Medically Complex Patients (MCP) WebinarTheories of Change
Onil Bhattacharyya, MD, PhDFrigon-Blau Chair in Family Medicine
Research, Women’s College HospitalUniversity of Toronto
Gary Naglie, MDHunt Family Chair in Geriatric
Medicine, Baycrest Health SciencesUniversity of Toronto
October 27, 2014
2
1. Recognize the maturity and complexity of your models and how this impacts the key goals for your project
2. Introduce the concept of theory of impact as a starting point for thinking about your models
3. Provide a framework to test key aspects of your model and identify opportunities for improvement
OBJECTIVES
PROJECT MATURITY – SETTING THE RIGHT GOALS
• Developing new program• Major modification to existing
project• Minor modification to existing
project• Scale up/replication
3
Kaiser Permanente Innovation Consultancy 4
“If things are fundamentally working in your system, then you are operating in the world of improvement. ”
“If you fundamentally believe that what you have is broken, then you are operating in the world of innovation.”
5
Features Improvement
Typical problem
Improve uptake of hand washing
Goal How to deliver service better
Parameters Clear user and outcome
Strategy Iterative, tests of smaller breadth
Innovation
Improve access for frail elderly
Develop the appropriate service
Tentative solution, user and outcome
Iterative, tests of larger breadth
IMPROVEMENT VS. INNOVATION
Developing a Theory of Impact
Why might your intervention work?
7
THEORY OF IMPACT
1. Problem – Something important but also manageable
2. Solution (intervention/mechanism) – A target group, a provider and a mechanism to address problem
3. Outcomes – Key outcomes that can be attributed to solution (shorter- and longer term)
8
THEORY OF IMPACT - COPD
1. Problem – COPD is a major cause of readmissions and COPD action plans are rarely used
2. Solution (intervention/mechanism) – Nurse case managers can increase self-management and use of action plans
3. Outcomes - Symptom scores, ED visits and hospitalizations,
THEORY OF IMPACT - ICCT
1. Problem – Growing frail senior population receive fragmented care that is expensive and does not meet their needs
2. Solution (intervention/mechanism) – Integrated primary, community and specialty care outreach service providing intensive case management and coordinated care across transitions
3. Outcomes – Better care experience, smoother transitions, reduced health care utilization
9
Original Model:Baycrest Community Outreach Team (COT)
10
Frail Older Adult/Caregiver
Referring Community Primary
Care Physicians
• Consultation
Community Outreach Team
New Model:The Integrated Community Care Team (ICCT)
Integration at the Point of Care
Frail Older Adult/Caregiver
Community “Solo” Primary Care Physicians
COT + COE + NP AcuteHospital
CCACIntensive Case
Managers + Pharmacist
• Consultation• Shared Care• Assumed Primary Care
Testing Key Hypotheses About Your Program
13
• Most programs have many untested elements related
• May relate to target group, intervention or context
• Articulating assumptions and testing them will help you find and fix problems early on
WHY IS THIS IMPORTANT?
14
KEY CHALLENGES FOR CARE INTEGRATION PROJECTS
• Difficulty implementing• Slow recruitment• Poor fit between between
intervention and target population not identified or modified
• Success rate <40% in well-conducted studies
• Variable results when replicated
15
INTEGRATION EXISTS ALONG A CONTINUUM
2-Way Communication
Joint Care Delivery
Joint Management Across
Institutions
Engagement
Communication & Behaviour
Culture & Policy
Low Medium High
Common Strategies
Common Challenges
Adapted From: Blank, S. Harvard Business Review, May 2013.
User Discovery
User Validation
Recruitment Program Building
Search Execution
Change user or intervention
16
FINDING THE RIGHT PATIENTS, BUILDING THE RIGHT PROGRAM
17
TESTING HYPOTHESES AT EACH STEP
• Feasibility of Implementation• Recruitment of patients• Recruitment of providers• Intervention• Outcomes
FEASIBILITY OF IMPLEMENTATION
• Hiring staff – clerical, providers, managers• Organizational support• Data sharing • Divergent institutional processes • Governance
18
ICCT EXAMPLE: IMPLEMENTATION CHALLENGES
• Hiring staff
• Data sharing
• Divergent institutional processes
• Governance
19
20
PATIENT RECRUITMENT
• Why would patients join?• Which patients will benefit?• Are there enough patients?• Are referral mechanisms effective?• Will patients show up?• Are the people who are being
referred different than expected?
21
PROVIDER RECRUITMENT
• What is the benefit for providers?• Is it easy to join or refer patients?• Consider steps in adoption
Enrollment First use Regular use
22
ICCT EXAMPLE: PATIENTS AND PROVIDERS
• Are people referred different than those being targeted? Yes – not all require in-home
assessment • Is it easy to refer patients?
Not from community docs perspective
23
INTERVENTION
• Is the intervention doable?• Are the elements of the
intervention working?• If reaching the target group, does
the intervention meet their needs?• Are there any missing
components?
24
ICCT EXAMPLE: FEATURES OF INTERVENTION
• Are elements of the intervention working? Consultation stream and shared care
require adjustments in hand-off and communication
• Are there any missing components? Over 50% of referrals from Central LHIN
25
• Do the outcomes match the maturity of the model?
• Are the outcomes appropriate given the mechanism of the intervention?
• Are the outcomes appropriate given the target patients?
ICCT EXAMPLE: OUTCOMES
ICCT EXAMPLE: OUTCOMES
• Do the outcomes match the maturity of the model? Premature to focus on health care
utilization Focus on patient and care provider
experience• Are the outcomes appropriate given the
target patients? Add quality end-of-life care
26
27
Use questions to inform yourself about how various parts of your project are working
Systematic review of quality improvement studies found that less than 20% documented changes through iteration or used monthly cycles
ITERATION IS HARD WORK
If you’re worried about your model, you will test it!
BMJ Quality and Safety, Taylor MJ et al 2013
28
“The real measure of success is the number of experiments that can be crowded into twenty-four
hours”Thomas Edison
29
CONCLUSIONS
1. Models are at varying levels of maturity and levels of complexity
2. Start from a high-level theory of impact
3. Drill down and test all of the aspects of your model to identify opportunities for improvement
4. This will help you find the right patients and build the right program
Questions