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UNIVERSITY OF MISSOURI
Family & Community Medicine
Making it easier to do better: a team approach to providing primary care
for patients with chronic disease
Joseph LeMaster MD MPH
Steve Zweig MD MSPH
Robin Kruse PhD
UNIVERSITY OF MISSOURI
Family & Community Medicine
Background
• Two-thirds of Medicare beneficiaries have multiple chronic illnesses
• Risk of death and hospitalization is high
• Between 2000 and 2030, this population will double but the US primary care workforce will increase only 4-5% during this period
• Primary care delivery is organized to manage acute illnesses, not preventing disease exacerbations or preserving function
UNIVERSITY OF MISSOURI
Family & Community Medicine
What’s been done?
• “Patient navigator” developed for cancer patients in large systems
§ Adapted for those with chronic diseases
§ Care coordination: coordinating physician referrals, diagnostic investigation, treatments, monitoring disease severity and complications, promotion of self-management
UNIVERSITY OF MISSOURI
Family & Community Medicine
What’s been done?
• “Patient navigator” for chronic disease works well in large systems
§ Usually on-site PA/Nurse practitioners using patient registries
§ Unclear how this translates to:
•Small, solo practices
•Other staffing models
UNIVERSITY OF MISSOURI
Family & Community Medicine
Hypotheses for study series
• Hypotheses: Management of patients with chronic illnesses via nurse ‘navigators’:
§ Decreases mortality, hospitalizations and ED visits without increasing primary care visits.
§ Improves intermediate outcomes (BP, HbA1c, LDL cholesterol)
§ Can be carried out satisfactorily by staff with less training
§ Improves patients’ perceptions about their care experience
UNIVERSITY OF MISSOURI
Family & Community Medicine
Study 1 : 5-year cohort elderly chronically ill
• Quasi-experimental prospective cohort of Medicare retirees
§130 navigator-managed, 249 controls, from 2 adjacent clinics
§Frequently seen (> 3 visits) during 1998
§5 years of follow-up
§Outcomes: mortality, utilization
`
UNIVERSITY OF MISSOURI
Family & Community Medicine
Deaths: 26.9% in the intervention group and 27.3% in the control group (p = 0.94). After controlling for age and sex there was no survival difference (p = 0.56).
Results: Mortality
UNIVERSITY OF MISSOURI
Family & Community Medicine
Results: Fewer ED visits
UNIVERSITY OF MISSOURI
Family & Community Medicine
Results: Fewer Urgent Care visits
UNIVERSITY OF MISSOURI
Family & Community Medicine
Study 2: Factors associated with good self-care behavior
• Cross-sectional survey in 77 navigator-managed patients
§Study 1 intervention clinics (representative)
§Type 2 diabetes mellitus + > 1 other disease
§Outcomes: followed DM diet, exercised, measured BG
UNIVERSITY OF MISSOURI
Family & Community Medicine
Study 2: Factors associated with good self-care behavior
§ Independent variables: • Co-morbidity (1-16 diseases)
• Self-rated understanding of diabetes
• Self-rated general and mental health (SF-36)
• Self-efficacy (Perceiv. Competence for DM)
• Self-rated social support (MOS-SSS)
• Health literacy (REALM, newest vital sign)
•Motivation (autonomous v. controlled)
UNIVERSITY OF MISSOURI
Family & Community Medicine
Study 2: Descriptives
• Caucasian-75%
• Women-64%
• High school graduates-87%
• Less than 8th grade-4%
• Self-rated understanding of DM rx-53%
• Mental health (SF-36 MCS)-75 (SD 18)
• Social support (MOS-SSS)- 76 (SD 19)
• Mean No. chronic conditions- 4.6
UNIVERSITY OF MISSOURI
Family & Community Medicine
Study 2: Outcomes
UNIVERSITY OF MISSOURI
Family & Community Medicine
Study 2: Associations
• Only autonomous motivation associated with maintaining diet and glucose-monitoring
• No associations with exercise
• Healthcare organizational system not examined but motivational approach suggested
UNIVERSITY OF MISSOURI
Family & Community Medicine
Study 3: One-year cohort Type 2 diabetes mellitus
• Quasi-experimental study in 6 rural primary care practices
§546 LPN navigator-managed (5 clinics), 302 controls (1 clinic)
