Retrospective

Mixed Methods Analysis of

Practice Transformation

Michael K Magill, MD Professor and Chairman

Department of Family and Preventive Medicine

University of Utah School of Medicine and Community Clinics

AHRQ Grants # HS019136-01 (TPC)

HS20106-01 (ARRA-SSCM)

Interdisciplinary Team

Julie Day, MD

University of Utah Community Clinics

JaeWhan Kim, PhD

School of Medicine, Dept of Family & Preventive Medicine

Annie Sheets Mervis, MSW

University of Utah Community Clinics

Debra L. Scammon, PhD David Eccles School of Business, Dept of Marketing

Andrada Tomoaia-Cotisel, MPH, MHA

School of Medicine, Dept of Family & Preventive Medicine

Norman J Waitzman, PhD

College of Social and Behavioral Science, Dept of Economics

Visits: 300,000+

Active patients: 157,000

11 Community Clinics

University of Utah Community Clinics

Clinic Year Opened Total

Providers Primary Care

Providers Visits Per

Year (FY09)

Madsen 1975 6 5 18,970

Greenwood 1976 17 10 54,475

Redwood 1985 20 10 93,110

Westridge 1988 7 6 29,208

Parkway 1989 6 5 19,488

Sugar House 1996 10 9 20,344

Stansbury 1999 7 6 24,145

Redstone 2001 7 5 26,309

South Jordan 2003 3 2 11,359

Centerville 2007 4 4 8,044

Care by DesignTM

• Appropriate Access – 2003 • Balance supply and demand of visits

• Standardized schedules

• Care Team – 2004 • Expanded MA role

• Providers and MAs working in teams

• EMR tools

• Planned Care – 2006 • Pre-visit planning

• Registries

• Labs prior to visit

Retrospective Analysis:

Qualitative Aims AHRQ Grant # 1R18 HS019136-01 Transforming Primary Care

Aim Method

Document and measure the

transformation

• Archival Search

Determine impact on the

experiences and satisfaction

of providers, staff and

patients

• Provider and Staff Surveys

• Provider and Staff Interviews

• Patient Satisfaction Survey

• Patient Focus Groups

Explore organizational &

contextual factors

• Clinic Environmental Audit

• In-Clinic Observations

Assess in depth how the

transformation was

implemented

• Archival Search

• Leadership Interviews

• Provider and Staff Interviews

Care by DesignTM

• Appropriate Access – 2003 • Balance supply and demand of visits

• Standardized schedules

• Care Team – 2004 • Expanded MA role

• Providers and MAs working in teams

• EMR tools

• Planned Care – 2006 • Pre-visit planning

• Registries

• Labs prior to visit

Qualitative Data: Care Teams

8

Component Type of Information Gathered

Archival search • when/how the care team was rolled out

Clinic

Environmental Audit

• size of clinic, team composition, patient volume,

presence of specialists

In-clinic observations • feeling in the clinic, background info

Employee Interviews • personal experience with implementing care

team + experimenting with local adaptations:

how + why

Leadership interviews • personal experience with leading the care team

roll out + managing the evolution: what + why

Provider & Staff

Survey

• trends in team development, employee burn out,

organizational culture

Patient Sat. Surveys • patients’ satisfaction with visits

Patient Focus Groups • changes noticed and patient perspective

Care Team Structure

& MA Role

CBD Care Team Model

Variations

Traditional Model

Team

Members:

• Providers

• MAs

“Care Team”

• 5 MAs: 2 Providers

• Working together

• Doing it all!

MA specialists

• (V1): 1 MA phlebotomist does all draws

• Others are 5 MAs :2 Providers

• (V2): 1 MA rooms patients + 1 MA scribes in the room : 1 Provider

Clinic-wide team

• All of the MAs are in one pool

• Room patients in a rotation

• Outside visit work done in between

Hybrid

Traditional Model

• 1 MA : 1 Provider

• Variation – 2 MAs : 1 Provider

Team

Members:

• Providers

• MAs

Care Team Structure

& MA Role

• (V1): 5 MAs : 2 Providers for patient visits, but

• 2 MAs: 1 Provider for outside visit work

• (V2): 5 MAs : 2 Providers, but

• 1 “primary” MA : 1 Provider

Example of Insights from

Quantitative Research

Clinic Culture

An illustration of possible

explanations for the observed

differences in implementation

of Care Teams

Organizational Culture

Assessment Instrument: “Competing Values”

Quinn, Rohrbaugh: http://www.ocai-online.com/

Greenwood

Parkway

Redstone

Senior Leadership

Organizational Culture In Community Clinics

Aim Method

Document and measure the

transformation and impact on

the quality of patient care

delivery

• Clinical Data

• CBD Implementation

Determine impact of the

transformation on cost to the

clinics

• Operational Data

Determine impact of

transformation on overall costs

of healthcare services,

including direct costs to

patients

• Centers for Medicare &

Medicaid Services Data

• Utah All Payer Claims

Database

Retrospective Analysis:

