Organizational Policy and Systems Change


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The Alliance to Reduce Disparities in Diabetes

The Alliance is working to improve communication between patients and health care providers. Effective communication among providers, patients and their family members is a critical component of efforts to promote optimal care outcomes, enhance prevention and management of diabetes and reduce disparities in care.

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  • Belinda’s Welcome
  • Belinda
  • Belinda
  • The Merck Company Foundation launched the Alliance to Reduce Disparities in Diabetes in 2009 to address the growing problem of health care disparities in Type 2 diabetes in the United States among low-income and underserved adult populations. Through this Alliance, the foundation supports comprehensive, multifaceted, community-based programs to improve health outcomes for people living with diabetes in five grantee communities: Camden, New Jersey; Chicago, Illinois; Dallas, Texas; Wind River Reservation, Wyoming; and Memphis, Tennessee. These sites are working to change the systems and policies related to diabetes management and prevention in their communities.
  • This presentation has three objectives: To develop a common understanding of what is meant by “policy and systems change” Provide some examples of policy and systems change efforts currently underway around the country ; and Facilitate discussion and peer-to-peer learning.
  • For the purposes of the Alliance work, what do we mean by policy and policy change?
  • First, we make the distinction between two kinds of policy: public and organizational.
  • Public policy is: A set of agreements about how government will address society’s needs and spend public funds that are articulated by leaders in all three branches of the government and embedded in many different policy instruments (for example, laws and regulations)
  • Organizational policy is: A set of written rules and policies that govern behavior and practice within an organization, business or agency.  
  • Routine practices, cultural norms, customs, and unwritten agreements about behavior are not policy, but can influence and be influenced by policy Example: It may be a custom or normative practice in a clinic that a receptionist greets and welcomes a patient and refers to him/her by name. “Hello Mr. Jones. Good to see you.” This practice is common but its not written down anywhere.   For the purpose of this webinar, we will focus on formal policy change (rather than customs and practices) and look specifically at organizational policy examples rather than public policy examples.
  • What is organizational policy change? It’s the creation of new written policies or rules or a change in the current policies or rules of an organization. The change is generally agreed upon by a decision-making body or by an individual in a leadership position.
  • Now, for the purposes of the Alliance work, what do we mean by systems and systems change?
  • A system is a group of independent but interrelated and interacting elements–individuals, institutions and infrastructure–that form a unified whole. For instance, the health care delivery system is a large and complex system with many interacting components that affect our health and well-being. There are doctor’s offices, clinics, hospitals, health departments, pharmaceutical companies, insurers etc. that combined comprise the health system. Other systems also affect our health, such as the food system.
  • Systems are not static entities. They are constantly changing and evolving. So what does it mean to talk about systems change? Systems change occurs when one or several elements in a system, change, altering both their relationship to one another and the overall structure of the system itself. In addition, change in one system can effect change in other systems.
  • There are a number of ways in which systems can change. Changes in new or existing policies, organizational practices, social and cultural norms and changes to infrastructure all have an impact on systems.
  • What is the relationship between policy and systems change? Policy change is an important driver of systems change and will help to ensure the sustainability of the changes over the long-term. By setting anew policy the practices and relationships within and between organizations change.
  • Now I’d like to talk about some examples of organizational changes going on around the country related to diabetes management, education and prevention. Health care organizations around the country are experimenting with new and innovative approaches to diabetes management.
  • One such example is in the rural Pee Dee region of South Carolina. CareSouth Carolina is a community health center that has grown from a small, one-physician office to a regional health provider serving more than 35,000 patients at nine different medical centers. Despite this growth, CareSouth has remained committed to it’s community-based approach to health care and has been recognized by the Institute for Healthcare Improvement for its innovative approach to diabetes care. While CareSouth has adopted many changes to their health care delivery system over the last several years, the change that we are going to discuss is their implementation of a “health care team approach”.
  • The team approach consists of a care manager, behavioral health counselor, nurse and a physician. While the physician remains a strong partner in the team, CareSouth added care managers to the team and enhanced the roles of nurses and behavioral health counselors in caring for diabetes patients.
  • CareSouth added a new member to their traditional doctor/nurse team – a care manager. A written job description was drafted and the health center’s Board of Directors had to approve the new position. One challenge was that the new position required additional funding, so the Board had to allocate funding for the new position. In order to persuade the Board to make this change, the CEO of CareSouth used a business model plan to show that adding care managers would mean that the Center could increase the number of patients seen and this would offset the additional cost. It worked and the funding was allocated. This change meant that the health care team is now able to spend more time with patients. Care managers meet with patients individually to provide prevention and self-management education and help with individual goal setting. Care managers also hold group classes for diabetes patients and are able to get to know patients.
