Download Riverside and PACE_Case Study FINAL 2014

Kaiser Permanente Southern California Region
ALL and ALL HEART Initiatives in the Safety Net
Diabetes Care Management Models in Pasadena and Riverside, CA
March 2014
BACKGROUND
Providing coordinated care management for patients with diabetes is challenging, particularly for those with
limited income and resources living in underserved areas. This case study describes how two ambulatory care
sites within the safety net system implemented diabetes care management programs using resources and
support from Kaiser Permanente Southern California Region Community Benefit’s ALL Initiative to improve care
provided to patients suffering from diabetes.
The ALL (Aspirin, Lisinopril, and Lipid-Lowering medication) Initiative was developed by Kaiser Permanente in
2003 to reduce cardiovascular disease among patients with diabetes over age 50 within the Kaiser Permanente
system by systematically prescribing the ALL triad of medications. Based on the success of ALL, Kaiser
Permanente Southern California Region Community Benefit began to support the translation of the Initiative to
safety net clinics and providers. Since 2006, Kaiser Permanente Southern California Region Community Benefit
has supported the implementation of ALL in over 60 community clinics, health centers, and hospital systems
serving over 40,000 low-income, uninsured, medically underserved and vulnerable patients with diabetes. The
most recent incarnation is ALL HEART. The HEART (Heart Smart Diet, Exercise, Alcohol Limits, Rx Medicine
Compliance, Tobacco Cessation) aspect emphasizes care coordination, self-management, and health education,
such as tobacco cessation, increasing physical activity, and other such lifestyle changes.
This case study focuses on the diabetes care management established by Riverside County Health System
(“Riverside”) and the City of Pasadena Public Health Department (“Pasadena”) through the ALL Initiative. At
Riverside, the program is called ALL, and at Pasadena the program is called PACE (Prevention, Adherence,
Collaboration and Education).
METHODS
The Center for Community Health and Evaluation (CCHE) conducted day-long site visits at Riverside County
Health System and the City of Pasadena Health Department. We observed a provider and a diabetes educator
conducting one-on-one health education with patients. We also conducted interviews with physician
champions, clinical support staff (registered nurses and medical assistants), data or IT staff, and health
education/care managers. In addition, we obtained diabetes outcome data to examine the impact of the
program on patient clinical outcomes.
ORGANIZATION DESCRIPTION
The Riverside and Pasadena care management programs
are organized in fundamentally different ways, reflecting
the differences in the two health care systems.
Riverside County Health System (“Riverside”) is an
integrated county health care system with one hospital,
80 specialty care clinics and 10 Federally Qualified
Riverside County Health System
Health Center (FQHC) Look-Alike clinics. Riverside’s
Diabetes Care Clinic was opened in 2010 with a grant
from the ALL Initiative and is housed within the hospital along with the Family Care Clinic and Internal Medicine
(the designated medical homes for primary care patients). When a patient with diabetes—in either the Family
Care Clinic or Internal Medicine—has an uncontrolled hemoglobin A1c greater than 9%, they are referred to the
Diabetes Care Clinic for intensive care management; once their diabetes is under control and the patient
achieves an A1c of 7% or lower, they are returned to Family Care or Internal Medicine for continued care.
Diabetes Care Management Models in Pasadena and Riverside, CA
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Pasadena Public Health Department
(“Pasadena”) is a city-based public health
department that provides infectious disease
control, primary prevention, education,
outreach, and other services. Pasadena, which
does not provide primary care clinical services
other than immunizations, partners with the
largest FQHC provider in the city, Community
Health Alliance of Pasadena (“ChapCare”), to
send clients for primary care and dental services.
ChapCare Health Center
Pasadena Public Health Dept.
ChapCare’s patients with diabetes who are ages
55 and older, are referred to Pasadena to be a
part of the diabetes care management program, known as PACE. The PACE program is led by a physician
champion and a program coordinator who are employees of the health department. The main role of the PACE
physician champion is to ensure that ChapCare providers are trained on the ALL medication protocol and are
prescribing the ALL medications to eligible patients with diabetes. The PACE program coordinator provides
intensive care management to a panel of 100 patients with diabetes. After working with a patient, the program
coordinator documents the results of the encounter into ChapCare’s electronic health record to maintain
continuity of care.
DIABETES CARE MANAGEMENT PROGRAMS
Despite the differences in the structure of their organizations, the care management programs share a number
of common elements: planned visits,* health education, coaching, care coordination, and specialty referrals (see
Table 1).
Table 1. Summary of Intensive Care Management Programs at Riverside and Pasadena
Riverside (Diabetes Care Clinic)
Overview: A team-based approach to care management
where multiple staff members provide and coordinate
components of care management.
Number of patients with diabetes served:
Over 800 unique patients since opening of the Diabetes
Care Clinic, with an average of 1800-1900 visits annually.
Pasadena (PACE)
Overview: a team consisting mainly of a Provider
Champion, and a Care Coordinator who leads a series of
structured health education sessions and coordinated
follow-up visits.
Number of patients with diabetes served:
Total number served as of October 2013 is 103, with 12
patients dropping out due to changes in primary care
physician or relocation outside of Los Angeles/Pasadena.
Eligibility criteria:
• All individuals with diabetes A1c > 9 (age 50+ with
diabetes is criterion specifically for ALL).
• Provider/clinician initiated referral for any person
with diabetes who can benefit from intensive
intervention (e.g., patients who may need more
intensive, coordinated care).
Eligibility criteria:
• Age 55+ with diabetes is target population for PACE,
but staff will see any patient with diabetes who are
interested in the program.