Quantitative Aims AHRQ Grant # 1R18 HS019136-01 Transforming Primary Care

Quantitative Data

Component Type of Information Gathered

CBD Implementation • Use of EMR tools

• Appointment availability

• Continuity with PCP

• Use of pre-visit planning tools and processes

• Flow and processes of Care Team

• Efficiency of visit/wait times

Impact on Operations • Provider productivity

• Financial performance

• Patient population characterization

Clinical Outcomes • Quality performance (chronic & preventive)

• Patient, Provider, Staff satisfaction

Cost of Care • Utilization and cost of care

• CMS

• Utah Population Data Base (UPDB)

• Utah All Payer Claims Database (APCD) Gray = data analysis pending

10%

20%

30%

40%

50%

60%

70%

80%

2003 2004 2006 2008 2009

Quality Measures Percent of Patients Receiving Recommended Care

CAD* Preventive Care* Diabetes* Heart Failure*

Note: Sample size=14 providers who had all measures in FY 2003, 2004, 2006, 2008, and 2009; *p≤0.05

20%

30%

40%

50%

60%

70%

80%

90%

100%

2003 2004 2006 2008 2009

Patient Satisfaction Percent of Patients Reporting "Very Satisfied"

Recommend provider* Explanation of what was done*

Visit overall* Time spent with physician*

Length of time waiting at office*

Note: Sample size=16 providers who had all measures in FY 2003, 2004, 2006, 2008, and 2009; *p≤0.05

Overview of Quantitative Design: Link data from multiple sources to assess

impact of transformation to CBD

Cost & Utilization

CBD Implementation

Clinical Data

Operations Data

Level of CBD Implementation:

2008

1.00

1.20

1.40

1.60

1.80

2.00

2.20

All elements

Examples of Correlation between

CBD Implementation and Patient Satisfaction

Patient Satisfaction CBD Implementation Measure

2008

Same Day Appointments Efficient Visit

Length of time waiting at the office 0.61** 0.33*

Time spent with the physician/health

care professional you saw 0.20 -0.21

Explanation of what was done for you 0.14 -0.13

The visit overall 0.50** 0.20

Would you recommend the

physician/health care professional to

your friends and family? 0.34* -0.17

N=16 providers *p≤0.1, **p≤0.05

Correlation between CBD

Implementation and Quality Measures

CBD Implementation

Measure 2008

Quality Measures

Diabetes

Coronary Artery

Disease

Preventive Care

Seen by PCP last visit 0.60* 0.61* 0.57*

Use of X-files by MA 0.33* 0.18 0.18

Best Practice Alerts 0.34* 0.26 0.29

After-Visit summary 0.23 0.18 0.11

Labs done prior to

visit 0.54** 0.47* 0.36*

N=14 providers with data across five years *p≤0.1, **p≤0.05

Impact of practice redesign

• Quality improves

• Continuity matters

• Pre-visit planning and EMR reminders help

• Patients notice

• Access improves patient satisfaction

• Level of implementation varies across

clinics

• Clinic culture impacts implementation

• Culture is a critical factor in translational

research

Future analysis:

impact of redesign on…

• Internal cost and

productivity of clinics

• Overall utilization

• Total cost of care

Future: Internal Performance Analyses

Cost & Utilization

CBD Implementa-

tion

Clinical Data

Operations Data

• Provider productivity

• Financial performance

• Patient population

characterization

Future: Cost and Utilization

Cost & Utilization

CMS, APCD

CBD Implementa-

tion

Clinical Data

Operations Data

CMS Data

• All Medicare Claims

at individual level for

Utah (2007+)

• For the following:

• Outpatient

• Inpatient

• Home Health

• Nursing Home

• Prescription

Drug (Part D)

•Linked to State Vital

Statistics and facility

data (Utah Population

Database )

All Payer Claims

Database (APCD)

• Data elements:

• Charges

• Reimbursements

• Utilization

• For the following:

• Outpatient,

Inpatient,

Rehabilitation

• Prescription Rx

• Linked to State

Vital Statistics and

facility data

Challenges in Assembling

Cost, Utilization and Demographic Data

• Gaining access

• Navigating layers of documentation,

requests, approvals (CMS)

• Obtaining IRB and other database

approvals

• Building APCD platform as 1st user

• Translating utility into usable research database

• Creating files linkable at individual level

• Linking data – hospital, ED, vital statistics

Challenges of Retrospective

Mixed Methods Research

• Timing of all the components

• Recall isn’t perfect – current events color

memory

• Data used for operations differ from data

required for research

• IRB & HIPAA rules for linking PHI to

operations and external data

Benefits of

Mixed Method Research

• Multiple components inform each other throughout data collection • Participant selection

• Instrument development

• Sequencing

• Multiple components inform each other throughout data analysis • Convergent/consensual validation

• Multiple components facilitate integration of different perspectives