Tisa Vorce RRT, MAMichigan Department of Community Health

VorceT@michigan.gov 517.335.9463

AIM Partnership Forum – May 31, 2012

Guideline Implementation: Opportunities & Challenges

GuidelinesAvailable

GuidelinesUsed

Lackofawareness Lackoffamiliarity Lackofagreement Lackofself‐efficacy,time Lackofoutcomeexpectancy Inertiaofpreviouspractice

Barriers pediatricians face when using asthma practice guidelines.Arch Pediatric Adolescent Med 2000 Jul;154(7):685‐93.

Useinhaledcorticosteroids tocontrolasthma. Usewrittenasthmaactionplans toguidepatientself‐management.

Assessasthmaseverity attheinitialvisittodetermineinitialtreatment.

Assessandmonitorasthmacontrol andadjusttreatmentifneeded.

Schedulefollowupvisits atperiodicintervals. Controlenvironmentalexposures thatworsenthepatient’sasthma.

Guideline Implementation Panel (GIP) ReportKey Messages

ProgramdevelopedbyAIMProjectTeam,includingasthmaandpracticeredesignexperts

Goal:tohelpcliniciansmakediagnosisandcaredecisionsbasedontheEPR‐3asthmaguidelines,andincorporatethesetoolsintotheireverydaypractice

DevelopmentanddisseminationfundedbyNationalAsthmaControlInitiative(NACI)

Nowavailablefordistributionandimplementationinanyprimarycarepractice

“QuestionsAboutYourBreathing”or

“AsthmaControlTest™”

“AsthmaDiagnosisTool”or

“AsthmaPatientFollow‐UpTool”

“StepwiseApproachtoManagingAsthma”

AsthmaGuidelineImplementationSteps&Tools(GIST)AprovidereducationandpracticeredesignprojectbytheMichiganDepartmentofCommunityHealthbasedonthe2007NAEPPAsthmaGuidelines.GISTmakesiteasierforprimarycareclinicianstousetheasthmaguidelinesintheireverydaycareofpatientswithasthma.VisitGetAsthmaHelp.org/GISTformoreinformation.

Givenpriortoseeingclinician• Gets“Questions”formifbeingseenforrespiratorycomplaints‐ historyandsymptomquestionnaire

•“ACT™”formforreturningasthmapatient,patientcontrolassessment

Patientwithclinician,whouses:•“Diagnosis”formifpatientinforrespiratorycomplaints‐ diagnoses/rulesoutasthma,findsseveritylevelifasthma,stepcarestarted

• “Follow‐Up”formforreturningasthmapatient‐ findscontrollevel,stepsup,downormaintainsasneeded

• UseStepwiseApproachtofindmedicationneeds,managementapproach• Opportunityforpatiented aboutasthmatriggers,meds,barriers,etc.• Patientreceivesprescription(s)andAsthmaActionPlan• NospecifiedAAPforGIST,manygoodonesavailableatGetAsthmaHelp.org

Monitorprogressbytrackingtheseorotheroutcomes:• numberofasthmapatientsinpractice• number(or%)ofasthmapatientswithcurrentasthmaactionplan• number(or%)ofasthmapatientswithcontrolassessmentatlastvisit• number(or%)ofasthmapatientswithappropriateprescriptionofICS

Evaluate,improvesystem,

repeat

AsthmaActionPlan,Ed&Meds

Action Plans, Medication & Education

Important! GetAsthmaHelp.org/GIST AsthmaActionPlans,medicationhandoutsandeducationalinformation

ToolsandresourcesforGISTimplementation

2011 – Two Pilot Practices

Learnedalotabouthowpracticeswork Sawimprovementsinonepractice‐ hadmotivatedphysicianchampion,committedofficemanager,experienceinQIactivities

Theotherfailedtoimplementeffectively→noimprovement.Physiciannotachampion,officemanagertriedtodoitall,staffnotmotivatedtochange

BothhadEMRissues

Implementation Challenges

Forbothpractices

Peak‐flowbasedAAP ImplementingpracticenowusingUMAAP

Gettingallthecliniciansonboard Implementingphysicianchampionabletouseoutcomemeasurestogainbuy‐in

ForthepracticethatimplementedGIST

Jugglingforms‐ whogetswhatwhen? UseACTscoretoindicateneedforFollow‐UpToolatnon‐asthmavisit

EMRs

Subjective Feedback

Alittletimeconsumingifpatientcameinfrequently‐ learnedhowtoadaptsystemtohandlethat

Docsdon’tliketobetoldwhattodo…buteasiertosellGISTbecause“justlikeNIHguidelines”

Seedifferenceinpracticebehavior,notjustinreporting

Measurementwasarealwakeupcall AAPcanbeimportantopportunitytolearn

howpatientactuallyhandlesasthmasymptoms

GIST Champions Project

ProvidedsmallincentivestophysicianchampionstopromoteGISTandasthmaQIin5newprimarycarepracticesfor6months Staffandcliniciantrainings StartedsomeQIactivities,ACT EMRchallenges

Commitmentfromallstaff,needphysicianchampion Emphasizepracticereviewofdatawithimplementation Musthaveuseful/belovedAAP Practicemustbecommittedtoroutine,notjustepisodic

asthmacare Changesmayneedtobeinbabysteps ImportanceofEMRanddifficultyofEMR Needforimplementationresources:

alwaysgrowingatGetAsthmaHelp.org/GIST

Lessons Learned

Next Steps

NeedhelppromotingGIST– howcanyouhelp? GISTinEMRs GISTinphysicianspecialtyaccreditation Findfundingfornextsteps…

Why Asthma?

Asthma QITargets: Severityandcontrolassessments

ACTtoassessasthmacontrol

Prescriptionofinhaledsteroids

Useofasthmaactionplans

Educationalsessions

Outcomes ACTusehasimprovedto50%‐ targetwas75%

Educationalsessionsweresuccessful,wellliked

Challenges Systemfactors

Personnelfactors

Physicianfactors

Patientfactors

System factors

Personnel factors 

Physician factors  Residentsandfacultywerenotawareofthenewguidelines

Onlyoneslotforgrandroundsforresidenteducation

Residentschedulesondifferentdays

Lackofcontinuityaffectingmedicalrecords

Multiple responsibilities

My project not our project

Fellowship + SOBRAP + GIST 

Regular duties 

Patient factors Noplannedvisits

Multiplemedicalproblemstoaddressinsinglevisit

Asthmaadoorknobcomplaint

Notenoughnumbers‐ actsofGod?

Educational sessions

Next stepsEveryjourneybeginswithasmallstep

Thank You