Large-scale Implementation of Collaborative Care Management for - - PowerPoint PPT Presentation

Large-scale Implementation of Collaborative Care Management for Depression and Diabetes and/

• r Cardiovascular Disease

Claire Neely, MD, FAAP Chief Medical Officer Institute for Clinical Systems Improvement

• No conflicts to declare

A health care quality improvement collaborative in Minnesota focused on achieving the Triple Aim of better care, smarter spending, healthier people.

3

Institute for Clinical Systems Improvement

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

5

COMPASS Consortium: Ten National Partners

The Partnership

6

• 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

7

Collaborative Care Model

Complex Complex

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

9

Hypertension Outcomes

89 67 25 100 62 64 76 34 46 50 57 65 27 54 70 46 44 52 10 20 30 40 50 60 70 80 90 100 A B C D E F G H i J K L M N O P Q R %BP<140/90 * COMPASS Organiza7on *Denominator: PaHents with BP >140/90 at enrollment and enrolled at least 4 months

10

HgbA1c Outcomes

8 20 7 30 28 17 32 20 30 33 30 16 14 20 27 29 11 25 5 10 15 20 25 30 35 A B C D E F G H i J K L M N O P Q R % A1C less than 8 * *Denominator: PaHents with HgbA1c >8 at enrollment and enrolled at least 4months

11

Depression Outcomes

• 45 54 52 59 52 45

73 59 63 63 62 70 32 23 60 62 44 70 10 20 30 40 50 60 70 80 90 100 A B C D E F G H I J K L M N O P Q R % Improved* *%paHents enrolled at least 4 months, with a 5 point drop in PHQ9 or score <10

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

• Semi-structured

interviews

– Site visits – Care Teams interviews – SCR interviews – 1:1 interviews

• Observation
• Follow up survey

gathering additional data on themes identified in qualitative analysis

14

Data collection methods

This work was not conducted using formal framework, but CFIR used as a guide and context for understanding and

• rganizing the identified

themes

• Intervention

characteristics

• Outer/Inner setting
• Implementation

Climate

• Characteristics of

individuals

• Process

15

CFIR

Advantages

• COMPASS model was

seen to have advantages

• ver existing care

management models

• Supported by high quality

evidence

• Cost savings potential

Complex Innovation

• New teams
• Re-allocation of

resources

• Coordination of

resources in novel ways

16

Translating RCTs Requires Adaptation

Design Program designed to be time-limited, but no specific time limit required. Once goals met, patient returned to primary care team. Adaptations

• Sites created specific

time limits of 6-12 months to manage case load

• Sites kept ”fragile”

patients engaged for entire project

• Patients discharged

when hard to reach

• Comprehensive outreach

plans devised

17

Length of Enrollment [CFIR Intervention]

Design Common, stand alone care management tracking system (registry) provided to participants Adaptations

• Used native EHRs
• Built own registry
• Used commercial

products

18

Registry Use [CFIR Intervention]

Design Patient population and needs defined by medical and behavioral health problems. Adaptations

• Large subset with social

complexity

• Social workers added to

teams

• Care managers took care
• f wide variety of social

problems, decreasing time available for medical interventions

19

Patient Social Needs [CFIR Outer Setting]

Design Integrate model as the standard way of caring for this population to support primary care teams. Care manager part of the patient’s primary care team and is on site. Adaptations

• Need to integrate with

existing care management programs

• Low engagement with

PCPs in some settings required deliberate processes to gain trust

• Central location, with

phone/virtual contact

20

Care Management History: [CFIR inner setting]

Design Professional degree (RN) Medical knowledge of key importance Adaptations

• RN
• LCSW
• Psychologists
• Pharmacists
• Health Coaches
• Ability to build and

maintain relationships as key

21

Care Manager Characteristics [CFIR individuals]

Design Weekly, in person, systematic consultation team meetings Adaptations

• Need to dedicate time to

learning team skills

• Scheduling/resource use

challenges for weekly meetings

• Virtual teams designed

22

Care Team Dynamics [CFIR Process]

Design Weekly reports on outcome and process measures for use by teams to improve processes and population health. Adaptations

• High use of reports to no

use.

• Local reports designed

locally

• Data aggregated

centrally and used by project leadership as “early signal”

23

QI and Outcomes Measures [CFIR Process]

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

cneely@icsi.org More information about COMPASS available: ICSI.org General Hospital Psychiatry July/August 2016 Special thanks to Wayne Katon, MD who pioneered and studied this model of care and was a supporter and advisor to this work.

Thank you