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Final Outcomes Congress VPQHC Chronic Care Collaborative The Outcomes Congress for the second VPQHC Chronic Care Collaborative was held on Friday, October 28 at the Capital Plaza in Montpelier. Approximately 120 guests and team members were in attendance and early feedback about the day and the collaborative was extremely positive. The celebration began with an overview of the model for the prospective team members and invited guests in the audience. Then the agenda highlighted four teams and their experiences “From Great Beginnings…To Amazing Progress.” Two second year teams, the Veteran’s Administration and St. Johnsbury and two first year teams, Cold Hollow and Greater Falls, shared their successes, surprises, challenges and enthusiasm. The Greater Falls Family Medical practice in Bellows Falls found the patient registry invaluable. Their planned visits created more focused and efficient patient interactions. Key areas were regularly scheduled team meetings to assess changes and the role the self-management component played in actively engaging their patients. Surprises included an unexpected change for the team from initially feeling overwhelmed to seeing visible success quickly. The team became re-energized and morale improved. They were surprised with their success to re-engage patients that had previously been written off. Finally they noted that pneumovax had previously not been given to anyone over 65 years of age! Challenges at Greater Falls included financial concerns of patients that prevent them from seeking care, the time and work required for the registry component to be useful and spread-able to other clinicians and finally time to meet as a team. Cold Hollow Family Practice in Enosburg Falls was another first time team working in the collaborative. They were surprised by the time requirements of managing the patient registry much greater than expected. They estimate an average of 1.5 hours per day is needed for entering data, running reports, analyzing data, flagging paper charts and contacting patients. In addition, some gains were lost over the summer; perhaps attributable to high caloric barbeques? Future challenges are incorporating activities to address obesity and ensuring that health benefits are available to all patients since preliminary data suggests a correlation of better outcomes for those patients with insurance. Overall, the process and clinical improvements were impressive for Cold Hollow. Foot exams went from >2% to 95%; eye exams increased from 3% to 86%; microalbumin testing improved from 0% to 97%; LDL testing increased from 46% to 94% and HbA1c testing every 6 months improved to 94%. The practice was able to document clinical improvements during their first year. Patients with A1c < 7 improved by 2% and LDL < 100 improved by 13%. VA team outlined their journey, through a second collaborative, showing important gain in every aspect. They increased the number of participating providers from 1 to 5, doubled the pilot population, continued to lower the average A1c from 8.2 to 7.29, increased the measures from 7 to 16 and achieved 10 of those goals. Some of their most creative work was in the area of self-management. The VA teams developed an Eat Healthy Workshop and refresher course for self-management education. A room was transformed into a “grocery store” to provide hands on education about shopping. A MOVE program for weight loss was used. In the area of delivery system design, the VA improved upon guidelines for a diabetes management visit by implementing provider group visits. Other diabetes educator staff was involved in group visits and the use of registry, reminders and monthly reports improved follow up and planned care. Decision support was enhanced with regular feedback and the diabetes registry data. The VA plans to continue to spread the model through the “House.” Next Dana Kraus, MD from the Saint Johnsbury Family Practice described their “Second Time ‘Round” as a process of building on the solid foundation from the first collaborative. Those “bricks” included labeled charts, a functional registry, toolkits well stocked in examining rooms and routinely used, a revitalized diabetes education program, identification of high risk individuals through the registry and a working knowledge on PDSAs. The key new “bricks” developed during V3C were planned visits and weekly chart reviews that created a “prepared, proactive practice team.” The team was able to catch missing labs, review the prior visit, use a checklist and avoid distractions during an encounter, make management decisions in advance and increase the efficiency and effectiveness of the office. The St. J team was able to find time for regular team meetings from time management savings due to the improved organization and practice design. Encounters with diabetic patients could be reduced to 15 effective minutes from the previously typical 30 minute visit. Challenges remain and they hope to address them during the next collaborative. Linkages with the community, case management for critical patients, reimbursement for group visits, finding the lost PDSAs and successfully motivating patients to move i.e. exercise. Finally the improved clinical outcomes achieved by the patients in their pilot population were extraordinary. The percent of patients with A1c < 7 went from 53% to 72%. Patients receiving a microalbumin test increased from 53% to 80%. LDL < 100 increased from 42% to 55% and 71% of patients reduced their blood pressure to < 135/85, up from 50%. These results clearly show the potential for clinical gains in the second year and speak to the need for a systems change approach versus a finite project view. Commissioner of Health Paul Jarris congratulated the work of each team and outlined the design for the Vermont Blueprint for Health. He pointed out how the collaborative acts as the laboratory for the Blueprint and encouraged the next steps. The next presentations highlighted the experiences of the teams who partnered with health plans. Dennis Plante described the gains the FAHC team made and the focus on defining a group visit, determining the codes for insurance coverage of their group visit and efforts to understand and support this element of care with OVHA and MVP. Dr. Josh Plavin from the Chelsea Clinic then described their experience with BCBS. They had focused on planning a day designed to bring together, at one location, patients with diabetes and their various providers. The patients received group interventions and the opportunity for planned visits with each specialist. BCBS is figuring out how to bill for the experience. The morning’s celebration finished with a panel of all the teams addressing questions from the audience about how to keep the effort going. Paul Bengtson, CEO of Northeastern Vermont Regional Hospital, offered closing remarks. He described the community health advisory board created by the select board of St. Johnsbury and its aim to work with VPQHC’s next collaborative to link the community with the CCM. The day concluded with a luncheon for the teams complete with Halloween treats, awards and fun ‘survival kit’. Work continues on designing the next collaborative, scheduled to begin in March 2005. A number of practices have indicated their interest in participating. The health plans have also agreed to partner with teams and continue their important work of aligning payment with best practice. To date there is interest in continuing a focus on diabetes and adding cardiac disease. Some returning practices will use the next collaborative as a spread facilitator to other practices or additional chronic illnesses. Potential new participation includes DHMC’s Lebanon PCIM group and their regional practices. Southwestern Medical Center will host two practices and the Burlington Community Health Center and a few free clinics have expressed interest. Two VPQHC staff members will attend a week long class in Microsystems at Dartmouth College. Two or three staff from the QIO will also attend. The training they receive will enhance practice redesign and promote adoption of the CCM. We will be able to offer on sight evaluation and assistance in office practice design. Efforts to figure out registry options for the practices are underway and remain a challenge. |
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Email: mail@vpqhc.org
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Vermont
Program for Quality in Health Care, Inc. |
