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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.
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ASTHMA CARE COORDINATIONTEAM-BASED STRATEGIES ACROSS HEALTH SYSTEMS
DIANE LIU, MDASSISTANT PROFESSOR,
DEPARTMENT OF PEDIATRICSDIRECTOR, UTAH PEDIATRIC PARTNERSHIP TO IMPROVE HEALTHCARE QUALITY
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No Conflicts to Disclose
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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
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• Heterogeneous disease
• Variable symptoms• Chronic airway
inflammation• Smooth muscle
tightening• Expiratory airflow
limitation Image Source: Hackensack Pulmonary Medicine https://hackensacksleep.com/asthma/4
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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
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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
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WHAT AREPOTENTIAL SOLUTIONS
TO SUCHCOMPLEX CHALLENGES?
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EXAMPLE SOLUTIONS/PERSPECTIVES
• From a patient’s perspective• From an emerging business
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Gabe’s Care Map
“What It Takes to
Raise One Boy With Special Needs”-Huffington
Post
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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
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CARE COORDINATION?
• What is it?
• What is the history of bringing care coordination into health-care delivery?
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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
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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
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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
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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
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WHAT DOES THIS MEAN?
effective care coordination requires productive interactions between
• Informed and activated patient• Prepared practice
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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)
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OBJECTIVES
• Understand the value of team-based approaches to asthma care
• Apply principles of team- science to care coordination efforts across healthcare delivery systems
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What is a Team?
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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
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EXAMPLES OF HOW…
• Office cycle time• Access to care• Preventative health screening• Self-management goal-setting• Medication reconciliation
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TEAM-BASED CARE ACROSS SYSTEMS
• A Culture of Safety Requires – Psychological safety
– ‘Just’ culture to learn from error
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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
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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
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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
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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
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STATE IMPROVEMENT PARTNERSHIP• Local stakeholders
– UDOH– U AAP Chapter– Medicaid Payers– Dept of Peds
• Experienced in leading physicians
• National network29
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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
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Kaplan HC, Provost LP, Froehle CM, Margolis PA. BMJ Qual Saf. 2012 Jan;21(1):13-20.
IMPLEMENTATION SCIENCE
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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
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THANK YOU! QUESTIONS?
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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.
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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
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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
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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
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