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Improving Asthma Care in Cincinnati: The Journey Stephen Pleatman, MD Pediatrician, Suburban Pediatric Associates, Inc. Board Member, Ohio Valley Primary Care Associates, L.L.C. Cincinnati, Ohio AAP Chapter Quality Network Asthma Pilot Project Ohio Chapter Learning Session #1 October 9 – 10, 2009 Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved I have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity. Objectives To describe our improvement journey, what’s been achieved, and key challenges along the way To describe what we have learned To describe the impact to patients, families, staff and physicians Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved Network Perspective Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved PHO: Background/Structure Primary Care Practices (IPA) PHO Focus PHO Focus 39 pediatric practices Effectiveness/ efficiency 40% of regional pediatric population Effectiveness/ efficiency 12,500 asthma patients Specialists Hospital CCHMC Focus Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved PHO Asthma Initiative: Key Driver Diagram KEY DRIVERS/INTERVENTIONS AIM To improve evidence-based care for 12,500 children with asthma across 39 primary care practices (40% of regional pediatric population), with at least 90% of all-payor asthma population receiving “perfect care” (composite measure), thus reducing asthma-related ED/urgent care visits, admissions, acute office visits, missed school days, missed work days, and activity limitation; and, improving parent/patient confidence and degree of asthma control (high scalability focus) Physician leadership at Board and practice level Network-level goal setting by Board (network-level performance defines success) Measurable practice participation expectations/requirements (linked to ABP-MOC approval) Multidisciplinary practice quality improvement teams Web-based registry, with all-payor population identification/reconfirmation Real-time patient, practice, and network-level data/reporting Transparent, comparative practice data on process and outcome measures Concurrent data collection/use of decision support tool, based on high reliability principles/workflow changes AIM To strengthen improvement knowledge/capability within primary care practices, thus enhancing sustainability of current and future improvement efforts Aligning P4P/incentive design with improvement objectives Key components of evidence-based care (“perfect care”) Population segmentation, with focus on “high-risk” cohort Cross-practice communication/shared learning to spread successful interventions Integration of multiple administrative/electronic data sources (hospital, practice, payor) Network and practice-level sustainability plans Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved Network-Level Asthma Data/Results Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved Network Performance: Process Measures (as of September 8, 2009) Population-Based Measures (Network all-payor asthma population = 12,500) PHO Literature % of asthma population with flu shot: 2008-2009 flu season 2007-2008 flu season 2006-2007 flu season (delayed vaccine delivery) 2005-2006 flu season 2004-2005 flu season 2003-2004 flu season (baseline) 66% 60% 54% 62% 40% 22% % of asthma population with management plan 93% 50% % of population with “persistent” asthma on controller medication* 96% 70% % of asthma population with severity classified 95% 50% % of asthma population receiving “perfect care”** 92% not available 10-40% * “Persistent” asthma defined per NHLBI severity classification criteria. ** “Perfect care”: composite measure of severity classification, written management plan, and controller medications (if patient has “persistent” asthma) Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved PHO vs. Comparison Group Asthma Admissions: Pre/Post Impact Asthma Admissions/10K Asthma Admissions/10K 14 12 56% 10 8 PHO 6 Comparison Group 4 36% 2 0 Baseline Post Commercial insurance only Baseline: 3 year average (10/1/00-9/30/03) Post: 2 year average (10/1/06-9/30/08) CCHMC encounters only Patients ≥ 2 yrs. of age 8 county primary service area ICD-9 code of 493.xx in primary position Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved PHO vs. Comparison Group Asthma ED/Urgent Care Visits: Pre/Post Impact Asthma ED/Urgent Care Visits/1K Asthma ED/Urgent Care Visits/1K 4 3.5 55% 3 2.5 PHO 2 Comparison Group 1.5 1 9% 0.5 0 Baseline Post Commercial insurance only CCHMC encounters only Baseline: 3 year average (10/1/00-9/30/03) Post: 2 year average (10/1/06-9/30/08) Patients ≥ 2 yrs. of age 8 county primary service area ICD-9 code of 493.xx in primary position ED/urgent care visits not tied to admissions Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved PHO Network: Asthma Outcome Measures Baseline 8/04 - 7/05 Current 8/08 - 7/09 % parents missing ≥ 2 work days due to child's asthma over prior 6 months 18.0% 