Case Examples Designing & Measuring Education in Today s Changing Healthcare Market: The Expanded Learning Model for Systems (TELMS) John Ruggiero, PhD, MPA, CHCP Associate Director, U.S. Medical Affairs Learning & Clinical Integration Genentech
Humans live in an environment of tangible matter. Inside every object is energy waiting to be released it can be as gentle as a candle s glow or as violent as a nuclear explosion it has built the world around us. 100 Big Ideas, Science Breakthroughs and Inventions National Geographic The Power of Matter
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Genentech Working Group (2014) Discussed how emerging learning resources could be integrated into evolving health care delivery models that advance patient care Formed/validated a model to measure the effectiveness of the integration of education with initiatives tied to the Triple Aim Why?
Why is the Conversation Necessary? Convergence of Challenges for Today s Healthcare Stakeholders Increased push for population health management; healthcare decisions increasingly made via team effort Increased emphasis on patient-centered and coordinated care New payment and delivery models; Growth in data infrastructure and dependency on real-world data Unacceptable 17-year Adoption Curve* Challenges for clinicians & systems will continue to develop as health reform implementation matures * American Medical Association, 2013
Traditional IME models are based on theories that do not adequately address practice-based gaps and system-based learning Patient-Centricity
The Answer: A Wave of Tools & Strategies Oncology Care Model CMS Core Measures & MIPS Progress Toward Value-Based Care Leverage What Exists
FOR EXAMPLE: Metrics to Measure Hospitals' Progress Toward Value-Based Care Aligning hospitals, physicians and other clinical providers across the continuum of care % of physicians aligned with designated networks to improve care coordination Utilizing evidence-based practices to improve quality and patient safety Effective measurement to show management of care transitions; Management of utilization variation; Active patient engagement in design and improvement Improving efficiency through productivity Immediately making the correct choices Developing integrated information systems Understanding of population disease patterns Real-time information exchange Source: Sabrina Rodak, 19 Metrics to Measure Hospitals' Progress Toward Value-Based Care, 2013.
How can you collectively help? The results of the Working Group formed TELMS We can all help build upon TELMS 14
The Expanded Learning Model for Systems (TELMS) What it is What it is NOT A framework to create a conversation about what healthcare stakeholders need today A framework that discusses behavior modifications A framework that may become an expanded design and measurement model for education that moves systems of people X A one-fit-all approach to medical education X A framework that is complete or opposed to various metrics that meet the specific disease state or gap(s) X A replacement for existing models that address traditional and equally beneficial education 16
Activate > Understand the Gap Advance > Address the Gap Aspire > Practice the Solution Allocate > Extend the Solution
What s different? The movement of systems, not just individuals
What s different? The incorporation of behavior theory to accelerate evidence into practice
TELMS Case Study: Interprofessional Education Background American Academy of Pediatrics (AAP) has released a new clinical practice guideline that provides evidence-based recommendations for the diagnosis and treatment of children diagnosed with attention-deficit/hyperactivity disorder (ADHD). This guideline is intended for use by clinicians working in primary care settings. The guideline replaces two previously published clinical guidelines that were published by AAP in 2000 and 2001. CDC conducted the systematic review of evidence for the diagnosis and evaluation of ADHD. For preschool-aged children (4 5 years of age), the primary care clinician should prescribe evidence-based parent- and/or teacher-administered behavior therapy as the first line of treatment and may prescribe recommended treatments if the behavior interventions do not provide significant improvement and there is moderate-to severe continuing disturbance in the child s function. Related Quality Measure: Behavior Therapy as First-Line Treatment for Preschool-Aged Children with ADHD; Measure Developer: Pediatric Measurement Center of Excellence (PMCoE) Content sources: Division of Human Development and Disability, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, 2015. American Academy of Pediatrics. A process of care and diagnosis for treatment, 2015. http://www.ahrq.gov/sites/default/files/wysiwyg/policymakers/chipra/factsheets/chipra_1415-p005-2-ef.pdf Ruggiero, J, Robinson, CO. TELMS Case Study, 2015.
