Transcript Slide presentation - Multiple Chronic Conditions

From Evidence to Practice:
Improving the Quality and Outcomes of Care
Arlene Bierman, M.D., M.S.
Director, Center for Evidence and Practice Improvement
Agency for Healthcare Research and Quality
AHRQ’s mission
To produce evidence to
make health care safer,
higher quality, more
accessible, equitable and
affordable
www.ahrq.gov
To work with HHS and
other partners to make
sure that the evidence is
understood and used
AHRQ Organizational Focus
NIH
Clinical research to
develop effective new
treatments
CDC
Population health and
community-based
interventions to improve
health
CMS
Payment and
incentives for delivery
of effective treatments
AHRQ
Research to help health
care systems deliver
safe and effective
treatments
Legislative History
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Created in 1989 as Agency for Health Care Policy
and Research
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Reauthorized in 1999 as Agency for Healthcare
Research and Quality
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Dual mission of supporting research and implementation
of findings
New centers for primary care research and patient safety
Patient Safety Quality Improvement Act of 2005
creating patient safety organizations
Affordable Care Act in 2010 established PatientCentered Outcomes Research Trust Fund and
mandated activities
Center for Evidence and
Practice Improvement (CEPI)
• Generates new knowledge, synthesizes
evidence, translates science on what works in
health and health care delivery, and catalyzes
practice improvement across health care
settings.
Center for Evidence and
Practice Improvement
• Evidence-based Practice Center Program
• U.S. Preventive Services Task Force Program
• Division of Decision Science and Patient
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Engagement
Division of Health Information Technology
Division of Practice Improvement
National Center for Excellence in Primary Care
Research
National Quality Strategy:
Three Broad Aims
Created Under the Affordable Care Act
Better Care
Improve the overall quality, by making
health care more patient-centered, reliable,
accessible and safe
Healthy People/
Healthy Communities
Improve the health of the U.S. population
by supporting proven interventions to
address behavioral, social and
environmental determinants of health, in
addition to delivering higher-quality care
Affordable Care
Reduce the cost of quality health care for
individuals, families, employers and
government
www.healthcare.gov/center/reports/quality03212011a.html
HHS’ Delivery System
Reform Initiative
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Goal: Better Care, Smarter Spending, Healthier People
How we get there:
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Improve the way providers are paid
o Promote value-based payment systems
o Bring proven alternative payment models to scale
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Improve and innovate care delivery
o Encourage integration, coordination of clinical and support services
o Improve population health
o Promote patient engagement
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Share information with providers, consumers, and
others to support better decisions; maintain privacy
o Create transparency on cost and quality information
o Bring electronic health information to the point of care
How AHRQ Makes a Difference
• AHRQ invests in research and evidence to
understand how to make health care safer and
improve quality
• AHRQ creates materials to teach and train
health care systems and professionals to
catalyze improvements in care
• AHRQ generates measures and data used to
track and improve performance and evaluate
progress of the U.S. health system
Improvements in Patient Safety
2010 - 2014
17% reduction
in HACs
87,000 lives
saved
$19.8 billion in
savings
2.1 million
patient harms
avoided
Project ECHO: Bringing Specialty and
Behavioral Care to Rural New Mexico
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Project Extension for Community Care Outcomes
(ECHO): AHRQ-funded health IT grant (2003) that
links rural health providers to U-New Mexico medical
school to better manage chronic illnesses using
telemedicine
Started with hepatitis C; added mental health,
substance abuse and diabetes
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Focus on providing education, training, and ongoing support
of primary care physicians
New Mexico launched ECHO project to expand
access to addiction treatment in 2006
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By 2010, trained 156 physicians, 62 mid-level providers.
Project trained approximately 60% of physicians certified to
prescribe buprenorphine in NM
Evidence Cycle
Coopey M, Nix MP, Clancy CM. Translating Evidence Into
Evidence-based Nursing Practice and Evaluating Effectiveness. J
Nurs Care Quality 21(3): 195-202. Used with permission of
Lippincott, Williams & Wilkins, 2006.