§Diagnosis of type 2 DM in past 3 years
§Specific aim to engage low-income and minority patients
UNIVERSITY OF MISSOURI
Family & Community Medicine
Study 3: One-year cohort Type 2 diabetes mellitus
• All LPN-navigators were full-time engaged in this work, and trained in ‘motivational interviewing’ to support autonomous motivation
§ Intermediate disease-related outcomes: HbA1c, LDL cholesterol, SBP, DBP
UNIVERSITY OF MISSOURI
Family & Community Medicine
Change in HbA1c < 7
UNIVERSITY OF MISSOURI
Family & Community Medicine
Change in BP < 130/80
UNIVERSITY OF MISSOURI
Family & Community Medicine
Change in LDL < 100
UNIVERSITY OF MISSOURI
Family & Community Medicine
Study 3 sub-study: community activism
• Community advisory boards in both Study 3 counties worked to engage low-income and minority residents
• Conducted “Working-on-Wellness” a 6-month campaign (contest) to increase fruit-&-veg consumption and daily exercise
• Let by local grocers, churches, newspapers
UNIVERSITY OF MISSOURI
Family & Community Medicine
Study 3 sub-study: community activism
• Results:
§ 160 contestants joined, 128 remained
§ 68% increased fruit and vegetable intake and 78% increased daily exercise, both significantly.
§ Medical practice staff participated, but perceived the effort as unrelated to clinical functions
UNIVERSITY OF MISSOURI
Family & Community Medicine
Study 4: Interviews with patients and providers, observations of provider-patient interactions
• Patients had overwhelmingly positive regard for the nurse navigators
• Appreciated availability of the navigator
• Perceived stronger partnership with healthcare provider team compared to prior healthcare experiences
UNIVERSITY OF MISSOURI
Family & Community Medicine
• Both MDs, NPs and LPNs focus on out-of-range lab values & medication compliance
• No one made it a priority to help patients make diet and exercise goals or check progress on goals§ No place to document it in the EMR
Study 4: Interviews with patients and providers, observations of provider-
patient interactions
UNIVERSITY OF MISSOURI
Family & Community Medicine
Study 4: Direct observations of provider-patient interactions/provider interviews
• Less-well trained staff (LPNs, MAs) CAN do this work, but the context MUST provide optimal support:
§Physician/health system buy-in
§Adequate time & space, and on-going training for LPN/MA
§When these are absent, nurse side-tracked, subverted or stolen
UNIVERSITY OF MISSOURI
Family & Community Medicine
Implications
• Even optimal NP/PA-led ‘navigator’management does not reduce mortality or hospital admissions long-term, though reduces ED utilization
• Change in intermediate outcomes (LDL, BP, HbA1c) depends on behavior–change: self-care goals met/set!
UNIVERSITY OF MISSOURI
Family & Community Medicine
Implications
• Connecting the community to clinics may be critical in engaging low-income and minority families and helping them establish a primary care “home”
CommunityResources
Health Care System
Self-Management Support
Clinical Information System
Decision Support
Delivery System Re-design
Informed, Activated Patient
Prepared, proactive
practice team
UNIVERSITY OF MISSOURI
Family & Community Medicine
The PCMH opportunity
• HIT “Meaningful Use” = PCMH
(overlaps): § Will providing financial incentives without local, ongoing practice facilitation be
enough to drive transformation?
• How do patients perceive the process?§ TransforMed: patients did not rate PCMH practices highly
§ Ferrante et.al.:“High-tech” practices provide less preventive care than “high touch”practices
UNIVERSITY OF MISSOURI
Family & Community Medicine
A Primary Care Extension Service would:
• Provide > 1 person/U.S. county as a “relational link” between practices and:
§ Vetted vendors/technicians/researchers with the aim of achieving PCMH and ‘meaningful use’ certification
§ community agencies and public health entities to improve PCP access and services for the whole population
UNIVERSITY OF MISSOURI
Family & Community Medicine
A Primary Care Extension Service:
Let’s get it funded!
