Data Review Risk Stratification Working with Specialists November 2012 Webinar Data Review Risk Stratification Working with Specialists

How are we doing in each region? Data Review How are we doing in each region? The second change concept is about how we work together.

Why Trending Wrong Way?

Things to Consider Self management support Who are these patients? Have they been in recently? Depression screening? Need to start insulin? Diabetes educators

GREAT JOB! What’s working?

WOW! … How Can We Build on Success?

How Can We Close the Gap?

LDL Control Tips Lowers risk of heart disease and STROKE Can get non-fasting lipids What % on statins vs. need to titrate more? Most myalgias not from statin

Key to Your Return on Investment Risk Stratification Key to Your Return on Investment

Why risk stratify? Identify patients with highest needs – prioritize. Utilize limited practice resources effectively. Use to determine visit frequency. Maintain access to care. Biggest bang for the buck is to focus on high risk! Prevent unnecessary transitions in care for the patient (ER visits and hospitalizations) – prevent sentinel events. Decrease the utilization of resources downstream. Decrease the overall cost of care. Shift resources to PCP.

Delivery System Design Define roles and distribute tasks among team members. Give “planned care” at every visit — planned interactions that routinely use evidence-based care. (Team and MD/Provider Role) Intensify patient medication if goals not reached —stepped care. (MD/Provider Role) Follow-up care for medium/high risk patients. (MD/Provider and Team Role) Care management intervention for highest risk patients. (Care Manager Role) Give patient-centered care that patients understand and that fits their culture. Delivery system design: Assure the delivery of effective, efficient clinical care and self-management support. Delivery system design is where we all work everyday--(WHO is there and WHAT do they do to contribute to good quality care. This is about HOW we interact with patients.) Most successful chronic care interventions involve increased clinical involvement of the non-physician members of the care team. We are talking about actually having a team who discusses the work they do, how they are going to do it, and how to improve on it. Taplin S, Galvin MS, Payne T, Coole D, Wagner E. Putting Population-Based Care Into Practice: Real Option or Rhetoric? J Am Board Fam Pract. 1998; 11(2):116-26. Planned interactions have an agenda, like a routine physical or a prenatal visit. Planned visits can be either 1:1 or in groups. We can use a registry and tools to help set the agenda and not leave out critical parts of the care. McCulloch et al. Effective Clinical Practice 1998; 1:12-22 and Disease Management 2000; 3(2):75-82 Patients with complex needs, or engaged in an acute transition or exacerbation, often benefit from more intensive attention. The use of a clinical case or care manager, usually a nurse or a pharmacist, has been shown to be effective in diabetes, CHF, depression, and other illnesses. Follow-up is not left to chance. Better outcomes in chronic illness care are due to proactive follow-up by the health care team. In real estate, they say, Location, Location, Location. In chronic illness, it is Follow-up, Follow-up, Follow-up. Support for telephone follow-up: Nurses increase exercise in elderly primary care pts using phone calls: Journal of Geront: Medical Sciences 2002 vol 57A no 11 M733-M740. Piette et al. Impact of automated phone calls and nurse calls on diabetes in the VA, Diabetes Care 2001; 24:202 (better HbA1c, more lipid testing, fewer sx, better satisfaction) Patients should be routinely asked to “teach back” to check comprehension and if they are comfortable with the plan. Providers need to check in with patients to make sure that the interaction style is compatible with their cultural norms, values, and beliefs.

Care Management Someone whose job is to work with high-risk patients. Usually a nurse. Who in your practice can do this? Good people skills Good listener Problem solver Empathetic

Decision Support Utilize standing orders for team members. Use stepped care protocol for medications. Integrate specialist expertise and primary care. Complete risk assessment at every visit. Decision support: Promote clinical care that is consistent with scientific evidence and patient preferences. Many people think that decision support is only about guidelines, but it is much more than that. Guidelines can be found at http://www.guidelines.gov 1) We need to not only have guidelines, but get them off the shelf or the computer screen and use them. Make it hard to do it wrong. Grimshaw & Russell Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 1993;342:1317 Good guidelines describe stepped care. 2) Our typical way of interacting with specialists is to send a patient and hope to get a letter back. We need ways to work more closely together. Some examples are by practice agreements or by sharing team members. Go beyond traditional referral letters to real-time consultation and email exchanges. Quinn et al. Overcoming turf battles: developing a pragmatic, collaborative model to improve glycemic control in patients with diabetes. Jt Comm J Qual Improv 2001;27:255 Katon et al. Collaborative management to achieve treatment guidelines. Impact on depression in primary care. JAMA. 1995 Apr 5; 273(13):1026-31 3) We know lots of ways that don’t change provider behavior, like lecturing you (which I am doing now. The good news is that a collaborative like you will be working in, has been shown to change the ways systems work and improve outcomes for patients. Providers and care teams benefit from problem or case-based learning, academic detailing, modeling by expert providers.) Wagner EH, et al. Quality improvement in chronic illness care: a collaborative approach.. Jt Comm J Qual Improv. 2001 Feb;27(2):63-80 4) Another thing we can do is to inform patients of guidelines pertinent to their care. (Sometimes written as “Expectations for Care” to let patient know what their care should be like.) An example is a wallet card for diabetes. This information is designed to encourage patient participation in all aspects of care, from shared decision-making to adjusting treatment according to shared care plans.

BOTTOM LINE: YOU ARE TRYING TO IDENTIFY YOUR SICKEST 5-10%.

