Disclosures: Asthma Care Coordinationhealth.utah.gov/.../AsthmaCareCoordination2018.pdf ·...

Disclosures: Asthma Care Coordination June 6, 2018

• The content of this webinar presentation has been approved for RN and RT CE credit. Not all topics qualify for AE-C re-certification. See www.naecb.org for more details.

• The Western Multi-State Division is accredited as a provider of continuing

nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

• Participants must complete the pre-test, attend the entire live event, and complete the post-test with a score of 80% or greater to earn 1.5 contact hour.

• No conflicts of interest are involved in this series. This includes no content relevant to commercial interest and no presence of commercial support.

• Please note that due to reporting guidelines, you will have three weeks after the live webinar to complete your post-test and print your certificate. You will NOT be able to access or earn continuing education credits after the three week time frame.

© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7

ASTHMA CARE COORDINATIONTEAM-BASED STRATEGIES ACROSS HEALTH SYSTEMS

DIANE LIU, MDASSISTANT PROFESSOR,

DEPARTMENT OF PEDIATRICSDIRECTOR, UTAH PEDIATRIC PARTNERSHIP TO IMPROVE HEALTHCARE QUALITY

© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7

No Conflicts to Disclose

© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7

OBJECTIVES

• Understand the value of team-based approaches to asthma care

• Apply principles of team- science to care coordination efforts across healthcare delivery systems

• Design/develop quality improvement strategies to promote effective care coordination for patients with asthma

3

© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7

• Heterogeneous disease

• Variable symptoms• Chronic airway

inflammation• Smooth muscle

tightening• Expiratory airflow

limitation Image Source: Hackensack Pulmonary Medicine https://hackensacksleep.com/asthma/4

© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7

THE ASTHMA PROBLEM

• Disease burden– 8-10% of children– 10-14% of adults

• Cost– 3 billion dollars direct costs– Missed school days

• Disparity (higher burden of disease)– Socioeconomic Status -Ethnicity

5

© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7

THE HEALTHCARE DELIVERY PROBLEM

• Overwhelming ‘evidence’ resulting in dense guidelines for care (NAEPP EPR-3; GINA 2018)

• Fragmented visits• Lack of resources

(and/or access to)• Environmental factors 6

© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7

WHAT AREPOTENTIAL SOLUTIONS

TO SUCHCOMPLEX CHALLENGES?

7

© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7

EXAMPLE SOLUTIONS/PERSPECTIVES

• From a patient’s perspective• From an emerging business

8

9

Gabe’s Care Map

“What It Takes to

Raise One Boy With Special Needs”-Huffington

Post

10

© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7

EX. SOLUTIONS WITHIN HEALTHCARE SYSTEMS• Ignore the challenges

– Continued ED visits / admits– Primary care clinicians burn out

• Longer primary care visits with the nurse educator

• More referrals out for specialist management• Build up primary care capacity (PCP manages

asthma more effectively)• Invest in resources like care coordination

11

© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7

CARE COORDINATION?

• What is it?

• What is the history of bringing care coordination into health-care delivery?

12

© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7

WHAT IS CARE COORDINATION?• Deliberate & Intentional efforts• Organizing patient care activities• Sharing information among all of the participants

concerned with a patient's care including the patient• Achieve safer and more effective care• Patient's needs and preferences are known ahead of

time and communicated at the right time to the right people

• Information is used to provide safe, appropriate, and effective care to the patient 13

© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7

HISTORY OF ‘CARE COORDINATION’

• HMOs 1990s– Cost reduction– Denial of access to services

• CMS Case Management 1990s– Discontinued in 2007– Case managers had no personal connection– Patients felt harassed

14

© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7

CURRENT MODELS OF CARE COORDINATION

• Represent a broad range of approaches (inpatient, ED, payer, school, ambulatory / community / public health)

• Aimed at both the service delivery and systems level

• May include sophisticated clinical support/info management capability

15

© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7

CURRENT MODELS OF CARE COORDINATION

• Built on the successes of the 1990s• Key defining characteristics of the

relationship with patients re: those involved in coordinating a patient’s care:– Personal– Trusting– Supportive

16

© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7

WHAT DOES THIS MEAN?

effective care coordination requires productive interactions between

• Informed and activated patient• Prepared practice

17

© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7

WHO IS RESPONSIBLE FOR BEING ‘PREPARED’?

• Who does the coordinating?– Nurse manager– Social worker– Community Health Worker– Clinic care coordinator

• How is it accomplished?– Silo / support staff– Team-based (not a new concept)

18

© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7

OBJECTIVES

• Understand the value of team-based approaches to asthma care

• Apply principles of team- science to care coordination efforts across healthcare delivery systems

19

© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7

What is a Team?