  • In this new team approach, nurses have an expanded role that allows them to order lab tests, refill medications and adjust insulin doses. According to the CEO of CareSouth, this has made patient office visits much more efficient. CareSouth implemented this change by creating a series of standard written “standing orders” from physicians for things such as drawing blood, ordering lab tests or EKGs, and refilling medications. Creation of the standing orders had to be approved by the chief medical officer at CareSouth, which was not difficult, according to the CEO because the Chief Medical Officer realized that the change would save physicians time and make the process much more efficient. All procedures and guidelines for creating and implementing these new standing orders were documented in the Center’s Clinical Manual of written policies and procedures.
  • CareSouth also integrated behavioral health counselors into the regular care of patients. While counselors were available to patients before on a pre-scheduled basis, CareSouth integrated same day, same location behavioral health counseling services for all patients. Having a counselor available to patients when they come in for other appointments and on an as needed basis, has made all the difference according to CareSouth. They did this by adopting a 45/15 appointment scheduling rule that requires all on-site health counselors to keep the first 15 minutes of every hour open and available for patients with immediate counseling needs. The health counselors are licensed, maters-level social workers with experience working with patients on issues related to depression and problem solving. This change took the form of a written appointment rule change and was documented in the Center’s Clinical Manual. Also, the job description for the behavioral health counselors was revised to include the 45/15 model. The CEO of CareSouth approved this change. Since it was not considered a new formal policy per se, but rather a change in practice and procedure, the Center’s Board of Directors did not need to approve.
  • CareSouth clinicians have reported that implementing the “team approach” has improved health outcomes and helped to reduce disparities among patients. Before the “team approach” was implemented only 15% of patients had A1c Hemoglobin levels under control with a measurement of 7 or less. Today 54% of diabetes patients at CareSouth have levels of 7 or less. In addition, the “team approach” has helped them move toward their goal of 0% disparities in hemoglobin A1c levels. Currently, their disparity level measures 6%, indicating that A1c levels are about 6% higher in non-white populations than white populations. Although CareSouth has not yet reached their target, their level of 6% is vastly better than surrounding rural communities which experience disparities at a level of approximately 100%.
  • The next example we will discuss includes recent changes implemented at St. Peter Family Medicine Clinic in Olympia, Washington. St. Peter is one of 14 family medicine programs affiliated with the University of Washington and is one of the Robert Wood Johnson Foundation’s Diabetes Initiative grantees. With funding from the Foundation’s Diabetes Initiative, St. Peter was able to redesign their diabetes care.
  • St. Peter now offers three different types of non-traditional medical office visits along with the more traditional 1-on-1 patient/doctor visit. These include: planned visits, mini-group medical visits and open office group visits.
  • “ Planned visits” between a medical assistant and patient serve to prepare both the patient and physician for their scheduled visit in the following 1-2 weeks. Medical assistants initiate lab testing, routine measurements, and goal setting at the “planned visit” in order for the results to be ready for the traditional physician-patient visit. This change required that explicit standing orders be created for the medical assistants to follow during these visits in a sort of “cookbook “ fashion. The creation of “planned visits” redefined the role of medical assistants and added new protocols and curriculum to their training. Despite apprehension, the staff at St. Peter’s reports that after a period of adjustment, the medical assistants became comfortable with the new responsibilities and many report higher job satisfaction now.
  • St. Peter also implemented “mini- group” medical visits as an option to replace the traditional office visit with a physician. “Mini-group” visits involve 2 or 3 patients meeting at one time with a doctor and a medical assistant for a longer visit, allowing more opportunities for patients to question their health care provider and to share experiences with one another. “ Mini-group” visits include discussion of medications, hemoglobin levels, blood pressure and other health measures. The cohort of patients are offered the opportunity to schedule follow-up “mini-group” sessions, and many times patients develop ongoing supportive relationships. Patients participating in the “mini-group “ visits were required to sign HIPAA- compliant patient confidentiality forms agreeing not to share the health information of other patients. According to clinic providers it was very important to make sure it was all HIPAA compliant. And, of course, the clinic manual had to be changed to reflect these new policies and procedures.
  • An additional option for patients is an “open office group” visit which includes 7 to 12 patients at one time in a 2-hour session that is coordinated usually by 1 or 2 physicians, medical assistants, and nurses. This structure provides patients with the opportunity to ask questions and talk openly with each other. An extensive training curriculum was developed by St. Peter’s to prepare their physicians for the counseling role of “open office group” visits. Not all physicians at St. Peter are willing to lead these group visits, but they are all willing to refer patients into the group visits . The changes required approval by the Chief Medical Officer.
