Dr. Shondra Williams, Jefferson Community Health Center Chronic Care in a PCMH Julie Peskoe, PCDC Dr. Shondra Williams, Jefferson Community Health Center This presentation will quickly run through the basics of Chronic Care management to make sure that we’re all on the same page, then we’ll have a presentation by Dr. Shondra Williams from Jefferson Community Health Centers in Lousiana on how her 4 health centers transitioned from acute care to chronic care. Finally, we’ll have a discussion of some of the challenges that you all face with the chronic care model and hopefully have a discussion of strategies and solutions.

Building Blocks of High Performing Primary Care Consistent with CCM Just as a refresher – the CCM reuqires many of these building blocks of high performing primary care. Name which ones?

Chronic Disease Care Chronic conditions such as diabetes, depression, asthma and cardiovascular disease are the major cause of illness, disability, and death in the United States today. In 2010, the medical costs of chronic disease amounted to 75% of healthcare spending. Why do we focus on chronic disease? Why is NCQA, Joint commision so concerned? In 2010 the medical costs chronic disease amounted to 75% of health care spending.

Percent of types of visits seen in primary care nationwide-2006 From Thomas Bodenheimer-Caring for People with Chronic Illness presentation Chronic Care is a Primary Care problem Chronic care happens in the primary care setting. Take a look – 76% of the asthma visits seen nationwide were seen not in a specialists office but in a primary care setting. Often patients in CHC have not just one of these chronic conditions but severa.

Traditional Delivery system Responds primarily to acute, and urgent healthcare problems Focus: diagnosis, ruling out serious conditions, and relieving symptoms. Less focus: education, prevention and helping patients learn to care for themselves better. So, with our traditional system of care which responds to acute and urgent health problems there is less focus on education, prevention and helping patients learn to care for themselves. There simply isn’t enough time in the visit for the clinician by herself to do all she needs to do for chronic care management. According to one study there are about 100,000,000 people in the united states with at least one chronic condition. About ½ of them have more than one condition.

The Case for Chronic Care Model To deliver high-quality chronic care to all our patients in a way that a busy community health center can manage, we need to rethink how we deliver the care The Chronic Care Model provides us with a framework for thinking about this, and essential tools to help improve our processes In particular, a focus on care teams and use of registries can help you get started on redesigning your care delivery to better meet the needs of chronically ill patients. The CCM is a framework for thinking about how to redesign your care model to address the realities of the types of patients we’re seeing. Focus on team care, where the clinician isn’t doing it all, using registries, empaneling patients, proactively reaching out to patients, is a more effective model for delivering high quality care to our patients.

Chronic Care Management Those with chronic conditions, better served by systematic approach that emphasizes: Patient self-management Care planning with mulit-disciplinary team Ongoing assessment and follow-up To make it all work need engaged patients, working with a multidisciplinary team that has clear divisions of responsibilities. It absolutely doesn’t work when there is no clear understanding of who is doing what and the patient isn’t engaged.

Key Components of Chronic Care Model Informed, Activated Patient Productive Interactions with Prepared, Proactive Practice Team Decision Support Clinical Information Systems Delivery System Redesign Self-Management Support Patient needs to be engaged in care. To do that you need time and resources Team needs time to plan visits Decision support to serve as reminders and build evidence based guidelines into care. Also a way to build trust and measure performance Clinical information systems remind care team members to comply with practice guidelines, provide feedback to the care team on how patients are doing and registries for planning patient care and population health. For people with chronic disease – self management can be taught to patients (diet, exercise and self-monitoring)

Care Management How do we make the Chronic Care Model work in a busy, stressed, community healthcare practice? So how do you make it work in a busy health center. It can involve some pretty radical change. How do you go from an acute focus to chronic focus? Individual provider visit to team visit? Provider responsibility to team responsibility? Waiting for the patients to call to proactively scheduling? Easiest way to move is incrementally – can’t change an entire system overnight. With Jefferson, who we’ll hear from in a bit – their first step was to introduce care managers and the concept of a very basic registry. Moved on from there. We’ve seen other health centers start with just one chronic condition, develop protocols, workflows and team responsibilities around that one condition before branching out to other chronic conditions.

Simplify Registries Teams Simplify the Chronic Care Model from Thomas Bodenheimer “Caring for People with Chronic Illness” presentation Decision support Clinical practice guidelines Clinician education Clinical information systems Clinician feedback Reminders/Alerts Registries Delivery system redesign Planned visits Care management Primary care teams Self-management support Simplify Registries Teams The basic, most essential building blocks for introducing the chronic care model involve registries and teams. Registries to identify who is in need of chronic care services. Can start with the highest risk and then teams to address their needs.

Registries Registries: Lists of patients your practice is responsible for that includes clinical information Example: diabetes Date of last A1c, LDL, blood pressure, eye exam, foot exam, microalbumin Results of A1c, LDL, blood pressure, etc. What patient education was done? Registries can get mores sophisticated over time. Start with basic. Can even start with paper lists of highest risk patients.