21

© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7

RESEARCH SHOWS…

…team-based care in the primary care setting is associated with…

1. improved quality and safety of care 2. better health and functioning of

individuals with chronic disease3. higher patient and provider satisfaction

4. lower per capita costs22

© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7

EXAMPLES OF HOW…

• Office cycle time• Access to care• Preventative health screening• Self-management goal-setting• Medication reconciliation

23

© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7

TEAM-BASED CARE ACROSS SYSTEMS

• A Culture of Safety Requires – Psychological safety

– ‘Just’ culture to learn from error

24

© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7

TEAM-BASED CARE STRATEGIES

• Structured communication (e.g.SBAR)– Hand-offs between systems

• Discharge to PCP• ED RT to ED clinician• School nurse to parents

• Team huddles• Checklists• Standardized tools

25

© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7

OBJECTIVES

• Understand the value of team-based approaches to asthma care

• Apply principles of team- science to care coordination efforts across healthcare delivery systems

• Design or develop quality improvement strategies to promote effective care coordination for patients with asthma

26

© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7

DESIGNING A QI EFFORT

• Select a QI project or effort• Assemble a QI team

– Professional diversity matters!• Use a QI roadmap to guide activities

– See the next slide• Measure your progress• Identify ideas to spread and sustain

27

Breakthrough Results

A PS D

Small Scale Testing

Follow-up tests

Test new conditions

Wide-scale implementation of change

What are we trying to accomplish?

How will we know that a change is an improvement?

What change can we make that will result in an improvement?

Model for Improvement

Sequential Building of Knowledge with multiple PDSA Test CyclesFigure 7.2 ‘The Improvement Guide’ Langley, et al. 2009

A PS D

Theories, hunches, and best practices

© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7

STATE IMPROVEMENT PARTNERSHIP• Local stakeholders

– UDOH– U AAP Chapter– Medicaid Payers– Dept of Peds

• Experienced in leading physicians

• National network29

© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7

QI TEAM

• A group of individuals that work together on the QI project– shared goals and mutual accountability – plan/conduct tests of change– data collection and management – physicians, nurses, pharmacists, data

managers, administrative staff, therapists, etc

30

Kaplan HC, Provost LP, Froehle CM, Margolis PA. BMJ Qual Saf. 2012 Jan;21(1):13-20.

IMPLEMENTATION SCIENCE

31

Seeds Planting Tools & Techniques

Climate & Soil

Change ContentNature of the Evidence

ContextCulture, Leadership,

Resources

Facilitation of Change Process

QI methods – PDSA cycles, six sigma, Model for Improvement

© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7

THANK YOU! QUESTIONS?

32

© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7

REFERENCES• Centers for Disease Control. Asthma Surveillance Data 2016 [February 9, 2017].

Available from: https://www.cdc.gov/asthma/asthmadata.htm. • Agency for Healthcare Research and Quality. Overview of Hospital Stays for

Children in the United States, 2012 2014. Available from: https://www.hcup-us.ahrq.gov/reports/statbriefs/sb187-Hospital-Stays-Children-2012.jsp.

• Agency for Healthcare Research and Quality. Overview of Children in the Emergency Department 2013 [February 9, 2017]. Available from: https://www.hcup-us.ahrq.gov/reports/statbriefs/sb157.pdf.

• Leyenaar JK, Ralston SL, Shieh MS, Pekow PS, Mangione-Smith R, Lindenauer PK. Epidemiology of pediatric hospitalizations at general hospitals and freestanding children's hospitals in the United States. Journal of hospital medicine. 2016;11(11):743-9.

• PediatricAsthma.org. The Burden of Children's Asthma [February 9, 2017]. Available from: http://www.pediatricasthma.org/about/asthma_burden.

33

© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7

REFERENCES• Kaplan HC, Provost LP, Froehle CM, Margolis PA. The Model for Understanding

Success in Quality (MUSIQ): building a theory of context in healthcare quality improvement. BMJ Qual Saf. 2012 Jan;21(1):13-20.

• Kaplan HC, Froehle CM, Cassedy A, Provost LP, Margolis PA. An exploratory analysis of the model for understanding success in quality. Health Care Manage Rev. 2013 Oct-Dec;38(4):325-38

• Nadeem E, Olin SS, Hill LC, Hoagwood KE, Horwitz SM. Understanding the components of quality improvement collaboratives: a systematic literature review. Milbank Q. 2013 Jun;91(2):354-94

• Harvey G, Kitson A. PARIHS revisited: from heuristic to integrated framework for the successful implementation of knowledge into practice. Implement Sci. 2016 Mar 10;11:33

• Damschroder LJ1, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009 Aug 7;4:50 34

© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7

REFERENCES• Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering

implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009 Aug 7;4:50

• Kirk MA, Kelley C, Yankey N, Birken SA, Abadie B, Damschroder L. A systematic review of the use of the Consolidated Framework for Implementation Research. Implement Sci. 2016 May 17;11:72

• Birken S, Powell B, Presseau J, Kirk MA, Lorencatto F, Gould NJ, Shea CM, Weiner BJ, Francis JJ, Yu Y, Haines E, Damschroder L. Combined use of the Consolidated Framework for Implementation Research (CFIR) and the Theoretical Domains Framework (TDF): a systematic review. Implement Sci. 2017 Jan 5;12(1):2

• Rycroft-Malone J. The PARIHS framework--a framework for guiding the implementation of evidence-based practice. J Nurs Care Qual. 2004 Oct-Dec;19(4):297-304.

• McDonald, K, et al. Considering context in quality improvement interventions and implementation: concepts, frameworks, and application. Acad Pediatr. 2013 Nov-Dec;13(6 Suppl):S45-53.

• Craig C, Eby D, Whittington J. Care Coordination Model: Better Care at Lower Cost for People with Multiple Health and Social Needs. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2011

35

© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7

REFERENCES• Craig C, Eby D, Whittington J. Care Coordination Model: Better Care at Lower

Cost for People with Multiple Health and Social Needs. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2011

36