A DVANCING P RIMARY C ARE A T HOUSAND C LINICS AT A T IME : L ESSONS F ROM E VIDENCE NOW PCORI A NNUAL M EETING Deborah Cohen, PhD September, 2019
EvidenceNOW Targets | P RACTICE C APACITY AND ABCS
E VIDENCE NOW C OOPERATIVES | R EGIONAL M AP
C HARACTERISTICS O F E VIDENCE NOW P RACTICES EvidenceNOW ORPRN Characteristic, n(%) N=1,495 N=94 Practice location Urban 951 (63.6) 33 (35.1) Large Town 202 (13.5) 32 (34.0) Rural 235 (15.7) 18 (19.1) Suburban 107 (7.2) 11 (11.7) Classified as Medically Underserved Area 494 (33.0) 41 (43.6) Practice size Solo practice 357 (23.9) 7 (7.4) 2 to 5 clinicians (MD, DO, NP, PA) 699 (46.8) 47 (50.0) 6 to 10 clinicians 205 (13.7) 20 (21.3) 11 or more clinicians 159 (10.6) 20 (21.3) Practice ownership Clinician 605 (40.5) 36 (38.3) Hospital / health system / HMO 342 (22.9) 43 (45.7) Government clinics (FQHC, RHC, IHS) 322 (21.5) 12 (12.8) Other 166 (11.1) 3 (3.2)
B ASELINE P RACTICE C APACITY D ISTRIBUTION
B ASELINE ABCS P ERFORMANCE Mean (sd) Cooperative Measure performance mean range Smoking 0.55 (0.33) 0.24-0.75 Cholesterol 0.56 (0.24) 0.34-0.68 Blood Pressure 0.63 (0.17) 0.57-0.69 Aspirin 0.60 (0.28) 0.3-0.73
Ono SS, Crabtree BF, Hemler JR, Balasubramanian BA, Edwards ST, Green LA, Kaufman A, Solberg LI, Miller WL, Sweeney SM, Woodson TT, Cohen DJ. Takin ing g Inno novatio ion to S Scale i le in P Prim imary C Care P e Practic ices: T : The F he Func nctio ions o of Healt lth h Care Extensio ion. n. Health Affairs. Febru ruary ry 2018. 2018.
P RACTICE F ACILITATOR W ORKFORCE Cooperative Cooperative Cooperative Cooperative Cooperative Cooperative Cooperative Total 1 2 3 4 5 6 7 Number of 9 7 2 2 2 16 2 40 Practice Facilitator Organizations Number of 31 17 17 16 19 35 23 158 Practice Facilitators Mean EN 7.9 13.2 16.1 12.8 11.5 6.9 11.0 11.3 ± Practice Panel Size*
F ACILITATION
D OSE | I N -P ERSON P RACTICE F ACILITATION
M ETHODS I NTERLUDE
C ONFIGURATIONAL C OMPARATIVE M ETHODS
C HANGE IN ABCS | S MOKING
O UTCOME C LUSTERS | S MOKING 1, 2 AND 3
O UTCOME C LUSTERS | S MOKING 4, 5 AND 6
O UTCOME C LUSTERS | S MOKING 7 AND 8
O UTCOME C LUSTERS | S MOKING 9 AND 10
P RACTICE C HANGES | C HANGES R EPORTED TO I MPROVE S MOKING Documentation Process improvement Referral resources Track referral to quit line Outreach Staff Education
P RACTICE C HANGES | C HANGES R EPORTED TO I MPROVE S MOKING Practice Change Definition Documentation Evidence that someone in practice learned they were not documenting correctly and reported working with vendor and/or PF to change documentation behavior Process Improvement Changes to practice workflows beyond documentation; might include working with clinicians to make sure they do brief counseling changing workflow so that Mas do something different to provide brief counseling/referral for patients Referral Resources Give information about quit lines and other resources to patients Staff Education Efforts to educate staff in the practice about importance of smoking cessation counseling
S MOKING | N EGATIVE S OLUTIONS Practices that did not achieve a 5-point gain in smoking performance had: Absence of process improvement and a smaller dose of facilitation (less than 10 hrs.) Were hospital or health system owned Baseline 90-95%- started at a higher baseline
Ownership – control over QI process Health systems voluntold practices Facilitators did not always work directly with health system practices HS practice, even if they were engaged, didn’t have control of the change process and the change process was slower and more complex Didn’t have the data needed to do data informed QI and slow to get this from system might be told what workflows to implement (which could reduce engagement, even among the engaged) when staff developed their own change plan, these needed system level approvals.
