overview and results: what we have accomplished
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California Chronic Care Learning Communities Initiative Collaborative. Overview and Results: What We Have Accomplished. Final Outcomes Congress - December 9, 2005 Wendy Jameson, Director Angela Hovis, Improvement Advisor. Prevalence of Chronic Disease in California. - PowerPoint PPT PresentationTRANSCRIPT
Overview and Results:What We Have Accomplished
Final Outcomes Congress - December 9, 2005
Wendy Jameson, DirectorAngela Hovis, Improvement Advisor
California Chronic Care Learning Communities Initiative Collaborative
Prevalence of Chronic Disease in California
• 12 million in CA with chronic disease– Hypertension– Asthma– Congestive Heart Failure– Diabetes
• 4 million of chronically ill Californians seek care in the safety net2 million have diabetes
Bodenheimer, T., Examining Chronic Care in California’s Safety Net,Oakland: California Health Care Foundation, July 2003.
What Do Patients with Chronic Illness Need?
• Care geared towards:– Preventing bad outcomes (amputation,
blindness, cardiovascular disease)– Motivating and helping patients make lifestyle
changes
• A tracking system, or patient registry, to make sure no one slips through the cracks
Informed,ActivatedPatient
ProductiveInteractions
Prepared,ProactivePractice Team
DeliverySystemDesign
DecisionSupport
ClinicalInformation
Systems
Self-Management
Support
Health SystemResources and Policies
Community Health Care Organization
Chronic Care Model
Improved Outcomes
In General, In General, American Medicine Does a Poor Job Caring for the Chronically Ill
• Half of patients hospitalized with congestive heart failure are readmitted within 90 days.
• 63% with diabetes have HbA1c levels > 7.0%.
• 66% hypertensives have BP out of control.
Ni et al. Arch Intern Med 1998;158;231. Saydah et al. JAMA 2004;291:335. JNC 7. JAMA 2003;289:2560.
California Chronic Care Learning California Chronic Care Learning Communities CollaborativeCommunities Collaborative
Brought to You By...Brought to You By...
• California Health Care Safety Net Institute• California HealthCare Foundation• Kaiser Permanente• Core faculty representing:
– Improving Chronic Illness Care, Group Health Cooperative
– Institute for Healthcare Improvement (training)– Chronic care champions from 3 CAPH member public
hospital systems
California Chronic Care Learning California Chronic Care Learning Communities CollaborativeCommunities Collaborative
ParticipantsParticipants
• Alameda County Medical Center• Arrowhead Regional Medical Center• Contra Costa Health Services• San Francisco Department of Public Health• San Francisco General Hospital• San Mateo Medical Center• Santa Clara Valley Medical Center
Breakthrough Series Collaborative Model
Select Topic
(develop mission)
Planning Group & Faculty
Participants (teams/pilot sites)
Pre-work: (Aims and Measures)
LS 1
P
S
A DP
S
A D
LS 2
SupportsEmail Visits
Phone Assessments
Monthly Team Reports
Congress,
Next StepsA D
P
S
Review Measures & Change Package
LS 3
California Chronic Care Learning California Chronic Care Learning Communities CollaborativeCommunities Collaborative
GoalsGoals
For diabetic patients served by nine public hospital clinics, our goal was to:• Improve care processes• Decrease complications• Reduce cardiovascular risk
Three Key Focus AreasThree Key Focus Areas
• Use of data and information systems to support pro-active care
• Control of clinical risk factors• Each team set goals, based on Bureau of Primary
Health Care Health Disparities Collaboratives
• Better use of self-management support strategies by patients and providers
Where did we start?Where did we start?
