Integration at all Levels - new buzz word talk at SC PCA.ppt · New Buzz Word George Rust, MD, ......
Transcript of Integration at all Levels - new buzz word talk at SC PCA.ppt · New Buzz Word George Rust, MD, ......
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National Center for Primary Care
Morehouse School of Medicine
Integration: The New Buzz Word
George Rust, MD, MPH, FAAFP, FACPM
Father of Dan & Christina, Husband of Cindy,
Professor of Family Medicine
Director, National Center for Primary Care
Patient-Centered Medical Home Best Practice Model:
JCAHO-Accredited,
Patient-Centered, Open-Access,
Culturally-Relevant,
Community-Governed,
Quality-Driven,
Behaviorally-Enhanced,
System-Integrated,
Primary Care Health Home
• West Orange Farmworker Health
Association’s Family Health Centers circa
1989 -- Apopka, FL
Integration“We need a comprehensive,
integrated approach to service
delivery. We need to fight
fragmentation.”
-- WHO Director-General, 2007
Silos for a Healthier U.S.!
• Silos:
– Public health
– Medical care
– Behavioral Health
– Mental health
– Substance Abuse
– Faith Communities
– Neighborhood zoning
– Business / employees
– Legislators / policymakers
– Payors / Funders
Example: Why Do We Need Teamwork to
Improve Outcomes in Obesity & Diabetes?
Example: To prevent complications of obesity and
diabetes, all you have to do is modify a
person’s health beliefs and attitudes, daily habits, eating preferences, daily activities, exercise habits, grocery stores, neighborhood walk-ability, food advertising, self-care, employability, economic
empowerment, access to medical care, provider quality, and medication adherence, all in the context of his or her family and social relationships.
Silo: Separating Below-the-Neck
Obesity from Above-the-Neck
Motivations, Attitudes, and Emotions
The Continuum of Behavioral Health
Integration of What?
• Person-Level:– Primary Care / Behavioral health
• Practice-Level:– Panel-based Care Management
• Systems Level: – Information Systems
– Delivery Systems (Pharmacy, Specialty Care,
Emergency Dept, Hospital, etc.)
• Community Level:– Family and sociocultural context
– Social Determinants of health
• Population Level:– Outcomes Management (Accountable Care)
Mental Health ��Physical Health
“Baseball is 90% mental -- the other half is physical."
-- Yogi Berra
Cherokee Health Systems
“Integrated Care” Model:
2
Burden of Disease in
Industrialized Nations
Percent
of Total
All cardiovascular conditions 18.6
All mental illness including suicide 15.4
All malignant disease (cancer) 15.0
All respiratory conditions 4.8
All alcohol use 4.7
All infectious and parasitic disease 2.8
All drug use 1.5
WHO Global Burden of Disease
Murray CJL, Lopez AD, eds. The global burden of disease and injury series, volume 1: a comprehensive assessment of
mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Cambridge, MA: World
Health Organization and the World Bank, Harvard University Press, 1996. www.who.int/msa/mnh/ems/dalys/intro.htm
All Behavioral Health -- Mental Illness, Suicide, Alcohol, & Drug Use = 21.6%
Prevalence of Depression in Chronic Disease
Prevalence of Depression in Chronic Disease
51%
42%
23%
17% 16%12% 11%
27%
Par
kinso
n's
Can
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Dia
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esCVA
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IHIV
Alzhei
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's
Why Primary Care?Why Primary Care? Choices Real People Make
Diabetic
Patient with
Depression
Agree to Accept Referral and then Don’t Go
Accept Referral to Psychiatry Practice
Deal with Mental Health Problem in Primary Care Setting Only
Get Help X ���� ����
Avoid Stigma ���� X ����
Get Optimal Treatment
X ���� X
Coordinate Medical & Psych Rx
X ? ����
Clinical Scenarios
• Schizophrenia patient
gains 100 lbs, and
develops diabetes
• Bipolar patient on lithium
has hypothyroidism and
high blood pressure
• Diabetic patient with
depression
• Insomnia patient with
nervios
• CHF patient who
self-treats PTSD
with alcohol
• Chronic back pain
patient develops
opioid addiction
“Best-Practices” Integrating
Behavioral Health & Primary Care
• Cherokee Health System
• Intermountain Health
• Alaska Native Tribal Health Consortium
Behaviorally-Enhanced Primary Care
Gregory E. Simon, MD, MPH; Wayne J. Katon, MD; Elizabeth H. B. Lin, MD, MPH; Carolyn Rutter, PhD; Willard G. Manning, PhD; Michael
Von Korff, ScD; Paul Ciechanowski, MD; Evette J. Ludman, PhD; Bessie A. Young, MD, MPH Cost-effectiveness of Systematic Depression Treatment Among People With Diabetes Mellitus. Arch Gen Psychiatry. 2007;64(1):65-72.