  • At St. Peter the policy changes came AFTER they were able to show positive outcomes from a small pilot project undertaken by one physician and one medical assistant. Their aim was to show small, rapid, cycle improvements . These improvements provided convincing evidence for a clinic-wide change to the office visit structure. Given the scope of the project, the clinic-wide change took close to 5 years to fully adopt and implement.
  • After they were able to show these initial positive outcomes they had to get buy-in from the clinic’s medical director to move forward with larger scale clinic-wide changes. After they had this, they began discussing these changes with their Organizational Operations Committee or OOC committee. This is a leadership committee made up of doctors and nurses that meet weekly and set the policy for the clinic. While there was not a formal process of voting on the policy changes related to office visits, they had to go slowly and could only move forward when they had consensus from this group.
  • St. Peter found that changing their office visit structure did make a difference. Survey data showed that patients felt well-cared for, better supported and more successful and confident. Medical assistants reported gaining knowledge and confidence and increased job satisfaction. Physicians reported becoming more comfortable with providing self management support.
  • The changes also yielded some positive health outcomes. They found that patients participating in group visits were more likely to have lower A1c levels than other clinic patients and they were more likely to have greater A1c reductions. They also found significant reductions in LDL cholesterol levels for patients participating in planned visits.
  • Belinda
  • Belinda
  • The changes also yielded some positive health outcomes. They found that patients participating in group visits were more likely to have lower A1c levels than other clinic patients and they were more likely to have greater A1c reductions. They also found significant reductions in LDL cholesterol levels for patients participating in planned visits.
  • Belinda’s Welcome
  • Organizational Policy and Systems Change

    1. 1. Organizational Policy and Systems Change
    2. 2. Agenda <ul><ul><li>Welcome (Belinda Nelson) </li></ul></ul><ul><ul><li>Overview and Examples of Organizational Policy and Systems Change (Martha Quinn) </li></ul></ul><ul><ul><li>Systems Change in Dallas: Community Health Workers (James Walton) </li></ul></ul><ul><ul><li>Systems Change in Chicago: Clinic Redesign (Monica Peek and Marshall Chin) </li></ul></ul><ul><ul><li>Q & A (Darla Williams) </li></ul></ul>
    3. 3. Presenters <ul><ul><li>Martha Quinn </li></ul></ul><ul><ul><li>University of Michigan, Center for Managing Chronic Disease </li></ul></ul>
    4. 4. Alliance Grantees Camden, New Jersey Memphis, Tennessee Dallas, Texas Chicago, Illinois Wind River Indian Reservation Fort Washakie, Wyoming
    5. 5. Objectives <ul><li>Develop a shared understanding of what we mean by “policy and systems change” </li></ul><ul><li>Highlight current examples of policy and systems change efforts </li></ul><ul><li>Facilitate discussion and peer-to- </li></ul><ul><li>peer learning </li></ul>
    6. 6. Why is this important? <ul><li>An overarching goal of the Alliance is to CHANGE the SYSTEMS and POLICIES that have negative impact on people with diabetes and introduce new policies that will have a positive impact </li></ul><ul><li>So that, the work of the Alliance will outlive the funding and be sustained over the long-term </li></ul>
    7. 7. Policy and Policy Change
    8. 8. What is policy? <ul><li>Public policy </li></ul><ul><li>Organizational policy </li></ul>
    9. 9. Public policy <ul><ul><li>A set of agreements about how government will address societal needs and spend public funds. These agreements are: </li></ul></ul><ul><ul><ul><li>articulated by leaders </li></ul></ul></ul><ul><ul><ul><li>in all three branches of government, and </li></ul></ul></ul><ul><ul><ul><li>embedded in many different policy instruments (for example, laws and regulations). </li></ul></ul></ul>
    10. 10. Organizational policy <ul><ul><li>A set of written rules and policies that govern behavior and practice within an organization, agency or business </li></ul></ul>
    11. 11. Custom and Practice <ul><ul><li>Routine practices, cultural norms, customs, and unwritten agreements about behavior are not policy , but can influence and be influenced by policy </li></ul></ul>
