a population health management diabetes case study · a population health management . diabetes...
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A Population Health Management Diabetes Case Study
Rona Y. Sonabend, MD
Medical Director, Clinical Systems Integration Process Improvement Texas Children’s Hospital
Session #27
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Learning Objectives
1Describe the population
health model for pediatric
diabetes care delivery at
Texas Children's
Hospital (Texas Children’s).
2Illustrate disease
management with the
development of clinical
programs.
Explain the use of data
analytics to drive
meaningful quality
improvement.
3Demonstrate the value of a maturity model
in process improvement
and associated outcomes.
4
Indicate lessons learned.
5
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Poll Question #1
How would you rate the quality of care your organization delivers for patients with diabetes?
1) Poor2) Fair3) Good4) Very good5) Excellent6) Unsure or not applicable
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Texas Children’s vision statement for diabetes mellitus…
We must…“Deliver the highest quality of care to patients with
diabetes mellitus at Texas Children’s.”
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About 208,000 children and adolescents have been
diagnosed with diabetes, approximately 0.25% of the U.S. population.
The number of children and adolescents
in the U.S. with type 1 or type 2 diabetes is increasing.
The national burden of all diabetes mellitus
was as high as $245B in 2012.
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• Internationally renowned. • Committed to creating a community of healthy children through
excellence in patient care, education, and research.• Three inpatient facilities in Houston and one in San Antonio. • Multiple satellite ambulatory care centers.• Manage more than 1 million patient encounters each year.
Cy-FairMain Campus
Clear Lake
The Woodlands West Campus
Sugar Land
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The Need to Reduce Variation and Improve Care
• Texas Children’s leaders noted a measurable degree of variation in its management of diabetes across the continuum of care.
• This variation had been increasing over several years, leading to gaps in quality of care for diabetic patients.
• Diabetes care met criteria for a focused improvement effort:
• Large population of patients.• High degree of variation in care.• Measurable gaps in the consistency and quality of care.• Organizational readiness.
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Turning Point
Texas Children’s recognized that
incremental change would not suffice to
transform diabetes care.
A comprehensive, cross continuum care improvement program for diabetes patients was necessary.
1.
2.
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Mission Statements A Multidisciplinary, Cross-continuum Approach
Ambulatory
High Risk
CommunityEducation
Inpatient
Create innovative diabetes outpatient program that provides coordinated, family-centered, multidisciplinary care to our patients and their families.
Identify risks and barriers to optimal care and institute multidisciplinary processes to improve access to care and health outcomes in high-risk patients.
Build partnerships with care providers in the community by providing resources, education, and accessibility to provide comprehensive care for children with diabetes.
Develop diabetes and related health education for integration into
diabetes care delivery.
Eliminate unnecessary variations in inpatient care delivery and ease
transition to outpatient care.
Diabetes CPTs
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What Texas Children’s Did
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Improving Preventative CareResults
10%
0%
20%
40%50%
60%
70%
80%
90%
100%
30%
28.2%
recommended annual TSH testing.
Current performance
at 90.4%.
10%
0%
20%
40%50%
60%
70%
80%
90%
100%
30%
23%
recommended annual lipid testing.
Current performance
at 90.3%.
10%
0%
20%
40%50%
60%
70%
80%
90%
100%
30%
37.9%
recommended annual microalbumin testing.
Current performance
at 91.8%.
10%
0%
20%
40%50%
60%
70%
80%
90%
100%
30%
54.1%
annual retinal examinations.
Current performance
at 94.9%.
Relative improvement in the percentage of patients receiving:
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Impact of Risk-based InterventionResults
Relative reduction in recurrent diabetic
ketoacidosis (DKA)admissions per fiscal year.
Established patients with diabetes who have a predictive
risk score for future hospitalizations.
Patients with new onset diabetes who
received a risk assessment at
diagnosis.
30.9%90% 100%
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Population Health ManagementResults
34.4%
26.3%
90%Relative improvement in the percentage of patients with diabetes
who received the influenza vaccine.
Percent of patients who have individualized school packets (orders for management of diabetes at school) available in the EHR.
Relative improvement in pediatric provider knowledge, measured by
pre- and post-tests, following completion of the pediatric provider
diabetes education sessions.
