1. AAP Oregon State Chapter Shared Vision Sandra E. Miller, MD, FAAP

2. I have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity.

3. Goals Learn about Oregon’s strategic QI plan Understand the “gap” in care Understand why this work is important Become familiar with the goals for this project

4. Oregon Quality Improvement Strategic Plan OPS QI Committee Founded to: –Help define “quality” of care for Oregon children –Assist in negotiation of quality-based reimbursement –Increase quality of care for Oregon children –Assist Pediatricians in closing the “quality gap” in their own practices

5. Oregon Quality Improvement Strategic Plan Dr Art Jaffe, OHSU

6. What is the Quality Gap? How QI came to me…. The gap between the care we know is best and our ability to deliver it, every time, to every patient in the way they need it.

7. Our Clinic’s Goals Know our patients and be prepared for their visit Use our time efficiently Empower our patients to take charge of their own healthcare Work as a team and use systems to guide our care

8. “Open Access” at WEMC Beginning access: 2-3 weeks for wellness visits Changes made: –Review all visits to be sure shots, wellness are up to date –MOA vaccine prep when I am in the room –Preschedule well visits when possible –Reminder card system for wellness with phone followup Current access: 1-3 days for wellness visits

9. Defining the Gap: Asthma Affecting nine million children, childhood asthma is the most common serious pediatric chronic disease. The incidence of pediatric asthma continues to grow; it accounts for 14.7 million missed school days a year and 44% of all asthma hospitalizations[1][1] During August 2007, under the auspices of the National Heart, Lung, and Blood Institute (NHLBI) the National Asthma Education and Prevention Program (NAAEP) issued the first comprehensive update in a decade of asthma guidelines for the diagnosis and management of asthma (NHLBI asthma guidelines). The guidelines emphasize the importance of asthma control and introduce new approaches for monitoring asthma. The AAP recognizes that increased exposure to the new guidelines coupled with implementation support will decrease gaps in care and help move towards optimal care for children with asthma. [1][1] American Academy of Allergy, Asthma and Immunology. http://www.aaaai.org/media/resources/media_kit/ asthma_statistics.stmhttp://www.aaaai.org/media/resources/media_kit/

10. Satisfaction -Access to Care -Positive relationship with provider -Empowerment -Peace of Mind Functional - School Attendance -Sports and Activities -Improved Sleep - Family Dynamics Costs Hospital Costs Medication Costs Outpatient Costs Caretaker’s Work Loss Clinical Hospitalizations ER Visits Use of Inhaled Steroids - Asthma Action Plans - Patient Education

11. Adherence to Guidelines “An intervention to enhance compliance … will need to address … barriers…” Prim Care Respir J 2007 Dec; 16(6): 369-77 “Adherence to recommended guidelines in asthma/COPD was low.” Pharmacoepidemiol Drug Saf. 2009 May; 18(5):393-400. “Guideline nonadherence was widespread…” Health Serv Res 2001 Jun; 36(2): 357-71 “Physician prescribing of asthma pharmacotherapy does not adequately comply with EPR-2 treatment guidelines.” Ann Allergy Asthma and immunology 2008 Mar; 100(3): 216-21

12. Oregon’s Asthma Gap In 2007, approximately 75,000 children were estimated to have asthma Oregon OHP recipients with asthma ages 4-8 years had the highest ED use In 2005, 70% of children with asthma received information on recognizing and treating asthma 32% received an asthma action plan 47% of children on Medicaid had a low medication ratio (All data courtesy, Oregon Asthma Program)

13. Why is there a gap? Busyness Low reimbursement Absence of systems of care Reliance on memory Other?

14. AAP CAQI Asthma Pilot An answer to the gap

15. CQN Impact MAINE OHIO OREGON ALABAMA

16. Oregon’s CQN Aim Global Aim The Oregon Pediatric Society will establish and support a sustainable infrastructure to facilitate pediatric practice-based quality improvement activities for its membership, to achieve measurable improvements in health outcomes, consistent with the highest quality of evidence based treatment and long term disease management for children with asthma and their families. Specific Aim From April 2009 to November 2010, we will recruit and lead a collaborative of 10-15 pediatric practices within Oregon for the purpose of measurably improving outpatient asthma management and outcomes through implementation of quality improvement methods and the NHLBI/NAEPP guidelines.

17. Oregon Care Goals By September 2010, practices will achieve 75% of optimal care. By September 2010, practices will use a structured encounter form 90% of the time. By September 2010, 85% of patients with asthma will have a written asthma action plan. By September 2010, 70% of practices will be using an asthma registry. By September 2010, 80% of patients with persistent asthma will have a controller prescribed. By September 2010, 75% of patients will have assessment of “well controlled” asthma status documented in chart notes.

18. Optimal Care >90% of patients have “optimal” asthma care (all of the following) assessment of asthma control using a validated instrument stepwise approach to identify treatment options and adjust therapy written asthma action plan patients >6 mos. of age with flu shot (or flu shot recommendation)

20. Change Concepts Engaging Your Asthma QI Team and Your Practice *The QI team and practice is active and engaged in improving practice processes and patient outcomes

21. Change Concepts Developing an Approach to Employing Protocols * Standardize Care Processes * Practice wide asthma guidelines implemented

22. Change Concepts Using a Planned Care Approach to Ensure Reliable Asthma Care in the Office *Care team is aware of patient needs and work together to ensure all needed services are completed

23. Change Concepts Providing Self management Support * Realized patient and care team relationship * Patient/Parent understand how to manage asthma and access appropriate care

24. Change Concepts Using a Registry to Manage Your Asthma Population *Identify each asthma patient at every visit *Identify needed services for each patient *Recall patients for follow-up

25. Key Driver Diagram

26. The Story of Improvement Steve Pleatman M.D.

27. Asthma Care a Year From Now Easier use of the asthma guidelines by physicians and staff Better understanding of asthma for patients and families Better systems so your office members can function as an efficient team Knowing your patients and being ready for their visits The best care for every patient, every time