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Transcript of ICIC Website: / Decision Support: More Than Guidelines Winston F. Wong, M.D., M.S. The Care...
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ICIC Website: http://www.improvingchroniccare.org/
Decision Support: More Than Guidelines
Winston F. Wong, M.D., M.S.The Care Management Institute
Kaiser Permanente
CAPH CCLC November 2, 2004
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Informed,ActivatedPatient
ProductiveInteractions
Prepared,ProactivePractice Team
Functional and Clinical Outcomes
DeliverySystemDesign
Decision Support
ClinicalInformation
Systems
Self-Management
Support
Health System
Resources and Policies
Community
Health Care Organization
Chronic Care Model
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Decision Support Systems
• A process for incorporating guidelines, education, expert advice and practice aids into routine clinical practice
NCQA
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Decision Support• Embed evidence-based guidelines which
describe stepped-care into daily clinical practice.
• Integrate specialist expertise and primary care.
• Use proven provider education methods.
• Share evidence-based guidelines and information with patients to encourage their participation.
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Knowledge Management…One Approach
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What Works & What Doesn’t?
• Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance. A systematic review of the effect of continuing medical education strategies. JAMA. 1995 Sep 6;274(9):700-5.
• Meta-analysis of 99 trials, 160 interventions designed to change physician behavior –
– Effective change strategies
• Provider reminders
• Patient-mediated interventions
• Outreach visits (academic detailing)
• Opinion leaders
• Multifaceted interventions
– Less Effective
• Audit with feedback and educational materials
– Not Effective
• Formal CME conferences or activities, without enabling or practice-reinforcing strategies.
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What is evidence-based medicine?
Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.
-David Sacket, BMJ 13 Jan 1996
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What is evidence-based medicine?
• Evidence-based medicine is an approach to health care that promotes the collection, interpretation, and integration of valid, important and applicable evidence.
• The best available evidence, moderated by patient circumstances and preferences, is applied to improve the quality of clinical judgments.
McMaster University
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What is evidence-based practice?
• Efforts made to base clinical & other healthcare decisions on the best available evidence
• Evidence is critically appraised & synthesized
• The evidence synthesis is adapted to assist providers & patients in making decisions about specific clinical conditions.
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Embed evidence-based guidelines
into daily practice
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Clinical Practice Guidelines
• Clinical guidelines are systematically developed statements to assist practitioners and patients in choosing appropriate healthcare for specific conditions.
-The Institute of Medicine
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Clinical Practice Guidelines
Efforts to distill a large body of medical knowledge into a convenient, readily usable format.
- Eddy. The challenge. JAMA 1990;263:287-290
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The purpose of clinical practice guidelines
CurrentPractice
Currentoutcomes
OptimalPractice
OptimalOutcomes
GAP
Health statusSatisfactionCostUtilization
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A quality gap persists: “…on average, Americans receive about half of recommended medical care processes.” — McGlynn, et al, NEJM, 6/26/03
IOM: “What is perhaps most disturbing is the absence of real progress toward restructuring health care systems to address both quality and cost concerns, or toward applying advances in information technology…”
Overall care 439 54.9%
Preventive 38 54.9%
Acute 153 53.5%
Chronic 248 56.1%
Screening 41 52.2%
Diagnosis 178 55.7%
Treatment 173 57.5%
Follow-up 47 58.5%
Fu
nc
tio
nT
yp
e o
f C
are
NEJM 348:26, Rand study
# of Indicators
% Recommended Received
QUALITY
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Need for Information at the Point of Care
Clinicianscarry
frequently used
informationresources with them
Information systems goal: Empty the lab coat pocket
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Evidence-based Practice• Begin with NIH Guidelines
– all team members should be familiar
• Identify thought/opinion leaders
– within your organization and outside
– systematic literature review
– organized learning within organization
Steve Simpson, MD Kansas University
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Stickies wereubiquitous
Labels with patient Information and pre-visit summaries are also used as reminders
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Evidence-based practice, cont.• Customize guidelines to your setting
• Embed in practice: able to influence real time decision-making
Flow sheets with prompts
Decision rules in EMR
Share with patient
Reminders in registry
Standing orders
• Have data to monitor care
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Attributes of Good Guidelines
• Clear definition of condition and population
• Exceptions are described
• Evidence summaries are available with links to key articles
• Clinical actions for stepped-care are clearly stated
• “Nice-to’s” that are not evidence-based are omitted
• Regularly updated to incorporate new data
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http://pkc.kp.org
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Stepped Care
• Often begins with lifestyle change or adaptation (eliminate triggers, lose weight, exercise more)
• First choice medication
• Either increase dose or add second medication, and so on
• Includes referral guideline
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4Overvi ew
Level 3Patients are complex. High intensitymanagement of the patient’s care is required.
