1. Spread How we engaged patients, community and staff to improve care of patients with chronic conditions Mary McDonough RN Jeff Aalberg MD Maine Medical Center Portland, ME STFM Conference on Practice Improvement November 10, 2006

2. Goals of this presentation Define elements surrounding the way we care for patients with chronic illness Describe a large system change: Spread Realize the challenges, and successes, in engaging residents in change

3. Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Care Model

4. Initiative History ‘entropy’

5. Implementing Change Implementing change is hard --- most innovations diffuse at a slow rate…it is passive 3 influences that can change the rate of spread (from passive to active) Understanding what we’re trying to do Characteristics of those being asked to adopt it Contextual factors; leadership, communication, management, etc

6. There are some challenges

7. Challenge Our practice-your practice Family Medicine Centers-Portland and Falmouth 20,000 patients Each year –45,000 office visits –160,000 phone calls 100 employees –14 Attending physicians –21 Residents –65 staff Portland site

8. Challenge Role of primary care 58% of all visits are to primary care physicians 90% of all diabetic visits are to primary care physicians Responsibility for coordination of patient care throughout the health care system Acute as well as chronic care

9. Challenge Multiple chronic illnesses DiabetesCancer Asthma Hyperlipidemia Cardiovascular diseaseDementia HypertensionDepression Lung DiseaseStroke ArthritisPeptic Ulcer disease And others…

10. So….how to change? Know what you’re trying to change Infrastructure (are we ready for this?) Communication (many times, many ways) Social System (our people, our culture) Measurement & Feedback (responding to the data) Make it a campaign: we called ours ‘Spread’ Essentials for success

11. Spread the Aim T o improve care of patients with chronic illness by spreading the work of our collaboratives, enlisting support from our community, and supporting patient self management.

12. Our aim is broad “How do you eat an elephant?” Answer: One bite at a time Recognize that it’s a large complex system and we need work on one step at a time.

13. Lets get started… Know what you’re trying to change Social System Infrastructure Communication Data

14. First : Know what you’re trying to change… the Care model concepts Improve processes: Standardize care processes Integrate all components of care Close gaps in care---transitions Measure and report performance Achieve quality outcomes: Exceed regional and national performance benchmarks

15. Know what you’re trying to change… the Care model at the point of care Traditional Model Care usually reactive Providers are leaders Physician management Experience dictates Limited information Data hard to access Practice isolation Care Model Care is proactive Patient & teamwork Patient self management Evidence based support Immediate education Data: patient, team, provider Community involvement

16. Next: the social system or culture

17. Social System ‘nothing new, nothing added’ -build trust- No additional work burden but a different style of patient care Yes, it will be CHANGE Finish what we have started –Some aspects feel better –Some feel worse –Some the same

18. Social System Team Building SPREAD ADVISORY COUNCIL –Previous FM Collaborative leaders, residents, EMR Leader, Learning Resource Rep, Social Worker, Patient SPREAD CORE TEAM –Representatives from our midst: RN, MA, PSR, Med Rec, Faculty, Resident, managers CLINICAL TEAMS –5 teams, both sites

19. Social System: Physicians What motivates them to change? Patients deserve quality care Expectations are changing: –Payers/employers…population-based outcomes –Regulatory bodies…quality, access, cost –Consumers….increasingly informed Health care has a gap: –Knowledge---------------practice –Theory--------------------application We know… We suspect… Physician centered care isn’t working

20. Social System Faculty Request: support the initiative Team meetings: be a champion Clinical work plans: abide by Know your responsibilities (‘toolbox’) Follow your outcomes Let go…let your team help with care

21. Social System Residents Request: be aware of the initiative Team meetings: a must-this is the classroom Clinical work plans: learn from staff Know your responsibilities (‘toolbox’) Follow your numbers Let go…let your team help with care

