2. Challenges of Sustaining, Scaling, and Spreading Innovations in Cardiovascular Care AHRQ Annual Meeting Session 34, Track C Sept. 10, 2012

3. Session Goals 1. To share two heart health innovations from the Health Care Innovations Exchange 2. To consider how organizations might explore adoption of these and similar innovations

4. Heart Health Focus National Quality Strategy National Quality Strategy – Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease Million Hearts TM Campaign Million Hearts TM Campaign – National initiative to prevent 1 million heart attacks and strokes over five years. – millionhearts.hhs.gov millionhearts.hhs.gov

5. Agenda Introduction Introduction – Judi Consalvo, AHRQ Language Concordant Health Coaches Innovation Language Concordant Health Coaches Innovation – Hali Hammer, San Francisco General Hospital Family Health Center Heart360 ® Innovation Heart360 ® Innovation – David Magid, Kaiser Colorado Activity: How Can I Implement This Innovation? Activity: How Can I Implement This Innovation? – Veronica Nieva, Westat

6. What Is the Health Care Innovations Exchange? Goal: Goal: – To accelerate sharing of innovations and online tools to improve health care services and reduce health care disparities. Components of the Exchange: Components of the Exchange: 1. The Web site: innovations.ahrq.gov innovations.ahrq.gov 2. Learning and Networking Activities

7. What Is the Health Care Innovations Exchange? Web site features profiles of successful and attempted innovations and practical tools Web site features profiles of successful and attempted innovations and practical tools – Service Delivery – Policy Learning and Networking Learning and Networking – Webinars – Meetings to promote spread – Videos

8. The Innovations Exchange  Visit our Web site: innovations.ahrq.gov/ innovations.ahrq.gov/  Follow us on Twitter: #AHRQIX  Send us email: info@innovations.ahrq.gov info@innovations.ahrq.gov

9. Health Coaches as Members of the Health Team Hali Hammer San Francisco General Hospital, Family Health Center

10. San Francisco General Hospital Family Health Center Hospital-based full scope family medicine clinic Hospital-based full scope family medicine clinic Part of the San Francisco Department of Public Health’s primary care network Part of the San Francisco Department of Public Health’s primary care network Participating in access and quality improvement initiatives as part of the 1115 California Medicaid Waiver (CMS Incentive Program), which ties federal funding to milestones, including PCMH standards (team-based care, clinical outcomes) Participating in access and quality improvement initiatives as part of the 1115 California Medicaid Waiver (CMS Incentive Program), which ties federal funding to milestones, including PCMH standards (team-based care, clinical outcomes) 10,700 patients served; 1500+ adults with diabetes 10,700 patients served; 1500+ adults with diabetes 50,000+ patient visits per year 50,000+ patient visits per year Teaching clinic: 41 family practice residents and many medical and nursing students Teaching clinic: 41 family practice residents and many medical and nursing students Diverse patient population Diverse patient population – 42% Latino, 26% Asian, 14% Caucasian, 12% African American – 51% Medicaid, 33% uninsured (almost all enrolled in Healthy San Francisco), 15% Medicare – 31 different languages spoken 48% English, 30% Spanish, 9% Cantonese/ Mandarin 48% English, 30% Spanish, 9% Cantonese/ Mandarin

11. Description of health coaching at the SFGH Family Health Center Health Coaches are members of the health care team who provide self-management support to a stable panel of patients with chronic illness (in our setting, primarily diabetes). Health Coaches: – are language-concordant with all their patients – are trained in motivational interviewing, panel management, diabetes basics, and medication adherence – work collaboratively with a patient’s Primary Care Provider, unlike promotoras or community health workers in other settings – are primarily in the job classification “Health Worker,” but may also be Medical Assistants, pre-medical students, trained peers.