Staffing involved in care management:
• Medical Assistants (MA)
• Registered Nurse (provide health education and care
coordination)
• Nurse Practitioner
• Physicians
• Dietician/Nutritionist
• Retinal Photographer
Staffing involved in care management:
• Diabetes Care Coordinator – Health Department
• Physician Champion – Health Department
• Medical Assistants (MA) – ChapCare
• Registered Nurses – ChapCare
• Physicians – ChapCare
Diabetes Care Management Models in Pasadena and Riverside, CA
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Riverside (Diabetes Care Clinic)
Pasadena (PACE)
Key components:
• Planned visits*
• Extended patient visit (30 minutes)
• One-on-one health education provided during
majority of patient visits
• Coordinated referrals to specialists and other support
• MA and scheduling staff call patients to remind them
of their next visit at least twice
• Lifestyle and self-management goals are discussed
and established
Key components:
• Planned visits* with ChapCare providers
• Three, one-on-one health education and coaching
sessions, held at health department (1-2 hour per
session)
• Follow-up with ChapCare clinic staff and patient for
referrals to specialists
• Care Coordinator and student interns call patients to
remind them of health education sessions or provide
education over the phone if patient is unable to come
in or repeatedly misses appointments
• Lifestyle and self-management goals are discussed
and established
* A planned patient visit is initiated by the practice to focus on care management for chronic conditions as opposed to care provided at acute visits. These
visits are typically scheduled at regular intervals and structured to deliver evidence-based care and patient support, such as health education, selfmanagement goal setting, and shared decision making (Bodenheimer T (2005). Helping Patients Improve Their Health-Related Behaviors: What System
Changes Do We Need? Disease Management, 8(5):319-330).
PATIENT OUTCOMES
Based on early data, both Riverside and Pasadena care management programs are showing positive patient
outcomes for control of diabetes. In both clinics, the percent of patients with hemoglobin A1c greater than 9%
declined over time more in the care management programs than in patients seen in the usual primary care
clinics.
Figure 1 shows data from
Riverside comparing patients’
first and last HbA1c test. There
was a 20% drop (from 61% to
41%) in the number of patients
with HbA1c greater than 9% for
patients seen in the Diabetes
Care Clinic compared to drops
of 1% and 6% in Family Care
Clinic and Internal Medicine,
respectively.
Figure 1. Riverside: Diabetes Care Clinic vs. Family Care and Internal Medicine
Percent of Patients with HbA1c >= 9
70%
60%
50%
40%
61%
41%
30%
37%
26% 25%
31%
First A1C Test
Last A1c Test
20%
10%
0%
Diabetes Clinic
Family Care
Internal Medicine
Figure 2. Pasadena: Care Management Clients vs. ChapCare Diabetic Patients
Percent of patients with A1c >= 9
50%
43%
40%
30%
29%
17%
20%
19%
10%
0%
PACE Program
ChapCare
Time 1 (Sept 30, 2012)
Time 2 (June 30, 2013)
Figure 2 shows data from Pasadena
at two time intervals. The results
show that, for PACE patients, the
percentage of patients with HbA1c
greater than 9% dropped nearly
14%, from 43% to 29% compared
to a trivial change among patients
with diabetes not in the program.
Diabetes Care Management Models in Pasadena and Riverside, CA
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SUMMARY & NEXT STEPS
Using support from their ALL grants, both Riverside and
Pasadena have successfully established integrated care
management for patients with diabetes within their
health systems, and these care management programs
have improved outcomes related to control of diabetes.
Both health organizations credited their participation
in ALL as instrumental for helping them implement
quality improvement activities and provide better
patient care. Additionally, the organizations also
identified other benefits of participating in ALL, such as
promoting a team approach to care, using data and
information technology to support decision making, and
developing a culture that promotes continuous quality
improvement.
“Without ALL we wouldn’t have
blossomed with what we are doing
with diabetes care. The team has really
focused on teaching patients skills so
they can manage their diabetes and
chronic conditions. We now have the
Diabetes Clinic as a result of our
participation in ALL, which is the most
effective QI program we have
currently.” – Dr. Leung (Chief of Family
Medicine for Riverside)
As for next steps and long-term sustainability, for Riverside,
the care management is integrated within the clinic
workflow and is part of the standard of care for the
Diabetes Care Clinic. As such, the care management they
provide is likely to be sustained. However, staff expressed
some concern about the unpredictability of the funding
environment, which could present challenges to sustaining
the current level of staffing and resources needed for
intensive care management. Similarly, Pasadena is
exploring ways to continue PACE within a larger chronic
disease management program and possibly training lowerlevel staff to provide care management with oversight from
nurses. ChapCare is also planning to strengthen their care management for patients with diabetes, modeling
after PACE by expanding the role of RNs and MAs. RNs will be used to teach diabetes courses at ChapCare sites,
while MAs will provide self-management support proactively during patient visits.
“PACE benefit patients by helping them build
diabetes self-management skills, including
patient-initiated goal-setting for lifestyle
change. Although we measure our impact
through improvements in glucose levels, we
also see our patients making health attitude
and behavior changes.” – Dr. Goh (PACE
Provider Champion for Pasadena)
The intended impact for ALL is to improve clinical outcomes and create sustainable changes in clinical quality
improvement efforts in order to improve population health. These two health systems have reached this
objective through different care management approaches. Not unlike most care management/care
coordination programs, the sustainability of these programs will require ongoing funding to support a more
robust, team-based staffing model to provide more intensive support to patients. Until reimbursement
mechanisms for these types of activities are established, ongoing support—even at reduced levels—will be
needed to sustain the current level of care management.
For more information about Kaiser Permanente’s ALL and ALL HEART Initiatives, please contact Mercy Siordia,
[email protected], (626) 405-4612.
Prepared by the Center for Community Health and Evaluation
Part of Group Health Research Institute
www.cche.org