Patient-Centered Primary Care in Prison

53

description

Patient-Centered Primary Care in Prison. Renee Kanan, MD, MPH, FACP [email protected] (916) 201-4531. Discussion Outline. Purpose of the Presentation Overview of CDCR/CPHCS Case Study: PCPC in a Prison Conclusion Questions. Purpose of the Presentation. - PowerPoint PPT Presentation

Transcript of Patient-Centered Primary Care in Prison

Page 1: Patient-Centered Primary Care in Prison
Page 2: Patient-Centered Primary Care in Prison

Patient-Centered Primary Care in Prison

Renee Kanan, MD, MPH, FACP

[email protected]

(916) 201-4531

Page 3: Patient-Centered Primary Care in Prison

Discussion Outline

• Purpose of the Presentation

• Overview of CDCR/CPHCS

• Case Study: PCPC in a Prison

• Conclusion

• Questions

Page 4: Patient-Centered Primary Care in Prison

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

Page 5: Patient-Centered Primary Care in Prison

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)

Page 6: Patient-Centered Primary Care in Prison

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

Page 7: Patient-Centered Primary Care in Prison

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

Page 8: Patient-Centered Primary Care in Prison

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)

Page 9: Patient-Centered Primary Care in Prison

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

Page 10: Patient-Centered Primary Care in Prison

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

Page 11: Patient-Centered Primary Care in Prison

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

Page 12: Patient-Centered Primary Care in Prison

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

Page 13: Patient-Centered Primary Care in Prison

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

Page 14: Patient-Centered Primary Care in Prison

Case Study: PCPC in a Prison

Motivating Change

Page 15: Patient-Centered Primary Care in Prison

Welcome to Folsom’sWelcome to Folsom’sGated Community Gated Community

Page 16: Patient-Centered Primary Care in Prison

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

Page 17: Patient-Centered Primary Care in Prison

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)

Page 18: Patient-Centered Primary Care in Prison
Page 19: Patient-Centered Primary Care in Prison

There is no in TeamThere is no in Team

• Common PurposeCommon Purpose

• Defined AIMSDefined AIMS

• Defined RolesDefined Roles

• Mutual AccountabilityMutual Accountability

Page 20: Patient-Centered Primary Care in Prison

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

Page 21: Patient-Centered Primary Care in Prison

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

Page 22: Patient-Centered Primary Care in Prison

Model for Improvement

Page 23: Patient-Centered Primary Care in Prison

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:

Page 24: Patient-Centered Primary Care in Prison

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.

Page 25: Patient-Centered Primary Care in Prison

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.

Page 26: Patient-Centered Primary Care in Prison

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.

Page 27: Patient-Centered Primary Care in Prison

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

Page 28: Patient-Centered Primary Care in Prison

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

Page 29: Patient-Centered Primary Care in Prison

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

Page 30: Patient-Centered Primary Care in Prison

Diabetes Care

Diabetic Patients Degree of Control by LDL

70Patients

68Patients

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<=100 >100

Page 31: Patient-Centered Primary Care in Prison

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

Page 32: Patient-Centered Primary Care in Prison

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

Page 33: Patient-Centered Primary Care in Prison

• 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 #

Page 34: Patient-Centered Primary Care in Prison

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

Page 35: Patient-Centered Primary Care in Prison

DM Outcomes by Medical Home 05-2009

Page 36: Patient-Centered Primary Care in Prison

DM Outcomes by Medical Home 05-2009

Page 37: Patient-Centered Primary Care in Prison

DM Outcomes by Medical Home 05-2009

Page 38: Patient-Centered Primary Care in Prison

DM Outcomes by Medical Home 05-2009

Page 39: Patient-Centered Primary Care in Prison

DM Outcomes by Medical Home 05-2009

Page 40: Patient-Centered Primary Care in Prison

DM Outcomes by Medical Home 05-2009

Page 41: Patient-Centered Primary Care in Prison

• 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 #

Page 42: Patient-Centered Primary Care in Prison

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

Page 43: Patient-Centered Primary Care in Prison

Benefits of PCPC-1

• Improved patient outcomes

• Better cost-efficiency & utilization

• Reduced waste & cost

Page 44: Patient-Centered Primary Care in Prison

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.

Page 45: Patient-Centered Primary Care in Prison

Benefits of PCPC-2

• Reduced patient grievances

• Positive patient experiences

• Positive staff experiences

Page 46: Patient-Centered Primary Care in Prison

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

Page 47: Patient-Centered Primary Care in Prison

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

Page 48: Patient-Centered Primary Care in Prison

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)

Page 49: Patient-Centered Primary Care in Prison

Conclusion: Keys to Motivating Change

Enjoy the Journey because…

Page 50: Patient-Centered Primary Care in Prison

Conclusion: Keys to Motivating Change

You never reach your destination because…

Page 51: Patient-Centered Primary Care in Prison
Page 52: Patient-Centered Primary Care in Prison

Acknowledgements

• California Prison Health Care Services

• Folsom State Prison Staff

Page 53: Patient-Centered Primary Care in Prison

Questions?