Potential Approach One Example: From the outcomes section of a recent grants This grant has the potential of measuring the following results pre- and post-education: Additive Moore s et al Levels 1 & 2 Level 3: Procedural Knowledge Improvement Level 4: Competence Improvement Level 5: Subjective Performance TELMS Description of the baseline metrics the system currently needs to address/correct Post-education metrics that show an improvement in awareness of that specified local problem Post-education metrics that describe how the system intends to address/correct the problem to enhance the baseline metrics Not currently applicable for this knowledgebased grant
TELMS Case Study: Knowledge Acquisition Education Intervention Problem A certain system of ambulatory healthcare providers has identified a deficit in knowledge pattern: Primary care physicians (PCPs), who may (or may not) have been introduced to the new clinical guidelines and associated quality measure related to preschool-aged children with ADHD, are still prescribing treatments to 50% of preschool children diagnosed with ADHD prior to testing evidence-based administered behavior interventions. What s happening in the healthcare institution How education MAY be able to help PLAN: To use baseline data as an assessment of need to develop an education intervention that corrects a deficit in knowledge surrounding new AAP guidelines and associated quality measure. DO: Provide baseline data to PCPs within this ambulatory healthcare setting regarding their own and their peers metrics on this quality measure; Provide/test an appropriate education intervention on a scalable level. STUDY: Analyze the results of the education intervention to show how learners used education to improve their awareness of the localized gap so that information was converted into appropriate educational case responses surrounding: 1) an improved knowledge baseline regarding the AAP guideline and measure, 2) an improved belief in the presented evidence of all recommendations, 3) a connection between education and a potential reduction of the baseline quality metrics. ACT: Based on what was learned, identify how this refines the gap and the need for a continued learning framework. Content source: http://www.ihi.org/resources/pages/howtoimprove/scienceofimprovementhowtoimprove.aspx Ruggiero, J, Robinson, CO, Paynter, N. TELMS Case Study, 2015.
TELMS Case Study Planning Phase Who attended? What is the impact of the activity? What is the nature, severity and context of the identified problem and why are these specific clinicians participating in the activity? What is the intended improvement if clinicians participate? Current Measurements Conceivable Additive Measures Pre- versus posteducation clinical survey questions (knowledge) and case studies (competence): Did the participants demonstrate learning in the educational setting and the ability to make new decisions? Educational providers might select and observe a stratified group of clinicians to: Demonstrate through pre- vs postquantitative or qualitative data how clinicians became more aware of the locally identified problem Pre- vs post % of clinicians across the system who are now aligned on a plan to address that awareness Pre- vs post metrics that show clinicians have identified the encountered barriers and agree on future interventions to minimize or remove barriers to improved care That approach suggests a rapid correction to the problem Ruggiero, J, Robinson, CO, Paynter, N. TELMS Case Study, 2015.