    12. 12. What is organizational policy change? <ul><li>The creation of new written policies or rules, or a change in the current written policies or rules of an organization </li></ul>
    13. 13. Systems and Systems Change
    14. 14. What is a system? <ul><li>A group of independent but interrelated and interacting elements (individuals, institutions and infrastructure) that form a unified whole </li></ul>For example: health care delivery system
    15. 15. What is systems change? <ul><li>Systems change occurs when one or several elements in a system change, altering their relationship to one another and the overall structure of the system itself </li></ul>
    16. 16. <ul><li>What drives systems change? </li></ul><ul><ul><li>Changes in existing policies or creation of new policies </li></ul></ul><ul><ul><li>Organizational practices </li></ul></ul><ul><ul><li>Social or cultural norms </li></ul></ul><ul><ul><li>Changes to infrastructure </li></ul></ul>
    17. 17. <ul><li>What is the relationship between policy and systems change? </li></ul><ul><ul><li>Policy change is an important way to achieve systems change </li></ul></ul>
    18. 18. Examples of Organizational Policy and Systems Change
    19. 19. Health Care Team Approach CareSouth Carolina
    20. 20. Health Care Team Approach <ul><li>Care manager </li></ul><ul><li>Behavioral health counselor </li></ul><ul><li>Nurse </li></ul><ul><li>Physician </li></ul>Change: Health Care Team Approach includes
    21. 21. Health Care Team Approach <ul><li>Related Policy Changes: </li></ul><ul><li>Written job descriptions </li></ul><ul><li>Board of Director’s approval </li></ul><ul><li>Funding allocated </li></ul>Change : Care managers (new position)
    22. 22. Health Care Team Approach <ul><li>Change : Nurses have expanded role </li></ul><ul><li>Related Policy Changes: </li></ul><ul><li>Creation of “standing orders” </li></ul><ul><li>Chief Medical Officer approval </li></ul><ul><li>Clinical Manual of policies/procedures </li></ul>
    23. 23. Health Care Team Approach <ul><li>Change: Behavioral health counselors integrated into regular care </li></ul><ul><li>Related Policy Changes: </li></ul><ul><li>Implement 45/15 rule </li></ul><ul><li>Changes in written job description </li></ul><ul><li>Clinical Manual of policies/procedures </li></ul><ul><li>CEO approval </li></ul>
    24. 24. Health Care Team Approach <ul><ul><li>Overall lower HbA1c levels </li></ul></ul><ul><ul><li>Reduction in diabetes disparities </li></ul></ul>Impact : Health outcomes
    25. 25. Medical Office Visits Providence St. Peter Family Medicine Clinic in Olympia, Washington
    26. 26. Medical Office Visits <ul><li>Change : patients have a choice to participate in three different types of non-traditional office visits: </li></ul><ul><ul><li>Planned visits </li></ul></ul><ul><ul><li>Mini-group medical visits </li></ul></ul><ul><ul><li>Open office group visits </li></ul></ul>
    27. 27. Medical Office Visits <ul><li>Change : Planned visits </li></ul><ul><li>Related Policy Changes: </li></ul><ul><li>Creation of “standing orders” </li></ul><ul><li>New job descriptions for MAs </li></ul><ul><li>Curriculum for training formally adopted by the clinic </li></ul><ul><li>Clinic Manual of policies/procedures </li></ul>
    28. 28. Medical Office Visits <ul><li>Change : Mini-group visits </li></ul><ul><li>Related Policy Changes: </li></ul><ul><li>Patient Confidentiality Forms required </li></ul><ul><li>HIPAA compliance required </li></ul><ul><li>Clinical Manual of policies/procedures </li></ul>
    29. 29. Medical Office Visits <ul><li>Change : Open office group visits </li></ul><ul><li>Related Policy Changes: </li></ul><ul><li>Changes in physician job descriptions </li></ul><ul><li>Creation and adoption of training curriculum </li></ul><ul><li>Clinical Manual of policies/procedures </li></ul><ul><li>Chief Medical Officer approval </li></ul>
    30. 30. Medical Office Visits <ul><li>St. Peter’s Approach : policy change came after showing positive outcomes from small pilot </li></ul><ul><ul><li>First small pilot project </li></ul></ul><ul><ul><li>Rapid cycle improvements </li></ul></ul><ul><ul><li>Showed positive outcomes </li></ul></ul><ul><ul><li>Changed clinic-wide policies and practices </li></ul></ul>
