Chronic Disease Management: Driving Quality Improvement in Primary Care August 1, 2008
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Chronic Disease Management:Driving Quality Improvement in
Primary CareAugust 1, 2008
Jan Norman, RD, CDEWashington State Department of Health
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Quality Improvement Initiative
• Aimed at primary care providers
• Focus on prevention-based care
• Redesigns care delivery to deliver population-based care
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The IOM Quality report: A New Health System for the 21st Century
http://www4.nas.edu/onpi/webextra.nsf/web/chasm?OpenDocument
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The IOM Quality Report:Selected Quotes
• “The current care systems cannot do the job.”
• “Trying harder will not work.”• “Changing care systems will.”
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A Framework for System ChangeED
UC
ATI
ON
COMMUNICATIONC
OO
RD
INA
TION
Consumer Purchasers
Providers Health Plans
CONFIDENTIALITY
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Collaborative MethodsIHI
Breakthrough Process Planned
Care Model
Model for Improvement
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Collaborative Process
Select Topic
Planning Group
Identify Change
Concepts
Participants
Prework
LS 1
P
S
A DP
SA D
LS 3LS 2
SupportsE-mail Visits Web-site
Phone Assessments
Senior Leader Reports
Outcomes Congress
A DP
S
(13 month time frame)
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Community Resources and Policies
Informed,ActivatedPatient
ProductiveInteractions
Prepared,ProactivePractice Team
Functional and Clinical Outcomes
Health SystemHealth Care Organization
DeliverySystemDesign
Decision Support
ClinicalInformation
Systems
Self-Management
Support
Chronic Care Model
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What are we trying toaccomplish?
How will we know that achange is an improvement?
What change can we make thatwill result in improvement?
Model for Improvement
Act Plan
Study Do
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.
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History 1999 to 2008
Oct 1999 – Nov 2000 Diabetes 17 Teams
Feb 2001 – Mar 2002 Diabetes 28 Teams
Nov 2002 – Nov 2003 Diabetes 30 Teams
Jun 2004 – June 2005 Diabetes & Heart Disease 40 Teams
Feb 2006 – Mar 2007 Diabetes & Heart Disease 28 Teams
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Collaborative vs Non Collaborative (DMI, DMII, Spread vs Non Collab)
77% 76%
53%
80% 80%
60%
49%
74%
62% 63%
43%
30%
17%
31%
76%
91%91%
45%
83%91%
71%
35%
0%10%20%30%40%50%60%70%80%90%
100%
CollabNon Collab
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Washington State Collaborative 5 Diabetes Results
* Percent with average blood sugar < 150
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Tacoma Spokane
Large, urban or for profit clinicsCommunity, rural or IHS clinics
Seattle
Washington State Collaborative Graduates
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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
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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
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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.”
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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.”
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2ESSB 5930 2007Governors 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
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ESSHB 2549 - 2008•Implement a Collaborative on
Medical Home•Redesign the funding to pay for the implementation of Medical
Home
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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
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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.