12. Description of health coaching at the SFGH Family Health Center The Health Coach role includes: Self management support supporting their patients to have the knowledge, skills, and confidence to become active participants in their care Bridge clarifying information provided by the provider, pharmacy, or insurance company bridging cultural/ linguistic gaps Clinical continuity following patients who are in their continuity panel, with a goal to maximize continuity between patient and health coach Emotional support language- and often cultural-concordance enhances trust and engagement in learning how to self-manage the chronic illness Clinical Navigation Health Coaches may be more accessible because they are in clinic every day and can be the primary clinic contact person for patients throughout the week help with making and keeping appointments, accessing pharmacy and other services

13. Health outcome measures for a population of patients working with Health Coaches Measures Baseline Dec. 2009 (n=281) June 2010 (n=268) Jun. 2011 (n=265) Dec. 2011 (n=261) HbA1c at goal (<8)43% 40%50% HbA1c up to date (2 in last year— > 90 days apart) 36%73%77%66% LDL cholesterol at goal (<100) 51% 64%63% LDL up to date91%83%81%80% Self-management goal documented 3%21%50% no recent data

14. Costs associated with health coaching Health Coach program cost considerations Health Coach program cost considerations – Salary ($58,000 per year in our setting, which is 44% of an RN) – A full time Health Coach can manage a patient panel of 200 patients – Physician or Nurse Practitioner supervision (approximately 5% time) – Training costs (6-8 sessions) – Must consider how Health Coaches are assigned and interface with other members of the care team (i.e. case managers, social workers)?

15. Factors to consider in the business case for health coaching Review of symptoms, diagnosis, medications, addressing urgent problems Review of symptoms, diagnosis, medications, addressing urgent problems Family Community Patient Assessment of medication adherence, education, self- management support, phone follow-up (between-visits) Assessment of medication adherence, education, self- management support, phone follow-up (between-visits) Provider Health Coach Health Coach Communication about medical and psychosocial issues, goals of care, medication problems Communication about medical and psychosocial issues, goals of care, medication problems Visit Post-visit Pre-visit Team huddle or other communication Who provides self-management support and education in a traditional primary care visit? What is the most cost-effective and efficient way to provide this important component of chronic illness care? Health coaching may be the answer.

16. Factors to consider in the business case for health coaching The business case for Health Coaching relies on showing that it decreases long-term complications, hospitalizations, and emergency department use. The business case for Health Coaching relies on showing that it decreases long-term complications, hospitalizations, and emergency department use. Self-management support does improve health outcomes in patients with chronic illness. Self-management support does improve health outcomes in patients with chronic illness. So, the question for health care organizations is: who should provide the self-management support? So, the question for health care organizations is: who should provide the self-management support? The answer is based on the payer mix for the organization, as well as staffing costs. The answer is based on the payer mix for the organization, as well as staffing costs. In our organization, Health Coach salaries are approximately 36% of physicians and 44% of registered nurses. In our organization, Health Coach salaries are approximately 36% of physicians and 44% of registered nurses. Health coaching can be done effectively by a non-licensed, trained member of the staff under appropriate supervision. Health coaching can be done effectively by a non-licensed, trained member of the staff under appropriate supervision.

17. Lessons learned in scaling and spreading Health coach resources should be allocated to patients at highest risk of poor outcomes if they are not able to self-manage their chronic illness. In our setting, we targeted diabetic patients with hgbA1c > 8. Health coach resources should be allocated to patients at highest risk of poor outcomes if they are not able to self-manage their chronic illness. In our setting, we targeted diabetic patients with hgbA1c > 8. Highest risk patients may also be most in need of emotional support: Health Coaches must be trained to place limits on patients so that coaching is possible. Highest risk patients may also be most in need of emotional support: Health Coaches must be trained to place limits on patients so that coaching is possible. Communication, a patient’s perception of access, and self- management education are best provided by trained staff who speak the patient’s language. Communication, a patient’s perception of access, and self- management education are best provided by trained staff who speak the patient’s language. Other health coaching models which use RNs include the added roles of medication adjustment by protocol and symptom assessment; we prioritize self-management support and medication adherence education, which can be provided by an unlicensed coach. Other health coaching models which use RNs include the added roles of medication adjustment by protocol and symptom assessment; we prioritize self-management support and medication adherence education, which can be provided by an unlicensed coach.