• 9 clinics serving over 13,000 diabetics; many poorly controlled
• All at risk for cardiovascular disease
• Each clinic chose a small pilot population of 100-200 patients of 1-3 physicians
National data - Source: NHANES III (1994) and Behavioral Risk Factor Surveillance System data (1995); Saaddine, J.B. et. al, Annals of Internal Medicine 2002; 136:565-574.HEDIS data - Source: The State of Health Care Quality: 2005, National Committee for Quality Assurance, Washington, DC, 2005.Chobanian AV et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure JAMA 2003;289:2560-2572
Outcomes for Patients with Diabetes Public Hospital CCLC Patients vs National Indicators
0
10
20
30
40
50
60
70
80
90
100
HbA1c < 7.0% BloodPressure:
CCLC 130/80;JNC 140/90
LDL < 100mg/dl
Self-management
goals
HbA1c Test>1/yr.
Annual eyeexam
Annual footexam
Pneumococcalvaccine
Perc
ent CCLC
National
HEDIS (Medicaid)
JNC 7
How Did We Do?Mean Assessment Scores and Comparisons
State Collaborative Means
0.00.51.01.52.02.53.03.54.04.55.0
1 3 5 7 9 11 13 15 17
Months
1-5
Ass
essm
ent S
core
CA PubHos-CCLCAlaska meanWSDC I meanWSDC II meanCVC MeanNew Mexico MeanVT DiabetesNorth Carolina MeanOR Diab Collab MeanChicago MeanMaine MeanRI MeanCA BCCP mean
CCLC Mean Assessment by Month
00.5
11.5
22.5
33.5
44.5
5
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov
Month of Collaborative
Ass
essm
ent S
core
Roll-Up GraphsPnuemococcal Vaccine -2 Teams
0
10
20
30
40
50
60
70
80
90
100
% P
atie
nts
with
Vac
cine
% pts. Vaccine 58.5 72.2 77.7 79.6 82.0 85.0 85.9 86.6 87.6 89.4 90.4 91.3 91.8
# all patients 123 205 206 206 206 206 206 201 201 198 197 196 196
Goal 90 90 90 90 90 90 90 90 90 90 90 90 90
Oct 04
Nov 04
Dec 04
Jan 05
Feb 05
Mar 05
Apr 05
May 05
Jun 05
Jul 05
Aug 05
Sep 05
Oct 05
Foot Exam - 4 Teams
0
10
20
30
40
50
60
70
80
90
100
% P
atie
nts
with
Foo
t Exa
m
% pts. w /exam 4.6 23.5 27.2 37.9 43.7 51.4 55.1 58.9 62.1 66.4 71.2 75.9 77.1
# all patients 274 234 500 533 549 563 571 569 570 565 576 573 571
Goal 90 90 90 90 90 90 90 90 90 90 90 90 90
Oct 04
Nov 04
Dec 04
Jan 05
Feb 05
Mar 05
Apr 05
May 05
Jun 05
Jul 05
Aug 05
Sep 05
Oct 05
Roll-Up Graphs (cont.)Eye Exam - 3 Teams
0
10
20
30
40
50
60
70
80
90
100%
Pat
ient
s w
/Eye
Exa
m
% pts.EyeExam 53.3 42.3 50.6 53.4 50.9 55.1 58.4 60.9 60.9 60.6 60.9 61.2 51.5
# all patients 274 234 356 356 352 350 346 338 338 335 335 327 326
Goal 70 70 70 70 70 70 70 70 70 70 70 70 70
Oct 04
Nov 04
Dec 04
Jan 05
Feb 05
Mar 05
Apr 05
May 05
Jun 05
Jul 05
Aug 05
Sep 05
Oct 05
ACE/ARB - 5 Teams
0
10
20
30
40
50
60
70
80
90
100
% P
atie
nts
over
55
w/ A
CE/
AR
B
% pts. ACE/ARB 42.0 63.0 62.5 61.6 67.1 67.6 67.1 68.1 68.2 67.3 67.0 66.4 66.8
