Translational Research at CHCI Informing Practice with Research on - - PowerPoint PPT Presentation

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Translational Research at CHCI Informing Practice with Research on - - PowerPoint PPT Presentation

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Translational Research at CHCI Informing Practice with Research on the Front Lines of Primary Care Daren Anderson, MD Vice-President/Chief Quality Officer Community Health Center, Inc. 1 Research Tapas menu Outline: CHC overview

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Translational Research at CHCI

Informing Practice with Research on the Front Lines of Primary Care

1

Daren Anderson, MD Vice-President/Chief Quality Officer Community Health Center, Inc.

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Research “Tapas menu”

Outline:

  • CHC overview
  • How research informs practice: 4 brief

case studies:

– Completed projects: Telephonic disease management for diabetes, diabetes self management – Current project: Improving pain management – Design phase projects: improving specialty access with eConsults and video conferencing

  • Questions/Discussion

2

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218Locations

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Middletown, CT Groton, CT Old Saybrook, CT Meriden, CT Clinton, CT New Britain, CT New London, CT Stamford, CT Norwalk, CT Enfield, CT Bristol, CT

4

Danbury, CT

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  • Patients who consider CHC their health care home: 130,000
  • Health care visits:

: 350,000 per year

0% 25% 50% 75% 100% 90.80% 22% 64.8% 42% 6% 65%

CHC Patient tient Demographics aphics

CHC Patient Profile

5

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CHC Model of Primary Care

  • Patient Centered Medical Home (Level 3)
  • Advanced access scheduling
  • Clinical dashboard drives improvement
  • Expanded hours
  • Clinical integration of all services
  • Formal research program
  • Electronic health records
  • Residency training for nurse practitioners
  • W.Y.A. (Wherever You Are) Health Care for the homeless
  • Mobile dentistry services to 150 schools
  • Outreach and eligibility screening and enrollment

6

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  • Fully integrated EMR
  • Patient portal and HIE
  • Integrated primary care

and behavioral health

  • Mobile dentistry serving over 150 schools
  • Automated clinical dashboards
  • Nation’s first NP residency training program
  • “In house” IRB
  • Research partnerships: Yale, VA, Dartmouth,

Harvard , UCONN

7

Innovations

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What types of research?

  • Implementation science
  • Qualitative
  • RCT
  • Financial/health econ
  • Organizational change
  • QI

8/19/10 8

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Challenges

  • Busy practices
  • Poor patient adherence
  • Language/literacy issues
  • Financial constraints
  • Staffing

8/19/10 9

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Managing the Space Between Visits: Telephonic Disease Management for Patients with Diabetes in a Community Health Center

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Things a diabetic patient should do:

  • Take meds: QD, QHS, BID,
  • Check FS: fasting, 2hr post

meals, qhs

  • Check feet/safe shoes
  • Reduce carbs
  • Reduce fat/cholesterol
  • Increase fiber
  • Exercise daily: CV and

resistance

  • Understand A1C, lipids,

complications

  • Floss
  • See dentist
  • See ophtho
  • See PCP at least q3mo
  • Attend nutrition/ed

sessions

  • Quit smoking
  • Manage hypoglycemia
  • Home monitor bp
  • Meal planning
  • Healthy shopping
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How would you do with this regimen?

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How would you do if you were:

  • Depressed
  • Living in a foreign country
  • Unable to read
  • Unable to speak the same language as your doctor?
  • Eating a different diet than “typical”
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Not well…

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Practice question #1:

  • How can we provided added support for

patients struggling to manage type 2 diabetes?

8/19/10 15

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Hypothesis

Culturally and linguistically appropriate telephonic disease management, modeled after the DM industry, will lead to improved behavioral and intermediate clinical outcomes in a population of poor, largely non-English speaking medically underserved patients in a community health center

Design: RCT

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Intervention

  • Trained staff using DM consultants/

Lorig SM methods

  • Outbound calls to patients

– High risk: weekly – Moderate risk every 2 weeks – Low risk: Monthly

  • 15 minute duration
  • Call content: patient driven

– Brief assessment – Medication review/adherence – Self management support: diet, exercise, self care goals – Reminders/prompts for needed care

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Outcomes: 6 months and one year