    31. 31. Medical Office Visits <ul><li>Clinic policies and procedures approved by: </li></ul><ul><ul><li>Medical Director </li></ul></ul><ul><ul><li>Organizational Operations Committee (OOC) </li></ul></ul>
    32. 32. Medical Office Visits <ul><li>Impact : Planned and Group medical visits </li></ul><ul><li>Results of survey data: </li></ul><ul><ul><li>Patients: “..felt well cared for, better supported and more successful and confident” </li></ul></ul><ul><ul><li>Medical Assistants: “...gained knowledge and confidence in diabetes and self management, and were more satisfied with their jobs.” </li></ul></ul><ul><ul><li>Physician: “…modest improvements in comfort with, and perceived effectiveness in providing self management support.” </li></ul></ul>
    33. 33. Medical Office Visits <ul><li>Impact : Health Outcomes </li></ul><ul><ul><li>Patients participating in group visits were more likely to have lower A1C levels than other patients and greater A1C reductions </li></ul></ul><ul><ul><li>Significant reductions in LDL cholesterol for patients participating in planned visits </li></ul></ul>
    34. 34. Presenters <ul><ul><li>Dr. James Walton </li></ul></ul><ul><ul><li>Baylor Health Care System in Dallas, Texas </li></ul></ul>
    35. 35. Grantee Efforts Underway - Dallas <ul><li>Establishment of Community Care Coordination </li></ul><ul><ul><li>Baylor Health Care System’s Office of Health Equity established a dedicated “new” workforce, providing specialized culturally-sensitive care coordination and self-management training for historically underserved populations with chronic illnesses (i.e. Diabetes) </li></ul></ul>
    36. 36. Grantee Efforts Underway - Dallas <ul><li>Components of Systems Change: </li></ul><ul><ul><li>Creation and adoption of the Community Health Worker (CHW) role within BHCS’ human resources structure </li></ul></ul><ul><ul><li>Development of strategies that allow providers to confer “authority” to CHWs, extending the reach of the health care team </li></ul></ul><ul><ul><li>Establishment of accountability and outcomes measurement systems </li></ul></ul>
    37. 37. Grantee Efforts Underway - Dallas <ul><li>Creation & adoption of CHW role </li></ul><ul><li>Embed Community Health Worker (CHW) job code within BHCS’ Human Resources structure </li></ul><ul><ul><li>Designed job description and compensation of Diabetes Health Promoter (CHW) </li></ul></ul><ul><ul><ul><li>Utilized CoDE ™ Medical Assistant qualifications to serve as minimum job requirements </li></ul></ul></ul><ul><ul><ul><li>Required market research on CHW/MA salaries </li></ul></ul></ul><ul><ul><li>Required BHCS Human Resources and Compensation formal review and approval </li></ul></ul><ul><li>Determine training and continuing education necessary for job role </li></ul><ul><ul><li>Developed training curriculum for CHWs functioning as Diabetes Health Promoters in outpatient setting </li></ul></ul><ul><ul><ul><li>Includes training manual, practicum (traditional DSME classes, skills certification, AADE Healthcare Technician training) </li></ul></ul></ul><ul><ul><ul><li>Training/continuing education funded annually as a distinct budget line item </li></ul></ul></ul><ul><ul><li>Integrated state certification as CHW into curriculum </li></ul></ul><ul><li>Build career progression for CHW’s </li></ul><ul><ul><li>Developing promotional levels within job code </li></ul></ul><ul><ul><ul><li>Differentiation “case” being developed between medical assistants and CHWs (for HR approval process) </li></ul></ul></ul><ul><ul><li>Working to define CHW career path within health system </li></ul></ul>
    38. 38. <ul><ul><li>Develop strategies that allow providers to confer “authority” to CHWs </li></ul></ul><ul><ul><li>Protocol, policies and procedures developed </li></ul></ul><ul><ul><ul><li>Protocol Handbook (including educational materials, forms) approved by Physician Vice-President, Office of Health Equity and consulting endocrinologist </li></ul></ul></ul><ul><ul><ul><li>Policies and procedure handbook utilized evidence-based resources (existing BHCS policies, US Department of Health and Human Services, manufacturer procedures for use of equipment) </li></ul></ul></ul><ul><ul><ul><li>Formal PCP Communication Guidelines developed by consulting endocrinologist and Physician Vice-President, Office of Health Equity </li></ul></ul></ul><ul><ul><ul><ul><li>Reviewed by primary care practices referring to the Diabetes Equity Project </li></ul></ul></ul></ul><ul><ul><li>Consulting endocrinologist and RN manager </li></ul></ul><ul><ul><li>Developing new care model utilizing Nurse Practitioner and CHW as “case management” team (with physician oversight) for “Hot Spot” patients </li></ul></ul><ul><ul><ul><li>In sixth month of pilot currently </li></ul></ul></ul><ul><ul><ul><li>Comprehensive Patient Assessment tools developed (assessing self-management behaviors, social barriers) </li></ul></ul></ul><ul><ul><ul><li>Utilizes DiaWEB ™ registry and clinic EMR for data tracking </li></ul></ul></ul><ul><ul><ul><li>Preliminary data analysis will take place July 2011 </li></ul></ul></ul>Grantee Efforts Underway - Dallas