22. Social System Providers toolbox What to let go of –Scheduling for Chronic Care Visits –The ‘automatic’ Chronic Care labs –Struggling to find measures –Some of the charting (eg Diabetes & Asthma forms) What you own –Support of your staff & the process improvement –Review schedules before every session –Evaluation, diagnoses, treatment plans –Sharing the load: time, patient education, data entry

23. Data If you don’t measure it, It is hard to manage it and to improve it. “If you are not keeping score, you are just practicing” ~V. Lombardi Measure what matters:

24. Denial “Those aren’t MY numbers” Anger/resentment “ Who got those numbers?” Bargaining “ How about if we re-run it again?” Depression “Why are we even doing this?” Acceptance “ How can we get better?” ____________________________________________ ____ “Stages of Grief”–E. Kubler-Ross: adapted by M. Albaum MD Measurement and feedback the ‘5 stages of data’

25. Our early data tracking

26. Free of entropy ?

27. Then came the ‘CIR’

28. Next: the infrastructure M

29. Infrastructure

30. Infrastructure: before

31. Infrastructure: after

32. Those very important teams… SPREAD ADVISORY COUNCIL –Previous FM Collaborative leaders, residents, EMR Leader, Learning Resource Rep, Social Worker, Patient SPREAD CORE TEAM –Representatives from our midst: RN, MA, PSR, Med Rec, Faculty, Resident, managers CLINICAL TEAMS –5 teams, both sites

33. Teamwork: the teams’ many roles Designing changes Building workflows Educating each other, and us Identifying the patients Ordering labs, letters, visits Working the CIR Filling.DM,.Asthma metrics forms Peak Flows, foot exams, vitals, patient educ, etc Meetings, meetings, meetings

34. Designing changes…

35. Those workflows

36. Workflows…ouch!

37. Screenshot.asthma EMR: Asthma Metrics

38. Asthma Process Measures

39. Next: Communication many times, many ways

40. Communication MaineHealth Learning Resource Center Spread Brochure

41. Diabetes Self-Care Report Card Communication

42. (and celebrations)

43. Communication A newsletter

44. Communication A data CD

45. How well are we communicating?

46. Timeline (the first year) Prework –Define goals, select teams, strategize –Spread the concept Action Phase –Evaluate microsystems –Begin PDSA work –Develop data collection tools Diffuse and sustain –Spread (diffuse); expect outcomes & assess progress –Look to year 2 J

47. Our report card Improve processes Standardize care processes We changed the culture: the Care Model ‘is what we do’ We educated on standards of care, redesigned workflows Integrate all components of care Reliability due to teamwork, staff, care managers Vertical integration of staff & physicians Close gaps in care---transitions Measure performance: we’ve learned how

48. Improve Processes: Success

49. Pediatric Asthma 2006 CIR Report process measures

50. Diabetes 2006 CIR Report process measures

51. Our report card Achieve quality outcomes Exceed regional and national and performance benchmarks The bar has been raised: all are accountable We’ve risen above regional & national diabetes benchmarks

52. Diabetes 2006 CIR Report outcome measures

53. Real Success Patients like the Care model Staff participate more in patient care Physicians realize the benefits of team care Staff and patients feel empowered Patient Care is improved and… there is still much work to do

54. Why does it work for us? Executive support & a champion Communication: we work hard at it Access to good data (Electronic Medical Record)* Decision support (Clinical Improvement Registry)* Community linkages* Delivery system (re)design* Care Managers and prepared, proactive teams* *Elements of the Care Model

55. Spread of the Care Model -Pearls- A must: visible executive support A must: a relentless champion Be creative with residents (they don’t have time) Build trust with staff (they will be the pillars of success)

56. What's next? Sustain the progress Teach all who enter the system: –Patients –Providers –Staff Expand into other clinical realms: –Cardiovascular disease, depression, prevention Caution not to overburden the people and systems

57. We’d love to hear from you… Mary McDonough RN mcdonm@mmc,org Jeff Aalberg MD aalbej@mmc.org