Patient-Centered Primary Care in Prison
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Transcript of Patient-Centered Primary Care in Prison
Discussion Outline
• Purpose of the Presentation
• Overview of CDCR/CPHCS
• Case Study: PCPC in a Prison
• Conclusion
• Questions
Purpose of the Presentation
• Share experience establishing a care management system in a correctional setting founded on:Patient-Centered Medical Home
Care Model
Model for Improvement
• Demonstrate that “best practices” can occur anywhere including behind bars
Overview-1
• 170,000 inmates (11% Women)
• 60% recidivism rate (3 years)
• 70,000 employees (7,000 health care staff)
• 470 physicians & midlevel practitioners
• 3,700 nursing staff
• 33 prisons (3 women’s prisons; 7 major RC prisons)
Overview-2
• $10 billion operating budget (7% General Fund)
• $2 billion operating budget for health care (HC)
• 100% increase in HC budget since 2006
• 70% budget for salary & benefits
• $48,500 annual cost per inmate
• $16,000 annual health care cost per inmate
Overview-3
• 170,000 inmates
• 25% > 40 years old; 15% > 50 years old
• 50% inmates have chronic conditions
• HTN, DM, Asthma, COPD, CAD
• HCV, ESLD
• Mental illness, chronic pain, substance abuse
Overview-4
• Courts oversight all aspects of healthcare
• Require board certification in primary care (2004-)
• Require proof of competence in primary care (2004-)
• > 30% turnover physician staff (~2004-2006)
• Significant provider vacancies (2005-)
• Federal Receiver over medical program (2006)
• Significant provider salary increases (2007)
Overview-5
• Partial paneling of patients with PCP (2006-2007)
• “Officially” adopted primary care model (2008-2009)
• Annualized death rate 291 inmates per 100,000 (2006)
to 203 inmates per 100,000 (2008)
• Reduction in preventable deaths noted
Overview-6*
• Written policies for access & communication
• Patient grievance system; no survey of experiences
• Stand alone legacy patient scheduling & tracking system
• No enterprise wide EMR or clinical registry
• Many charting forms & documentation mandates
* NCQA PPC PCMH tool
Overview-7*
• Physicians’ & non-physicians’ roles evolving
• Primary care team huddles
• Track referrals, tests, f/u (paper-based & electronically)
• Limited patient self management support
* NCQA PPC PCMH tool
Overview-8*
• Disease management guidelines & decision support
• InterQual for specialty referrals & hospitalizations
• Electronic pharmacy & medication system
• Centralized clinical data repository in progress
* NCQA PPC PCMH tool
Overview-9*
• Review of RAND performance metrics in progress
• Court-driven and cost-driven data
• Limited standardized reports at institution & PCP level
• Some benchmarking and adjusted comparison data
• Limited tracking of evidence-based clinical outcomes
* NCQA PPC PCMH tool
Case Study: PCPC in a Prison
Motivating Change
Welcome to Folsom’sWelcome to Folsom’sGated Community Gated Community
CCP1
CCP2
CCP3
Reception
Pre
vent
ion
Case / C
are Managem
ent
Planned Primary Care
COMMUNITY HOSPITALIZATION
TTA CARE
“SICK CALL”
COMMUNITY ED CARE
Discharge
SPECIALTYCARE
Clinical Needs Assessment & Classification
Planned Primary Care
Discharge
Case Study-1
• Paneled every patient with consistent PCP
• Reorganized into consistent primary care teams
• Each team included RN, PCP, LVN(s), OT
• Collective goals, objectives and strategies to improve outcomes based on PCMH, CCM and MFI (Aims & PDSA)
There is no in TeamThere is no in Team
• Common PurposeCommon Purpose
• Defined AIMSDefined AIMS
• Defined RolesDefined Roles
• Mutual AccountabilityMutual Accountability
Case Study-2
• Created decision support & self management tools
• Created clinical data repository & e-registry
• Created reports to use at the point of care
• Created reports for performance monitoring & improvement at team and population levels
Case Study-3
• Disseminated baseline and monthly performance information at team level
• Conducted lots of training using adult-based learning methods focused on evidence-based practice and QI
• Established/leveraged forums to discuss & act upon clinical/performance data over time
Model for Improvement
DIABETES CAREQuality Improvement Project 2009
•Goal:Improve processes of care and clinical outcomes for the patient population with Diabetes as evidenced through the following Aims:
Diabetes Care: MAJOR AIMS
• By June 30, 2009 > 75% of diabetic patients at FSP will have a HgbA1C < 7.5 and LDL < 100 and SBP/DBP <130/<80.