“Every system is perfectly designed to
get the results that it gets”
-Paul Batalden, MD
(often attributed to Don
Berwick of IHI fame)
Multiple Chronic Conditions:
Some Stats
Prevalence
- 26% of Americans have MCC
- 68% of FFS Medicare beneficiaries have MCC
- 67% of Medicaid beneficiaries w/ disabilities have 3 or more
conditions
Outcomes
- As conditions increase, so does the frequency of mortality, poor
functional status, hospitalizations, readmissions, and adverse drug
events
Costs
- 66% of US health care costs are for individuals with MCC
- 93% of Medicare expenditures are for individuals with MCC
Sources: Anderson, RWJF, 2010; Chronic Conditions Chartbook, CMS, 2012; Kronick, CHCS, 2009; Lee, JGIM, 2007; Machlin, AHRQ, 2011; Vogeli, JGIM, 2007;
Ward, PCD, 2013; Warshaw, Generation, 2006; Wolff , Arch Intern Med, 2002.
Source: Centers for Medicare and Medicaid Services. Chronic Conditions among Medicare Beneficiaries, Chart book: 2012 Edition
Baltimore, MD. 2012.
Source: Centers for Medicare and Medicaid Services. Chronic Conditions among Medicare Beneficiaries, Chart book: 2012 Edition
Baltimore, MD. 2012.
Source: Centers for Medicare and Medicaid Services. Chronic Conditions among Medicare Beneficiaries, Chart book: 2012 Edition
Baltimore, MD. 2012.
Ensuring that primary care practices have the
latest evidence on cardiovascular health and that
they use it to help their patients live healthier and
longer lives.
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Implement PCOR findings in primary care practice
to improve health care quality
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Focus on heart health (ABCS)
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Build primary care practices’ capacity to receive and
incorporate other PCOR findings in the future
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Research Question – Does externally provided QI
support accelerate the dissemination and
implementation of PCOR findings?
EvidenceNOW: Improving Heart
Health
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EvidenceNOW:
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AHRQ initiative to transform health delivery to help smaller primary
care practices apply latest medical research to patient care
7 regional cooperatives serving 12 states in metro/rural settings;
co-ops engage 230-300 small and medium primary care practices
All work with federally qualified health centers, community health
centers
AHRQ provides practice facilitation tools to help patients adopt
ABCS of cardiovascular disease prevention:
o Aspirin in high-risk individuals
o Blood pressure control
o Cholesterol management
o Smoking cessation
EvidenceNOW
Regional Cooperatives
Healthy Hearts in the Heartland
(Midwest Cooperative)
HealthyHearts NYC
(New York City Cooperative)
Heart Health Now!
(North Carolina Cooperative)
Healthy Hearts Northwest
(Northwest Cooperative)
Healthy Hearts for Oklahoma
(Oklahoma Cooperative)
Evidence Now Southwest
(Southwest Cooperative)
Heart of Virginia Healthcare
(Virginia Cooperative)
Scale
• Reach:
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Over 1500 small to medium sized primary care
practices
► 5000 primary care professionals
► 8,000,000 patients
Quality Improvement Services
What is a Practice Facilitator?
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Practice facilitators are specially trained individuals
who work with primary care practices “to make
meaningful changes designed to improve patients’
outcomes. [They] help physicians and improvement
teams develop the skills they need to adapt clinical
evidence to the specific circumstance of their practice
environment” (DeWalt, Powell, Mainwaring, et al.,
2010)
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Evaluation
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The rate of ABCS delivery for all practices
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Measures of practice capacity
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At baseline
Every 3 months during active intervention
And at 3 and 6 months after end of intervention
Utilizing validated surveys
Collected at baseline, end of intervention, and post-intervention
Mixed methods evaluation of implementation of
intervention
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Utilizing CFIR framework
Examining internal and external context at the practice and
cooperative level
Opioid Overuse Among Adults: A
Steadily Growing Epidemic
The cumulative increase in hospital stays rose by 153% between 1993 and 2012;
by 2012
Source: AHRQ, Center for Delivery, Organization, and Markets, Healthcare Cost and
Utilization Project, August 2014.
