Collaborative Assessment Scores

Collaborative Assessment Scores

California Chronic Care Learning Communities Initiative Collaborative Overview and Results: What We Have Accomplished Final Outcomes Congress December 9, 2005 Wendy Jameson, Director Angela Hovis, Improvement Advisor Prevalence of Chronic Disease in California 12 million in CA with chronic disease Hypertension Asthma Congestive Heart Failure Diabetes 4 million of chronically ill Californians seek care in the safety net 2 million have diabetes Bodenheimer, T., Examining Chronic Care in Californias Safety Net,Oakland: California Health Care Foundation, July 2003. What Do Patients with Chronic Illness Need? Care geared towards: Preventing bad outcomes (amputation, blindness, cardiovascular disease) Motivating and helping patients make lifestyle changes A tracking system, or patient registry, to make sure no one slips through the cracks Chronic Care Model Community Health System Health Care Organization Resources and Policies SelfManagement Support Informed, Activated Patient Delivery System Design Productive Interactions Decision Support Clinical Information Systems Prepared, Proactive Practice Team Improved Outcomes In General, American Medicine Does a Poor Job Caring for the Chronically Ill Half of patients hospitalized with congestive heart failure are readmitted within 90 days. 63% with diabetes have HbA1c levels > 7.0%. 66% hypertensives have BP out of control. Ni et al. Arch Intern Med 1998;158;231. Saydah et al. JAMA 2004;291:335. JNC 7. JAMA 2003;289:2560. California Chronic Care Learning Communities Collaborative Brought to You By...

California Health Care Safety Net Institute California HealthCare Foundation Kaiser Permanente Core faculty representing: Improving Chronic Illness Care, Group Health Cooperative Institute for Healthcare Improvement (training) Chronic care champions from 3 CAPH member public hospital systems California Chronic Care Learning Communities Collaborative Participants Alameda County Medical Center Arrowhead Regional Medical Center Contra Costa Health Services San Francisco Department of Public Health San Francisco General Hospital San Mateo Medical Center Santa Clara Valley Medical Center Breakthrough Series Collaborative Model Participants (teams/pilot sites) Select Topic (develop mission) Review Measures & Change Package Planning Group & Faculty Pre-work: (Aims and Measures) P A P D A S LS 1 P D A S D S LS 3 LS 2 Supports Email Visits Phone Assessments Monthly Team Reports Congress, Next Steps California Chronic Care Learning Communities Collaborative Goals For diabetic patients served by nine public

hospital clinics, our goal was to: Improve care processes Decrease complications Reduce cardiovascular risk Three Key Focus Areas Use of data and information systems to support pro-active care Control of clinical risk factors Each team set goals, based on Bureau of Primary Health Care Health Disparities Collaboratives Better use of self-management support strategies by patients and providers Where did we start? 9 clinics serving over 13,000 diabetics; many poorly controlled All at risk for cardiovascular disease Each clinic chose a small pilot population of 100-200 patients of 1-3 physicians Outcomes for Patients with Diabetes Public Hospital CCLC Patients vs National Indicators 100 90 80 Percent 70 60 CCLC 50 National HEDIS (Medicaid) 40 JNC 7 30 20 10 0 HbA1c < 7.0% Blood Pressure: CCLC 130/80; JNC 140/90 LDL < 100 mg/dl Selfmanagement goals HbA1c Test >1/yr. Annual eye exam Annual foot exam Pneumococcal vaccine National data - Source: NHANES III (1994) and Behavioral Risk Factor Surveillance System data (1995); Saaddine, J.B. et. al, Annals of Internal Medicine 2002; 136:565-574. HEDIS data - Source: The State of Health Care Quality: 2005, National Committee for Quality Assurance, Washington, DC, 2005. Chobanian AV et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure JAMA 2003;289:2560-2572 How Did We Do? Mean Assessment Scores and Comparisons Ju M ar A pr M ay n

Ju l A ug S ep O ct N ov 5 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 N ov D ec Ja n Fe b Assessment Score CCLC Mean Assessment by Month Month of Collaborative 1-5 Assessment Score State Collaborative Means 5.0 4.5 4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0.0 CA PubHos-CCLC Alaska mean WSDC I mean WSDC II mean CVC Mean New Mexico Mean VT Diabetes North Carolina Mean OR Diab Collab Mean Chicago Mean Maine Mean RI Mean 1 3 5 7 9 Months 11 13 15 17 CA BCCP mean Roll-Up Graphs Pnuemococcal Vaccine -2 Teams

