Change is Good: You Go First Judith Schaefer Better Self Management of Diabetes Missouri Foundation for Health St. Louis, Missouri December 2 nd, 2009
Foundation s goals Support organizations that: Strengthen shared collaboration and partnership among relevant stakeholders, primary care agencies, faith-based organizations, community health organizations, social service agencies and community resources such as exercise and nutrition programs and medication/medical supply provides or other alternative community resources; Practice evidenced-based interventions that improve patient clinical outcomes; Are ready to make permanent changes to integrate diabetes self-management support throughout their care delivery systems; View self-management as an agency-wide, comprehensive approach to chronic illnesses Leverage resources (dollars, talent, shared responsibilities, services, etc) that improve patient care and their selfmanagement
Collaborative Partnership
Other Activated Patients The Patient Integrated plan Medical & SMG The Provider The Medical Assistant
Organizational Partnerships Community based peer support Primary Care Clinicians Patient Education Classes
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
Planned Care Model Community Resources and Policies Self- Management Support Emphasize the patient's central role. Delivery System Design Health System Organization of Health Care Decision Support Clinical Information Systems Use effective selfmanagement support strategies that include Informed, Activated Patient assessment, goalsetting, action planning, problemsolving and follow-up. Productive Interactions Prepared, Proactive Practice Team Organize resources to provide support Functional and Clinical Outcomes
Three Key Components Patients with confidence and skills Health care team prepared and organized System with necessary supports
Current Practice What strategies or tools are you currently using to engage patients in managing their conditions?
Site Reviews - Teams Jordan Valley Short meaningful encounters Woven into flow of visit Optimal use of team esp nurses Should have engaged entire staff Provider buy in Right fit in hiring/tasking
Site Reviews - Teams CoxHealth Diabetes Center Multidisc Case Mgmt team Nurse, dietitian, counselor Cross training, scripting, MI skills Sustainability? Group visits?
PCRS and surveys PCRS lowest org. score Integration of SMS into primary care < 50% PCP s believe in the benefit of SMS PCRS lowest patient score emotional support
Site Reviews Teams/PCP Connection Barton County Mem. Hospital Group visits How to integrate more with office staff? Goals not always in front of PCP Eliciting barriers and follow up with tell us how you ve been doing relapse prevention
Site Reviews Teams/PCP Connection Morgan County Consult and referral, community supports Contracts signed by client and physician explain what we expect Consult notes Monitor progress every 3 months phone
Site Reviews Teams/PCP Connection Mississippi County Health Department Onsite educ session but still disconnect from PCP Best Flow Educ. visit before PCP? Some offices full day booked, others not Patients move from provider to provider
Who should be on your TEAM? How does a patient experience the flow of care before, during and after a visit with me or my team? How can I expand thinking about who could be on your team and how do you engage those folks to form a team? What could I do to increase information flow and coordination between parts of this team? Who are we not using?
Defining Tasks
Visit Flow RN reviews MD s upcoming schedule for patients with Hypertension and sends letters MD recruits patient during visit for SMS Patient declines Ask again at next visit Patient accepts MD/ RN huddle SMS with RN
SMS Flow RN provides SMS Patient s folder Action Plan Negotiate follow up My Care brochure Living Well Workshop brochure Patient Survey
Taking Perspective How can your work save others time? Protocols? Agreements? Can you offload tasks? What coordination efforts would help? Reimbursement issues? How to collaborate on follow up?
A Broader Definition of System Community what are the functions and what needs to happen. How do I do what I do best and help make sure we cover all of these things for patients.? Coordination of care and reducing waste Relationship building among parts of the system.
