care by design magill retrospective mixed methods analysis sep 21 2011
DESCRIPTION
a look back of a decade of build PCMH level care at the university of Utah.TRANSCRIPT
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Retrospective
Mixed Methods Analysis of
Practice Transformation
Michael K Magill, MD Professor and Chairman
Department of Family and Preventive Medicine
University of Utah School of Medicine and Community Clinics
AHRQ Grants # HS019136-01 (TPC)
HS20106-01 (ARRA-SSCM)
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Interdisciplinary Team
Julie Day, MD
University of Utah Community Clinics
JaeWhan Kim, PhD
School of Medicine, Dept of Family & Preventive Medicine
Annie Sheets Mervis, MSW
University of Utah Community Clinics
Debra L. Scammon, PhD David Eccles School of Business, Dept of Marketing
Andrada Tomoaia-Cotisel, MPH, MHA
School of Medicine, Dept of Family & Preventive Medicine
Norman J Waitzman, PhD
College of Social and Behavioral Science, Dept of Economics
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Visits: 300,000+
Active patients: 157,000
11 Community Clinics
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University of Utah Community Clinics
Clinic Year Opened Total
Providers Primary Care
Providers Visits Per
Year (FY09)
Madsen 1975 6 5 18,970
Greenwood 1976 17 10 54,475
Redwood 1985 20 10 93,110
Westridge 1988 7 6 29,208
Parkway 1989 6 5 19,488
Sugar House 1996 10 9 20,344
Stansbury 1999 7 6 24,145
Redstone 2001 7 5 26,309
South Jordan 2003 3 2 11,359
Centerville 2007 4 4 8,044
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Care by DesignTM
• Appropriate Access – 2003 • Balance supply and demand of visits
• Standardized schedules
• Care Team – 2004 • Expanded MA role
• Providers and MAs working in teams
• EMR tools
• Planned Care – 2006 • Pre-visit planning
• Registries
• Labs prior to visit
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Retrospective Analysis:
Qualitative Aims AHRQ Grant # 1R18 HS019136-01 Transforming Primary Care
Aim Method
Document and measure the
transformation
• Archival Search
Determine impact on the
experiences and satisfaction
of providers, staff and
patients
• Provider and Staff Surveys
• Provider and Staff Interviews
• Patient Satisfaction Survey
• Patient Focus Groups
Explore organizational &
contextual factors
• Clinic Environmental Audit
• In-Clinic Observations
Assess in depth how the
transformation was
implemented
• Archival Search
• Leadership Interviews
• Provider and Staff Interviews
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Care by DesignTM
• Appropriate Access – 2003 • Balance supply and demand of visits
• Standardized schedules
• Care Team – 2004 • Expanded MA role
• Providers and MAs working in teams
• EMR tools
• Planned Care – 2006 • Pre-visit planning
• Registries
• Labs prior to visit
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Qualitative Data: Care Teams
8
Component Type of Information Gathered
Archival search • when/how the care team was rolled out
Clinic
Environmental Audit
• size of clinic, team composition, patient volume,
presence of specialists
In-clinic observations • feeling in the clinic, background info
Employee Interviews • personal experience with implementing care
team + experimenting with local adaptations:
how + why
Leadership interviews • personal experience with leading the care team
roll out + managing the evolution: what + why
Provider & Staff
Survey
• trends in team development, employee burn out,
organizational culture
Patient Sat. Surveys • patients’ satisfaction with visits
Patient Focus Groups • changes noticed and patient perspective
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Care Team Structure
& MA Role
CBD Care Team Model
Variations
Traditional Model
Team
Members:
• Providers
• MAs
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“Care Team”
• 5 MAs: 2 Providers
• Working together
• Doing it all!