• By June 30, 2009 >95% of diabetic patients at FSP will have had an annual monofilament foot exam and annual eye exam and annual urine microalbumin.
INCREMENTAL AIMS
• By 3/26/09, in each Medical Home, >95% of the diabetic patients will have a current LDL level within the last 12 months.
• By 3/26/09, in each Medical Home,>95% of diabetic patients will have an average BP of < 130 / < 80 based on at least 3 documented BP checks over the last 3 months.
• By 3/26/09, in each Medical Home, >95% of the diabetic patients will have at least one HbgA1C level checked within the last 6 months.
INCREMENTAL AIMS
• By 4/23/09, in each Medical Home, >80% of the diabetic patients will have an average fasting glucose (FS) < 130mg/dl based on an average of at least 3 morning fasting checks and no FS <70mg/dl or >180mg/dl.*
• By 5/28/09, in each Medical Home, > 80% of the diabetic patients with HgA1c levels still > 7.5 % will have an average 2-hour post-prandial glucose less than 180 mg/dl based on at least 3 checks.
• By 6/30/09, in each Medical Home > 95% of diabetic patients will have had an annual monofilament foot exam done and an annual dilated eye exam done and an annual microalbumin level checked.
* This incremental aim does not have to be implemented if last HbA1C ≤ 6.5 and last fasting glucose ≤ 130mg/dl and last 2 hour post prandial < 180 and no history of hypoglycemia in at least the last 12 months.
Diabetes CareDiabetic Patients with HbA1C Completed in Last 6 months
33
Patients
124
Patients
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Done Not Done
Diabetes CareDiabetic Patients and Degree of Control by HbA1C in Last 6 Months
74
Patients
50
Patients
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
<=7.5 >7.5
Diabetes CareDiabetic Patients with Completed LDL
Within Last 12 Months
138Patients
19Patients
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Done Not Done
Diabetes Care
Diabetic Patients Degree of Control by LDL
70Patients
68Patients
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
<=100 >100
Diabetes CareDiabetic Patients with BP Readings in Last 3 Months
47Patients
110Patients
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Done Not Done
Diabetes Care
Diabetic Patients with Average BP Results in Last 3 Months
15Patients
32Patients
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
<=130/80 >130/80
• Test #:
• Describe the Test of Change/Responsible Person/When/Where
• PLAN: Describe tasks needed for test/Responsible Person/When/Where
1. 2. 3. 4.
What do we want to happen?How will we know if it did?
1. 2. 3.
Evaluation Schedule Date: Location: Time:
• DO: Describe what happened during test
• STUDY: Did what we want to happen actually happen? Yes/No Why/Why Not
• ACT: Describe what modifications will be made for next cycle from what was learned.
By _____, >95% of DM pts in _______________AIM #
Diabetes Incremental AIMS by Medical HomeJune 30, 2009 Incremental AIM 1: By 3/26/09, in each Medical Home >95% of the diabetic patients will have a current LDL level within the last 12 months.
Medical Home
Test of Change
Desired Outcome
< 100 mg/dL
Primary Care Team RN
Benchmark 100%
Compliance 1A LDL 1C LDL 2 LDL 3 LDL
4 & FM LDL 5 LDL
Incremental AIM 2: By 3/26/09, in each Medical Home >95% of the diabetic patients will have at least one BP checked over the past 3 months.