Pre- v Post-Education Results Outcomes Additive Impact Metrics 1.Total Learners = 150 2.75% were PCPs 3.32% Improved knowledge gain about updated AAP Guidelines 4.46% demonstrated competence in Guideline case-study 5.27% committed to performance change as a result of the education STEP 1: 90% of participants demonstrated an improved awareness of the local problem, 75% are aligned on goals, such as STEP 2: As a result, the healthcare ambulatory center has committed to the following plan... STEP 3: The timeline for completion is 3 months which will accelerate evidence into practice at a rate of (Y). FOLLOW-UP: The percentage of system patients now adhering to evidence-based care: Guideline: 50% to 70% Behavior Plan: 70% Treatment A : 24% Treatment B : 6%
TELMS Case Study: Application-based Education Intervention Problem A certain system of ambulatory healthcare providers has identified a deficit in practice pattern: primary care physicians have already been exposed to new clinical guidelines but are still prescribing treatments to approximately 30% of preschool children diagnosed with ADHD prior to testing evidence-based administered behavior interventions. There is evidence of a lack of belief among PCPs in behavior interventions and a gap in systems-based care coordination. What s happening in the healthcare institution How education MAY be able to help PLAN: To develop an education and process intervention that identifies and then corrects practices that limit a relevant patient s ability to receive guideline recommended evidence. DO: Provide/test the intervention on a scalable level. STUDY: Analyze the results to show how education was used to commit to long-term practice plans that include, but are not limited to: 1) the educational provider s ability to re-educate PCP learners about AAP updates and to have learners compare their own results to institutional results, 2) the educational provider s ability to have PCPs better communicate and coordinate patient cases with those managing the patients behavior interventions (nurses, social workers), and 3) the educational provider s use of institutional tools that track care patterns post-education ACT: Based on what was learned, identify how this refines the gap and the need for a continued learning framework. Ruggiero, J, Robinson, CO, Paynter, N. TELMS Case Study, 2015.
TELMS Case Study Planning Phase Who attended? What is the impact of the activity? What is the nature, severity and context of the identified problem and why are these specific clinicians participating in the activity? What is the intended improvement if clinicians participate? Current Measurements Through surveys and observational reports: Did the participants commit to applying learning in order to improve practice? Did the participants maintain certification requirements? Conceivable Additive Measures Educational providers might have already Identified the barriers that clinicians encountered. Selecting and observing a stratified group of clinicians to: Quantify commitments to long-term project plans that address these barriers Pre- vs post-data that shows management of care transitions, real-time exchange Demonstrate practice improvements by using administrative, claims or registry datasets and/or other office/system metrics Report data-driven interpretations and final conclusions that can be made through the outcomes Provide examples of how specified needed certification may help identify a change in process that addresses the original identified problem Ruggiero, J, Robinson, CO. TELMS Case Study, 2015.
TELMS Case Study Planning Phase Who attended? What is the impact of the activity? What is the nature, severity and context of the identified problem and why are these specific clinicians participating in the activity? What is the intended improvement if clinicians participate? Current Measurements Expanded Conceivable Measurements Not currently applicable Educational providers might: Pre- vs post-data that identifies a change in process of care specific to guidelines and measures Pre- vs post-data of how interventions / tools were integrated into workflow to sustain positive change or adherence to evidence-based care and system requirements Eventually: Pre- vs post data that identifies a collaboration between interprofessional HCP team members and/or patients surrounding improvements in topics such as communication about care plans, satisfaction of care/treatment, and measures patients take to make better healthy living decisions away from the clinic that enable the adherence of the care plan Ruggiero, J, Robinson, CO. TELMS Case Study, 2015.
Pre- v Post-Education Results Outcomes Additive Impact Metrics 1.Total Learners = 150 2.75% were PCPs 3.32% Improved knowledge gain about updated AAP Guidelines 4.46% demonstrated competence in Guideline casestudy 5.27% committed to performance change as a result of the education STEP 1: Education improved system efficiency by 15%: 5 month observation posits improvement, reducing time for evidence-based practice improvements in < 1 year 75% of physicians are now immediately making the correct choice aligned to the diagnosis 50% of physicians are regularly communicating with behavioral specialists, increasing real-time exchange To maintain engagement and show an increase in partnership, the ambulatory healthcare system intends to STEP 2: Education improved utilization of evidence by 73%: Claims data indicates 22% more patients are now referred to behavioral specialists (from 30% to 18%) Post behavior intervention, % of patients adhering to Treatment A = 24%; Treatment B = 6%
Her notions [about naturally occurring elements] conflicted with the understanding of atoms at that time. She held to her convictions against a sometimes skeptical scientific establishment, and eventually her views were not just accepted [but also proven correct.] 100 Big Ideas, Science Breakthroughs and Inventions National Geographic Marie Curie
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