Why Does Mental Health
Need More Primary Care?
• S Brown. Excess mortality of schizophrenia. A meta-analysis The British
Journal of Psychiatry 171: 502-508 (1997)
• 25-year survival deficit --
Schizophrenia Excess Mortality
• 28% due to ↑ suicide
• 12% due to ↑ accidents
• 60% due to ↑↑↑↑ everything else
Continuum of Integration
Separate Referral Coordinated Collaborative Integrated
Separate Co-Located Common
Coordinated Care
• Tracking & Confirmation
of Referrals & Follow-up
• Sharing of Medical Records
• Sharing of Prescribing
Changes & Medication Lists
• Inter-Operable
Electronic Health Records
• Mutual Participation in Effective
Health Information Exchange
3
Collaborative Care
• All of the Above plus . . .
– Team-Based Case Conferences
– Frequent Interaction on Therapeutic Strategy
– Patient-Centered, Shared Decision-Making
– Shared Care Management
– Joint Decision-Making on
Medication Changes
– Frequent, secure communication by
phone, e-mail, & videoconferencing
The Power of Integration
What would
happen if all
the health
professionals
came
together and
created a
therapeutic
community of
healers for
whole
people?
Faith
Communities
Mental
Health
Substance
Abuse
Treatment Primary
Care
Patient-Centered Medical Home
Primary Caring-- Healing
with our “Radical Human Presence”
• Listening
• Touching
• Affirming
• Comforting
• Diagnosing
• Treating
• Grieving
• Supporting
• Healing
Radical Human
Presence is a
phrase used in a
presentation
called “How the
Heart Learns”
by Landon
Saunders;
AAMFT, 2004
annual mtg.
Is Primary Care Part of the Problem?
•Usual
Care = Sub-
Optimal
Care
NCQA / HEDIS Quality Measures for
Comprehensive Diabetes Care
Quality
Indicator
Performance
(Medicaid)
Performance
(Medicare)
Performance
(Commercial)
A. Good HbA1c
Control (< 7)30.9% 45.9% 41.8%
B. Partial BP
Control (<140/90)57.3% 57.8% 61.4%
B. Good BP
Control (<130/80)30.4% 30.2% 29.9%
C. Cholesterol
Control (LDL <100)30.6% 46.9% 43.0%
Primary Care in
Underserved Settings
• Uninsured Patients
• Limited Resources
• Cultural & Linguistic Barriers
• Professional Isolation
Five Preventive Services Could
Save over 100,00 Lives*
• Aspirin advice � 45,000 lives
• Smoking advice � 42,000 lives
• Colorectal CA screening
� 14,000 lives
• Flu shots � 12,000 lives
• Breast CA screening � 3,700 lives
116,700 lives
* If we increased from current levels of performance to 90%.
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Teamwork! • Community Health Workers
(Promotoras)
• Medical Assistants
• Nurses / Nurse Practitioners
• Pharmacists
• Social Workers
• Health Educators
• Oral Health Professionals
• Physical Therapists
• Primary Care Practitioners
• Psychologists
• Behaviorists
• Sub-Specialty Physicians
• Administrators
Nurse Care Managers
• Impact of a diabetes
resource nurse (DRN)
case manager in a
suburban 12-physician
family practice on
quality care and
outcomes
Proc (Bayl Univ Med Cent). 2003 Jul;16(3):336-40. Clinical outcomes in patients with type 2 diabetes managed by a diabetes resource nurse in a primary care practice. Couch C, Sheffield P, Gerthoffer T, Ries A, Hollander P. Family Medical Center, HealthTexas
Provider Network, Baylor Health Care System, Garland, Texas, USA. [email protected]
7.2%6.6%
8.9%
6.8%
0.0%
1.0%
2.0%
3.0%
4.0%
5.0%
6.0%
7.0%
8.0%
9.0%
Geriatric Non-Geriatric
Before
After
Teamwork! Enhanced Asthma
Education via Community Pharmacists
– Symptom scores � 50%
– PEFR values � 11%
– Beta-Agonist Use � 50%
– Days off school / work � 0.6 days/month
– ED Visits � 75%
– Medical Office Visits � 75%
– Quality of Life Scores � 19%
McLean W, Gillis J, Waller R. The BC Community Pharmacy Asthma Study: A study of clinical, economic and holistic outcomes influenced by an asthma care protocol provided by specially trained community pharmacists in British Columbia. Can Respir J. 2003 May-Jun;10(4):195-202.