  • Diabetes clinical outcomes
  • A1C
  • BP
  • LDL
  • BMI
  • Behavioral Outcomes:
  • Self management goal attainment (attainment score 1-

4)

  • Dietary habits (survey tool)
  • exercise (RAPA survey)
  • Financial outcomes
  • Total healthcare cost
  • Qualitative assessment
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Results Summary

  • Qualitative:

– high degree of acceptance and support from patients for this intervention – Significant “navigator” function played by the disease manager – May not be captured by our outcomes assessment

  • Quantitative

– No treatment effect for overall study population for multiple clinical and behavioral outcomes – Trend towards benefit in HbA1C 7-9 group

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8/19/10 23

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Impact of the study on practice

  • Remote telephonic support did not

provide added benefit.

  • DM call center was shut down
  • Future efforts focused on more

comprehensive, onsite support with multiple team members: PharmD, CDE, nursing

8/19/10 24

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Practice question #2:

  • Can SM goal setting be effectively

deployed and have benefit for underserved patients cared for at CHC?

8/19/10 25

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Enhancing Diabetes Care Through Self Management

8/19/10 26

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8/19/10 27

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8/19/10 28

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8/19/10 29

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Impact of the study on practice

  • All nurses and incoming APRN’s trained

in self management goal setting

  • SM goal setting incorporated into diabetes

care and other chronic illnesses

  • Universal screening for depression
  • Co-location of behavioral health in

primary care

8/19/10 30

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Project STEP-ing Out

A Collaborative Project between VA Connecticut and CHC Inc. to Improve the Care of Patients with Chronic Pain

8/19/10 31

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Practice question #3

  • What is the impact of pain on primary

care practice

  • What gaps exist between “best practices”

for pain care and our own clinical practice?

  • How should we design an agency wide

pain QI intervention to improve our care

  • f patients with pain?

8/19/10 32

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Project Goals

– Conduct a formative evaluation of pain and pain management in primary care at a large, statewide Community Health Center. – Adapt the VA Stepped Care Model to meet the needs of CHCI unique settings and patient population. – Study the adoption and implementation of the stepped care model at a non-VA site. – Reduce the impact of pain and suffering on CHC patients – Reduce the community burden of unintended

  • pioid addiction, diversion, and street use

8/19/10 33

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Data sources

  • EHR data
  • Chart review
  • Staff surveys

8/19/10 34

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Pain Frequency

H O W C O M M O N I S PA I N AT C H C A N D W H AT P E R C E N TAG E O F O U R V I S I T S I N VO LV E PAT I E N T S W I T H C H R O N I C PA I N

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142089 49834 (35%) 24090 (17%) 10333 (7%)

20000 40000 60000 80000 100000 120000 140000 160000 All visits Visits with pain score >=4 Visits with pain score >=8 Visits with NULL pain scores

Adult Pain Scores at CHCI

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5.78 11.16 12.11 15.03 0.00 2.00 4.00 6.00 8.00 10.00 12.00 14.00 16.00 Agency-wide Opioid Cohort Pain >=4 Cohort Chronic Opioid Cohort

Average Number of Visits per Patient

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2% 0% 4% 7% 5% 3% 9% 15% 6% 2% 5% 17% 1% 20% 29% 19% 15% 36% 39% 20% 13% 18% 2% 2% 36% 20% 24% 25% 48% 52% 43% 37% 39%

0% 25% 50% 75% 100%

Norwalk Medical (n=929) Stamford Medical (n=3773) Bristol Medical (n=3792) Groton Medical (n=15773) Enfield - Medical (n=14204) Danbury Medical (n=14735) Clinton Medical (n=11011) New London Medical (n=24769) Middletown Medical (n=34180) New Britain Medical (n=43871) Meriden Medical (n=53460)

Percent Total Visits by Patients in Each Cohort

Visits in Pain Cohort Visits in Opioid Cohort Visits in Chronic Opioid Cohort

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Knowledge and confidence

W E W I L L L O O K AT C H C P R I M A RY C A R E P R OV I D E R’ S S C O R E S O N A PA I N K N OW L E D G E A S S E S S ME N T A N D T H E I R E X P RE S S E D AT T I T U D E S A B O U T PA I N C A R E