10.2% 43% ↓ % parents rating confidence in managing child's asthma < 7/10 11.1% 6.7% 40% ↓ % asthma population missing ≥ 2 school days due to asthma over prior 6 months 26.5% 17.1% 35% ↓ % activity limitation reported as “not at all” or “a little of the time” % receiving oral steroids within prior 12 months % parents rating asthma as “well” or “completely” controlled % physicians rating asthma as “well” or “completely” controlled %∆ 89.7% Not captured as these questions were initiated in 6/06 % parent and physician agreement on rating degree of asthma control Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved 19.4% 89.6% 90.0% 89.9% n/a Practice Perspective Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved Urgency for Change • Parental perceptions of variation in care. • Adoption of medical advances in asthma care. • Population identification and severity classification. • Data collection made knowledge gaps visible. • Documenting quality. • Earning P4P reward. • Transparency of comparative practice data. Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved Challenges • “Our practice is already busy enough.” • “There’s no additional pay for the extra work.” • “We’re already doing a good job.” • “I already have my way of doing things—it’s ok if others want to go down this path.” • Sensitivity to measuring quality of care among physicians. • Reluctance to “standardize” practice around evidence-based care. • “Research project.” • “Not sure initiative will improve care.” • Communication within practice. Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved Getting Started Pre-existing focus on asthma population. Recruiting practice commitment—connected with inherent desire to “do the right thing.” Leadership. Committed quality team. Defining key roles. Communication, communication, communication. “Realistic” decision support/data collection tool. Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved Executing the Work Developing the data collection tool Mapping our process to build a foundation of highly reliable data collection Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved October, 2003 Asthma Patient Data Collection Form How severe is patient’s asthma? (circle appropriate level) SEVERE PERSISTENT --------------------------------- MODERATE PERSISTENT --------------------------------- MILD PERSISTENT --------------------------------- MILD INTERMITTENT --------------------------------- Days Continual (more than 1 episode/day) Days Daily (1 episode/day) Days 3-6 days/week but, not every day Days 0-2 days/week OR OR OR OR Nights Frequent Nights 5 or more nights/month Nights 3-4 nights/month Nights 0-2 nights/month Typical asthma symptoms: cough, shortness of breath, wheezing, chest tightness, waking at night, decreased ability to perform usual activities Is patient on controller medication? (circle yes or no; if yes, circle one or more medications listed below, as applicable) Yes inhaled steroid long-acting bronchodilator oral steroid leukotriene modifier cromolyn or nedocromil theophylline other (please specify) ____________________________________________________________________ No Was a written asthma management plan provided to family? (circle one) Yes No Parents should answer the following two questions . . . Has patient had a flu shot during the 2003-2004 season? (circle one) Yes No If “No”, please indicate action taken: ________________________________ If patient is 6 years of age or older, how many days of school were missed over the last three months due to asthma? _________________ (write in number of days) Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved 10 months later… ASTHMA DATA COLLECTION FORM Patient Name: _________________________________ Provider Name: _____________________________________ Date of Birth: _________________________________ Practice Name: _____________________________________ Date of Visit: _________________________________ Other patient identifier (OFFICE USE ONLY):_________________ Insurance Company: _____________________________ Well Visit Asthma Sick Visit Other Sick Visit PARENTS - PLEASE COMPLETE THE FOLLOWING SECTION: My child does not attend school or daycare 1. *How many days of school or daycare has your child missed due to asthma in the past 6 months? 2. *How many days of work have you or your spouse missed due to your child’s asthma in the past 6 months? 3. *How many times has your child visited the Emergency Room or Urgent Care Clinic due to asthma in the past 6 months? 4. *How many times has your child been admitted to the hospital due to asthma in the past 6 months? 5. *How confident are you in your ability to manage your child’s asthma on a scale of 1-10? (PLEASE CIRCLE) NOT CONFIDENT = 1 6. 