The document discusses the importance of organizational policy and systems change, particularly in the context of diabetes care across various locations, including Dallas and Chicago. It highlights examples of successful systems changes through community health workers and clinic redesigns, emphasizing the positive impacts on health outcomes and disparities. The overarching goal is to create sustainable policies that improve chronic disease management and support historically underserved populations.

1. Organizational Policy and Systems Change

2. Agenda Welcome (Belinda Nelson) Overview and Examples of Organizational Policy and Systems Change (Martha Quinn) Systems Change in Dallas: Community Health Workers (James Walton) Systems Change in Chicago: Clinic Redesign (Monica Peek and Marshall Chin) Q & A (Darla Williams)

3. Presenters Martha Quinn University of Michigan, Center for Managing Chronic Disease

4. Alliance Grantees Camden, New Jersey Memphis, Tennessee Dallas, Texas Chicago, Illinois Wind River Indian Reservation Fort Washakie, Wyoming

5. Objectives Develop a shared understanding of what we mean by “policy and systems change” Highlight current examples of policy and systems change efforts Facilitate discussion and peer-to- peer learning

6. Why is this important? 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 So that, the work of the Alliance will outlive the funding and be sustained over the long-term

7. Policy and Policy Change

8. What is policy? Public policy Organizational policy

9. Public policy A set of agreements about how government will address societal needs and spend public funds. These agreements are: articulated by leaders in all three branches of government, and embedded in many different policy instruments (for example, laws and regulations).

10. Organizational policy A set of written rules and policies that govern behavior and practice within an organization, agency or business

11. Custom and Practice Routine practices, cultural norms, customs, and unwritten agreements about behavior are not policy , but can influence and be influenced by policy

12. What is organizational policy change? The creation of new written policies or rules, or a change in the current written policies or rules of an organization

13. Systems and Systems Change

14. What is a system? A group of independent but interrelated and interacting elements (individuals, institutions and infrastructure) that form a unified whole For example: health care delivery system

15. What is systems change? 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

16. What drives systems change? Changes in existing policies or creation of new policies Organizational practices Social or cultural norms Changes to infrastructure

17. What is the relationship between policy and systems change? Policy change is an important way to achieve systems change

18. Examples of Organizational Policy and Systems Change

19. Health Care Team Approach CareSouth Carolina

20. Health Care Team Approach Care manager Behavioral health counselor Nurse Physician Change: Health Care Team Approach includes

21. Health Care Team Approach Related Policy Changes: Written job descriptions Board of Director’s approval Funding allocated Change : Care managers (new position)

22. Health Care Team Approach Change : Nurses have expanded role Related Policy Changes: Creation of “standing orders” Chief Medical Officer approval Clinical Manual of policies/procedures

23. Health Care Team Approach Change: Behavioral health counselors integrated into regular care Related Policy Changes: Implement 45/15 rule Changes in written job description Clinical Manual of policies/procedures CEO approval

24. Health Care Team Approach Overall lower HbA1c levels Reduction in diabetes disparities Impact : Health outcomes

25. Medical Office Visits Providence St. Peter Family Medicine Clinic in Olympia, Washington

26. Medical Office Visits Change : patients have a choice to participate in three different types of non-traditional office visits: Planned visits Mini-group medical visits Open office group visits

27. Medical Office Visits Change : Planned visits Related Policy Changes: Creation of “standing orders” New job descriptions for MAs Curriculum for training formally adopted by the clinic Clinic Manual of policies/procedures

28. Medical Office Visits Change : Mini-group visits Related Policy Changes: Patient Confidentiality Forms required HIPAA compliance required Clinical Manual of policies/procedures

29. Medical Office Visits Change : Open office group visits Related Policy Changes: Changes in physician job descriptions Creation and adoption of training curriculum Clinical Manual of policies/procedures Chief Medical Officer approval

30. Medical Office Visits St. Peter’s Approach : policy change came after showing positive outcomes from small pilot First small pilot project Rapid cycle improvements Showed positive outcomes Changed clinic-wide policies and practices

31. Medical Office Visits Clinic policies and procedures approved by: Medical Director Organizational Operations Committee (OOC)

32. Medical Office Visits Impact : Planned and Group medical visits Results of survey data: Patients: “..felt well cared for, better supported and more successful and confident” Medical Assistants: “...gained knowledge and confidence in diabetes and self management, and were more satisfied with their jobs.” Physician: “…modest improvements in comfort with, and perceived effectiveness in providing self management support.”

