1. Clinical Care Improvement System Mark Murray, MD, MPA Mark Murray & Associates

2. System Elements Organization of Healthcare System – clinical care management programs can be more effective if the overall system (organization) in which care is provided is oriented and led in a manner that allows for a focus on clinical care Delivery System – delivery system design, based on an understanding of the fundamental dynamic of balancing demand to supply is critical for success in optimizing clinical care

3. System Elements (cont’d) Community Linkages – linkages between the health delivery system (or provider practice) and community resources play important roles in the management of clinical care

4. Organization of Healthcare system Leadership with a clinical perspective Develop will Integration of clinical quality into performance and business plans Commitment of leadership to lead

5. Organization of Healthcare System: change strategies Leadership Commitment to Improvement of Clinical Care Clearly Articulated Goals Around Clinical Care Measurement Commitment Incentives Based on Quality of Clinical Care Agreements that Facilitate Care Coordination Within and Across the Organization

6. Delivery System Planned care for every encounter “Opportunistic” care Proactive care No wait culture Balance demand and supply for all services Right person, doing right work, right away

7. Delivery System: change strategies Access Commitment—No-Wait Culture Commitment to Panel Management and Continuity Activated Practice Teams with Strong Leadership on Teams Clinical Care Teams with Clarified Roles Delivery System that Plans for Care

8. Community Linkages Identify community resources Mobilize these resources Integrate the resources

9. Community Linkages: change strategies Linking Patients to Outside Resources Partnerships with Community Organizations

10. Practice Elements Self-Management – can help patients and families cope with the challenges of living with and treating clinical conditions both “acute” and “chronic,” and reduce complications and symptoms Decision Support – effective clinical condition management programs assure that providers have access to evidence-based information necessary to care for patients—decision support. Includes evidence-based practice guidelines or protocols, specialty consultation, provider education, and activating patients to make provider teams aware of effective therapies

11. Practice Elements (cont’d) Clinical Information Systems – timely, useful information about individual patients and populations of patients with clinical conditions is a critical feature of effective programs, especially those that employ population-based approaches

12. Self Management Empowerment Occurs in an environment of reliability and trust Won’t happen unless there is linkage to a specific provider Requires a plan

13. Self-Management: change strategies Patient Involvement in Care Choices System for Patient Support Strategies, Including Assessment, Goal-Setting, Action Planning, Problem-Solving and Follow-up Options for Effective Behavior Change Interventions and/or Peer Support

14. Decision Support Information available at the right time and place, just in time Proactive Population based Requires embedded guidelines Guidelines inform the “Registry” design

15. Decision Support: change strategies Use of Evidence-Based Guidelines or Pathways Linkage with Specialists Through Service Agreements, Focused Education Efforts and Consultation Opportunities Provider Continuing Education for Clinical Care Involvement of Patients in Guideline Participation

16. Decision Support (cont’d) Pre-visit Preparation and Planning, Including “Screening” and “Huddles” Customized Treatment Plans for Challenging Situations, Including the Development of Case Management

17. Clinical Information Systems Provide ongoing summary of clinical interaction for individual patients and for the population of patients Provides information for proactive intervention both for the population and prior to the clinical visit Allows view of “exceptions” Monitors performance of individuals Provides performance feedback

18. Clinical Information Systems:change strategies Identification of Practice and Individual Clinical Profile from the Practice and Individual Panels Identification of Patients with Targeted Conditions and Entry into “Registry” Pre-Visit Signals or Prompts and Planned Response for Patient Needs Population Signals and Planned Response for Patient Needs from the Panels Measurement and Monitoring of Care