100 90 % Patients with Vaccine 80 70 60 50 40 30 20 10 0 Oct 04 Nov Dec 04 04 Jan 05 Feb Mar 05 05 Apr May Jun 05 05 05 Jul 05 Aug Sep Oct 05 05 05 % pts. Vaccine 58.5 72.2 77.7 79.6 82.0 85.0 85.9 86.6 87.6 89.4 90.4 91.3 91.8 # all patients 123 205 206 206 206 206 206 201 201 198 197 196 196 Goal 90 90 90 90 90 90 90 90 90 90 90 Foot Exam - 4 Teams 90 100 90 80 % Patients with Foot Exam 90 70 60 50 40 30 20 10 0 Oct

04 Nov 04 Dec 04 Jan 05 Feb 05 Mar 05 Apr 05 May 05 Jun 05 Jul 05 Aug Sep 05 05 Oct 05 % pts. w /exam 4.6 23.5 27.2 37.9 43.7 51.4 55.1 58.9 62.1 66.4 71.2 75.9 77.1 # all patients 274 234 500 533 549 563 571 569 570 565 576 573 571 Goal 90 90 90 90 90 90 90 90 90

90 90 90 90 Roll-Up Graphs (cont.) Eye Exam - 3 Teams 100 90 % Patients w/Eye Exam 80 70 60 50 40 30 20 10 0 Oct Nov Dec Jan Feb Mar Apr May Jun 04 04 04 05 05 05 05 05 05 Jul Aug Sep Oct 05 05 05 05 % pts.EyeExam 53.3 42.3 50.6 53.4 50.9 55.1 58.4 60.9 60.9 60.6 60.9 61.2 51.5 # all patients 274 234 356 356 352 350 346 338 338 335 335 327 326 Goal 70 70 70 70 70 70 70 70 70 70 70 70 ACE/ARB - 5 Teams 100 90 % Patients over 55 w/ ACE/ARB 70 80 70 60 50 40 30 20 10 0 Oct 04 Nov Dec 04 04 Jan Feb 05 05 Mar

05 Apr 05 May 05 Jun 05 Jul 05 Aug Sep Oct 05 05 05 % pts. ACE/ARB 42.0 63.0 62.5 61.6 67.1 67.6 67.1 68.1 68.2 67.3 67.0 66.4 66.8 # pts.55 yrs. 169 138 352 385 404 414 432 436 440 440 448 452 452 Goal 75 75 75 75 75 75 75 75 75 75 75 75 75 Roll-Up Graphs (cont.) Self-Management Goals-6 Teams 100 % of Patients w/ SM Goal 90 80 70 60 50 40 30 20 10 0 Oct 04 Nov 04 Dec 04 Feb

05 Mar 05 Apr 05 May 05 Jun 05 Jul 05 Aug 05 Sep 05 % SM Goal 4.0 3.1 12.6 19.8 26.0 31.2 34.4 37.9 39.4 41.4 45.4 51.4 52.4 # all patients 397 486 738 853 849 845 840 832 831 824 823 812 808 Goal 70 70 70 70 70 70 70 70 70 70 70 70 70 Oct 05

BP Control 70 % of Patients with BP<130/80 Jan 05 60 50 40 30 20 10 0 Oct 04 Nov 04 Dec 04 Jan 05 Feb 05 Mar 05 Apr 05 May 05 Jun Aug Jul 05 05 05 Sep 05 Oct 05 % BP Control 35.6 40.8 34.1 34.4 33.8 32.8 37.0 37.1 38.7 36.5 36.4 38.2 39.6 # w /BP value 284 309 519 640 680 689 709 710 707 703 711

725 712 Goal 40 40 40 40 40 40 40 40 40 40 40 40 40 Roll-Up Graphs (cont.) LDL Test 100 90 % Patients with LDL Test 80 70 60 50 40 30 20 10 0 Oct 04 Nov Dec 04 04 Jan 05 Feb Mar 05 05 Apr 05 May 05 Jun 05 Jul 05 Aug Sep Oct 05 05 05 % pts. w /LDL Test 67.3 75.7 73.7 72.9 76.4 72.7 72.3 77.2 76.7 73.2 73.6 75.1 75.2 # all patients 397 609 875 908 924 938

946 944 945 940 950 946 944 "goal" 90 90 90 90 90 90 90 90 90 90 90 90 LDL Control 100 90 % of Patients wi/ LDL<100 90 80 70 60 50 40 30 20 10 0 % LDL Control Oct Nov Dec Jan Feb Mar Apr May Jun 04 04 04 05 05 05 05 05 05 Jul Aug Sep Oct 05 05 05 05 49.4 38.6 40.9 42.1 40.8 43.4 46.2 46.5 47.4 54.7 56.9 55.1 56.5 # w /LDL w /in yr 267 461 645 662 706 682 684 729 725 688 699 710 710 Goal 70 70 70 70 70 70 70 70 70 70 70 70

