Retrospective
Mixed Methods Analysis of
Practice Transformation
Michael K Magill, MD
Professor and Chairman
Department of ...
Interdisciplinary Team
Julie Day, MD
University of Utah Community Clinics
JaeWhan Kim, PhD
School of Medicine, Dept of Fam...
Visits: 300,000+
Active patients: 157,000
11 Community Clinics
University of Utah Community Clinics
Clinic Year Opened
Total
Providers
Primary Care
Providers
Visits Per
Year (FY09)
Mads...
Care by DesignTM
• Appropriate Access – 2003
• Balance supply and demand of visits
• Standardized schedules
• Care Team – ...
Retrospective Analysis:
Qualitative Aims
AHRQ Grant # 1R18 HS019136-01 Transforming Primary Care
Aim Method
Document and m...
Care by DesignTM
• Appropriate Access – 2003
• Balance supply and demand of visits
• Standardized schedules
• Care Team – ...
Qualitative Data: Care Teams
8
Component Type of Information Gathered
Archival search • when/how the care team was rolled ...
Care Team Structure
& MA Role CBD Care
Team
Model
Variations
Traditional
Model
Team
Members:
• Providers
• MAs
“Care
Team”
• 5 MAs: 2 Providers
• Working together
• Doing it all!
MA
specialists
• (V1): 1 MA phlebotomist does all
draw...
Example of Insights from
Quantitative Research
Clinic Culture
An illustration of possible
explanations for the observed
di...
Organizational Culture
Assessment Instrument: “Competing Values”
Quinn, Rohrbaugh: http://www.ocai-online.com/
Greenwood
Parkway
Redstone
Senior Leadership
Organizational Culture In Community Clinics
Aim Method
Document and measure the
transformation and impact on
the quality of patient care
delivery
• Clinical Data
• CB...
Quantitative Data
Component Type of Information Gathered
CBD Implementation • Use of EMR tools
• Appointment availability
...
10%
20%
30%
40%
50%
60%
70%
80%
2003 2004 2006 2008 2009
Quality Measures
Percent of Patients Receiving Recommended Care
C...
20%
30%
40%
50%
60%
70%
80%
90%
100%
2003 2004 2006 2008 2009
Patient Satisfaction
Percent of Patients Reporting "Very Sat...
Overview of Quantitative Design:
Link data from multiple sources to assess
impact of transformation to CBD
Cost &
Utilizat...
Level of CBD Implementation:
2008
1.00
1.20
1.40
1.60
1.80
2.00
2.20
All elements
Examples of Correlation between
CBD Implementation and Patient Satisfaction
Patient Satisfaction
CBD Implementation Measur...
Correlation between CBD
Implementation and Quality Measures
CBD Implementation
Measure 2008
Quality Measures
Diabetes
Coro...
Impact of practice redesign
• Quality improves
• Continuity matters
• Pre-visit planning and EMR reminders help
• Patients...
Future analysis:
impact of redesign on…
• Internal cost and
productivity of clinics
• Overall utilization
• Total cost of ...
Future: Internal Performance Analyses
Cost &
Utilization
CBD
Implementa-
tion
Clinical
Data
Operations Data
• Provider pro...
Future: Cost and Utilization
Cost & Utilization
CMS, APCD
CBD
Implementa-
tion
Clinical
Data
Operations
Data
CMS Data
• Al...
Challenges in Assembling
Cost, Utilization and Demographic Data
• Gaining access
• Navigating layers of documentation,
req...
Challenges of Retrospective
Mixed Methods Research
• Timing of all the components
• Recall isn’t perfect – current events ...
Benefits of
Mixed Method Research
• Multiple components inform each other
throughout data collection
• Participant selecti...
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Care by design magill retrospective mixed methods analysis sep 21 2011

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a look back of a decade of build PCMH level care at the university of Utah.

