Regenstrief Chin Qi Disparities 100307

50 %
50 %
Information about Regenstrief Chin Qi Disparities 100307

Published on October 6, 2007

Author: ShawnHoke

Source: slideshare.net

Description

Implementing Quality Improvement to Reduce Disparities: The Case of the Health Disparities Collaboratives

Implementing Quality Improvement to Reduce Disparities: The Case of the Health Disparities Collaboratives Marshall H. Chin, MD, MPH Associate Professor of Medicine University of Chicago Director, RWJF Finding Answers: Disparities Research for Change National Program Office

Goals Describe Health Disparities Collaboratives (HDC) Review impact on quality of care Analyze financial ramifications Outline factors important for organizational change List summary conclusions Discuss future research recommendations

Describe Health Disparities Collaboratives (HDC)

Review impact on quality of care

Analyze financial ramifications

Outline factors important for organizational change

List summary conclusions

Discuss future research recommendations

RWJF Finding Answers: Systematic Review of Interventions to Reduce Racial and Ethnic Disparities Medical Care Research and Review 10/07 supplem Intro, Cardiovascular, Depression, Diabetes, Breast cancer, Culture, Pay-for-Performance www.SolvingDisparities.org Articles and Searchable database of 200 interv.

Medical Care Research and Review 10/07 supplem

Intro, Cardiovascular, Depression, Diabetes, Breast cancer, Culture, Pay-for-Performance

www.SolvingDisparities.org Articles and Searchable database of 200 interv.

RWJF Finding Answers: Disparities Research for Change Lessons from Systematic Reviews Multifactorial interventions that target multiple levers of change Culturally tailored quality improvement Nurse-led interventions in context of wider systems change

Multifactorial interventions that target multiple levers of change

Culturally tailored quality improvement

Nurse-led interventions in context of wider systems change

Community Health Centers 5000 sites 16 million patients 40% uninsured 64% minority population National Association of Community Health Centers, 2006

5000 sites

16 million patients

40% uninsured

64% minority population National Association of Community Health Centers, 2006

Health Disparities Collaboratives: A Quality Improvement Collaborative National effort in > 1000 health centers beginning in 1998 3 Components CQI: Rapid Plan-Do-Study-Act cycles Chronic Care Model Learning sessions

National effort in > 1000 health centers beginning in 1998 3 Components

CQI: Rapid Plan-Do-Study-Act cycles

Chronic Care Model

Learning sessions

Plan-Do-Study-Act Cycles (PDSA) Associates in Learning / Institute for Healthcare Improvement

Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Functional and Clinical Outcomes Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization MacColl Institute Chronic Care Model

Breakthrough Series Commitment of CEO HDC QI team in each of health center 4 regional learning sessions Cluster coordinator support Monthly telephone conference calls Monthly written progress reports Computer listserver

Commitment of CEO

HDC QI team in each of health center

4 regional learning sessions

Cluster coordinator support

Monthly telephone conference calls

Monthly written progress reports

Computer listserver

Organizational Schema of Intervention Collaborative Team Center 15-20 HCs / Trainers HDC QI Team Providers & Patients at HC

Collaborative Team Center

Methods Systematic review of literature Focus on key studies in this presentation

Systematic review of literature

Focus on key studies in this presentation

Results: Participants’ Perceptions of Outcomes HDC is a success and worth effort > 80% Improved patient outcomes 88% Improved processes of care 83% Improved patient satisfaction 71% Qualitative interviews Similar Chin et al.; Chin et al. Diabetes Care 2004; 27:2-8.

HDC is a success and worth effort > 80%

Improved patient outcomes 88%

Improved processes of care 83%

Improved patient satisfaction 71%

Qualitative interviews Similar

Chin et al.; Chin et al. Diabetes Care 2004; 27:2-8.

Short-Term Clinical (1-2 years): Diabetes Random chart review Pre-post improvement in 7 diabetes processes of care No improvement in intermediary outcomes Chin et al. Diabetes Care. 2004.

Random chart review

Pre-post improvement in 7 diabetes processes of care

No improvement in intermediary outcomes Chin et al. Diabetes Care. 2004.

Short-term Clinical: Asthma, Diabetes, Hypertension Pre-post controlled (1 yr pre and 1 yr post) Improvements in processes of care for asthma and diabetes Asthma – Rx anti-inflam med 14% Diabetes – HbA1c measurement 16% No improvement in intermediary outcomes Landon et al. NEJM 2007; 356:921-934.

Pre-post controlled (1 yr pre and 1 yr post)

Improvements in processes of care for asthma and diabetes

Asthma – Rx anti-inflam med 14%

Diabetes – HbA1c measurement 16%

No improvement in intermediary outcomes

Landon et al. NEJM 2007; 356:921-934.