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Continuing Education Physicians, Nurses, Staff, Patients
Results
Implementation of a standardized
diabetes education model to improve care across the
continuum.
Relative annual improvement in number of patients with an education visit by a registered dietician.
~33%
Relative annual improvement in number of patients with an education visit by acertified diabetes educator (CDE).
~50%
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Standardization and Improvement of Inpatient CareResults
Relative decrease in length of stay (LOS) for patients
with DKA.
Relative increase in patients with DKA receiving insulin within one hour of order.
Improvement in the percentage of patients transitioning to
subcutaneous (SQ) insulin in <4 hours after medical readiness.
Patients with DKA receiving an evidence-based
evaluation and order sets.
100% 19% 50% 44%
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Poll Question #2
How effective are your organization’s efforts to improve the care of patients with diabetes across the continuum?
1) Not effective2) Somewhat effective3) Moderately effective4) Very effective5) We are not focusing on it6) Unsure or not applicable
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How Texas Children’s Did It
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A Focus on Population Health
Put simply, how one manages patients with certain diseases or how one manages the entirety of all patients served in the region.
“Population health” is a relatively new and imprecise term, relating the health outcomes of a group of individuals to health determinants, policies, and interventions that effect those outcomes.
Kindig, D., Stoddart, G., (2003). What is population health? American Journal of Public Health, 93:380-83
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Model for Culture Change
Transparent vision
Leadership
Support and infrastructure
Dissemination of information Inclusive spirit
Multidisciplinary
Culture of change
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Clinical Program Vision
• Active use of clinical data by clinicians organized around patient conditions—care process teams (CPTs).
• Decrease in variation of care delivery.
• Learning as a result of data translation.
• Evidence-based clinical guidelines embedded within electronic medical record.
• Rapid PDSA cyclic improvements.
• Strategic alignment towards managing populations across the continuum of care.
• CPTs focused on important aspects of each clinical condition.
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Diabetes CPT Members
Diabetes Educators
ED rep.
Practice administrator
Executive leadership
Director Ambulatory Services
Dietitians
Clinical Data Specialist
Nursing co-lead
Nurse Practitioners
Asst. Dir. Ambulatory Nursing
Asst. Dir. Inpatient Nursing
Asst. Dir. Clinical Outcomes & Data Supp.
PhysiciansSystems Analyst
Nursing leadership
Social workers
Nursing
Acute Care rep.
Intensive Care rep.
Pharmacy
Content experts
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Maturity of Informatics (Data to Analytics)
Organizational evolution over time.
Data reporting• EMR clinical
reports.• Financial reports.
Data analytics• Shortening event
to reporting time.• Transforming
data and translating to meaningful clinical relevance.
Predictive analytics
• Linking likelihood of outcomes to care decisions for populations.
• Predicting financial outcomes.
• Linking strategies across former silos in infrastructures.
Prescriptive analytics• Integrating best
evidence into delivery system infrastructures.
• EMR based recommendations and alerts.
• Integrated plans of care across continuum.
• Utilizing big data bi-directionally.
Improved outcomes for Texas Children’s patients and the enterprise.
How many? Who and where? Who’s at risk? How do I prevent it in my patient?
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Data-Driven Focus
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Level of Maturity: Predictive Analytics
• Identification of patients at risk for undesirable outcomes (safety, quality, financial).
• Basis for development of a shared savings model.
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Provider Dashboard
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How Texas Children’s Did It
Developing infrastructure with
technological support.
PROGRESSSTART
Preparation readiness and engagement.
APPLICATION
Removal of barriers to
implementation.
SUCCESSTARGET
Alignment of goals and strategic
processes.
CARE ACROSS THE
CONTINUM
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Lessons Learned
IMPROVEMENT
Defining meaningful AIMs may require multiple iterations.It takes a village.
We’re On the Road…
Quality improvement is a data-driven sport.
Navigation of roadblocks require innovation.
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Future Plans
Continue to support progress
through all five CPTs
Ambulatory
High Risk
CommunityEducation
InpatientShared savings, prescriptive analytics.
Advocacy, support groups.
Transition, pathways for continuing education.
Ambulatory urgent care bay.
Quality of life, patient-reported outcomes.
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Thank You