MA specialists
• (V1): 1 MA phlebotomist does all draws
• Others are 5 MAs :2 Providers
• (V2): 1 MA rooms patients + 1 MA scribes in the room : 1 Provider
Clinic-wide team
• All of the MAs are in one pool
• Room patients in a rotation
• Outside visit work done in between
Hybrid
Traditional Model
• 1 MA : 1 Provider
• Variation – 2 MAs : 1 Provider
Team
Members:
• Providers
• MAs
Care Team Structure
& MA Role
• (V1): 5 MAs : 2 Providers for patient visits, but
• 2 MAs: 1 Provider for outside visit work
• (V2): 5 MAs : 2 Providers, but
• 1 “primary” MA : 1 Provider
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Example of Insights from
Quantitative Research
Clinic Culture
An illustration of possible
explanations for the observed
differences in implementation
of Care Teams
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Organizational Culture
Assessment Instrument: “Competing Values”
Quinn, Rohrbaugh: http://www.ocai-online.com/
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Greenwood
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Parkway
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Redstone
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Senior Leadership
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Organizational Culture In Community Clinics
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Aim Method
Document and measure the
transformation and impact on
the quality of patient care
delivery
• Clinical Data
• CBD Implementation
Determine impact of the
transformation on cost to the
clinics
• Operational Data
Determine impact of
transformation on overall costs
of healthcare services,
including direct costs to
patients
• Centers for Medicare &
Medicaid Services Data
• Utah All Payer Claims
Database
Retrospective Analysis:
Quantitative Aims AHRQ Grant # 1R18 HS019136-01 Transforming Primary Care
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Quantitative Data
Component Type of Information Gathered
CBD Implementation • Use of EMR tools
• Appointment availability
• Continuity with PCP
• Use of pre-visit planning tools and processes
• Flow and processes of Care Team
• Efficiency of visit/wait times
Impact on Operations • Provider productivity
• Financial performance
• Patient population characterization
Clinical Outcomes • Quality performance (chronic & preventive)
• Patient, Provider, Staff satisfaction
Cost of Care • Utilization and cost of care
• CMS
• Utah Population Data Base (UPDB)
• Utah All Payer Claims Database (APCD) Gray = data analysis pending
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10%
20%
30%
40%
50%
60%
70%
80%
2003 2004 2006 2008 2009
Quality Measures Percent of Patients Receiving Recommended Care
CAD* Preventive Care* Diabetes* Heart Failure*
Note: Sample size=14 providers who had all measures in FY 2003, 2004, 2006, 2008, and 2009; *p≤0.05
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20%
30%
40%
50%
60%
70%
80%
90%
100%
2003 2004 2006 2008 2009
Patient Satisfaction Percent of Patients Reporting "Very Satisfied"
Recommend provider* Explanation of what was done*
Visit overall* Time spent with physician*
Length of time waiting at office*
Note: Sample size=16 providers who had all measures in FY 2003, 2004, 2006, 2008, and 2009; *p≤0.05
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Overview of Quantitative Design: Link data from multiple sources to assess
impact of transformation to CBD
Cost & Utilization
CBD Implementation
Clinical Data
Operations Data
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Level of CBD Implementation:
2008
1.00
1.20
1.40
1.60
1.80
2.00
2.20
All elements
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Examples of Correlation between
CBD Implementation and Patient Satisfaction
Patient Satisfaction CBD Implementation Measure
2008
Same Day Appointments Efficient Visit
Length of time waiting at the office 0.61** 0.33*
Time spent with the physician/health
care professional you saw 0.20 -0.21
Explanation of what was done for you 0.14 -0.13
The visit overall 0.50** 0.20
Would you recommend the
physician/health care professional to
your friends and family? 0.34* -0.17
N=16 providers *p≤0.1, **p≤0.05
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Correlation between CBD
Implementation and Quality Measures
CBD Implementation
Measure 2008
Quality Measures
Diabetes
Coronary Artery
Disease
Preventive Care
Seen by PCP last visit 0.60* 0.61* 0.57*
Use of X-files by MA 0.33* 0.18 0.18
Best Practice Alerts 0.34* 0.26 0.29
After-Visit summary 0.23 0.18 0.11
Labs done prior to
visit 0.54** 0.47* 0.36*
N=14 providers with data across five years *p≤0.1, **p≤0.05
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Impact of practice redesign
• Quality improves
• Continuity matters
• Pre-visit planning and EMR reminders help
• Patients notice
• Access improves patient satisfaction
• Level of implementation varies across
clinics
• Clinic culture impacts implementation
• Culture is a critical factor in translational
research
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Future analysis:
impact of redesign on…
• Internal cost and
productivity of clinics
• Overall utilization
• Total cost of care
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Future: Internal Performance Analyses
Cost & Utilization
CBD Implementa-
tion
Clinical Data
Operations Data
• Provider productivity
• Financial performance
• Patient population
characterization
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Future: Cost and Utilization
Cost & Utilization
CMS, APCD
CBD Implementa-
tion
Clinical Data
Operations Data
CMS Data
• All Medicare Claims
at individual level for
Utah (2007+)
• For the following:
• Outpatient
• Inpatient
• Home Health
• Nursing Home
• Prescription
Drug (Part D)
•Linked to State Vital
Statistics and facility
data (Utah Population
Database )
All Payer Claims
Database (APCD)
• Data elements:
• Charges
• Reimbursements
• Utilization
• For the following:
• Outpatient,
Inpatient,
Rehabilitation
• Prescription Rx
• Linked to State
Vital Statistics and
facility data
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Challenges in Assembling
Cost, Utilization and Demographic Data
• Gaining access
• Navigating layers of documentation,
requests, approvals (CMS)
• Obtaining IRB and other database
approvals
• Building APCD platform as 1st user
• Translating utility into usable research database
• Creating files linkable at individual level
• Linking data – hospital, ED, vital statistics
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Challenges of Retrospective
Mixed Methods Research
• Timing of all the components
• Recall isn’t perfect – current events color
memory
• Data used for operations differ from data
required for research
• IRB & HIPAA rules for linking PHI to
operations and external data
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Benefits of
Mixed Method Research
• Multiple components inform each other throughout data collection • Participant selection
• Instrument development
• Sequencing
• Multiple components inform each other throughout data analysis • Convergent/consensual validation
• Multiple components facilitate integration of different perspectives