A Population Health Management Diabetes Case Study

Rona Y. Sonabend, MD

Medical Director, Clinical Systems Integration Process Improvement Texas Children’s Hospital

Session #27

Learning Objectives

1Describe the population

health model for pediatric

diabetes care delivery at

Texas Children's

Hospital (Texas Children’s).

2Illustrate disease

management with the

development of clinical

programs.

Explain the use of data

analytics to drive

meaningful quality

improvement.

3Demonstrate the value of a maturity model

in process improvement

and associated outcomes.

4

Indicate lessons learned.

5

Poll Question #1

How would you rate the quality of care your organization delivers for patients with diabetes?

1) Poor2) Fair3) Good4) Very good5) Excellent6) Unsure or not applicable

Texas Children’s vision statement for diabetes mellitus…

We must…“Deliver the highest quality of care to patients with

diabetes mellitus at Texas Children’s.”

About 208,000 children and adolescents have been

diagnosed with diabetes, approximately 0.25% of the U.S. population.

The number of children and adolescents

in the U.S. with type 1 or type 2 diabetes is increasing.

The national burden of all diabetes mellitus

was as high as $245B in 2012.

• Internationally renowned. • Committed to creating a community of healthy children through

excellence in patient care, education, and research.• Three inpatient facilities in Houston and one in San Antonio. • Multiple satellite ambulatory care centers.• Manage more than 1 million patient encounters each year.

Cy-FairMain Campus

Clear Lake

The Woodlands West Campus

Sugar Land

The Need to Reduce Variation and Improve Care

• Texas Children’s leaders noted a measurable degree of variation in its management of diabetes across the continuum of care.

• This variation had been increasing over several years, leading to gaps in quality of care for diabetic patients.

• Diabetes care met criteria for a focused improvement effort:

• Large population of patients.• High degree of variation in care.• Measurable gaps in the consistency and quality of care.• Organizational readiness.

Turning Point

Texas Children’s recognized that

incremental change would not suffice to

transform diabetes care.

A comprehensive, cross continuum care improvement program for diabetes patients was necessary.

1.

2.

Mission Statements A Multidisciplinary, Cross-continuum Approach

Ambulatory

High Risk

CommunityEducation

Inpatient

Create innovative diabetes outpatient program that provides coordinated, family-centered, multidisciplinary care to our patients and their families.

Identify risks and barriers to optimal care and institute multidisciplinary processes to improve access to care and health outcomes in high-risk patients.

Build partnerships with care providers in the community by providing resources, education, and accessibility to provide comprehensive care for children with diabetes.

Develop diabetes and related health education for integration into

diabetes care delivery.

Eliminate unnecessary variations in inpatient care delivery and ease

transition to outpatient care.

Diabetes CPTs

What Texas Children’s Did

Improving Preventative CareResults

10%

0%

20%

40%50%

60%

70%

80%

90%

100%

30%

28.2%

recommended annual TSH testing.

Current performance

at 90.4%.

10%

0%

20%

40%50%

60%

70%

80%

90%

100%

30%

23%

recommended annual lipid testing.

Current performance

at 90.3%.

10%

0%

20%

40%50%

60%

70%

80%

90%

100%

30%

37.9%

recommended annual microalbumin testing.

Current performance

at 91.8%.

10%

0%

20%

40%50%

60%

70%

80%

90%

100%

30%

54.1%

annual retinal examinations.

Current performance

at 94.9%.

Relative improvement in the percentage of patients receiving:

Impact of Risk-based InterventionResults

Relative reduction in recurrent diabetic

ketoacidosis (DKA)admissions per fiscal year.

Established patients with diabetes who have a predictive

risk score for future hospitalizations.

Patients with new onset diabetes who

received a risk assessment at

diagnosis.

30.9%90% 100%

Population Health ManagementResults

34.4%

26.3%

90%Relative improvement in the percentage of patients with diabetes

who received the influenza vaccine.

Percent of patients who have individualized school packets (orders for management of diabetes at school) available in the EHR.

Relative improvement in pediatric provider knowledge, measured by

pre- and post-tests, following completion of the pediatric provider

diabetes education sessions.