70 Roll-Up Graphs (cont.) A1c Test 100 %t of Patients w/A1c Test 90 80 70 60 50 40 30 20 10 0 Oct 04 Nov 04 %w /2A1cTests 45.1 # pts 397 Goal 90 Dec 04 Jan 05 Feb 05 Mar 05 Apr 05 39.8 50.8 54.4 53.4 58.9 609 875 908 924 938 90 90 90 90 90 May 05 Jun Aug Jul 05 05 05 Sep 05

56.7 62.2 60.0 62.3 60.7 61.8 63.2 946 944 945 940 950 946 944 90 90 90 90 90 90 90 A1c Control A1c Control 10 100 90 80 9 70 60 50 40 30 8 Average A1c % of Patients w/ A1c 7 Oct 05 20 10 0 7 6 5 Oct 04 Nov 04 Dec 04 Jan 05 Feb 05 Mar 05 Apr

05 May 05 Jun 05 Jul 05 Aug 05 Sep 05 Oct 05 %7 48.9 42.3 43.5 43.3 45.7 43.8 45.5 43.3 41.4 42.5 44.8 43.3 42.1 Ave. A1c 7.6329 7.8606 7.6469 7.6096 7.6577 7.5802 7.6484 7.8134 7.7184 7.5519 7.5467 7.5971 7.6204 # w / A1c 350 573 769 833 855 841 839 844 846 839 833 833 825 # pts 350 573 769 833 855 841

839 844 846 839 833 833 825 Goal 60 60 60 60 60 60 60 60 60 60 60 60 60 Goal 7 7 7 7 7 7 7 7 7 7 7 7 7 Oct 04 Nov 04 Dec 04 Jan 05 Feb 05 Mar 05 Apr 05

May 05 Jun 05 Jul 05 Aug 05 Sep 05 Oct 05 Highlights 100 90 80 70 60 50 40 30 20 10 0 % on Statins Goal # pts.40 yrs Statins 4 Teams 3 showed improvement 1 already at or above goal and sustained O No De Ja Fe M Ap M Ju Jul Au Se O No De De ct v c n b ar r ay n 05 g p ct v c c14. 21. 22. 28. 28. 30. 30. 33. 60 60 60 60 60 60 60 60 60 60 60 60 60 60 60 60 11 11 11 11 11 11 11 10 ACE/ARB-Arrowhead Reg. Med. Ctr. ACE-ARB 6 Teams 4 showed improvement 1 already at or above goal and sustained % Patients over 55 w/ ACE/ARB % Patients 40 on Statins Statins-Potrero Hill Hlth.Ctr. 100 90 80 70 60 50 40 30 20 10 0 Oct 04 No De Ma Au Se Jan Feb Mar Apr Jun Jul Octv c y g p 05 05 05 05 05 05 01 04 04 05 05 05 % pts. ACE/ARB 42.4 52.7 55.9 55.9 58.1 58.963.2 64.2 62.9 63.5 64.6 65.6 Goal 75 75 75 75 75 75 75 75 75 75 75 75

# pts.55 yrs. 92 93 93 93 93 95 95 95 97 96 96 96 Highlights Retinal Eye Exam 4 Teams 3 showed improvement Dilated Eye Exam-Potrero Hill Hlth. Ctr. 100 100 90 80 90 % of Patients w/ Eye Exam % Patients withDilated Eye Exam Dilated Eye Exam-Silver Ave. Fam. Hlth. Ctr. 70 60 50 40 EYE VAN EXAMS 30 20 10 0 # all patients 70 60 50 40 30 20 10 0 Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct 04 04 04 05 05 05 05 05 05 05 05 05 05 34.1 42.2 42.2 42.2 47.0 57.8 60.3 60.3 62.7 61.3 65.3 65.3 % Eye Exam Goal 80 75 % Exam 75 75 75 75 75 75 75 75 75 75 75 75 Goal

82 83 83 83 83 83 78 78 75 75 75 75 # all pts. Oc No De Fe Ma Ma Au Se Oc No De De Jan Apr Jun Jul t v c b r y g p t v c c05 05 05 05 04 04 04 05 05 05 05 05 05 05 05 01 8.9 8.9 8.7 18. 18. 18. 32. 45. 70 70 70 70 70 70 70 70 70 70 70 70 70 70 70 70 123 123 127 128 131 135 134 122 Highlights Foot Exam-Chinatown Pub. Hlth. Ctr. 100 Foot Exam 5 Teams 4 showed improvement No De Ja Fe Ma Ma Ju Au Se Oct Apr Jul Oct v c n b r y n g p 04 05 05 05 04 04 05 05 05 05 05 05 05 90 % Patients with Foot Exam % Patients w/ Foot Exam 100 90 80 70 60 50