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152.49 138 178 150 0.00 50.00 100.00 150.00 200.00 250.00 CHCI Providers (n=47) Davis et al. Validation Cohort: Internists (n=84) Davis et al. Validation Cohort: Pain Experts (n=22) Davis et al. Validation Cohort: Academic Physicians (n=27)

Avg CHCI KP50 Baseline Score Comparison (2 Standard Deviations) Max possible score=250

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3.74 1.15 1.36 1.81 2.04 2.17 2.55 4.45 3.77 2.77 1.53 0.00 1.00 2.00 3.00 4.00 5.00 SKILLED CHRONIC PAIN MANAGEMENT IS A HIGH PRIORITY FOR ME. MY MANAGEMENT OF CHRONIC PAIN IS INFLUENCED BY EXPERIENCE WITH ADDICTED

PATIENTS.

MY MANAGEMENT OF CHRONIC PAIN IS INFLUENCED BY FEAR OF CONTRIBUTING TO

DEPENDENCE.

I HAVE ADEQUATE TIME TO MANAGE MOST PATIENTS WITH CHRONIC PAIN. FEAR OF NARCOTIC REGULATORY AGENCIES/ADMINISTRATION INFLUENCES MY

DECISIONS REGARDING CHRONIC PAIN MANAGEMENT.

ANALGESIC SIDE EFFECTS HINDER MY EFFORTS TO TREAT PATIENTS WITH CHRONIC PAIN. PATIENTS I TREAT BECOME ADDICTED TO OPIOIDS. I USE AN OPIOID AGREEMENT WITH MY PATIENTS. I USE A PAIN ASSESSMENT OR MONITORING TOOL. I AM CONFIDENT IN MY ABILITY TO MANAGE CHRONIC PAIN. I AM SATISFIED WITH THE QUALITY OF RESOURCES AVAILABLE TO HELP ME MANAGE

PATIENTS WITH CHRONIC PAIN.

Average CHCI Clinician Attitudes Baseline Survey Score (n=47)

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Referrals/specialty support

H E R E W E L O O K AT T H E P E R C E N TAG E O F PAT I E N T S W I T H C H R O N I C PA I N R E F E R R E D T O O U T S I D E PA I N - R E L AT E D S P E C I A L I S T S

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0% 0% 0% 14% 7% 0% 7% 3% 16% 3% 0% 0% 0% 14% 9% 0% 6% 4% 20% 3% 0% 0% 0% 13% 12% 0% 6% 7% 25% 4%

Addiction Medicine Chiropractor Acupuncturist Physical Therapy Pain Management Physiotherapy Physical Med and Rehab Neurological Surgery Orthopedic Surgery Rheumatology

Pain Referrals by cohort

Chronic Opioid Cohort (n=1019) Opioid Cohort (n=3663) Pain Cohort (n=6746)

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Behavioral Health co- Management

W E W I L L L O O K AT T H E N U M B E R O F PAT I E N T S W I T H C H R O N I C PA I N B Y PA I N S C O R E A N D / O R C H R O N I C O P I O I D U S E W H O A L S O H A D V I S I T S W I T H C H C B H P R OV I D E RS

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25% 8% 25% 37% 0% 8% 26% 34% 36% 26% 50% 0% 0% 25% 50% 75% 100%

Chronic Opioid Cohort with 1+ CHC BH Visit

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Standard of Care

W E E X A M I N E C H C P R OV I D E R’ S A D H E R E N C E T O PA I N C A R E S TA N DA RD S

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68% 92% 90% 69% 84% 78% 46% 59% 62% 78% 50% 66% 92% 58% 69% 75% 55% 80% 36% 96% 65% 50%

0% 25% 50% 75% 100%

Opioid Contract and UTOX Adherence: Chronic Opioid Cohort

Opioid Contrac t Urine Tox

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W E E VA LUAT E T H E F R E Q U E N C Y W I T H W H I C H O P I O I D S, A N D H I G H D O S AG E S O F O P I O I D S, A R E U S E D F O R PA I N C A R E

Opioid Usage

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1 1 2 2 3 3 3 4 5 5 5 6 8 9 9 12 12 12 13 14 14 14 16 17 17 18 19 22 25 34 35 40 44 44 49 56 63 69 87 97 110

