1. A Systems Change Collaborative to Improve Asthma Care Peter Harper, MD, MPH University of Minnesota Kristi Van Riper, MPH, CHES American Lung Association of Minnesota Conference on Practice Improvement November 9, 2007

2. Today we will  Describe the Controlling Asthma Project in Minneapolis/St. Paul, MN  Emphasize the clinic systems-change project  Discuss the use of the Chronic Care Model, Continuous Quality Improvement, and PDSA cycles of change  Highlight Proven Pathways developed  Present quantitative and qualitative data

3. Controlling Asthma Project overview  A coalition focused on improving pediatric asthma in Minneapolis and St. Paul  Comprehensive focus  Funded primarily by the CDC  Funding Sept 2001—June 2009

4. Measurable broad outcomes 1. Hospitalizations of children with asthma have been reduced by 55%. 2. ED/urgent care visits have been reduced by 12%. 3. The proportion of parents who reported that asthma symptoms limited their child’s activities most or all of the time declined by 27%.

5. 4 areas of programming 1. School-based Interventions 2. Community-based Education 3. Policy Initiatives 4. Health Systems/ Professional Education Clinic Systems-change Project Asthma Education in the Emergency Department Provider Asthma Care Education Implementation and Interpretation of Spirometry Asthma Educator Certificate Course

6. Mission of clinic systems-change  A collaborative approach to implementing new systems into clinics to support and sustain adherence to National Heart, Lung and Blood Institute asthma guidelines using a continuous quality improvement process

7. Systems-change overview 38 participating clinics 5 cohorts  Conduct baseline chart audit  Choose a goal  Use CQI methodology  Measure monthly for process improvement  Attend quarterly collaborative meetings  Conduct 12 month and 18 month chart audits

8. Project outcomes measured  Asthma severity rating  Anti-inflammatory (controller) medication*  Asthma Action Plan*  Spirometry*  Asthma education* * for patients with persistent asthma

9. Systems-change inclusion  Letter of agreement signed by upper management and project team  Ability to conduct chart reviews  Ready for change

10. Launch party  Buy-in from all clinic staff is critical  Provide all staff breakfast or lunch  Explain project  Review clinic baseline chart audit  Review clinic goals

11. Collaborative model  Quarterly joint clinic meetings “Homework” Clinic sharing Didactics Team huddle  Benefits Shared learning Cross pollination Support Fun Accountable

12. Informed, Activated Patient Productive Interactions Functional and Clinical Outcomes Delivery System Design Decision Support Clinical Information Systems Health System Resources and Policies Community Health Care Organization Family Education & Self- Management Support Prepared, Proactive Practice Team Chronic Care Model

13. Continuous quality improvement  PDSA cycles of rapid change Plan, Do, Study, Act  Focus on one goal at a time  Use a multidisciplinary team

14. Residency programs  Six family medicine programs  Issues Chaos but flexible Eagerness to learn Better buy-in

15. Professional education  Provider Asthma Care Education (PACE) Adapted from the University of Michigan Asthma guidelines Asthma medications Spirometry Patient education Coding or delivery devices  Implementation of Spirometry  Interpretation of Spirometry

16. Proven Pathways  Developed to assist clinics—no need to reinvent the wheel  Seven pathways Albuterol refill Documentation Living with Asthma survey Planned visits Pre-completed asthma action plan Rooming Spirometry

17. Pathway format  Goals of pathway  Chronic care model component  Snapshot  Flow diagram  Implementation details/considerations

18. Pre-completed asthma action plan pathway

19. Proven Pathways  Developed to assist clinics—no need to reinvent the wheel  Seven pathways Albuterol refill Documentation Living with Asthma survey Planned visits Pre-completed asthma action plan Rooming Spirometry

20. Lessons learned  Who’s ready? Lack of strong leader Clinic chaos  EMR conversion  Change ownership  Loss of provider champion  Loss of staff champion  Focus on one measure  Meeting hygiene  Proscriptive evolved better

21. Project outcomes measured  Asthma severity rating  Anti-inflammatory (controller) medication*  Asthma Action Plan*  Spirometry*  Asthma education* * for patients with persistent asthma

22. Severity classification

23. Controller therapy

24. Asthma action plans

25. Spirometry

26. Asthma education

27. Perspectives from the clinics Collaborative model:  Each of the clinics expressed appreciation for the opportunity to be part of a collaborative discussion group and to share lessons learned and problem solve together. Each of the clinic teams found value in the Cohort Meetings and expressed the belief that this type of discussion allowed them to learn from each other in a practical manner.  “momentum was built at the group meetings and the sharing of successes, challenges, and collaborative problem solving that occurred during the meetings was helpful”

28. Perspectives from the clinics Opportunity to participate:  “We never have the opportunity to be involved with a project like this. Thank you.”

29. Turnover  Systems are necessary due to turnover of staff  Residency programs have “planned” turnover

30. Summary  Improved outcomes at 12 month  Sustained outcomes based on clinic characteristics  Tough clinical situations  Proven Pathways  Residency clinics can make change

31. What can you do? 1. Build systems within the clinic/program 2. Develop a collaborative with others 3. Use the Proven Pathways for asthma

32. For more information  Peter Harper, MD, MPH pharper@umphysicians.umn.edu  Kristi Van Riper, MPH, CHES kristi.vanriper@alamn.org