Registries and teams A registry is useless unless someone systematically manages it! Care gap = Lack of medical attention/care Process care gap: 60 year old woman: no mammogram for 5 years Patient with diabetes: no HbA1c for 1 year Outcome care gap: Patient with diabetes: HbA1c > 9 Patient with hypertension: Blood pressure 160/95 Requires a team to do this work Once you have a registry, need to work it. Can’t be one clinician alone. Requires a team and clear guidelines on who does what. Who sees the highest risk, who gets the patient education, the pedometer,

Teams Large teams are difficult - Smaller teams or teamlets are easier Divide the practice into small teams/teamlets Each teamlet responsible for a panel of patients Same teams always work together, Patients know them and they know the patients Bodenheimer and Laing, Ann Fam Med 2007;5;457;Bodenheimer T. Building Teams in Primary Care, Parts 1 and 2, California Healthcare Foundation, 2007. www.chcf.org Bodenheimer likes smaller teams so that patients know team members and team members build trust. Really hard to use team concept effectively if team members don’t trust each other. If I’m the clinician and I am now being asked to have my medical assistant handle patient education, I need to know that I can trust that she’s been well trained.

Three chronic care functions of primary care team Panel management: Making sure every patient with a chronic condition is identified proactively and has all their evidence based care done on time Health Coaching: making sure every patient with a chronic condition understands their disease, is assisted with health behavior change and medication adherence Complex Care management: Intensive management of high risk patients with multiple chronic conditions So, once you’ve established the teams what do they do?

Care Manager Role in CCM Relatively new job Defined differently by different people Ultimately, you have to shape the role to fit your center’s needs, and the needs of your patient population Not all patients need care management The focus of a Care Manager is usually on needs of chronically ill patients Some health centers the care manager focuses on a specific set of patients – diabetics or cardiovascular disease. In others care manager is called in to assist with specific patients in need of additional services or referrals.

Care Manager Role in CCM Registry work/Panel management Pre-Visit Planning Planned visits Health Coaching/Care Plans Linking patients to community resources Coordinating transitions of care Provide educational materials

Care Manager Establish what care management tasks need to be routinely completed for the chosen patient population Decide who is capable of, or could be trained to perform those tasks Everyone should work to the “top of their license” Establish what tasks and/or staff members care manager will oversee, as opposed to what they will do How to define the role? After you’ve established tasks need to be specific on goals – what is panel size, what’s being done directly by CM, where will it be documented?

Using the care team to expand the 15 minute provider visit Pre-Visit Huddles Agenda Setting Medication reconciliation Ordering routine services History Taking Visit Diagnosis and management Build relationship with patient Post-Visit Soliciting Patient Concerns Closing the Loop Goal Setting/Care Plan Navigating the System Between Visits Telephone calls or emails to patient to see how they are doing Health coach or care manager consults with provider on how patient is doing In CCM the 15 minute provider visit is only part of the interaction with the patient. There is also a pre-visit component, post visit, and work between visits.

System Redesign Pre-Visit Huddles Agenda Setting Medication Reconciliation Ordering routine services History Taking Visit Diagnosis and management Build relationship with patient Post-Visit Soliciting Patient Concerns Closing the Loop Goal Setting/Care Plan Navigating the System Between Visits Telephone calls or emails to patient to see how they are doing Health coach or care manager consults with provider on how patient is doing Neither necessary, nor desireable, to launch entire model at one time! Use PDSA methodology to test new model Use PDSA, start slow and manageable.

From Theory to Practice: Transition to the PCMH Model

Overview of Jefferson Community Health Care Centers, Inc. Established in 2004 Grew from 1-4 clinic locations in 10 years 2 of 4 locations grew as a result of 2 disasters-Hurricane Katrina & BP Oil Spill Serve nearly 14,000 unique patients annually Nearly a $10m budget Recognitions: PCMH Level 3-September, 2012 Joint Commission Accreditation-2011

Corporate Office Our Clinical Practice Avondale River Ridge Marrero Lafitte Marrero

Primary Care & Preventive Care Dental Service Offerings Primary Care & Preventive Care Dental Specialty Services: Behavioral Health, Pediatrics, Podiatry, Obstetrics, Gynecology, & Occupational and Environment Medicine

Transition to Care Coordination Beacon Community Identified a Team Lead Team Development Small Groups to conceptualize essential elements Policy Development Collaboration with other Partners to inform policy development Emphasis was focused on Chronic Care Diabetic Huddles Teaching Tool Development Referral into Care Management Team Approach to Healthcare

Our Process… Challenges Successes By In A1C Control Staffing Challenges Sustained Results Transitions Team Development Resources Communication Improvement Time Patient Satisfaction Chronically Ill Patient Population PCMH concepts have translated to enhanced preventive health screenings Economics of Patient Population *Medication Management *Cost of Visits *Transportation Care Coordinator Follow-up Productivity vs. Financial Partnerships & Coaching EMR Optimization-MU

Timeline for Transition January, 2012 September, 2012 March, 2012 Project Champion was Identified

Major Milestones EMR Optimization PCMH-Level 3 Recognition Clinical Staff are working to the top of their ability

Staff Considerations Job Descriptions Salary Requirements Care Management Role Care Coordinator Role Flow Coordinator

Executive Perspective Supporting the Clinical Leadership Staffing EMR Optimization Scheduling-Open Access Shifting and Allocating Resources Balance of Quality vs. Quantity

Challenges with CCM in a CHC Realities of a busy health center Change Management Staff buy in Limits of EMR Patient acceptance Other competing priorities Cost of delivering care this way

Questions How does your organization handle patients with chronic care management? Where do you think your organization will be in a year? What works well? What doesn’t work? How do you measure and document the work of care teams? How do you build trust in teams? How does leadership communicate goals? How do you make the roles of team members clear and transparent? How does payment/revenue affect your organizations implementation of the chronic care model? What about that 10th building block of high functioning primary care?