    39. 39. <ul><ul><li>Establish accountability and outcomes measurement systems </li></ul></ul><ul><ul><ul><li>DiaWEB ™ diabetes registry with reporting capability </li></ul></ul></ul><ul><ul><ul><ul><li>Web-based design with customized Diabetes Health Promotion assessments </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Produces both individual and aggregate data reports </li></ul></ul></ul></ul><ul><ul><ul><li>Patient experience satisfaction tool for real-time evaluation of CHW service quality </li></ul></ul></ul><ul><ul><ul><li>Chart audits </li></ul></ul></ul><ul><ul><ul><ul><li>Annual chart audits (random sample) are conducted by RN Manager </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Audit analysis completed by BHCS statisticians </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Utilize clinical trial standard of <5% error rate </li></ul></ul></ul></ul>Grantee Efforts Underway - Dallas
    40. 40. Grantee Efforts Underway – Dallas <ul><li>Specific strategies & tactics to change the system: </li></ul><ul><ul><li>Deployed BHCS employees (CHWs) into community aligned with collaborating safety net clinics </li></ul></ul><ul><ul><ul><li>Five sites serve as “community hubs” for care coordination </li></ul></ul></ul><ul><ul><ul><li>Established operational foundation </li></ul></ul></ul><ul><ul><ul><ul><li>For first 6 months, received referrals only from five sites to build competencies and fine tune processes </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Solicited regular feedback from stakeholders </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Slower patient ramp up </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Built team culture </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Diabetes Health Promoter team meetings bi-monthly </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Monthly meetings with site clinic staff </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Strong support from leadership to increase likelihood of employee engagement and successful implementation </li></ul></ul></ul></ul></ul>
    41. 41. Specific strategies & tactics to change the system (continued) <ul><ul><li>Marketed new CHW-led disease management training & care coordination service (referrals to community and health care based resources) to broad network of safety net providers </li></ul></ul><ul><ul><ul><li>Identified provider “targets” </li></ul></ul></ul><ul><ul><ul><ul><li>Utilized existing safety net organization’s (Project Access Dallas) administration‘s endorsement, data on practices with high prevalence of diabetics, and insights into practice partners to identify targets </li></ul></ul></ul></ul><ul><ul><ul><li>Marketing tactics </li></ul></ul></ul><ul><ul><ul><ul><li>Diabetes Health Promoter and Manager scheduled individual meetings with target practice leadership </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Presentation including preliminary outcome data, referral process overview (and forms), patient criteria, patient brochure, and administrative overview </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Utilized Project Access Dallas marketing department to build awareness (Dallas Medical Society Journal) </li></ul></ul></ul></ul><ul><ul><li>Expanded intervention to private practice physicians caring for vulnerable patients experiencing disease control disparities </li></ul></ul><ul><ul><ul><li>500 physician BHCS organization’s Disease Management Council approved twelve month pilot at four practices beginning summer 2011 </li></ul></ul></ul><ul><ul><ul><li>Tracking clinical outcomes via clinic EMR data </li></ul></ul></ul><ul><ul><ul><li>Will report results to Disease Management Council in 2012 </li></ul></ul></ul>