UNIVERSITY OF MISSOURI
Family & Community Medicine
References
1. Rastkar R, Zweig S, Delzell JE, Jr., Davis K. Nurse care coordination of ambulatory frail elderly in an academic setting. Case Manager.2002;13(1):59-61.
2. Kruse RL, Zweig SC, Nikodim B, LeMaster JW, Coberly JS, Colwill JM. Nurse Care Coordination of Older Patients in an Academic Family Medicine Clinic: 5-Year Outcomes. J Clinical Outcomes Meas. 2010; 17 (5): 209-215.
3. Shigaki C, Kruse RL, Mehr D, Sheldon KM, Ge B, Moore C, LeMaster J. Motivation and diabetes self-management. Chronic Illn. 2010; 6: 202-214.
4. Shigaki CL, Moore C, Wakefield B, Campbell J, LeMaster J. Nurse partners in chronic illness care: patients' perceptions and their implications for nursing leadership. Nurs Adm Q. 2010;34(2):130-140.
5. Ferrante JM, Balasubramanian BA, Hudson SV, Crabtree BF. Principles of the patient-centered medical home and preventive services delivery. Ann Fam Med. 2010;8(2):108-116.
6. Grumbach K, Mold JW. A health care cooperative extension service: transforming primary care and community health. JAMA.2009;301(24):2589-2591.
UNIVERSITY OF MISSOURI
Family & Community Medicine
Acknowledgements
• Steven Zweig MD MSPH (MU Family and Community Medicine Chair)
• David Mehr MD MS (Research Director)
• Robin Kruse PhD
• Richelle Koopman MD
• Karl Kochendorfer MD
• Rebecca Rastkar, RN, FNP
• Tamara Day RN
• Molly Vetter-Smith MS
• Jared Coberly, BS
Questions ?
UNIVERSITY OF MISSOURI
Family & Community Medicine
UNIVERSITY OF MISSOURI
Family & Community Medicine
Methods: Statistical analysis
• Compared age distribution and sex of participants using t-test and chi-square test, respectively
• Kaplan-Meier analysis produced unadjusted survival curves
• Compared survival between groups with Cox regression, including age and sex as covariates
• Compared outcome rates between groups with Poisson regression, including the natural logarithm of days in the study (offset variable),including age and sex as control variables.
• To determine if time since enrollment affected use of health services, we compared outcome rates between groups each year following enrollment, using the same regression techniques.
•
UNIVERSITY OF MISSOURI
Family & Community Medicine
Methods: Outcome variables
• Outcomes from billing and hospital databases for 5-year period starting July 1, 1999.
• Variables: patient demographics, number of hospital and observation stays; hospital days; ED and urgent care visits; outpatient visits (to primary care and specialties).
• Date of death from administrative data and search of National Death Index
• Outcomes expressed per 1000 days observed§ Through June 30, 2004, date of last contact, or death, whichever came earliest.
UNIVERSITY OF MISSOURI
Family & Community Medicine
Health care utilization
Measure Intervention Control P-value
ED visits .714 (.535 – .953) 1.04 (.859 – 1.27) 0.034
Urgent care visits .174 (.123 – .246) .426 (.362 – .502) <0.001
Reported as the mean/1000 patient-days (95% CI)
UNIVERSITY OF MISSOURI
Family & Community Medicine
Limitations
• Not RCTs so limited ability to control for confounding/disease severity or generalize widely
• Studies 1-3 had slightly different populations so not 100% comparable
• Unable to measure health care utilization outside University of Missouri Health Care but no reason to expect difference between groups
UNIVERSITY OF MISSOURI
Family & Community Medicine
Change in Annual Measurement (clinics)
Chi-square ∆ p between time intervals
Cholesterol, p = 0.003, HgbA1c, p = 0.002