Teamwork: LPN’s &
Medical Assistants (every team member working
up to the level of his/her license)
68%
77%
66%67%
60%
62%
64%
66%
68%
70%
72%
74%
76%
78%
Intervention Control
Before
After
• McCarthy BD, Yood MU, Bolton MB, Boohaker EA, MacWilliam CH, Young MJ. Redesigning primary care processes to improve the offering of mammography. The use of clinic protocols by nonphysicians. Gen Intern Med 1997 Jun;12(6):357-63
• Example: Empower
More Clinical Staff
to Initiate Preventive
Services • Medical assistants and
Licensed Practical Nurses
offer mammography as a
routine part of the clinic
encounter
DCA 2000: $8 / test
•CLIA waived
•Reagent-filled cartridges
•6 minutes to test result
•Also does micro-albumin
and Creatinine
Make
Excellence
Automatic
• Measure A1c on
every diabetic visit
A1c Now: $13 / test
•CLIA waived
•No maintenance - disposable
•8 minutes to test result
•Fingerstick or venipuncture
•FDA cleared for home use Bayer DCA2000
Staffing Models:
(8,000 patient
panel)
• 5 MD’s
• 2 PA’s
• 1 RPH
• 2.5 MD’s
• 3 PA’s
• 1 NP/Care Mgr
• 1 LCSW or
Psychol/Behav
• 1 DDS + hygienist
• 1 Pharm D
(+ pharm tech)
• 3 Promotoras
Systems Change :
Information Systems
• Use Information
Systems at the
Individual Patient
or Visit Level
• Example: Flags, triggers,
etc. to promote
compliance at each visit
and to decrease missed
opportunities
Don’t forget long-term control Rx!
Uncoordinated Care –
When We Just Don’t Talk
• Eleanor Rigby – 37 y/o F w/ Bipolar Disorder
– Lithium (Lithobid®)
– Aripiprazole (Abilify®)
– Divalproex Sodium (Depakote®)
• Eleanor Rigby – 37 y/o fertile female smoker with
HTN & two-weeks of productive cough
– Azithromycin (Zithromax Z-Pack®)
– ACE + HCTZ (Vaseretic®)
– OCP’s (Yaz®)
– Bupropion (Zyban® or Wellbutrin®)
Health Information Technologies
• Practice Level:
• Average A1c level
in all diabetics
• % of Patients with
A1c > 8
• Lists of patients
with A1c > 8 for
outreach / action
Individual Level:
• Flags or triggers to
promote compliance
at each visit and to
decrease missed
opportunities
• Evidence-based
guideline alerts
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Re-Engineering ��� “Lean”
• Maximize process speed
• Define “value-added work”
vs. non-value-added work
• Eliminate waste (non-value-added work)– Unnecessary Steps
– Unused Human Potential (LPN not working up to license)
– Unnecessary Waiting Time
– Backlog (charts, people, billing claims, etc.).
– Unnecessary Human Motion (physical distance)
– Defects (Work that Needs to be Fixed or “Done-Over”)
Re-Engineering ��� Lean
Front-Desk Check-In
Appointment
Phone Calls
Medical Records
Nursing – Vital Signs
Clinician Visit
Pharmacy Lab Tests
Cashier /
Check-Out
Waiting Room
Tele-Health
Home Monitoring
High Tech � High Touch
• Framingham Risk
Calculator for PDA
Appropriate
Technology
Teamwork Includes Patients!
• Keep Patients on the Team!