Two Views of SMS Portfolio of Tools and Techniques to help patients change behavior A fundamental transformation of the patient caregiver relationship into a collaborative partnership. Bodenheimer, CHCF.org 2007
Pt Education to SMS Not a Sage on the Stage, but a Guide on the Side Information is necessary, but not sufficient Patient should know what to do and feel confident they can do it
Site Reviews Partnering with patients and community U Miss Fam Medicine Expert, top down advice based vs Grass roots, bottom up cmty based CAB s/comm outreach-ongoing access to patient feedback Why are you not at the table? Nothing about me without me
Site Reviews Partnering with patients and community Missouri Highlands Healthcare Building Relationships lower the intimidation level Resource list, but real creative partnering community action agencies Relationships last after the funding ends sustainability Governing board and senior leader support
PCRS Patient supports PCRS lowest patient score emotional support Functional view of self management
Differences between Acute and Chronic Conditions ACUTE CHRONIC Beginning Rapid Gradual Cause Usually one Many Duration Short Indefinite Diagnosis Diagnostic tests Commonly accurate Often decisive Often uncertain Often limited value Treatment Cure common Cure rare
Differences Between Acute and Chronic Care Roles Role of Professional Role of Patient Lorig 2000 ACUTE Select and conduct therapy Follow orders CHRONIC Teacher/coach and partner Partner of health professionals responsible for daily management
Symptom Cycle Disease Fatigue Tense muscles Vicious Cycle Depression Stress/Anxiety Anger/Frustration/Fear
Dancing vs. Wrestling Tips on succeeding with SMS competencies Open the conversation in a positive way Offer a menu of options Ask what is important to the patient Make a plan Specify to make changes clear Support small changes Ask about confidence Adjust the plan until success is likely
My Health Choices Here are the things we have talked about. Which one is most important to work on right now? Irritating foods (write in others here) Testing Blood Sugar Walking Managing stress
Partner Exercise Using an Action Plan Something you WANT to do Behavior specific What When How much How often Confidence level Follow-up plan
Change is Good: YOU go first Making small, incremental changes in practice Making changes that we WANT to do Embedding changes in routine practice activities Engaging a multidisciplinary team Finding new ways to connect practice and patients in the community
Moving from a Perfect Change to the Next Test PDSA or PPPP Plan Do Study Act or Plan Plan Plan Panic! How can we get away from drive to be "perfect" and instead use the Model for Improvement to start with small tests of change? A Question: What kind of challenges are you having testing change ideas using PDSA cycles?
Model for Improvement Setting Aims Establishing Measures Developing Changes What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? Act Study Plan Do Adapted from Langley et al The Improvement Guide: A Practical Approach to Enhancing Organizational Performance 1996
The Plan-Do-Study-Act Cycle Plan: Do: Study: Act State the objective Predict what will happen and why Develop a plan (who, what, when, where, data to collect) Carry out the test. Document problems and unexpected observations Analyze the data Complete the analysis of the data Compare the data to your predictions Summarize what was learned What modifications should be made? What will happen in the next cycle?
What is a small PDSA? MODEL FOR IMPROVEMENT Cycle: Date: Objective(s) for this PDSA Cycle: Test new procedure getting patient s agenda for the visit: send out agenda form, front desk will check for form at check in and MA will provide additional form and explanation if patient hasn t brought it.. PLAN: QUESTIONS: (1) Will front desk remember to send form? (2) Will patient bring in completed form? (3) Will front desk check and MA provide? PREDICITONS: (1) Patients will complete the forms if they are provided by mail and in the office (2) Completed forms will give the physician time to introduce goal setting (3) Physician may still not introduce goal setting (4) Patients will like the forms and be more ready for the visit PLAN FOR CHANGE OR TEST: WHO, WHAT, WHEN, WHERE Who: physician, MA and front desk staff with 5 patients What: Use new agenda form with patients When: Week of November 28 Where: Five or more patients coming in for diabetes check back visits PLAN FOR COLLECTION OF DATA: WHO, WHAT, WHEN, WHERE MA will develop task list and place at front desk. review schedule will be reviewed to find
PDSA (Cont.) DO: CARRY OUT THE CHANGE OR TEST; COLLECT DATA AND BEGIN ANALYSIS. We planned to test the new form in five cases; however, two patients didn t fill in the form so we were able to test the change only three times. STUDY: COMPLETE ANALYSIS OF DATA; COMPARE TO PREDICTION, SUMMARIZE WHAT WAS LEARNED. The PCR remembered to send out the form and two patients brought them in. The MA gave the forms to the three other patients, but one refused it. One patient completed it in the room, the other read it but did not complete it. The physician did start the goalsetting conversation with four of the five patients, even though one patient had not filled it in. ACT: ARE WE READY TO MAKE A CHANGE? PLAN FOR NEXT CYCLE. Based on the initial test, the new plan is working pretty well. We plan to test again next week on five more patients with the PCR explaining the form a little more.