Barriers to Medication-Assisted
Treatment for Opioid Addiction
• Medication-assisted
treatment (MAT)
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Evidence-based approach
that uses FDA-approved
medications for opioid
abuse
Use of MAT by primary
care physicians more
difficult in rural areas:
o Limited training for physicians
o Negative perceptions about
people with substance abuse
disorders; treatment
effectiveness
o Lack of social support services
in rural communities
New AHRQ Research Seeks Solutions to
Barriers to Use of MAT
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AHRQ to fund three research demonstration
projects to support implementation of MAT for opioid
abuse in rural primary care areas
► Projects will explore and test solutions aimed at
overcoming barriers to the use of MAT
Solutions to address barriers to MAT and may
include:
► Online training for physicians
► In-office practice coaching
► Virtual counseling sessions for patients
Tools and Training Materials
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Patient Safety Culture Surveys
TeamSTEPPS® team training
materials
Comprehensive Unit-based
Safety Program (CUSP)
toolkits to reduce CLABSI,
CAUTI, etc.
Re-Engineered Discharge
(RED) tools to reduce
avoidable hospital
readmissions
Guide to Patient and Family
Engagement
NGC/NQMC
Resources for Quality Improvement and
Evidence-Based Care
National Quality Measures
Clearinghouse
http://www.qualitymeasures.ahrq.gov/
National Guideline
Clearinghouse
http://www.guideline.gov/
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PRACTICE IMPROVEMENT
Enhanced Care Delivery Resources
• In order to deliver accessible, coordinated,
comprehensive, patient-centered care
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It requires a team
Primary
care teams
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Helping Build Teams
http://teamstepps.ahrq.gov/
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Ambulatory Setting Audience
Primary care
offices
Specialty offices
(cardiology,
obstetrics, etc)
Pediatrics
Patient-centered
medical homes
Patients and
Families
Walk-in clinics
Large medical
office buildings
Small, rural
offices
Clinics in retail
settings
AHRQ Resources
for Primary Care Transformation
Resources developed specifically
for primary care
►PCMH Resource Center web site
►Primary Care Measures databases
►Improving Primary Care Practice –
Information for Health
Professionals
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PCMH Resource Center
http://www.pcmh.ahrq.gov/
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AHRQ’s Portfolio of Practice Facilitation Products
Competency-based
curriculum for
training entry-level
practice facilitators
Primary Care
Practice
Facilitation
Curriculum
How to
Guide
Support for
organizations
interested in
starting PF
programs
PF
Handbook
Essentials for
teaching and
learning the
knowledge and
skills for a new PF
http://www.pcmh.ahrq.gov/page/practice-facilitation
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Other New Primary Care QI
Products
Creating PatientCentered TeamBased Primary
Care
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Helping Primary Care Clinicians
Treat Alcohol Use Disorder
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New research summaries to
help primary care clinicians
and patients make evidencebased decisions about
treatments for alcohol use
disorder (AUD) were released
last week
More than 68 million adults
suffer from AUD at some point
in their lives; fewer than 10%
receive medication
Research summaries based
on review of 135 studies;
conducted through AHRQ’s
Evidence-based Practice
Center program
Measures and Data
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Consumer Assessment of
Healthcare Providers and
Systems (CAHPS)
Medical Expenditure Panel
Survey (MEPS) − Insurance
and Household Components
Healthcare Cost and
Utilization Project (HCUP)
Quality Indicators
National Quality and
Disparities Report
HCUP Fast Stats Online
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New AHRQ Web tool allows users to analyze
latest state-by-state info on hospital discharge.
Includes:
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All-payer data on discharges from 2014 from 17
states
Data on number of discharges paid by Medicare,
Medicaid, private insurance for surgical, mental
health, maternal, injury and medical categories
Example of relevance: Colorado, a Medicaid
expansion state, increased Medicaid-covered
hospital stays by 50%, uninsured stays dropped by
90%. Missouri did not expand Medicaid and saw no
change in either hospital stay category.
National Quality Strategy:
Three Broad Aims
Created Under the Affordable Care Act
Better Care
Improve the overall quality, by making
health care more patient-centered, reliable,
accessible and safe
Healthy People/
Healthy Communities
Improve the health of the U.S. population
by supporting proven interventions to
address behavioral, social and
environmental determinants of health, in
addition to delivering higher-quality care
Affordable Care
Reduce the cost of quality health care for
individuals, families, employers and
government
www.healthcare.gov/center/reports/quality03212011a.html
Questions?