• Patient Self-Management Education
Cochrane Database Systematic
Review (2003): Patient self-
management education reduces
relative risk of adverse outcomes:
• Hospitalizations RR = 0.64
• ED Visits RR = 0.82
• Days off work or school RR = 0.79
• Nocturnal Asthma RR = 0.67
Caveat: Little change in measurable
lung function
Doctor-Centered Medical Home:
the Exam Room and the
Doctor-Patient Visit
Teams that Match
Patient Realities
• Diabetic patient
• Eats at Irregular Hours
• Episodes of Hypoglycemia
� Migrant farmworker
�� Leaving tonight riding in back Leaving tonight riding in back of covered pickup truck to of covered pickup truck to drive 12 hours to pick drive 12 hours to pick yams in Ohioyams in Ohio
�� 1313--hour workday tomorrowhour workday tomorrow
�� No control over when she eatsNo control over when she eats
Community Health Workers
(Promotores de Salud)Silo #2: Separating
Healthy Kids from
Healthy Communities
The Continuum of Community Health
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Promotores / Promotoras &
Community Health Workers
� Enhanced Access to & Use of Complicated Health Systems (Navigators)
� Immunization Rates
� Breast & Cervical Cancer Screening
� Blood Pressure Control
� Control of Asthma Triggers in Households
� Healthy Eating & Exercise
� Safety Eyeware Use Among Farmworkers
� Compliance with Directly-Observed Treatment of Tuberculosis
Patient-Centered Medical HomePrimary Care Community Health Centers
Impact on Uninsured ED Visits
31% Excess
62% Excess
No CHC = 37% Excess ED Visits
Disparities = Human Tragedy
•A baby dies every day in Georgia, and
would not have died if there was no
black-white difference in infant
death rates
Unequal Care & OutcomesMental Health Co-Morbidities in the
Disabled Medicaid Population
49.0%28.0%35.7%52.5%5.1%1,798 Asthma
38.5%22.5%25.6%61.0%5.7%1,998 Cancer
47.1%29.2%30.7%77.6%6.0%2,099 Blood (not hemophilia)
44.0%30.7%25.1%87.3%6.1%2,130 Coronary Dz (CAD)
44.1%28.5%27.5%81.6%6.7%2,365 Vascular
41.9%28.4%24.9%78.4%7.2%2,530 Heart (not CHF/CAD)
56.1%38.2%35.7%75.4%8.4%2,944 COPD
100.0%100.0%48.5%72.7%10.6%3,735 Substance Abuse
32.9%14.2%25.0%67.1%14.8%5,187 Diabetes
39.4%17.8%29.7%63.2%21.6%7,613 Lipid / Metabolic
42.4%19.8%33.1%54.6%24.7%8,683 Musculoskeletal
36.5%17.6%26.7%60.2%30.0%10,545 Hypertension
% among Pop wth this Dx who also have
either Mental Health or
Substance Abuse (or both)
% among Pop with this Dx
who also have any
Substance Abuse
% among Pop with this Dx
who also have any Mental
Health Dx*
% among Pop with this Dx who also have at least 3 Other Co-Morbid Diseases
Prevalence of this
Diagnosis in adult,
non-pregnant
ABD Population n
Disease Diagnosis (Dx)
Diseases Associated with High Co-Morbidity Rates (> 50% with >3 comorbidities)
49.0%28.0%35.7%52.5%5.1%1,798 Asthma
38.5%22.5%25.6%61.0%5.7%1,998 Cancer
47.1%29.2%30.7%77.6%6.0%2,099 Blood (not hemophilia)
44.0%30.7%25.1%87.3%6.1%2,130 Coronary Dz (CAD)
44.1%28.5%27.5%81.6%6.7%2,365 Vascular
41.9%28.4%24.9%78.4%7.2%2,530 Heart (not CHF/CAD)
56.1%38.2%35.7%75.4%8.4%2,944 COPD
100.0%100.0%48.5%72.7%10.6%3,735 Substance Abuse
32.9%14.2%25.0%67.1%14.8%5,187 Diabetes
39.4%17.8%29.7%63.2%21.6%7,613 Lipid / Metabolic
42.4%19.8%33.1%54.6%24.7%8,683 Musculoskeletal
36.5%17.6%26.7%60.2%30.0%10,545 Hypertension
% among Pop wth this Dx who also have
either Mental Health or
Substance Abuse (or both)
% among Pop with this Dx
who also have any
Substance Abuse
% among Pop with this Dx
who also have any Mental
Health Dx*
% among Pop with this Dx who also have at least 3 Other Co-Morbid Diseases
Prevalence of this
Diagnosis in adult,
non-pregnant
ABD Population n
Disease Diagnosis (Dx)
Diseases Associated with High Co-Morbidity Rates (> 50% with >3 comorbidities)
Unequal
Benefit –
Breast
Cancer
Adoption S-Curve
Isolated or disenfranchised
or non-majority
cultural groups
Focus on Global Health Outcomes for Complex
Mental Health & Medical Co-morbidities
ip op md ot m2 dg total
$217,657 $7,105 $29,756 $10,498 $3,155 $12,182 $280,353
One Diabetic Patient:• Diabetes
• Arthritis
• COPD
• CHF
•Stroke
• Pneumonia
• Cancer
• Depression
•Alcohol / substance abuse