# pts.≥55 yrs. 169 138 352 385 404 414 432 436 440 440 448 452 452
Goal 75 75 75 75 75 75 75 75 75 75 75 75 75
Oct 04
Nov 04
Dec 04
Jan 05
Feb 05
Mar 05
Apr 05
May 05
Jun 05
Jul 05
Aug 05
Sep 05
Oct 05
Roll-Up Graphs (cont.)Self-Management Goals-6 Teams
0
10
20
30
40
50
60
70
80
90
100%
of P
atie
nts
w/ S
M G
oal
% SM Goal 4.0 3.1 12.6 19.8 26.0 31.2 34.4 37.9 39.4 41.4 45.4 51.4 52.4
# all patients 397 486 738 853 849 845 840 832 831 824 823 812 808
Goal 70 70 70 70 70 70 70 70 70 70 70 70 70
Oct 04
Nov 04
Dec 04
Jan 05
Feb 05
Mar 05
Apr 05
May 05
Jun 05
Jul 05
Aug 05
Sep 05
Oct 05
BP Control
0
10
20
30
40
50
60
70
% o
f Pat
ient
s w
ith B
P<13
0/80
% BP Control 35.6 40.8 34.1 34.4 33.8 32.8 37.0 37.1 38.7 36.5 36.4 38.2 39.6
# w /BP value 284 309 519 640 680 689 709 710 707 703 711 725 712
Goal 40 40 40 40 40 40 40 40 40 40 40 40 40
Oct 04
Nov 04
Dec 04
Jan 05
Feb 05
Mar 05
Apr 05
May 05
Jun 05
Jul 05Aug 05
Sep 05
Oct 05
Roll-Up Graphs (cont.)LDL Test
0
10
20
30
40
50
60
70
80
90
100%
Pat
ient
s w
ith L
DL
Test
% pts. w /LDL Test 67.3 75.7 73.7 72.9 76.4 72.7 72.3 77.2 76.7 73.2 73.6 75.1 75.2
# all patients 397 609 875 908 924 938 946 944 945 940 950 946 944
"goal" 90 90 90 90 90 90 90 90 90 90 90 90 90
Oct 04
Nov 04
Dec 04
Jan 05
Feb 05
Mar 05
Apr 05
May 05
Jun 05
Jul 05
Aug 05
Sep 05
Oct 05
LDL Control
0
10
20
30
40
50
60
70
80
90
100
% o
f Pat
ient
s w
i/ LD
L<10
0
% LDL Control 49.4 38.6 40.9 42.1 40.8 43.4 46.2 46.5 47.4 54.7 56.9 55.1 56.5
# w /LDL w /in yr 267 461 645 662 706 682 684 729 725 688 699 710 710
Goal 70 70 70 70 70 70 70 70 70 70 70 70 70
Oct 04
Nov 04
Dec 04
Jan 05
Feb 05
Mar 05
Apr 05
May 05
Jun 05
Jul 05
Aug 05
Sep 05
Oct 05
Roll-Up Graphs (cont.)
A1c Control
5
6
7
8
9
10
Ave
rage
A1c
Ave. A1c 7.6329 7.8606 7.6469 7.6096 7.6577 7.5802 7.6484 7.8134 7.7184 7.5519 7.5467 7.5971 7.6204
# pts 350 573 769 833 855 841 839 844 846 839 833 833 825
Goal 7 7 7 7 7 7 7 7 7 7 7 7 7
Oct 04 Nov 04
Dec 04
Jan 05 Feb 05
Mar 05
Apr 05
May 05
Jun 05 Jul 05 Aug 05
Sep 05
Oct 05
A1c Test
0
10
20
30
40
50
60
70
80
90
100
%t o
f Pat
ient
s w
/A1c
Tes
t
%w /2A1cTests 45.1 39.8 50.8 54.4 53.4 58.9 56.7 62.2 60.0 62.3 60.7 61.8 63.2
# pts 397 609 875 908 924 938 946 944 945 940 950 946 944
Goal 90 90 90 90 90 90 90 90 90 90 90 90 90
Oct 04
Nov 04
Dec 04
Jan 05
Feb 05
Mar 05
Apr 05
May 05
Jun 05
Jul 05 Aug 05
Sep 05
Oct 05
A1c Control
0102030405060708090
100
% o
f Pat
ient
s w
/A1c
≤7
%≤7 48.9 42.3 43.5 43.3 45.7 43.8 45.5 43.3 41.4 42.5 44.8 43.3 42.1
# w / A1c 350 573 769 833 855 841 839 844 846 839 833 833 825
Goal 60 60 60 60 60 60 60 60 60 60 60 60 60
Oct 04
Nov 04
Dec 04
Jan 05
Feb 05
Mar 05
Apr 05
May 05
Jun 05
Jul 05Aug 05
Sep 05
Oct 05
HighlightsStatins-Potrero Hill Hlth.Ctr.