    42. 42. Grantee Efforts Underway - Dallas <ul><li>Impacts Intended & Accomplished </li></ul><ul><ul><li>Use a CHW intervention to produce documented improvement in diabetes control and reduction of racial/ethnic disparities </li></ul></ul><ul><ul><ul><li>Statistically significant increase in percent of vulnerable patients enrolled in the intervention with “superior” diabetes disease control (HgbA1c < 7%) </li></ul></ul></ul><ul><ul><ul><li>No significant differences noted between minority and non-minority patient sub-populations </li></ul></ul></ul><ul><ul><li>Building awareness of CHW scope/role within a health system </li></ul></ul><ul><ul><ul><li>Human Resources – career paths </li></ul></ul></ul><ul><ul><ul><li>Added 2 FTE CHW in transitional care role </li></ul></ul></ul><ul><ul><ul><li>Received funding for 3 additional CHWs (Diabetes Health Promoter and Transitional Care) </li></ul></ul></ul><ul><ul><ul><li>2 other BHCS departments adding CHWs into their workforce </li></ul></ul></ul><ul><ul><li>Develop funding sources for long term sustainability </li></ul></ul><ul><ul><ul><li>Baylor Community Care incorporates Community Care Coordination as a core operating component with a dedicated budget for CHW roles (Community Health Education, Community Care Transitions, Specialty Care Transitions) </li></ul></ul></ul><ul><ul><ul><li>Planning has started for enlisting community organization funds for non-Baylor owned clinic </li></ul></ul></ul>
    43. 43. Presenters Dr. Monica Peek Dr. Marshall Chin University of Chicago, Pritzker School of Medicine Abby Wilkes, MPH
    44. 44. University of Chicago Improving Diabetes Care and Outcomes on the South Side of Chicago
    45. 45. South Side of Chicago <ul><li>Challenges: </li></ul><ul><ul><li>Poverty </li></ul></ul><ul><ul><li>Social challenges </li></ul></ul><ul><ul><li>Food deserts </li></ul></ul><ul><ul><li>Unsafe recreation </li></ul></ul><ul><ul><li>Mistrust of healthcare </li></ul></ul><ul><ul><li>Weakened hospital safety net </li></ul></ul><ul><li>Strengths </li></ul><ul><ul><li>Historical social, political and cultural traditions </li></ul></ul><ul><ul><li>Community resources and institutions </li></ul></ul><ul><ul><li>Healthcare institutions </li></ul></ul>
    46. 46. Intervention Components <ul><li>Six health centers </li></ul><ul><li>1) Patient activation trainin </li></ul><ul><li>2) Provider communication training </li></ul><ul><li>3) Community connections </li></ul><ul><li>4) Systems Change: CLINIC REDESIGN </li></ul>
    47. 47. Health System Change <ul><li>Clinic redesign </li></ul><ul><li>QI teams/coaches </li></ul><ul><li>Collaborative mtgs </li></ul><ul><li>PDSA cycles </li></ul>
    48. 48. Health System Change: Care Management <ul><li>Nurse care management </li></ul><ul><ul><li>Context: MD-led internal medicine practice </li></ul></ul><ul><ul><li>Intervention: Nurse Practitioner Care Management </li></ul></ul><ul><ul><ul><li>Diabetes education </li></ul></ul></ul><ul><ul><ul><li>Insulin initiation/titration </li></ul></ul></ul><ul><ul><ul><li>Care coordination </li></ul></ul></ul><ul><ul><ul><li>Telephone counseling/management </li></ul></ul></ul><ul><ul><ul><li>Involvement in community outreach </li></ul></ul></ul><ul><ul><li>Incorporate other systems changes </li></ul></ul><ul><ul><ul><li>Improve frequency and appropriateness of physician/staff referral to nutrition </li></ul></ul></ul><ul><ul><ul><li>Increase referrals to NP from each provider’s rosters of patients </li></ul></ul></ul>
    49. 49. Health System Change: Care Management <ul><li>Nurse care management: Lessons </li></ul><ul><li>Nurse is crucial member of clinic redesign team </li></ul><ul><li>Nurse cannot do it all - Now have staff to support outreach phone calls </li></ul><ul><li>Need to measure process measures as well as usual clinical measures – e.g. no-show rate and # of patients who are contacted to reschedule </li></ul><ul><li>Clinic redesign uncovers system capacity challenges - Limited number of appointments available for MDs, NP, and nutritionist </li></ul>
    50. 50. Health System Change: Group Visits <ul><li>Diabetes group visits </li></ul><ul><ul><li>Context: 2 federally-qualified health centers </li></ul></ul><ul><ul><li>Intervention: Shared medical appts </li></ul></ul><ul><ul><ul><li>Diabetes education </li></ul></ul></ul><ul><ul><ul><li>Medication titration/clinical care </li></ul></ul></ul><ul><ul><ul><li>Support group </li></ul></ul></ul><ul><ul><li>Some evidence re: reduced costs, hospitalizations, lower blood pressure, Improved patient/provider satisfaction </li></ul></ul>