33. Medical Office Visits Impact : Health Outcomes Patients participating in group visits were more likely to have lower A1C levels than other patients and greater A1C reductions Significant reductions in LDL cholesterol for patients participating in planned visits

34. Presenters Dr. James Walton Baylor Health Care System in Dallas, Texas

35. Grantee Efforts Underway - Dallas Establishment of Community Care Coordination 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)

36. Grantee Efforts Underway - Dallas Components of Systems Change: Creation and adoption of the Community Health Worker (CHW) role within BHCS’ human resources structure Development of strategies that allow providers to confer “authority” to CHWs, extending the reach of the health care team Establishment of accountability and outcomes measurement systems

37. Grantee Efforts Underway - Dallas Creation & adoption of CHW role Embed Community Health Worker (CHW) job code within BHCS’ Human Resources structure Designed job description and compensation of Diabetes Health Promoter (CHW) Utilized CoDE ™ Medical Assistant qualifications to serve as minimum job requirements Required market research on CHW/MA salaries Required BHCS Human Resources and Compensation formal review and approval Determine training and continuing education necessary for job role Developed training curriculum for CHWs functioning as Diabetes Health Promoters in outpatient setting Includes training manual, practicum (traditional DSME classes, skills certification, AADE Healthcare Technician training) Training/continuing education funded annually as a distinct budget line item Integrated state certification as CHW into curriculum Build career progression for CHW’s Developing promotional levels within job code Differentiation “case” being developed between medical assistants and CHWs (for HR approval process) Working to define CHW career path within health system

38. Develop strategies that allow providers to confer “authority” to CHWs Protocol, policies and procedures developed Protocol Handbook (including educational materials, forms) approved by Physician Vice-President, Office of Health Equity and consulting endocrinologist Policies and procedure handbook utilized evidence-based resources (existing BHCS policies, US Department of Health and Human Services, manufacturer procedures for use of equipment) Formal PCP Communication Guidelines developed by consulting endocrinologist and Physician Vice-President, Office of Health Equity Reviewed by primary care practices referring to the Diabetes Equity Project Consulting endocrinologist and RN manager Developing new care model utilizing Nurse Practitioner and CHW as “case management” team (with physician oversight) for “Hot Spot” patients In sixth month of pilot currently Comprehensive Patient Assessment tools developed (assessing self-management behaviors, social barriers) Utilizes DiaWEB ™ registry and clinic EMR for data tracking Preliminary data analysis will take place July 2011 Grantee Efforts Underway - Dallas

39. Establish accountability and outcomes measurement systems DiaWEB ™ diabetes registry with reporting capability Web-based design with customized Diabetes Health Promotion assessments Produces both individual and aggregate data reports Patient experience satisfaction tool for real-time evaluation of CHW service quality Chart audits Annual chart audits (random sample) are conducted by RN Manager Audit analysis completed by BHCS statisticians Utilize clinical trial standard of <5% error rate Grantee Efforts Underway - Dallas

40. Grantee Efforts Underway – Dallas Specific strategies & tactics to change the system: Deployed BHCS employees (CHWs) into community aligned with collaborating safety net clinics Five sites serve as “community hubs” for care coordination Established operational foundation For first 6 months, received referrals only from five sites to build competencies and fine tune processes Solicited regular feedback from stakeholders Slower patient ramp up Built team culture Diabetes Health Promoter team meetings bi-monthly Monthly meetings with site clinic staff Strong support from leadership to increase likelihood of employee engagement and successful implementation

41. Specific strategies & tactics to change the system (continued) 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 Identified provider “targets” 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 Marketing tactics Diabetes Health Promoter and Manager scheduled individual meetings with target practice leadership Presentation including preliminary outcome data, referral process overview (and forms), patient criteria, patient brochure, and administrative overview Utilized Project Access Dallas marketing department to build awareness (Dallas Medical Society Journal) Expanded intervention to private practice physicians caring for vulnerable patients experiencing disease control disparities 500 physician BHCS organization’s Disease Management Council approved twelve month pilot at four practices beginning summer 2011 Tracking clinical outcomes via clinic EMR data Will report results to Disease Management Council in 2012

42. Grantee Efforts Underway - Dallas Impacts Intended & Accomplished Use a CHW intervention to produce documented improvement in diabetes control and reduction of racial/ethnic disparities Statistically significant increase in percent of vulnerable patients enrolled in the intervention with “superior” diabetes disease control (HgbA1c < 7%) No significant differences noted between minority and non-minority patient sub-populations Building awareness of CHW scope/role within a health system Human Resources – career paths Added 2 FTE CHW in transitional care role Received funding for 3 additional CHWs (Diabetes Health Promoter and Transitional Care) 2 other BHCS departments adding CHWs into their workforce Develop funding sources for long term sustainability 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) Planning has started for enlisting community organization funds for non-Baylor owned clinic

