1. Chronic Disease Management: Driving Quality Improvement in Primary Care August 1, 2008 Jan Norman, RD, CDE Washington State Department of Health

3. Quality Improvement Initiative Aimed at primary care providers Focus on prevention- based care Redesigns care delivery to deliver population- based care

4. The IOM Quality report: A New Health System for the 21st Century http://www4.nas.edu/onpi/webextra.nsf/web/chasm?OpenDocument

5. The IOM Quality Report: Selected Quotes “The current care systems cannot do the job.” “Trying harder will not work.” “Changing care systems will.”

6. A Framework for System Change EDUCATION COMMUNICATION COORDINATION ConsumerPurchasers ProvidersHealth Plans CONFIDENTIALITY

7. Collaborative Methods IHI Breakthrough Process Planned Care Model Model for Improvement

8. Collaborative Process Select Topic Planning Group Identify Change Concepts Participants Prework LS 1 P S AD P S AD LS 3 LS 2 Supports E-mailVisits Web-site PhoneAssessments Senior Leader Reports Outcomes Congress AD P S (13 month time frame)

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

11. What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement ActPlan StudyDo The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. G. Langley, K. Nolan, T. Nolan, C. Norman, L. Provost. Jossey-Bass Publishers., San Francisco, 1996.

12. History 1999 to 2008 Oct 1999 – Nov 2000Diabetes17 Teams Feb 2001 – Mar 2002Diabetes28 Teams Nov 2002 – Nov 2003Diabetes30 Teams Jun 2004 – June 2005Diabetes & Heart Disease40 Teams Feb 2006 – Mar 2007Diabetes & Heart Disease28 Teams

13. Collaborative vs Non Collaborative (DMI, DMII, Spread vs Non Collab)

14. Washington State Collaborative 5 Diabetes Results * Percent with average blood sugar < 150

15. Tacoma Spokane Large, urban or for profit clinics Community, rural or IHS clinics Seattle Washington State Collaborative Graduates

16. May 2008 – May 2009 Adult topics –Diabetes –Depression –Asthma Pediatric topics –Asthma –Overweight prevention –Medical Home Partnership with Medicaid 33 teams $5,000 stipend plus incentive money for achievements Practice coaches Target practice with <5 providers

18. Policy Changes Medicaid established code to pay for group visits for diabetes and asthma Medicaid and BlueShield expanded diabetes education to all MD offices Uniform waived co-pay for Collaborative patients preventive visits

19. Key to Sustainability of Collaborative Outcomes “Quality improvement must be addressed on multiple fronts, just one of which is finding a way to build financial rewards for quality improvement into healthcare financing.”

20. Key to Sustainability of Collaborative Outcomes “Many plans and providers indicate a willingness to pursue such changes, but their efforts will depend on the support and commitment of the ultimate financiers of health care – government and private employers.”

21. 2ESSB 5930 2007 Governors Blue Ribbon Commission Bill Expand Medicaid to implement a medical home for all aged, blind and disabled clients Direct DOH to provide primary care training in chronic care management Design a reimbursement plan to reward quality

22. ESSHB 2549 - 2008 Implement a Collaborative on Medical Home Redesign the funding to pay for the implementation of Medical Home

23. Support tools for moving ahead AcademyHealth/Commonwealth Fund State Quality Improvement Institute Primary Care Coalition WSC Advisory Committee National Committee for Quality Assurance Physician Recognition Program Consensus definition of Medical Home across provider groups

24. What is a Medical Home? The patient-centered medical home is a model for care provided by Primary Care practices that seeks to strengthen the provider-patient relationship by replacing episodic care based on illnesses and patient complaints with coordinated care and a long-term healing relationship.