M EAN C HANGE O VER T IME | B LOOD P RESSURE
O UTCOME C LUSTERS | B LOOD P RESSURE C LUSTER 1 AND 2
O UTCOME C LUSTERS | B LOOD P RESSURE C LUSTER 3 AND 4
O UTCOME C LUSTERS | B LOOD P RESSURE C LUSTER 5
CCM | P RACTICE S AMPLE FOR B LOOD P RESSURE 5% Change Analysis 10% Change Analysis (N=69) (N=76) Practice Characteristics Number Percent Number Percent Ownership Clinician owned 41 59.4% 44 57.9% Hospital/Health System 15 21.7% 16 21.1% FQHC 9 13.0% 9 11.8% Other 4 5.8% 4 5.3% Parent Organizations Orgs with >1 practice in QCA sample 8 NA 8 NA Practices part of a parent organization 18 26.1% 19 25.0% Practice Size Solo practice 22 31.9% 22 28.9% 2-5 clinicians 37 53.6% 40 52.6% 6-10 clinicians 7 10.1% 8 10.5% 11 or more clinicians 2 2.9% 2 2.6% Geographic Region / Cooperative Midwest (IN, IL, WI) 14 20.3% 14 18.4% North Carolina 6 8.7% 11 14.5% Northwest (OR, WA, ID) 7 10.1% 7 9.2% New York City (five NY boroughs) 15 21.7% 16 21.1% Oklahoma 9 13.0% 9 11.8% Southwest (CO, NM) 11 15.9% 11 14.5% Virginia 7 10.1% 8 10.5% Urbanicity Rural Area 8 11.6% 9 11.8% Large Town 12 17.4% 12 15.8% Suburban 5 7.2% 5 6.6% Urban Core 44 63.8% 50 65.8%
CCM | P RACTICE C HANGES R EPORTED TO I MPROVE CMS B LOOD P RESSURE M EASURE Blood pressure measurement training Patient education Registry / outreach Subsequent blood pressure check Take 2 nd blood pressure measure during visit Auto blood pressure cuff Clinical guidance Documentation Alert doctor to add blood pressure to agenda
CCM | P RACTICE C HANGE D EFINITIONS Practice Change Definition Blood pressure Educating staff in the practice to take a proper blood pressure measurement training Patient education Practices using new educational materials directed to patients to teach them about blood pressure control Subsequent blood Encourage patients to get subsequent blood pressure checks (e.g., free nurse pressure check visit to check blood pressure) Take 2nd blood pressure When the intake blood pressure reading is elevated, someone take a second measurement at the end of the visit Documentation Developing system for how a second BP is documented in the EHR
R ECIPES FOR C HANGE | B LOOD P RESSURE 5%
R ECIPES FOR C HANGE | B LOOD P RESSURE 10%
B LOOD P RESSURE | N EGATIVE S OLUTIONS Practices that did not achieve a 5-point gain in blood pressure performance had: AND absence of “Take 2 nd Blood Pressure” Fewer than 5 visits with a facilitator AN Less than 5 hours of facilitation 5 to 10 hours of facilitation AND absence of “Blood Pressure Measurement Training” 10-25 hours of facilitation AND absence of “Subsequent Blood Pressure Checks” AND either absence of “Take 2 nd Blood Pressure” OR OR absence of “BP Measurement Training” 10-25 hours of facilitation AND “Rural Area” 25-50 hours of facilitation AND Substantial Presence of “Registry/Outreach” More than 50 hours of facilitation AND absence of “Take 2 nd Blood Pressure” AND absence of “Subsequent Blood Pressure Checks”
T HE T EAM
T HANK YOU escalates@ohsu.edu escalates.org @ESCALATESorg
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