Medical Home
Test of Change
Desired Outcome
< 130/80
Primary Care Team RN
Benchmark >95%
Compliance 1A Blood Pressure 1C Blood Pressure 2 Blood Pressure 3 Blood Pressure
4 & FM Blood Pressure 5 Blood Pressure
Incremental AIM 3: By 3/26/09, in each Medical Home, >95% of the diabetic patients will have had at least one HbA1c level checked within the past 6
months.
Medical Home
Test of Change
Desired Outcome
< 7.5%
Primary Care Team RN
Benchmark >95%
Compliance 1A HbA1c 1C HbA1c 2 HbA1c 3 HbA1c
4 & FM HbA1c 5 Hba1c
DM Outcomes by Medical Home 05-2009
DM Outcomes by Medical Home 05-2009
DM Outcomes by Medical Home 05-2009
DM Outcomes by Medical Home 05-2009
DM Outcomes by Medical Home 05-2009
DM Outcomes by Medical Home 05-2009
• Test #:
• Describe the Test of Change/Responsible Person/When/Where
• PLAN: Describe tasks needed for test/Responsible Person/When/Where
1. 2. 3. 4.
What do we want to happen?How will we know if it did?
1. 2. 3.
Evaluation Schedule Date: Location: Time:
• DO: Describe what happened during test
• STUDY: Did what we want to happen actually happen? Yes/No Why/Why Not
• ACT: Describe what modifications will be made for next cycle from what was learned.
By _____, >95% of DM pts in _______________AIM #
Diabetic Patient Outcomes
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
B1 A N=25 B1C N=23 B2 N=30 B3 N=18 B4/FM N=13 B5 N=41
Medical Homes
Co
mp
lian
ce P
erce
nta
ge
% LDL <100
% HbA1c ≤ 7.5
% BP <130/80
% all 3 variables
Benefits of PCPC-1
• Improved patient outcomes
• Better cost-efficiency & utilization
• Reduced waste & cost
STATE PRISON HEALTH CARE SERVICES
UNSCHEDULED PATIENT TRANSFERS
JAN-MAR 08 APR-JUN 09 % CHANGE
TOTAL 102 59 -42.16%
CODE 3 27 21 -22.22%
CODE 1/2 75 38 -49.33% Since the implementation of the primary care model, the number of unscheduled
transports decreased from a total of 102 (Jan-Mar 08) to 59 (Apr-Jun 09). This was a
42.16% decrease. During the same period, the number of Code 3 transports decreased by
22.22% while the number of Code 1/2 patient transports decreased by 49.33%. Assuming
that each transport requires a minimum of two custody staff, the significant decrease in the
total number of transports represents significant cost avoidance. In addition, the costs of
community ED and hospitalization costs were avoided.
Benefits of PCPC-2
• Reduced patient grievances
• Positive patient experiences
• Positive staff experiences
Patient Centered Medical HoodWired for connectivity
Patients
Primary Care TeamPCPRNLVNOTCO
_____________________
HuddlesPatient Care Reports
C MA A S N E A G E M E N T
Reception Discharge
CommunityHospitalization/
Emergency Dept.TTA
Unplanned Primary Care:
“Sick Call”
SpecialtyCare
Management SystemCare
Conclusion: Keys to Motivating Change
Crisis is Opportunity
Bottom line: it starts at the Top
Begin with the End in Sight• Aim high• Inspire commitment and curiosity not compliance• Cultivate CQI = JOB culture• Create people-centered place of care
Conclusion: Keys to Motivating Change
Plan your Drive• Patient-Centered Medical (Neighbor) Hood• Care Model• Model for Improvement
Drive your Plan• Don’t let the Perfect get in the way of the Good• Don’t let Immediate get in the way of Important• Excellence is a habit not an act• Can’t manage what you don’t measure (& report)
Conclusion: Keys to Motivating Change
Enjoy the Journey because…
Conclusion: Keys to Motivating Change
You never reach your destination because…
Acknowledgements
• California Prison Health Care Services
• Folsom State Prison Staff
Questions?