Long-term Clinical (2-4 years): Processes of Care (%) Chin et al. Medical Care. In press. 41 37 22 Aspirin 50 42 33 ACE inhibitor 70 65 52 Lipid assessment 92 88 71 At least 1 A1c 2002 2000 1998 Process of Care

Long-term Clinical: Outcomes Chin et al. Medical Care. In press. 78 80 79 Diastolic BP (mm Hg) 133 135 133 Systolic BP (mm Hg) 108 116 127 LDL (mg/dl) 7.9 8.5 8.6 HbA1c (%) 2002 2000 1998 Outcome

Societal Cost-Effectiveness Analysis: Diabetes Incorporate clinical results into a NIH simulation model of diabetes complications Simulation model needed to translate changes in processes and risk factor levels into complications Huang et al. HSR 2007 (OnlineEarly Articles).

Incorporate clinical results into a NIH simulation model of diabetes complications

Simulation model needed to translate changes in processes and risk factor levels into complications Huang et al. HSR 2007 (OnlineEarly Articles).

Base Case Results ICER = $33,386/QALY $101,770 10.93 24 20 15 15 Program 2: With HDC $90,085 Lifetime costs, mean 10.58 Quality-adjusted life years, mean 28 CHD,% 20 Amputation,% 18 ESRD,% 17 Blindness,% Program 1: Without HDC

Business Case: Case Study of 5 Health Centers with Diabetes Huang ES, et al. The cost consequences of improving diabetes care: the community health center experience. Joint Commission Journal on Quality and Patient Safety. In press. Brown SES, et al. Estimating the costs of quality improvement for outpatient health care organizations: a practical methodology. Quality and Safety in Health Care. 2007; 16 (4): 248-251.

Huang ES, et al. The cost consequences of improving diabetes care: the community health center experience. Joint Commission Journal on Quality and Patient Safety. In press.

Brown SES, et al. Estimating the costs of quality improvement for outpatient health care organizations: a practical methodology. Quality and Safety in Health Care. 2007; 16 (4): 248-251.

Local Economy External Environment Payor Mix Insurance reimbursement and incentives Internal Environ-ment Admini- strative Revenues Grants Donations - Costs Daily QI activities Personnel Equipment = Administrative Balance Clinical Patient care revenues Patient care costs = - Clinical Care Balance Overall Overall center revenues Overall Center Costs = - Direct Overall Balance + + + = = = Indirect Benefits Improved clinical care Morale - Costs Focus of leadership on other priorities = Indirect Balance Patient Demographics and numbers Accreditation Bodies Conceptual Model of the Short-Term Financial Impact of Quality Improvement for Outpatient Facilities Direct

Revenues

Grants

Donations

Costs

Daily QI activities

Personnel

Equipment

Benefits

Improved clinical care

Morale

Costs

Focus of leadership on other priorities

Business Case Study Results Additional admin cost = $6-$22 per patient (Year 1) No regular source of revenue for these costs Balance of diabetes clinical costs/revenues did not clearly improve Diabetes Collaborative 2-8% of health center budget QI programs represent a new cost

Additional admin cost = $6-$22 per patient (Year 1)

No regular source of revenue for these costs

Balance of diabetes clinical costs/revenues did not clearly improve

Diabetes Collaborative 2-8% of health center budget

QI programs represent a new cost

CEO Cost Survey Majority reported increased costs Costs per patient 72% Overall health center costs 73% Majority reported no change in funding Reimbursement for patient care 75% Funding from government agencies 73% Funding from private foundations 75% Divided over overall effect Worsened finances 38% No change 48% Improved finances 14% Huang et al. HSR 2007.

Majority reported increased costs

Costs per patient 72%

Overall health center costs 73%

Majority reported no change in funding

Reimbursement for patient care 75%

Funding from government agencies 73%

Funding from private foundations 75%

Divided over overall effect

Worsened finances 38%

No change 48%

Improved finances 14%

Huang et al. HSR 2007.

Organizational Change and Implementation Common barriers Lack of resources Lack of time Staff burnout Chin et al.

Common barriers

Lack of resources

Lack of time

Staff burnout Chin et al.

Wish List from Bureau of Primary Health Care 20 Training in quality improvement techniques 18 Information system technical support 26 Staff time spent on quality improvement 34 Data entry activities 44 Direct patient care services Percentage Ranked #1

Additional Support Help patients with self-management 73% Information systems 77% Get providers to follow guidelines 64%

Help patients with self-management 73%

Information systems 77%

Get providers to follow guidelines 64%

Predictors of Staff Morale and Burnout Low cost Personal recognition Career promotion Skills development Fair distribution of work More expensive – Funding, personnel Graber et al.