2 3 4 5 6 7 8 9 10 = VERY CONFIDENT How frequently has your child experienced episodes of cough, shortness of breath, wheezing, chest tightness, or reduced activity due to asthma during the DAY in the past month? (PLEASE CIRCLE) More than once per day Once per day 3-6 days per week, but not every day 0-2 days per week 7. How frequently has your child experienced episodes of cough, shortness of breath, wheezing, chest tightness, or waking up due to asthma at NIGHT in the past month? (PLEASE CIRCLE) 7 or more nights per month 5-6 nights per month 3-4 nights per month 0-2 nights per month PHYSICIANS - PLEASE COMPLETE THE FOLLOWING SECTION: 8. SEVERE PERSISTENT 9. Asthma diagnosis tentative *How would you classify the patient’s asthma severity? (PLEASE CIRCLE ONE) MODERATE PERSISTENT MILD PERSISTENT MILD INTERMITTENT *Is the patient on controller medication (e.g. inhaled steroid, leukotriene modifier, YES nedocromil, cromolyn, long-acting bronchodilator)? NO 10. *Does the family have a written asthma management plan? YES NO UNKNOWN 11. *Is the patient currently followed by a specialist? YES NO UNKNOWN YES NO Name of specialist:__________________________________ 12. *If NO, do you plan to refer the patient to a specialist? Name of specialist: Please fax to Tri State Child Health Services at (513)636-7540 Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved 2 ½ years later… Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved inical Assessment Process Map – Suburban Pediatrics Office Visit Patient signs in Medical Assistant gives parent responses on paper form to Physician Medical Assistant views patient record in EMR Physician decision to fill out form during the visit EMR alerts Medical Assistant if child has a diagnosis of asthma Medical Assistant gives assessment form to parent Parent completes top half of assessment form If time permits, Medical Assistant will enter parent responses into EMR Physician entry – preferred method Physician enters physician responses into EMR during visit Medical Assistant reviews assessment form and enters parent responses into EMR, if needed Medical Assistant/Asthma Nurse entry – alternate method Medical Assistant collects paper form, forwards to proper physician for entry into EMR Medical Assistant/ Asthma Nurse assists with form completion in EMR Paper forms are collected and entered into the EMR by the Asthma Nurse Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved Practice Improvement Capability: Areas of Focus • Commitment. • Leadership. • Communication. • Reliability of data collection. • Data entry. • Interventions to improve clinical asthma care. Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved The “Ideal”….. • Physician, nurse, and practice manager (quality leadership team) meets regularly to review project status/data/reports, and discuss improvement opportunities. • Physician administrative leader visibly supports project and encourages improvement work. • Project information/updates discussed with physicians and staff at regular practice meetings, data/information shared, and input/feedback recruited. • Quality leadership team discusses data collection process at regular intervals and identifies/pursues opportunities to improve reliability. • Accuracy and timeliness of data entry monitored and addressed. • Improvement interventions pursued using test of change methodology. Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved Using Registry/Data to Drive Improvement (deferred to registry presentation) Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved Key Learnings Leadership Develop quality improvement team Effective communication Build consensus within practice Use disconfirming data to drive improvements and sustain engagement Recruit parent involvement/feedback to accelerate improvement. Improve “reliability”—build improvement into daily work. Learn from others—don’t reinvent the wheel. Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved Impact on Our Practice • Parents more confident and knowledgeable. • Nurses report reduced volume of phone calls. • Positive feedback from families has energized practice and helped sustain improvement work. • Clinicians proactively engaging patients and parents in more meaningful dialogue to improve care vs. more “passive” approach of the past. • Data has uncovered issues/gaps not previously identified. • Discussing how to spread improvement work to other conditions. • Positioned to win on current/future P4P programs. • Appreciate value of registry. • Staff roles/responsibilities revised to sustain improvement efforts. Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved Patient/Parent and Staff Perspectives Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved This is Hard Stuff This takes lots of work to initiate and sustain. 1 8G Rik g ik R 4 Tik 2 c Thank You!! Questions? Contact Information Stephen Pleatman, MD Pediatrician, Suburban Pediatric Associates, Inc. Board Member, Ohio Valley Primary Care Associates, L.L.C. 513-336-6700 [email protected] Keith Mandel, MD Vice President of Medical Affairs, Physician-Hospital Organization Cincinnati Children’s Hospital Medical Center 513-636-4957 [email protected]