40 30 20 10 0 Foot Exam-Eastmont Sr. Wellness Clinic 80 70 60 50 40 30 20 10 0 Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct04 04 04 05 05 05 05 05 05 05 05 05 01 % w/ Foot Exam 4.6 21. 22. 33. 41. 50. 51. 60. 65. 73. 81. 80. 80. Goal 152 152 152 152 148 146 142 139 139 139 139 131 130 # all patients 14.3 41.8 53.3 66.7 67.9 67.9 68.4 69.8 70.9 71.6 76.5 % Foot Exam 90 90 90 90 90 90 90 90 90 90 90 90 90 Goal # all patients 90 90 90 90 90 90 3 14 55 75 93 106 112 114 116 127 134 136 90 90 90 90 Pnuemococcal Vaccine-Richmond Hlth. Ctr.-Contra Costa 100 90 % Patients with Vaccine 80 70 60 Pneumococcal Vaccine 4 Teams 50 40 2 showed improvement 30 20 10 0 Oct Nov Dec Jan 04

04 04 05 Feb 05 Mar 05 Apr 05 May 05 Jun 05 Jul 05 Aug Sep Oct05 05 01 % pts. Vaccine 58.5 63.4 65.0 68.3 72.4 76.4 78.0 80.5 82.1 83.7 85.2 86.8 87.6 Goal 90 # all patients 123 123 90 90 90 123 123 90 90 123 123 90 90 123 123 90 90 123 123 90 90 122 121 90 121 90 90 90 Self-Management Goals-Chinatown Pub. Hlth. Ctr. 100 % of Patients w/ SM Goal 90 Highlights 80 70 60 50 40

30 20 10 0 No De Ma Ma Au Se Oct J an Feb Apr J un J ul Oct v c r y g p 04 05 05 05 05 05 05 04 04 05 05 05 05 % SM Goal 0.0 0.0 0.0 0.0 16. 26. 34. 38. 39. 51. 63. 67. 68. Goal 50 50 50 50 50 50 50 50 50 50 50 50 50 # all patients 152 152 152 152 148 146 142 139 139 139 139 131 130 Self-Management Goal -Siver Ave. Fam.Hlth. Ctr 100 All 8 showed improvement! % of Patients w/ SM Goal 90 80 70 13 participate in group visit 60 50 40 30 20 10 0 Oct 04 % SM Goal Goal # all patients Self-Management Goals 8 Teams No De Ja Fe Ma Ma Ju Au Se No De Apr Jul Oct v c n b r y n g p v c 05

05 05 04 04 05 05 05 05 05 05 05 05 05 18. 18. 18. 22. 32. 38. 39. 41. 42. 44. 64. 64. 70 70 70 70 70 70 70 70 70 70 70 70 70 70 70 82 83 83 83 83 83 78 78 75 75 75 75 Highlights 100 90 80 70 60 50 40 30 20 10 0 A1c Tests 9 Teams 5 showed improvement 7.5 57.5 63.5 67.9 82.5 81.3 81.3 74.6 78.2 77.8 78.6 78.6 % w/2 tsts w/in yr. 3mnths apart Goal # all pts 1 already at goal and sustained Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct 04 04 04 05 05 05 05 05 05 05 05 05 05 90 90 90 90 90 90 90 90 90 90 90 90 90 252 252 252 252 252 252 252 252 252 252 252 252 LDL Test - Richmond Hlth. Ctr. - Contra Costa 100 90 LDL Test 9 Teams 5 showed improvement % P ts. w/LDL past 12 m nths %t Pts. w/A1c Test A1c Test-Santa Clara Valley Medical Center 80 70 60 50 40 30 20 10 0 Oct Nov Dec Jan Feb Mar Apr

04 04 04 05 05 05 05 Ma Jun Jul y 05 05 05 Au Sep Oct Nov g 05 -01 -01 05 % w / LDL Test 63.4 71.5 69.1 74.8 78.0 79.7 78.9 81.3 80.5 77.2 81.1 80.2 79.3 Goal all patients 90 90 90 90 90 90 90 90 90 90 90 90 90 123 123 123 123 123 123 123 123 123 123 122 121 121 90 Highlights % of Patients with BP<130/80 BP Control-Arrowhead Reg. Med. Ctr. 90 80 70 60 50 40 30 20 10 0 Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct04 04 04 05 05 05 05 05 05 05 05 05 01 % BP Control 20.4 Goal 40 # w /BP value 113 21.1 21.4 19.7 18.8 18.3 19.0 20.5 25.0 31.3 29.5 33.7 40 40 40 40 40 40 40 40 40