43. Presenters Dr. Monica Peek Dr. Marshall Chin University of Chicago, Pritzker School of Medicine Abby Wilkes, MPH

44. University of Chicago Improving Diabetes Care and Outcomes on the South Side of Chicago

45. South Side of Chicago Challenges: Poverty Social challenges Food deserts Unsafe recreation Mistrust of healthcare Weakened hospital safety net Strengths Historical social, political and cultural traditions Community resources and institutions Healthcare institutions

46. Intervention Components Six health centers 1) Patient activation trainin 2) Provider communication training 3) Community connections 4) Systems Change: CLINIC REDESIGN

47. Health System Change Clinic redesign QI teams/coaches Collaborative mtgs PDSA cycles

48. Health System Change: Care Management Nurse care management Context: MD-led internal medicine practice Intervention: Nurse Practitioner Care Management Diabetes education Insulin initiation/titration Care coordination Telephone counseling/management Involvement in community outreach Incorporate other systems changes Improve frequency and appropriateness of physician/staff referral to nutrition Increase referrals to NP from each provider’s rosters of patients

49. Health System Change: Care Management Nurse care management: Lessons Nurse is crucial member of clinic redesign team Nurse cannot do it all - Now have staff to support outreach phone calls Need to measure process measures as well as usual clinical measures – e.g. no-show rate and # of patients who are contacted to reschedule Clinic redesign uncovers system capacity challenges - Limited number of appointments available for MDs, NP, and nutritionist

50. Health System Change: Group Visits Diabetes group visits Context: 2 federally-qualified health centers Intervention: Shared medical appts Diabetes education Medication titration/clinical care Support group Some evidence re: reduced costs, hospitalizations, lower blood pressure, Improved patient/provider satisfaction

51. Health System Change: Group Visits Diabetes group visits: Lessons Pre-plan Identify schedule changes for staff Determine types of providers/staff needed Find out how to bill Work out patient co-pays

52. Health System Change: Diabetes Peer Support Group Diabetes Peer Support Group Context: Diabetes center in the section of Endocrinology Intervention: Group of patients brought together to try out local fitness/nutrition resources and provide peer support Focus on lifestyle modification while connecting to community Evidence for: Improved knowledge Improved psychosocial functioning Increased physical activity self-efficacy

53. Health System Change: Diabetes Peer Support Group Diabetes Peer Support Group: Lessons No attendance at first physical activity event: walking group Low attendance at grocery store tour Despite focus groups and survey feedback requesting help re: fitness, nutrition, and peer support, patients did not show. Changing QI focus to care coordination Innovative new approaches to interface with patients outside of health care system

54. Lessons Learned from QI Process Individualize to clinics What’s important to clinics vs. more ambitious change Crawl, walk, run Coaches are vital Learn from peer clinics Collaborative meetings Support network

55. Lessons Learned from QI Process Address challenges of health centers Staff turn-over Leadership buy-in Project scope and size Learning curve Perseverance pays off

56. Health Policy Relevance Integration of Quality and Disparities Using the tools of QI to reduce disparities Dept. of Health and Human Services, Centers for Medicare and Medicaid Services Coordinating care Organizational structures – Medical Home, ACOs Financing mechanisms – Bundled payments Move towards efficiency Regardless of whether Democrat or Republican

57. Our Project Team Marshall Chin Monica Peek Abigail Wilkes Tonya Roberson Anna Goddu Kristine Bordenave Michael Quinn Doriane Miller Lisa Vinci Andrew Davis Elbert Huang Jonathan Birnberg Jonathan Dick Mickey Eder Peggy Hasenauer Louis Philipson Marla Solomon Hui Tang Robert Nocon Katie Raffel Ndang Azang-Njaah Gwen Burrows Braunda Anderson Marjorie Kerr Shantanu Nundy Seo Young Park Neha Setha Emily Lu Rebecca Lipton Deborah Burnet Karen Kim Dawnavan Davis Sheila Harmon Quin Golden Eric Whitaker Shelley Scott

58. Questions? General Questions: Martha Quinn [email_address] Questions on Dallas or Chicago Initiatives: Darla Williams [email_address] Technical Questions: Gillian Mayman [email_address]

59. Organizational Policy and Systems Change www.ardd.sph.umich.edu