Low cost

Personal recognition

Career promotion

Skills development

Fair distribution of work

More expensive – Funding, personnel Graber et al.

Unintended Consequences Quality of care of chronic conditions not emphasized by HDC increased 45% HDC has drawn time, energy, resources away from other health center activities 61% Chien et al.

Quality of care of chronic conditions not emphasized by HDC increased 45%

HDC has drawn time, energy, resources away from other health center activities 61%

Chien et al.

Summary Conclusions HDC improve clinical processes of care over short-term 1-2 year time periods and improve both processes of care and outcomes over longer 2-4 year periods.

HDC improve clinical processes of care over short-term 1-2 year time periods and improve both processes of care and outcomes over longer 2-4 year periods.

Conclusions 2 Diabetes Collaborative is societally cost-effective, but there are no consistent financial streams for individual centers, raising concerns about the whether there is a business case for CEOs to adopt and sustain the HDC over the longterm.

Diabetes Collaborative is societally cost-effective, but there are no consistent financial streams for individual centers, raising concerns about the whether there is a business case for CEOs to adopt and sustain the HDC over the longterm.

Conclusions 3 Some methods to enhance implementation of the HDC are low-cost and reasonably feasible. Some methods to enhance implementation of the HDC will require more resources and work.

Some methods to enhance implementation of the HDC are low-cost and reasonably feasible.

Some methods to enhance implementation of the HDC will require more resources and work.

Non-Community Health Center Settings Pros Payor mix Possibly integrated delivery system Cons Size Culture

Pros

Payor mix

Possibly integrated delivery system

Cons

Size

Culture

Key Research Questions How to tailor implementation of the HDC to different HCs that may be at different stages of organizational readiness to change and that may have different strengths, weaknesses, organizational contexts, and patient populations?

How to tailor implementation of the HDC to different HCs that may be at different stages of organizational readiness to change and that may have different strengths, weaknesses, organizational contexts, and patient populations?

Research Questions 2 How to create a viable long-term business case for the HDC to complement the analysis demonstrating that the Diabetes Collaborative is societally cost-effective?

How to create a viable long-term business case for the HDC to complement the analysis demonstrating that the Diabetes Collaborative is societally cost-effective?

Research Questions 3 How to successfully spread the HDC across multiple diseases, conditions, and processes? How to sustain the HDC over time? How to integrate the general QI process of the HDC with menus of specific model programs?

How to successfully spread the HDC across multiple diseases, conditions, and processes?

How to sustain the HDC over time?

How to integrate the general QI process of the HDC with menus of specific model programs?

Funding AHRQ R01 HS 10479 AHRQ/HRSA U01 HS13635 NIA 1K23 AG021963 NIH/NIDDK P60 DK20595 Diabetes Research & Training Center NIDDK K24 DK071933 RWJF Generalist Physician Faculty Scholar

AHRQ R01 HS 10479

AHRQ/HRSA U01 HS13635

NIA 1K23 AG021963

NIH/NIDDK P60 DK20595 Diabetes Research & Training Center

NIDDK K24 DK071933

RWJF Generalist Physician Faculty Scholar

Add a comment

Related presentations

Related pages

Integrated Framework for Reducing Racial and Ethnic ...

Integrated Framework for Reducing Racial and Ethnic Disparities in the ... Culturally tailored QI more than ... partners into QI interventions. Chin ...
Read more

Reducing racial and ethnic disparities in health care: an ...

Reducing racial and ethnic disparities in health care: ... M H Chin 1, ... (QI) manuscripts ...
Read more

Chi Gong and Tai Chi (Qi Gong) Energy Healing Exercises ...

Chi Gong and Tai Chi, (also spelled Qi Gong) ... (Qi Gong) Energy Healing Exercises TheArtofUnity.com. Subscribe Subscribed Unsubscribe 18,057 18K.
Read more

AHRQ Activities to Reduce Racial and Ethnic Disparities in ...

QI Toolkit for ... This Program Brief briefly describes AHRQ's activities related to racial/ethnic disparities in health ... Chin MH. Incorporating ...
Read more

Future Directions for the National Healthcare Quality and ...

The National Healthcare Quality and Disparities Reports play a fundamental role in examining quality ... [Chin et al., ... Regenstrief Center for
Read more

Multicultural Health Care: A Quality Improvement Guide

3 Chin, Walters, Cook, Huang, Interventions to Reduce Racial and Ethnic Disparities in Health Care. ... or health disparities, the QI team should know
Read more

BALAncIng chInese InteRests On nORth kOReA And IRAn

Despite evident disparities in how Chinese experts ... Balancing Chinese Interests on North Korea ... zhanlue jiyu qi” (China Can Transform the Iranian ...
Read more