Large-scale Implementation of Collaborative Care Management for Depression and Diabetes and/ or Cardiovascular Disease � Claire Neely, MD, FAAP � Chief Medical Officer � Institute for Clinical Systems Improvement �
• No conflicts to declare
Institute for Clinical Systems Improvement � A health care quality improvement collaborative in Minnesota focused on achieving the Triple Aim of better care, smarter spending, healthier people . 3
Care of Mental, Physical, and Substance-use Syndromes � The project described was supported by Grant Number 1C1CMS331048 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. The research presented here was conducted by the awardee. Findings might or might not be consistent with or confirmed by the independent evaluation contractor. � � 4
COMPASS Consortium: Ten National Partners � 5
The Partnership � • 18 medical groups with 174 participating clinics � • urban, suburban and rural � • integrated systems and standalone primary care � • FQHC � • residency training � • 3 organizations skilled in QI project design and evaluation, including those who have done original research in collaborative care models � • 3 regional healthcare improvement collaboratives with broad experience in implementing complex care interventions � • 1 IPA, 2 ACOs, 3 Health Plans � 6
Collaborative Care � Model � Complex Complex � 7
Key Components � • A defined care management process � • Systematic case review teams � • Care management tracking system � • Systematic treatment intensification � • Monitoring for potentially preventable events � • Routine data reporting & QI processes � 8
Hypertension Outcomes � 100 90 80 70 %BP<140/90 * 60 50 100 89 40 76 70 67 46 50 57 65 62 64 30 54 46 44 52 20 34 27 25 10 0 A B C D E F G H i J K L M N O P Q R COMPASS Organiza7on *Denominator: PaHents with BP >140/90 at enrollment and enrolled at least 4 months 9
HgbA1c Outcomes � 35 30 % A1C less than 8 * 25 20 30 33 30 32 15 30 28 27 29 25 10 20 20 20 17 16 14 11 5 8 7 0 A B C D E F G H i J K L M N O P Q R *Denominator: PaHents with HgbA1c >8 at enrollment and enrolled at least 4months 10
� Depression Outcomes � 100 90 80 70 % Improved* 60 50 40 73 59 63 63 62 70 70 60 62 30 45 54 52 59 52 45 44 20 32 23 10 0 A B C D E F G H I J K L M N O P Q R *%paHents enrolled at least 4 months, with a 5 point drop in PHQ9 or score <10 11
Purpose of Analysis How did local settings adapt and maintain fidelity over the course of the project? � 12
Acknowledgements for this analysis • Arne Beck, PhD KP Colorado Institute for Research • Jennifer Boggs, MSW KP Colorado Institute for Research • Angelika Alem, MPH KP Colorado Institute for Research • Mark Williams, MD Mayo Clinic, Rochester • Robert Ferguson Pittsburgh Regional Health Initiative • Leif Solberg, MD HealthPartners Institute • Claire Neely, MD ICSI 13
Data collection methods • Semi-structured • Observation interviews • Follow up survey – Site visits gathering additional – Care Teams data on themes interviews identified in – SCR interviews qualitative analysis – 1:1 interviews 14
CFIR This work was not • Intervention conducted using formal characteristics framework, but CFIR • Outer/Inner setting used as a guide and • Implementation context for Climate understanding and • Characteristics of organizing the identified individuals themes • Process 15
Translating RCTs Requires Adaptation Advantages Complex Innovation • COMPASS model was • New teams seen to have advantages • Re-allocation of over existing care resources management models • Coordination of • Supported by high quality resources in novel ways evidence • Cost savings potential 16
Length of Enrollment [CFIR Intervention] Design Adaptations Program designed to be • Sites created specific time-limited, but no specific time limits of 6-12 months time limit required. Once to manage case load goals met, patient returned • Sites kept ”fragile” to primary care team. patients engaged for entire project • Patients discharged when hard to reach • Comprehensive outreach plans devised 17
Registry Use [CFIR Intervention] Design Adaptations Common, stand alone care • Used native EHRs management tracking • Built own registry system (registry) provided to • Used commercial participants products 18
Patient Social Needs [CFIR Outer Setting] Design Adaptations Patient population and • Large subset with social needs defined by medical complexity and behavioral health • Social workers added to problems. teams • Care managers took care of wide variety of social problems, decreasing time available for medical interventions 19
Care Management History: [CFIR inner setting] Design Adaptations Integrate model as the • Need to integrate with standard way of caring for existing care this population to support management programs primary care teams. • Low engagement with PCPs in some settings Care manager part of the patient’s primary care team required deliberate and is on site. processes to gain trust • Central location, with phone/virtual contact 20
Care Manager Characteristics [CFIR individuals] Design Adaptations Professional degree (RN) • RN Medical knowledge of key • LCSW importance • Psychologists • Pharmacists • Health Coaches • Ability to build and maintain relationships as key 21
Care Team Dynamics [CFIR Process] Design Adaptations Weekly, in person, • Need to dedicate time to systematic consultation learning team skills team meetings • Scheduling/resource use challenges for weekly meetings • Virtual teams designed 22
QI and Outcomes Measures [CFIR Process] Design Adaptations Weekly reports on outcome • High use of reports to no and process measures for use. use by teams to improve • Local reports designed processes and population locally health. • Data aggregated centrally and used by project leadership as “early signal” 23
Summary: Themes for further exploration • Length of enrollment in collaborative care programs and the target population • Patient psychosocial needs/social complexity effects on program elements • Use of registries for individual care and population and system improvement • Using resources effectively and efficiently 24
Thank you cneely@icsi.org More information about COMPASS available: Special thanks to ICSI.org Wayne Katon, MD who pioneered and studied General Hospital this model of care and Psychiatry July/August was a supporter and 2016 advisor to this work.
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