* 21 ER Visits * 143 hospital bed-days
7
Drivers of Health Disparities
Health
PotentialWorst
Minority
Average
Majority
Best / Optimal
Excess Cost Due to Racial Variation
in Hospital Admissions by Disease(mid-range estimate)
Excess
Hospital
Admissions
(mid-range)
Hospital Charges Attributable to Excess
Hospital Admissions
(mid-range)
Payer Costs Attributable to Excess
Hospital Admissions
(mid-range)
Asthma 2,044 $28,687,330 $13,339,608.45
Diabetes 3,955 $92,172,057 $42,860,006.51
Heart Disease 5,021 $187,289,234 $87,089,493.81
>Coronary
Artery Disease 1,287 $65,156,724 $30,297,876.66
>Congestive Heart
Failure 5,868 $162,561,372 $75,591,037.98
HIV 1,644 $76,784,134 $35,704,622.31
$ $ Charges Due to Uninsured Hospital
Admissions (All-Cause & ACS Conditions)
Hospital Admission Hospital admission for ACS Condition
age group Count Rate/100,000 Total Discharge
$$ Charges $$Count rate/100,000 Total Discharge
$$ Charges $$
<1yr infancy 3381 2166.8 13052692 30 19.2 240085
1-4 early childhood 533 89.6 4982660 278 46.7 1882363
5-12 later childhood 515 44.7 5938480 221 19.2 1914935
13-19 adolescence 2179 225.5 38505983 417 43.2 5008118
20-29 early adulthood 11959 847.1 295608834 2546 180.3 37563398
30-44 young adulthood 21240 1005.7 509586602 4801 227.3 80410161
45-59 middle adulthood 26799 1375.4 779924179 6409 328.9 124391039
60-74 later adulthood 6130 583.6 212189003 1379 131.3 28830299
75+ older adulthood 438 100.4 15137085 74 17.0 1829954
Sum $1,874,925,518 $282,070,352
Table 3. Uninsured patient hospital admission/ hospital admission for ACS condition
count and rate per 100,000 population and total hospital discharge by age group among Georgia residents in 2009
$
Indigent Care Hospital Costs (assuming
35.6% cost to charge ratio) – all-causes of
hospital admission
Indigent Care Hospital Costs (assuming 35.6%
cost to charge ratio) –hospital admissions
due to ambulatory care sensitive conditions
$667,473,484 $100,417,045
Closing the Loop,
Accelerating Cycle Times
• Practice-Level Data
• Monthly ED Visit Rate
• Hospital Bed-Days
• Preventable Adverse Events
• Person-Level Feedback
• Missed refills
• Inadequate Care
• ED Visit yesterday!
Triangulate Interventions
Children
Schools
Primary
Care &
Public
Health
Family &
Community
Psychologists &
Behavioral Health
Community-
Oriented
Primary Care
Moving Toward Optimal Health for All
in the Agalto Valley, Honduras
In the 1980’s, Infant Mortality
in the Olancho state of
Central Honduras was over 70
per 1,000 (7%); Since 2006,
there have been no infant
deaths in the 27 villages
covered by the comprehensive
community development
work of Honduras Outreach
(Rancho Paraiso)
What Accounts for Success
in the Agalto Valley, Honduras?
Was it Social Determinants?
Agricultural Development Pre-K & Kindergarten
Vocational Training Community Organizing
What Accounts for Success
in the Agalto Valley, Honduras?
Was it Public Health & Sanitation?
Latrines / Waste DisposalSafe Water to Households
Safe Housing / Indoor Air
Malaria PreventionSafe Housing / Chagas Dz
8
What Accounts for Success
in the Agalto Valley, Honduras?
Was it Health Literacy & Nutrition?
School –based Meals Nutrition Education
Nutrition Education Intensive Center for Mother-Child Malnutrition
What Accounts for Success
in the Agalto Valley, Honduras?
Was it Primary Care / Prenatal Care?
Satellite Clinic Nurse AuxilliairesFamily Practice Physician
Pediatric CarePrenatal UltraSounds
What Accounts for Success
in the Agalto Valley, Honduras?
Or Was it a Comprehensive, Integrated Approach?
Economic & Community Development
Prenatal Care / Primary Care
Public Health / SanitationEducation / Nutrition
Tying it All Together to Achieve
Optimal, Equitable Health Outomes
Community Health
Promotion
Health Outcomes
Primary Care
Medical Home
Accountable
Health Care
Entities
Think what
we-all could
accomplish
together!
29 babies saved!!!
Disparities Success Stories!
Decline represents 29 infant deaths prevented
(expected vs. actual)
Create A Real System of Caring
at the Community-Level
Emergency
Room
Primary Care
Mental
Health
Business &
Community
Leaders
Hospitals
Public
Health
Faith
Communities