18. Plans for scaling and spreading Capitation (instead of fee-for-service reimbursement) allows providers to prioritize outcomes and satisfaction. As reimbursement is increasingly tied to improved patient outcomes, team-based approaches to chronic illness care will be feasible for more organizations. Primary care workforce issues have also shed light on the increasing pressures and low job satisfaction among a decreasing pool of primary care providers. Engaging other members of the team to take on time-consuming, non- medical tasks, such as self-management support, may improve satisfaction and make primary care more sustainable. With funding incentives through the CMS Incentive Program / Medicaid Waiver, we will be able to expand health coaching if we continue to show improvement in patient care and access.

19. Heart360 ® David J. Magid Insitute for Health Research Kaiser Permanente Colorado

20. Rates of Hypertension Control in the U.S. are Low Benefits of hypertension therapy Benefits of hypertension therapy – 25% reduction in heart attack – 40% reduction in strokes – 50% reduction in heart failure NHANES (2005-2008) NHANES (2005-2008) – Treatment 70% – Control 46%

21. Focus Groups Kaiser Colorado Clinics Controlling my BP is critical Controlling my BP is critical Office visits are inconvenient and time-consuming Office visits are inconvenient and time-consuming Using a home BP cuff is appealing Using a home BP cuff is appealing

22. Provider Meetings Kaiser Colorado Clinics Providers Supportive

23. Home BP Monitoring supported by Pharmacists and Heart360 ®

24. For patients with hypertension, is a clinical pharmacy specialist-led Heart360 ® home BP monitoring program (HBPM) more effective than usual office-based care? Research Question

25. Study Setting

26. Study Population Uncontrolled HTN HBPM-Heart360 ® Initial visit Usual Care six month follow-up visit Initial visit Referral To PCP Home BP monitoring

27. Monitoring Protocol

28. Results

29. HBPM Patients Had Superior 6-month BP Control RR = 1.5 (1.2-1.9); p < 0.001 Usual Care HBPM 37% 57%

30. P <0.001 Usual Care Mean BP drop (mm Hg) Heart360 ® HBPM Group Had a Greater Drop in Systolic BP HBPM

31. Heart360 ® HBPM Patients Reported Greater Satisfaction with Care Very to Extremely Satisfied P <0.001

32. What are the cost implications for Heart360 ® HBPM? Intervention Costs Intervention Costs CV Events Prevented CV Events Prevented Cost of Events Prevented Cost of Events Prevented

33. Cost Benefit over 10 Years

34. Implementation Barriers Cost of BP cuffs Cost of BP cuffs Need for computer and internet Need for computer and internet Capitation vs. Fee for Service Capitation vs. Fee for Service

35. Translation to Routine Practice: A Tale of Two Regions Kaiser Colorado Kaiser Southern California

36. KP Colorado Enthusiastic response to presentations to health plan leaders and stakeholders Enthusiastic response to presentations to health plan leaders and stakeholders Initially little movement towards adoption in routine clinical practice Initially little movement towards adoption in routine clinical practice – Turnover in clinical champion – Change in organizational priorities – Limited bandwidth – Lack of sponsorship Director of Pharmacy Department stepped forward to sponsor rollout Director of Pharmacy Department stepped forward to sponsor rollout – Currently working toward broader implementation

37. KP Southern California Enthusiastic response to presentations to health plan leaders and stakeholders Enthusiastic response to presentations to health plan leaders and stakeholders Movement towards adoption Movement towards adoption – Stable clinical champion - > 20 years – Organizational priority – improve efficiency – Sponsorship by Associate Medical Director Current Plans Current Plans – Pilot at 2 medical centers – Subsidize cost of cuff, consider BP cuff library – Existing infrastructure to support rollout

38. Lessons Learned Clinical champion Clinical champion Sponsorship Sponsorship Organizational priorities Organizational priorities Bandwidth Bandwidth

39. Q&A

40. Activity How Can I Implement This Innovation in My Organization?