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Care by design magill retrospective mixed methods analysis sep 21 2011

  1. 1. Retrospective Mixed Methods Analysis of Practice Transformation Michael K Magill, MD Professor and Chairman Department of Family and Preventive Medicine University of Utah School of Medicine and Community Clinics AHRQ Grants # HS019136-01 (TPC) HS20106-01 (ARRA-SSCM)
  2. 2. Interdisciplinary Team Julie Day, MD University of Utah Community Clinics JaeWhan Kim, PhD School of Medicine, Dept of Family & Preventive Medicine Annie Sheets Mervis, MSW University of Utah Community Clinics Debra L. Scammon, PhD David Eccles School of Business, Dept of Marketing Andrada Tomoaia-Cotisel, MPH, MHA School of Medicine, Dept of Family & Preventive Medicine Norman J Waitzman, PhD College of Social and Behavioral Science, Dept of Economics
  3. 3. Visits: 300,000+ Active patients: 157,000 11 Community Clinics
  4. 4. University of Utah Community Clinics Clinic Year Opened Total Providers Primary Care Providers Visits Per Year (FY09) Madsen 1975 6 5 18,970 Greenwood 1976 17 10 54,475 Redwood 1985 20 10 93,110 Westridge 1988 7 6 29,208 Parkway 1989 6 5 19,488 Sugar House 1996 10 9 20,344 Stansbury 1999 7 6 24,145 Redstone 2001 7 5 26,309 South Jordan 2003 3 2 11,359 Centerville 2007 4 4 8,044
  5. 5. Care by DesignTM • Appropriate Access – 2003 • Balance supply and demand of visits • Standardized schedules • Care Team – 2004 • Expanded MA role • Providers and MAs working in teams • EMR tools • Planned Care – 2006 • Pre-visit planning • Registries • Labs prior to visit
  6. 6. Retrospective Analysis: Qualitative Aims AHRQ Grant # 1R18 HS019136-01 Transforming Primary Care Aim Method Document and measure the transformation • Archival Search Determine impact on the experiences and satisfaction of providers, staff and patients • Provider and Staff Surveys • Provider and Staff Interviews • Patient Satisfaction Survey • Patient Focus Groups Explore organizational & contextual factors • Clinic Environmental Audit • In-Clinic Observations Assess in depth how the transformation was implemented • Archival Search • Leadership Interviews • Provider and Staff Interviews
  7. 7. Care by DesignTM • Appropriate Access – 2003 • Balance supply and demand of visits • Standardized schedules • Care Team – 2004 • Expanded MA role • Providers and MAs working in teams • EMR tools • Planned Care – 2006 • Pre-visit planning • Registries • Labs prior to visit
  8. 8. Qualitative Data: Care Teams 8 Component Type of Information Gathered Archival search • when/how the care team was rolled out Clinic Environmental Audit • size of clinic, team composition, patient volume, presence of specialists In-clinic observations • feeling in the clinic, background info Employee Interviews • personal experience with implementing care team + experimenting with local adaptations: how + why Leadership interviews • personal experience with leading the care team roll out + managing the evolution: what + why Provider & Staff Survey • trends in team development, employee burn out, organizational culture Patient Sat. Surveys • patients’ satisfaction with visits Patient Focus Groups • changes noticed and patient perspective
  9. 9. Care Team Structure & MA Role CBD Care Team Model Variations Traditional Model Team Members: • Providers • MAs
  10. 10. “Care Team” • 5 MAs: 2 Providers • Working together • Doing it all! MA specialists • (V1): 1 MA phlebotomist does all draws • Others are 5 MAs :2 Providers • (V2): 1 MA rooms patients + 1 MA scribes in the room : 1 Provider Clinic- wide team • All of the MAs are in one pool • Room patients in a rotation • Outside visit work done in between Hybrid Traditional Model • 1 MA : 1 Provider • Variation – 2 MAs : 1 Provider Team Members: • Providers • MAs Care Team Structure & MA Role • (V1): 5 MAs : 2 Providers for patient visits, but • 2 MAs: 1 Provider for outside visit work • (V2): 5 MAs : 2 Providers, but • 1 “primary” MA : 1 Provider
  11. 11. Example of Insights from Quantitative Research Clinic Culture An illustration of possible explanations for the observed differences in implementation of Care Teams
  12. 12. Organizational Culture Assessment Instrument: “Competing Values” Quinn, Rohrbaugh: http://www.ocai-online.com/
  13. 13. Greenwood
  14. 14. Parkway
  15. 15. Redstone
  16. 16. Senior Leadership
  17. 17. Organizational Culture In Community Clinics
  18. 18. Aim Method Document and measure the transformation and impact on the quality of patient care delivery • Clinical Data • CBD Implementation Determine impact of the transformation on cost to the clinics • Operational Data Determine impact of transformation on overall costs of healthcare services, including direct costs to patients • Centers for Medicare & Medicaid Services Data • Utah All Payer Claims Database Retrospective Analysis: Quantitative Aims AHRQ Grant # 1R18 HS019136-01 Transforming Primary Care