Continuing Education Physicians, Nurses, Staff, Patients

Results

Implementation of a standardized

diabetes education model to improve care across the

continuum.

Relative annual improvement in number of patients with an education visit by a registered dietician.

~33%

Relative annual improvement in number of patients with an education visit by acertified diabetes educator (CDE).

~50%

Standardization and Improvement of Inpatient CareResults

Relative decrease in length of stay (LOS) for patients

with DKA.

Relative increase in patients with DKA receiving insulin within one hour of order.

Improvement in the percentage of patients transitioning to

subcutaneous (SQ) insulin in <4 hours after medical readiness.

Patients with DKA receiving an evidence-based

evaluation and order sets.

100% 19% 50% 44%

Poll Question #2

How effective are your organization’s efforts to improve the care of patients with diabetes across the continuum?

1) Not effective2) Somewhat effective3) Moderately effective4) Very effective5) We are not focusing on it6) Unsure or not applicable

How Texas Children’s Did It

A Focus on Population Health

Put simply, how one manages patients with certain diseases or how one manages the entirety of all patients served in the region.

“Population health” is a relatively new and imprecise term, relating the health outcomes of a group of individuals to health determinants, policies, and interventions that effect those outcomes.

Kindig, D., Stoddart, G., (2003). What is population health? American Journal of Public Health, 93:380-83

Model for Culture Change

Transparent vision

Leadership

Support and infrastructure

Dissemination of information Inclusive spirit

Multidisciplinary

Culture of change

Clinical Program Vision

• Active use of clinical data by clinicians organized around patient conditions—care process teams (CPTs).

• Decrease in variation of care delivery.

• Learning as a result of data translation.

• Evidence-based clinical guidelines embedded within electronic medical record.

• Rapid PDSA cyclic improvements.

• Strategic alignment towards managing populations across the continuum of care.

• CPTs focused on important aspects of each clinical condition.

Diabetes CPT Members

Diabetes Educators

ED rep.

Practice administrator

Executive leadership

Director Ambulatory Services

Dietitians

Clinical Data Specialist

Nursing co-lead

Nurse Practitioners

Asst. Dir. Ambulatory Nursing

Asst. Dir. Inpatient Nursing

Asst. Dir. Clinical Outcomes & Data Supp.

PhysiciansSystems Analyst

Nursing leadership

Social workers

Nursing

Acute Care rep.

Intensive Care rep.

Pharmacy

Content experts

Maturity of Informatics (Data to Analytics)

Organizational evolution over time.

Data reporting• EMR clinical

reports.• Financial reports.

Data analytics• Shortening event

to reporting time.• Transforming

data and translating to meaningful clinical relevance.

Predictive analytics

• Linking likelihood of outcomes to care decisions for populations.

• Predicting financial outcomes.

• Linking strategies across former silos in infrastructures.

Prescriptive analytics• Integrating best

evidence into delivery system infrastructures.

• EMR based recommendations and alerts.

• Integrated plans of care across continuum.

• Utilizing big data bi-directionally.

Improved outcomes for Texas Children’s patients and the enterprise.

How many? Who and where? Who’s at risk? How do I prevent it in my patient?

Data-Driven Focus

Level of Maturity: Predictive Analytics

• Identification of patients at risk for undesirable outcomes (safety, quality, financial).

• Basis for development of a shared savings model.

Provider Dashboard

How Texas Children’s Did It

Developing infrastructure with

technological support.

PROGRESSSTART

Preparation readiness and engagement.

APPLICATION

Removal of barriers to

implementation.

SUCCESSTARGET

Alignment of goals and strategic

processes.

CARE ACROSS THE

CONTINUM

Lessons Learned

IMPROVEMENT

Defining meaningful AIMs may require multiple iterations.It takes a village.

We’re On the Road…

Quality improvement is a data-driven sport.

Navigation of roadblocks require innovation.

Future Plans

Continue to support progress

through all five CPTs

Ambulatory

High Risk

CommunityEducation

InpatientShared savings, prescriptive analytics.

Advocacy, support groups.

Transition, pathways for continuing education.

Ambulatory urgent care bay.

Quality of life, patient-reported outcomes.

Thank You