    51. 51. Health System Change: Group Visits <ul><li>Diabetes group visits: Lessons </li></ul><ul><ul><li>Pre-plan </li></ul></ul><ul><ul><li>Identify schedule changes for staff </li></ul></ul><ul><ul><li>Determine types of providers/staff needed </li></ul></ul><ul><ul><li>Find out how to bill </li></ul></ul><ul><ul><li>Work out patient co-pays </li></ul></ul>
    52. 52. Health System Change: Diabetes Peer Support Group <ul><li>Diabetes Peer Support Group </li></ul><ul><ul><li>Context: Diabetes center in the section of Endocrinology </li></ul></ul><ul><ul><li>Intervention: Group of patients brought together to try out local fitness/nutrition resources and provide peer support </li></ul></ul><ul><ul><li>Focus on lifestyle modification while connecting to community </li></ul></ul><ul><ul><li>Evidence for: </li></ul></ul><ul><ul><ul><li>Improved knowledge </li></ul></ul></ul><ul><ul><ul><li>Improved psychosocial functioning </li></ul></ul></ul><ul><ul><ul><li>Increased physical activity self-efficacy </li></ul></ul></ul>
    53. 53. Health System Change: Diabetes Peer Support Group <ul><li>Diabetes Peer Support Group: Lessons </li></ul><ul><ul><li>No attendance at first physical activity event: walking group </li></ul></ul><ul><ul><li>Low attendance at grocery store tour </li></ul></ul><ul><ul><li>Despite focus groups and survey feedback requesting help re: fitness, nutrition, and peer support, patients did not show. </li></ul></ul><ul><ul><li>Changing QI focus to care coordination </li></ul></ul><ul><ul><li>Innovative new approaches to interface with patients outside of health care system </li></ul></ul>
    54. 54. Lessons Learned from QI Process <ul><li>Individualize to clinics </li></ul><ul><ul><li>What’s important to clinics vs. more ambitious change </li></ul></ul><ul><ul><li>Crawl, walk, run </li></ul></ul><ul><li>Coaches are vital </li></ul><ul><li>Learn from peer clinics </li></ul><ul><ul><li>Collaborative meetings </li></ul></ul><ul><ul><li>Support network </li></ul></ul>
    55. 55. Lessons Learned from QI Process <ul><li>Address challenges of health centers </li></ul><ul><ul><li>Staff turn-over </li></ul></ul><ul><ul><li>Leadership buy-in </li></ul></ul><ul><ul><li>Project scope and size </li></ul></ul><ul><ul><li>Learning curve </li></ul></ul><ul><li>Perseverance pays off </li></ul>
    56. 56. Health Policy Relevance <ul><li>Integration of Quality and Disparities </li></ul><ul><ul><li>Using the tools of QI to reduce disparities </li></ul></ul><ul><ul><li>Dept. of Health and Human Services, Centers for Medicare and Medicaid Services </li></ul></ul><ul><li>Coordinating care </li></ul><ul><ul><li>Organizational structures – Medical Home, ACOs </li></ul></ul><ul><ul><li>Financing mechanisms – Bundled payments </li></ul></ul><ul><li>Move towards efficiency </li></ul><ul><ul><li>Regardless of whether Democrat or Republican </li></ul></ul>
    57. 57. Our Project Team <ul><li>Marshall Chin </li></ul><ul><li>Monica Peek </li></ul><ul><li>Abigail Wilkes </li></ul><ul><li>Tonya Roberson </li></ul><ul><li>Anna Goddu </li></ul><ul><li>Kristine Bordenave </li></ul><ul><li>Michael Quinn </li></ul><ul><li>Doriane Miller </li></ul><ul><li>Lisa Vinci </li></ul><ul><li>Andrew Davis </li></ul><ul><li>Elbert Huang </li></ul><ul><li>Jonathan Birnberg </li></ul><ul><li>Jonathan Dick </li></ul><ul><li>Mickey Eder </li></ul><ul><li>Peggy Hasenauer </li></ul><ul><li>Louis Philipson </li></ul><ul><li>Marla Solomon </li></ul><ul><li>Hui Tang </li></ul><ul><li>Robert Nocon </li></ul><ul><li>Katie Raffel </li></ul><ul><li>Ndang Azang-Njaah </li></ul><ul><li>Gwen Burrows </li></ul><ul><li>Braunda Anderson </li></ul><ul><li>Marjorie Kerr </li></ul><ul><li>Shantanu Nundy </li></ul><ul><li>Seo Young Park </li></ul><ul><li>Neha Setha </li></ul><ul><li>Emily Lu </li></ul><ul><li>Rebecca Lipton </li></ul><ul><li>Deborah Burnet </li></ul><ul><li>Karen Kim </li></ul><ul><li>Dawnavan Davis </li></ul><ul><li>Sheila Harmon </li></ul><ul><li>Quin Golden </li></ul><ul><li>Eric Whitaker </li></ul><ul><li>Shelley Scott </li></ul>
    58. 58. <ul><li>Questions? </li></ul><ul><ul><li>General Questions: Martha Quinn [email_address] </li></ul></ul><ul><ul><li>Questions on Dallas or Chicago Initiatives: Darla Williams [email_address] </li></ul></ul><ul><ul><li>Technical Questions: Gillian Mayman [email_address] </li></ul></ul>
    59. 59. Organizational Policy and Systems Change