Level 2Patients are in poor metabolic control andmay benef it from participation in a shortterm care management program where theylearn self care skills
Level 1Patients can be supported by routineAPC team care but may need selfmanagement basic educa tion
Prevention & Wellness
Patients with diabetes canbe segmented into threecare levels based on needs.
IntensiveManagement
• Care Mgmt Programs:
– Group Visits– one-on-one F/U
Assisted Care
• Diabetes: The Basics• Living Well with Diabetes
• SMBG
Self Management
Prevention and wellness arethe foundation of basic care.
Population Management Concept
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Adult Asthma Presentati on 7
Outreach & triage
•Prior itize CV r isk factors :
•HTN, Dy slipidemia (LDL>100)
Treatment accor ding to protocols
•Behavior change/motivation
•Reinfor ce self-m anagem ent ski lls
•Patient r etur ns to Level 1
Outreach & triage
•Prior itize CV r isk factors :
•HTN, Dy slipidemia (LDL>100)
Treatment accor ding to protocols
•Behavior change/motivation
•Reinfor ce self-m anagem ent ski lls
•Patient r etur ns to Level 1
Diabetes Population Management
Week 2
Group Appt.Assessment
Care ManagerBehaviorist
Dieti tian
Mon ths 2-6
TelephoneFollow- up
Visit s(1:1 Of fice V isi t as
needed )
Mon thly
Group Appt Monthly
Clinical /behaviora lin terventions
Care ManagerBehavioristDieti tian
Week 1
Intake V isit
One-to-OneOffice Visit
Risk reductionGoal setting
Endocrinologist/DiabetologistConf irms diagnosis
Ident ifies co-m orbidit ies
Optim izes m edi cati on regim en
Mentors Case & Care Managers
Endocrinologist/DiabetologistConf irms diagnosis
Ident ifies co-m orbidit ies
Optim izes m edi cati on regim en
Mentors Case & Care Managers
Diabetes Population Management Program 2003
Level 3 Intensive Care
Level 2 Care Management
Level 1 Self Care Primary Care Team
Reviews, adjustsmedications
Regular screening tests
Reinforcesself-management
Primary Care Team
Reviews, adjustsmedications
Regular screening tests
Reinforcesself-management
• Complex medical issues
• Psycho-social barriers t oself-management
• ED visits
• Hospitalization
• HgA1c > 8.5%
• Microalbumin > 30
Any of above WITH
• HTN,/ Dyslipidemia
• Diabet es is well controlled
• Member practices effectiveself-care
Living W ell withDiabet es
Class and others
Living W ell withDiabet es
Class and others
As needed
EducationalResourcesHeal thwise Handbook,KP Onli ne
EducationalResourcesHeal thwise Handbook,KP Onli ne
Case ManagerCoaches members in crisis
Manages access
to specialty and ED care
Coordinates care across continuum
Case ManagerCoaches members in crisis
Manages access
to specialty and ED care
Coordinates care across continuum
DM care path 2003
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Yes We Can Stratification Model
Self-Management Support by Primary Care
Basic Case Management by Yes We Can Asthma team
Moderate Case Managementby Yes We Can Asthma team
IntensiveCase
Management
LEVEL 4LEVEL 4 Intensive Case ManagementChild with poor asthma control andFamily in need of self-management skills andHighly complex and unstable social/psychosocial criteria
LEVEL 3LEVEL 3Moderate Case ManagementChild with poor asthma control andFamily in need of self-management skills andModerately complex and unstable social/psychosocial issues
LEVEL 2LEVEL 2 Basic Case ManagementChild with poor asthma controlFamily in need of self-management skillsRelatively stable social/psychosocial issues
LEVEL 1LEVEL 1Self-Management SupportChild with relatively well controlled asthmaFamily has self-management skills Relatively stable social/psychosocial status
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Integrating Specialist and Primary Care Expertise
Clarifying roles and working together
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Definitions
• Referral: transfer of care
• Consultation: one-time or limited time
• Collaboration: on-going co-management
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Effective specialty-primary care interactions
• When to consult
– trouble making a diagnosis
– specialized treatment
– goals of therapy not met
Adapted from material by Steve Simpson, MD Kansas University
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Using Consultants EffectivelyMake your consultants partners
