above Clear vision Defining the problem Motivated providers Shared learning Collaboration Communication / Trust Staff MD feedback Patient feedback Data Celebrate success Business case
Questions Set priorities Timing of progress Communication Maintain top support What measures matter What chronic conditions / pts should we focus on Developing a business case Incentives and shared savings models How to best measure value Risk stratification Measuring cost of care Track referrals Change culture Staff changes MD incentive Role of centralization Patient self management Patient engagement