Risk Criteria BP A1c LDL Degree of Disease Severity- PICK A NUMBER AND DO SOME CALCULATIONS BP A1c LDL

Other Factors to Consider Utilization Frequency Office Visits Phone calls to the office ER visits Hospitalization Self-care Deficit Taking of meds Following diet Activity Social Issues Phone Transportation issues Lack of support at home Lack of resources $$$$$

High Risk Patient Categories Patients with hospital admissions and ER visits. Patients with co-morbidities. Patients with depression. Patients with functional or cognitive issues. Patients who have high utilization rates for office services (e.g., frequent visits, phone calls).

Looking at Your Highest Risk A1C >9? LDL >130? BP >160/95? Calculate how many you have? Maybe you need to start even higher. Have they been seen in last 6 months? BRING THEM IN! What can be done different? SELF-MANAGEMENT SUPPORT!

Step-wise Approach to Risk and Intervention Stratification Identifying Patients at Highest Risk, Determining Need, Initiating Care Manager Intervention STEP 3 Getting Medium and High Patients in for Follow-up Visits Step-wise Approach to Risk and Intervention Stratification STEP 2 Giving DM Planned Care at Every Visit STE P 1 Building Registry Functionality for Patients with DM

A Few Risk Stratification Tools. Ninth Street Internal Medicine A Few Risk Stratification Tools Ninth Street Internal Medicine Birdsboro Family Medicine

Birdsboro Family Medicine

NCQA Requires Risk Stratification and Care Management PCMH 3: Plan and Manage Care The second change concept is about how we work together.

PCMH 3: Plan and Manage Care Element B: Identify High-Risk Patients Factor 1: Establish criteria and a systematic process to identify high-risk or complex patients. High resource use (visits, medications, costs) Frequent urgent care/ER visits (2+ in 6 months) Frequent hospitalizations Multiple comorbidities Noncompliance with prescribed treatment, meds Terminal illness Psychosocial issues (social, financial support) Advanced age, frailty Multiple risk factors

PCMH 3: Plan and Manage Care Element B: Identify High-Risk Patients Factor 2: Determine the percentage of high-risk or complex patients in your patient population. Must show criteria and process for selecting. Must provide report showing numerator/denominator and percentage of high-risk or complex patients.

PCMH 3: Plan and Manage Care Element C: Care Management [MUST PASS!] Based on sample of high-risk patients identified. Must: Do pre-visit planning. Develop individual care plans and review/update at each visit. Give patients written plan of care. Assess and address barriers when goals not met. Give patients clinical summary at each visit. Identify and refer patients to community resources. Follow up with missed appointments.

Questions? The second change concept is about how we work together.

Working with Specialists It’s All About Communications!

Communications 62% of PCPs report getting consults from specialists. 81% of specialists report sending info to PCP. Lack of clarity of respective roles. 69% PCPs provide history and reason for consult ‘always’ or ‘most of the time.’

Definitions Referral: transfer of care Consultation: one-time or limited time Collaboration: ongoing co-management For our purposes, referral will refer to a transfer of care. For example, if you refer a patient whose depression is not improving to psychiatry, the psychiatrist will care for that issue in an ongoing basis. Consultation is a time-limited referral. A consultation may be one-time to reassure a patient. Collaboration refers to ongoing interaction of professionals on behalf of the patient. This is also referred to as shared care, and has been described for patients with depression or sharing care post-event for MI or CABG patients. In this system the providers develop a plan for the type of patients they will share care for, determine the visit intervals and communication strategy and share that information with the patient.

Using Consultants Effectively When to consult: Trouble making a diagnosis Specialized treatment Goals of therapy not met Make your consultants partners 1st principle of partnership - communication Communication begins with you Ask a specific question Specify type of consult: ongoing (referral), one time only, duration of specific problem The first thing to ensure when working with specialists is to make sure we are doing the traditional thing (consulting) well. Adapted from material by Steve Simpson, MD, at Kansas University.

Example of an Agreement: Primary Care Side State that you are requesting a consultation. The reason for the consultation and/or question(s) you would like answered. List of any current or past pertinent medications. Any work-up and results that has been done so far. Your thought process in deciding to request a consult. What you would like the specialist to do. This “Yellow card” was developed by the primary care providers and specialists at HealthPartners in Minneapolis. The goal was for effective, efficient care that took into account the needs of the providers and met the needs of patients for a clear plan. It is a two-sided card. This is the primary care side. Source: HealthPartners, MN

The Specialty Side Specialty Care State that you are returning the patient to primary care for follow-up in response to their consult request. What you did for the patient and the results. Answers to Primary Care Physician questions in their consult request. Your thought process in arriving at your answers. Recommendations for the Primary Care Physician and educational notes as appropriate. When or under what circumstances the Primary Care Physician should consider sending the patient back to you. This is the specialty side. Source: HealthPartners, MN

Questions? The second change concept is about how we work together.

Upcoming Meetings December Webinar PDSA Sharing and some fun;) Thursday, December 20: 12-1pm PDSA Sharing and some fun;) January Learning Sessions South Central: Tuesday, January 22 5-9pm, Penn State Hershey Conference Center Northwest: Tuesday, January 29 5-9pm, Location TBA

Here to help you! South Central – Sharon Adams 814-344-2222, sadams@scpa-ahec.org North West – Patty Stubber 814-217-6029, pstubber@nwpaahec.org