40 40 114 117 117 117 120 121 117 116 115 112 104 BP Control-San Mateo Med. Ctr. % of Patients with BP<130/80 90 70 60 50 40 30 20 10 % BP Control Goal # w /BP value 4 showed improvement 1 already at goal and sustained 80 0 BP Control 9 Teams Oc No De Ja Fe Ma Ap Ma Ju Au Se 4Jul t v c n b r r y n g p Oc 05 04 04 04 05 05 05 05 05 05 05 05 t 23. 24. 22. 21. 25. 27. 27. 31. 32. 34. 35. 40 40 40 40 40 40 40 40 40 40 40 40 40 64 114 111 107 107 106 108 105 105 105 103 Highlights LDL Control-San Mateo Med. Ctr. 100 90 80 70 60 50 40 30 20 10 0 % Pts. wi/ LDL<100 % of Patients wi/ LDL<100 100 90 80 70 60 50 40 30 20 10 0 LDL Control-Santa Clara Valley Medical Center Oc No De Ja Fe Ma Ap Ma Ju Au Se 4Jul t v c n b r r y n g p Oc 05

04 04 04 05 05 05 05 05 05 05 05 t 45. 47. 48. 50. 51. 54. 55. 57. 57. 60. 59. % LDL Control 70 70 70 70 70 70 70 70 70 70 70 70 goal 109 103101 97 94 94 98 102 100 99 97 # w /LDL w /in yr % w/Control Oct No De Ja Fe Ma Apr Ma Ju Jul Au Se Oct 04 v c n b r 05 y n 05 g p 05 37. 41. 40. 37. 41. 44. 45. 47. 72. 76. 63. 64. 55 55 55 55 55 55 55 55 55 55 55 55 55 goal # w/LDL w/in yr 197 196 189 226 188 184 210 196 170 172 176 171 % of Patients wi/ LDL<100 LDL Control - Richmond Hlth. Ctr. - Contra Costa 75 70 65 60 55 50 45 40 35 30 25 20 LDL Control 9 Teams 4 showed improvement Oct 04 No De Ma Au Se No Jan Feb Mar Apr Jun Jul Octv c y g p v05 05 05 05 05 05 01 04 04 05 05 05 01 %w /LDL Control 29.529.5 27.132.6 31.333.743.3 43.046.5 48.450.552.6 58.3 goal 50 50 50 50 50 50 50 50 50 # w /LDL w /in yr 78 88 85 92 96 98 97 100 99 50 50 50 50 50 95 99 97 96 Highlights Average HbA1c-Richmond Hlth. Ctr. - Contra Costa

Average HbA1c- SFGH Family Health Center 15 14 Average HbA1c 12 11 10 9 8 7 6 5 Oct Nov Dec J an Feb Mar Apr May J un 04 04 04 05 05 05 05 05 05 J ul Aug Sep 05 05 05 A1c Control-Santa Clara Valley Medical Center % Pts. w/A1c 7 Average HbA1c 13 8.2 8.1 8 7.9 7.8 7.7 7.6 7.5 7.4 7.3 7.2 7.1 7 6.9 6.8 6.7 6.6 6.5 100 90 80 70 60 50 40 30 20 10 0 A1c Control 9 Teams Average < 7: 2 showed improvement % < 7: 3 showed improvement Oct 04 # w / A1c Jan 05 Feb 05 Mar 05 Apr May Jun 05 05 05 Jul 05 Aug Sep 05 05 Oct 05

27.3 36.9 43.3 41.9 44.5 46.7 48.0 42.4 43.6 53.5 47.3 48.1 %7 goal Nov Dec 04 04 60 60 60 60 60 60 60 60 60 60 60 60 60 238 203 231 246 229 227 221 224 225 215 222 214 Challenges to Improving Chronic Care in Public Hospitals & Health Systems No reimbursement for non-physician care Information systems not geared for tracking chronic care patients Chaotic, overstressed primary care clinics Patients with limited English & low health literacy Difficulty changing job descriptions of clinic staff Bureacracy Delivery system geared toward acute illness Public hospital Systems Can Have the Most Impact on Disparities in Chronic Care Health disparities: patient population is 78% people of color, predominantly low-income Comprehensive systems of care: potential to improve along continuum of care Training next generation of health care professionals

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