Ayubcha MD, Soussan- FP Kim MD, Jennifer Lorilla MD, Ivy Pham APRN, Hao Quarles APRN, Kristie Trevey APRN, Martha Wessling MD, Kathleen Mewe Pira APRN, Ngozi-PD Olivier APRN, Anna Smith MD, Stephen LOCUM Weir MD, Lori Hassan MD, Syed Mohammadu MD, Fusaini Swan APRN, Amanda Bravo MD, Teresa-FP Gellrich MD, Gabriella-FP Lau MD, Wai Lang- IM Wilson APRN, Laura DeMarco APRN, Rachel-FP Long APRN, Sarah-FP Haddad MD, Marwan-ID Nguyen MD, Derek Channamsetty MD, Veena-FP Faith APRN, Sarah-FP Weischedel MD, Anne-Katrin Rausche MD, Melanie Freedman APRN, Debra-FP Thomas APRN, Bernadette--FP Wynn MD, Daisy--FP Kucharchik MD, Thomas-FP Eddinger APRN, Ann-FP Wagner APRN, Monte Borgonos MD, Ovanes-FP Doerwaldt MD, Hartmut-FP Barrow MD, Alvin Mathulla MD, Cible-FP Butler MD, Danielle-FP Rivera Godreau MD, Ivelisse--FP Westbrook MD, Tory--FP Lecce MD, Carl-FP Wilensky MD, Dan--FP Suozzi MD, Theresa Pathman MD, Anandhi--IM-PD Blankson APRN, Mary-FP Patel DO, Dipak--FP Huddleston MD, Matthew-FP Monroe, Jr. MD, John-FP Decker APRN, Patricia-FP

# Patients with 90 Days or More of Opioids

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Action plan

Lack of pain training/low knowledge scores Lack of pain specialty support Low behavioral health co- management Low use of CAM Poor documentation

  • f pain

assessment and treatment low rates of pain reassessment Low rates of

  • pioid

agreement/ u- tox monitoring

New CHC Policy

  • Utox q 6 month
  • Opioid agreement q yr
  • Documented f/u q 3

mo

  • Pain follow up HPI

folder

  • Pain dashboard

Project ECHO Online pain CME Chiropractic and (?) acupuncture svc at CHC Behavioral health pain referrals

Impact of the study on practice

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Practice question #4:

  • Can we improve access to specialty

consultation using technology and non- face to face consultation?

8/19/10 51

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Evaluating the Impact of eConsults

  • Problem:

– Only 40% of patients sent to specialists have documented evidence in chart of attending the visit – Many consults do not require face to face visits

  • Research question:

– What is the impact of an eConsult intervention on clinical and operational

  • utcomes?
  • Design:

– Wait list control (stepped wedge)

10/28/2011 52

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eConsults

  • Intervention: EHX information

exchange between PCP and cardiology

  • Outcomes of interest:

– Completed consults – # face to face consults avoided – Framingham scores – Total costs/utilization

8/19/10 53

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ECHO Pain Evaluation

  • Problem: Primary care providers manage

the vast majority of patients with pain, despite little training. Specialty support is not widely available

  • Research question: what is the impact of

Project ECHO on pain management

  • utcomes including provider

performance, patient function, and financial/utilization

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Project ECHO

  • Intervention: Project ECHO video case

conferences between PCP and pain multidisciplinary panel

  • Design: Randomized Case Control

– Sites randomized to ECHO or no ECHO – PCP’s within site randomized to participate or not

  • Outcomes:

– Knowledge, pain outcomes, referrals, pharm, cost/utilization

8/19/10 57

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Impact of research on practice

  • To be determined…

8/19/10 58

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Summary

  • CHCI practice is directly informed by

research

  • Translational research in this setting

provides the opportunity to bridge the gap between research and practice

  • Research in primary care setting is

challenging

  • Complicated, quasi-scientific methods are
  • ften needed

8/19/10 59

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Research Opportunities

  • PCMH implementation/outcomes
  • Social media and health promotion
  • Health IT:
  • Childhood obesity/school-based health
  • Chronic disease management
  • Behavior Modification
  • Integration of Behavioral Health and

Medicine

  • Primary care delivery: organization of the

care team

  • Care coordination in primary care

8/19/10 60