Improving Health with the Directors Chronic Care Initiative

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Improving Health with the Directors Chronic Care
Initiative NCCD Ty Reidhead
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Prevalence of Diagnosed Diabetes AI/ANs compared
to U.S. population
1980- 2004
Source IHS Program Statistics and National
Diabetes Surveillance System. Age-adjusted to the
2000 US standard population with the exception of
19811993 data for AIAN, which was age-adjusted
to the 1980 US standard population.
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Is there time for Management of Pts with Chronic
Conditions in primary care?

• Care according to guidelines of 10 chronic
  diseases
• If everyone in the patient panel was controlled
• 3.5 hours per work day
• If add some uncontrolled cases
• 6.7 hours per work day
• Assuming 1,949 hours/year spent in patient care

Ann Fam Med 20053(3)209-214
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Geographic Isolation
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International Comparison of Spending on Health,
19802004
EFFICIENCY
Average spending on healthper capita (US PPP)
Data OECD Health Data 2005 and 2006.
Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
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The Healthcare System Hope
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Crossing the Quality ChasmExecutive Summary

• The American health care delivery system is in
  need of fundamental change care delivered is
  not, essentially, the care we should receive
  frustration levels have never been higher
  Health care harms and routinely fails to deliver
  its potential benefits.

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Care Model
Health System
Community
Health Care Organization
Resources and Policies
ClinicalInformationSystems
DeliverySystem Design
Self-Management Support
Decision Support
Productive Interactions through effective asset
based partnering over time
Patient Driven
Coordinated
Informed, Empowered Patient and Family
Prepared, Proactive Practice Team
Timely and Efficient
Evidence-based and Safe
Improved achievement of patient and community
goals
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IOMs 6th Aim

• Equity
• Freedom from bias or favoritism
• Equitable
• Dealing fairly and equally with all concerned

www.m-w.com/dictionary Merriam-Websters Online
Dictionary
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The Healthcare System for
my patients, my family, and for me

• The care I need and want, when I need and want
  it!

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International Comparison of Spending on Health,
19802004
EFFICIENCY
Average spending on healthper capita (US PPP)
Data OECD Health Data 2005 and 2006.
Source Commonwealth Fund National Scorecard on
U.S. Health System Performance, 2006
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Optimism
Pockets of Excellence Islands of Innovation
The Energy of Few The Champions
Past performance is no guarantee of future
results
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Hope
Reliably high quality care Every patient, every
time, everywhere
Leadership Ideas Improvement Tools
The Energy of Many
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IHS Diabetes Care Outcomes Audit
Mean A1C, 1996-2007
A1C,

year
Source IHS National Diabetes Program Statistics
1996-2007
plt0.0001 comparing mean A1C levels in FY96 and
FY07
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Care Model
Health System
Community
Health Care Organization
Resources and Policies
ClinicalInformationSystems
DeliverySystem Design
Self-Management Support
Decision Support
Productive Interactions through effective asset
based partnering over time
Patient Driven
Coordinated
Informed, Empowered Patient and Family
Prepared, Proactive Practice Team
Timely and Efficient
Evidence-based and Safe
Improved achievement of patient and community
goals
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Productive Interactions through effective asset
based partnering over time
Informed, Empowered Patient and Family
Prepared, Proactive Practice Team
Patient Driven
Coordinated
Timely and Efficient
Evidence-based and Safe
Improved achievement of patient and community
goals
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Innovations in Planned Care Collaborative
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Powerful CIS tools for improvement DM
Comprehensive Care

• iCare

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Improvement is not easy DM Comprehensive Care
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What is a Care Team?

• Everybody who is part of the relationship with
  patients
• Includes people who are not typical partners
• Relationships within the Care Team are essential.

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What is a Care Team?

• Everybody who is part of the relationship with
  patients
• Includes people who are not typical partners
• Relationships within the Care Team are essential.

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• Ive worked here for 2 years and this is the
  first time I feel like Im part of something
  Im part of a team, and were working to make
  things better.
• - Information Resource Management

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Improvement is not easy DM Comprehensive Care
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1 Reason for Pilot Sites Reaching their Goals?

• Leadership!
• Attention is the currency of leadership -
  Ronald A. Heifetz

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LeadershipDiabetes Comprehensive Measure
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Importance of Nurses in Improvement (e.g.s)

• Leading improvement teams
• Leading huddles in preparation for visits
• Planning for visits
• Patient follow-ups
• Patient self-management
• Group visits

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Importance of Nurses in Improvement DM
Comprehensive Care
Nursing Order Entry of optometry consults when due
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Average visit cycle timePatient experience
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Care Across ConditionsIntake Bundle (Dep, BMI,
BP, IPV, Tob, Alc)
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Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
Act
Plan
Study
Do
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• Some is not a number, and soon is not a time
• - Donald Berwick, IHIs President and CEO

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Testing Changes
Changes That Result in Improvement in Practice
DATA and Learning
Implementation of adapted guideline(Large cost
of failure)
Wide-scale tests of adaptations
Adaptation and follow-up Tests
Very small scale test (Small Cost of failure)
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IPC-Pilot Sites Geographic Isolation
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Overcoming Isolation Working in a new way

• gt30 Webex sessions with all teams on.
• Two virtual (Webex) Learning Sessions
• Last two Open Door Forums with Webex
• CCI Staff
• CCI/IHI Partnership

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Hope

• I was thinking that I might retire until this
  stuff came along.
• - B.C, MD
• I have been in Indian Health for 28 years, and
  this is the first time that I have real hope that
  things can be better.
• - C.S., RN

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GPRA 2006

• Cancer Screening Colorectal
• AI/AN patients ages 51-80 who have received
  appropriate Colorectal Cancer Screening

Patients who received screening
Patients who did NOT receive screening
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Colorectal Cancer Screening
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Care Model
Health System
Community
Health Care Organization
Resources and Policies
ClinicalInformationSystems
DeliverySystem Design
Self-Management Support
Decision Support
Productive Interactions through effective asset
based partnering over time
Patient Driven
Coordinated
Informed, Empowered Patient and Family
Prepared, Proactive Practice Team
Timely and Efficient
Evidence-based and Safe
Improved achievement of patient and community
goals
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Synergythe phenomenon in which two or more
discrete influences or agents acting together
create an effect greater than that predicted by
knowing only the separate effects of the
individual agents
IHI Strategies

• IHS Mission...
• to raise the physical, mental, social, and
  spiritual health of American Indians and Alaska
  Natives to the highest level.

Motivate Build will and optimism for change
Innovate invent new solutions, create new
healthcare models with far superior value
CCI IPC/IHS
Get Results partnerships that can leverage
results for thousands learn from and assist
leaders to get results.
Raise Joy in Work
Support community and individual wellness and
strength
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Where do we go from here? (Spread)
Five Million Lives Campaign
Second Round of Full Scale
For sites not ready the first time around
National collaborative for 200 sites supported
by regional infrastructure
Full Scale
Training remaining sites (200) on models,
project management and leadership for improvement
Readiness Curriculum
Capacity Building
Training of initial coaching teams (6 12) to
support improvement in the field
Addition of 25 new sites to the IPC Includes
readiness stage, sequencing and staging changes
IPC II
IPC I
Intensive work with initial 14 pilot teams
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Lessons Learned

• Hope
• Improvement is everyones business
• Waste
• Improvement work can increase staff and patient
  satisfaction
• Dietitian is spelled with two ts

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Lessons

• Continuity (Relationships) are essential
• With the patient
• Within the care team
• I want to work in an Indian Health System where I
  dont have to ask for favors to get the best
  possible care for my daughter.

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