  19. 19. Quantitative Data Component Type of Information Gathered CBD Implementation • Use of EMR tools • Appointment availability • Continuity with PCP • Use of pre-visit planning tools and processes • Flow and processes of Care Team • Efficiency of visit/wait times Impact on Operations • Provider productivity • Financial performance • Patient population characterization Clinical Outcomes • Quality performance (chronic & preventive) • Patient, Provider, Staff satisfaction Cost of Care • Utilization and cost of care • CMS • Utah Population Data Base (UPDB) • Utah All Payer Claims Database (APCD) Gray = data analysis pending
  20. 20. 10% 20% 30% 40% 50% 60% 70% 80% 2003 2004 2006 2008 2009 Quality Measures Percent of Patients Receiving Recommended Care CAD* Preventive Care* Diabetes* Heart Failure* Note: Sample size=14 providers who had all measures in FY 2003, 2004, 2006, 2008, and 2009; *p≤0.05
  21. 21. 20% 30% 40% 50% 60% 70% 80% 90% 100% 2003 2004 2006 2008 2009 Patient Satisfaction Percent of Patients Reporting "Very Satisfied" Recommend provider* Explanation of what was done* Visit overall* Time spent with physician* Length of time waiting at office* Note: Sample size=16 providers who had all measures in FY 2003, 2004, 2006, 2008, and 2009; *p≤0.05
  22. 22. Overview of Quantitative Design: Link data from multiple sources to assess impact of transformation to CBD Cost & Utilization CBD Implementation Clinical Data Operations Data
  23. 23. Level of CBD Implementation: 2008 1.00 1.20 1.40 1.60 1.80 2.00 2.20 All elements
  24. 24. Examples of Correlation between CBD Implementation and Patient Satisfaction Patient Satisfaction CBD Implementation Measure 2008 Same Day Appointments Efficient Visit Length of time waiting at the office 0.61** 0.33* Time spent with the physician/health care professional you saw 0.20 -0.21 Explanation of what was done for you 0.14 -0.13 The visit overall 0.50** 0.20 Would you recommend the physician/health care professional to your friends and family? 0.34* -0.17 N=16 providers *p≤0.1, **p≤0.05
  25. 25. Correlation between CBD Implementation and Quality Measures CBD Implementation Measure 2008 Quality Measures Diabetes Coronary Artery Disease Preventive Care Seen by PCP last visit 0.60* 0.61* 0.57* Use of X-files by MA 0.33* 0.18 0.18 Best Practice Alerts 0.34* 0.26 0.29 After-Visit summary 0.23 0.18 0.11 Labs done prior to visit 0.54** 0.47* 0.36* N=14 providers with data across five years *p≤0.1, **p≤0.05
  26. 26. Impact of practice redesign • Quality improves • Continuity matters • Pre-visit planning and EMR reminders help • Patients notice • Access improves patient satisfaction • Level of implementation varies across clinics • Clinic culture impacts implementation • Culture is a critical factor in translational research
  27. 27. Future analysis: impact of redesign on… • Internal cost and productivity of clinics • Overall utilization • Total cost of care
  28. 28. Future: Internal Performance Analyses Cost & Utilization CBD Implementa- tion Clinical Data Operations Data • Provider productivity • Financial performance • Patient population characterization
  29. 29. Future: Cost and Utilization Cost & Utilization CMS, APCD CBD Implementa- tion Clinical Data Operations Data CMS Data • All Medicare Claims at individual level for Utah (2007+) • For the following: • Outpatient • Inpatient • Home Health • Nursing Home • Prescription Drug (Part D) •Linked to State Vital Statistics and facility data (Utah Population Database ) All Payer Claims Database (APCD) • Data elements: • Charges • Reimbursements • Utilization • For the following: • Outpatient, Inpatient, Rehabilitation • Prescription Rx • Linked to State Vital Statistics and facility data
  30. 30. Challenges in Assembling Cost, Utilization and Demographic Data • Gaining access • Navigating layers of documentation, requests, approvals (CMS) • Obtaining IRB and other database approvals • Building APCD platform as 1st user • Translating utility into usable research database • Creating files linkable at individual level • Linking data – hospital, ED, vital statistics
  31. 31. Challenges of Retrospective Mixed Methods Research • Timing of all the components • Recall isn’t perfect – current events color memory • Data used for operations differ from data required for research • IRB & HIPAA rules for linking PHI to operations and external data
  32. 32. Benefits of Mixed Method Research • Multiple components inform each other throughout data collection • Participant selection • Instrument development • Sequencing • Multiple components inform each other throughout data analysis • Convergent/consensual validation • Multiple components facilitate integration of different perspectives
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