Repeated Use of the PDSA Cycle Improve Goal Setting Number of Goals Documented in Charts SMS Toolkit Changes That Result in Improvement Implementation of Change Wide-Scale Tests of Change Hunches Theories Ideas Very Small Scale Test Follow-up Tests
Series of PDSA Cycles to Improve Goal Setting Increased Goal Setting A P S D Cycle 5: Implement standards and monitor their use Use of Agenda setting tool will increase Goal Setting A P S D Cycle 4: Standardize process and agenda setting tool for best changes Cycle 3 Test best change with 1-3 MDs patients Cycle 2: Compare changes tes for one week Cycle 1: Define a small number of changes and test with staff
Why Test-Why Not Just Implement??
Why Test? Possible Objectives of PDSA Cycles for Testing Increase your belief that the change will result in improvement Opportunity for learning from failures without impacting performance Document how much improvement can be expected from the change Learn how to adapt the change to conditions in the local environment Evaluate costs and side-effects of the change Minimize resistance upon implementation
Current Situation Low Confidence that change idea will lead to Improvement High Confidence that change idea will lead to Improvement Appropriate Scope for a PDSA Cycle Cost of failure large Cost of failure small Cost of failure large Cost of failure small Staff/Physician Readiness to Make Change Resistant Indifferent Ready Very Small Scale Test Very Small Scale Test Very Small Scale Test Small Scale Test Very Small Scale Test Very Small Scale Test Small Scale Test Large Scale Test Very Small Scale Test Small Scale Test Large Scale Test Implement
Thought Provoking Questions What changes have you tested using effective PDSA cycles?
DRAFT DELIVERY SYSTEM DESIGN Assure the delivery of effective, efficient clinical care and self-management support. New tests are in italics and highlighted. CHANGE CONCEPT KEY CHANGES EXAMPLES YOU CAN TEST Define roles and distribute tasks among team members Define and develop the team as a unit. Determine process for care and assign team members to tasks. Match the work to the individual s licensure and capability. Cross train staff. Use protocols and standing orders for care. See also, decision support. Have receptionist obtain history, recent health info and VS, MD examines, RN does self-management and follow-up. Determine back-up staff for each task. Use protocols. Discuss everyone s planned care tasks as a unit. WHAT OUR TEAMS ARE TESTING: DIABETES PCAs assist Pts with PHQ9 at time of vitals (Cumberland) System implemented to ensure transitional flow (from Health Educator to Nutritionist to SW to MD) resulting in Pt receiving comprehensive care from all team members (East NY) Social Worker added to Team for planned visit days (Woodhull) Team Meetings prior to planned visits (Woodhull) Psychologist joined care team (Woodhull) Using team huddles to deliver care as team (Coney Island, Harlem) Providing care as a team consisting of PCP, PCA, dietary staff, clerical staff (Lincoln. Gouverneur)
Change Concepts, Theories, Ideas
Multiple PDSA Cycle Ramps Agenda Setting Goal setting Use of a Care Plan Standard follow up procedures Change Concepts
Team roles And Tasks Tools It Takes Work in Multiple Areas: Testing in Parallel Office Flow Cross Training Sr Leader Support A P S A P S D A P S A P S D D D A P S A P S A P S A P S D D A P S D D D A P S A P S D A P S A P S D D D A P S D A P S A P S A P D A P S D D A P S A P S D A P S D D A P S A P S A P Testing.Implementation.Spread S D A P S D S D A P S D D D Aim: Increase SMS Goals by 80%
Principles for Testing on a Small Scale Have others possessing some knowledge about the change review and comment on its feasibility Test the new product or the new process on the members of the team that developed the change before introducing it to others Incorporate redundancy in the test by making the change side-by-side with the existing process or product Develop a plan to simulate the change in some way Conduct the test in one facility or office in the organization, or with one customer Conduct the test over a short time period
Tips to Accelerate the Rate of Improvement Plan multiple cycles to test and adapt change Think a couple of cycles ahead Scale down size of initial test (# of patients, # of locations, time period, etc.) Test with volunteers Do not try to get buy-in or consensus for the test Be innovative to make the test feasible Collect useful data during each test In later cycles, include a wide range of conditions
Promotoras/Community Health Workers
Peer Led Workshops
Outreach
Organizations
Partnering Relationships involvement collaborating cooperating commitment resources coordinating networking
Environment and Policy
Walkable Neighborhoods/ Cyclovia
It Takes a Region
Online Resources http://www.improvingchroniccare.org http://www.newhealthpartnerships.org http://www.chcf.org/topics/chronicdisease http://www.familycenteredcare.org