– 1st principle of partnership - communication
– communication begins with you
– ask a specific question
– specify type of consult: ongoing (referral), one time only, duration of specific problem
Steve Simpson, MD Kansas University
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Communicating
• Telephone or in person
• Letter
• Letter with supporting objective data
• e-mail must be encrypted
Steve Simpson, MD Kansas University
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Example of an agreement in place
Primary Care1. State that you are requesting a consultation
2. The reason for the consultation and/or question(s) you would like answered
3. List of any current or past pertinent medications
4. Any work-up and results that has been done so far
5. Your thought process in deciding to request a consult
6. What you would like the Specialist to do
Source: HealthPartners, MN
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The agreement in place
Specialty Care
1. State that you are returning the patient to primary care for follow-up in response to their consult request2. What you did for the patient and the results3. Answers to Primary Care Physicians questions in their consult request4. Your thought process in arriving at your answers5. Recommendations for the Primary Care Physician and educational notes as appropriate6. When or under what circumstances the Primary Care Physician should consider sending the patient back to you
Source: HealthPartners, MN
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Going beyond referral and consultation: integrating specialist expertise
• Shared care agreements
• Alternating primary-specialty visits
• Joint visits
• Roving expert teams
• On-call specialist
• Via nurse case manager
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Use proven provider education methods
Beyond CME…
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Effective educational methods
Interactive, sequential opportunities in small groups or individual training
• Academic detailing
• Problem-based learning
• Modeling (joint visits)
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Effective educational methods• Build knowledge over time
• Include all clinic staff
• Involve changing practice, not just acquiring knowledge
Result: better diagnosis, continuing care and guideline based care in children with asthma
Evans et al, Pediatrics 1997;99:157
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Share evidence-based guidelines and information
with patientsto encourage their participation.
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What is shared decision-making?
• Patient and clinician share information with each other (clinician shares medical information, patient shares personal knowledge of illness and values)
• Participate in a decision-making process
• Agree on a course of action
Sheridan et al Am Jrnl Prev Med 2004
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Guidelines for patients
• Expectations for care
• Wallet cards
• Web sites
• Workbooks
• Stoplight tools
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Example of a successful strategy: Adults with asthma
• Developed a skill-oriented self-help workbook
• Health educator session for 1 hour
• Support group
• Telephone calls
RCT: better inhaler skills and use, decreased symptoms, less ER use.
Bailey et al Arch Inter Med 1990;150:1664
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Stoplight tools: patient guidelines
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Supporting the Patient Role
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What Does Work?
• Interventions that increase use of adult immunization and cancer screening services: a meta-analysis. Ann Intern Med, 2002 May 7; 136(9):641-51. Stone EG, Morton SC, Hulscher ME, Maglione MA, Roth EA, Grimshaw JM, Mittman BS, Rubenstein LV, Rubenstein LZ, Shekelle PG.
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Important Web Addresses• PubMed
– http://www4.ncbi.nlm.nih.gov/PubMed/
• Guidelines
– http://www.guidelines.gov
• NIH
- http://www.nih.gov
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•www.improvingchroniccare.org
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