0102030405060708090
100
% P
atie
nts
≥ 40
on
Stat
ins
% on Statins 14. 21. 22. 28. 28. 30. 30. 33.
Goal 60 60 60 60 60 60 60 60 60 60 60 60 60 60 60 60
# pts.≥40 yrs 11 11 11 11 11 11 11 10
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul 05
Aug
Sep
Oct
Nov
Dec
Dec-
Statins – 4 Teams
3 showed improvement
1 already at or above goal and sustained
ACE/ARB-Arrowhead Reg. Med. Ctr.
0102030405060708090
100
% P
atie
nts
over
55
w/ A
CE/A
RB
% pts. ACE/ARB 42.4 52.7 55.9 55.9 58.1 58.963.2 64.2 62.9 63.5 64.6 65.6
Goal 75 75 75 75 75 75 75 75 75 75 75 75
# pts.≥55 yrs. 92 93 93 93 93 95 95 95 97 96 96 96
Oct 04
Nov 04
Dec 04
Jan 05
Feb 05
Mar 05
Apr 05
May 05
Jun 05
Jul 05
Aug 05
Sep 05
Oct-01
ACE-ARB – 6 Teams
4 showed improvement
1 already at or above goal and sustained
Highlights
Dilated Eye Exam-Potrero Hill Hlth. Ctr.
01020
30
40
5060
70
8090
100
% o
f Pat
ient
s w
/ Eye
Exa
m
% Exam 8.9 8.9 8.7 18. 18. 18. 32. 45.
Goal 70 70 70 70 70 70 70 70 70 70 70 70 70 70 70 70
# all pts. 123 123 127 128 131 135 134 122
Oct
04
Nov
04
Dec
04
Jan 05
Feb 05
Mar
05
Apr 05
May
05
Jun 05
Jul 05
Aug
05
Sep
05
Oct
05
Nov
05
Dec
05
Dec-01
Retinal Eye Exam – 4 Teams
3 showed improvement
Dilated Eye Exam-Silver Ave. Fam. Hlth. Ctr.
0102030405060708090
100
% P
atie
nts
with
Dila
ted
Eye
Exam
% Eye Exam 34.1 42.2 42.2 42.2 47.0 57.8 60.3 60.3 62.7 61.3 65.3 65.3
Goal 75 75 75 75 75 75 75 75 75 75 75 75 75
# all patients 82 83 83 83 83 83 78 78 75 75 75 75
Oct 04
Nov 04
Dec 04
Jan 05
Feb 05
Mar 05
Apr 05
May 05
Jun 05
Jul 05
Aug 05
Sep 05
Oct 05
EYE VAN EXAMS
HighlightsFoot Exam-Eastmont Sr. Wellness Clinic
0
10
20
30
40
50
60
70
80
90
100
% P
atie
nts
with
Foo
t Exa
m
% Foot Exam 14.3 41.8 53.3 66.7 67.9 67.9 68.4 69.8 70.9 71.6 76.5
Goal 90 90 90 90 90 90 90 90 90 90 90 90 90
# all patients 3 14 55 75 93 106 112 114 116 127 134 136
Oct 04
Nov 04
Dec 04
Jan 05
Feb 05
Mar 05
Apr 05
May 05
Jun 05
Jul 05
Aug 05
Sep 05
Oct-01
Foot Exam – 5 Teams
4 showed improvement
Pneumococcal Vaccine – 4 Teams
2 showed improvement
Pnuemococcal Vaccine-Richmond Hlth. Ctr.-Contra Costa
0
10
20
30
40
50
60
70
80
90
100
% P
atie
nts
with
Vac
cine
% pts. Vaccine 58.5 63.4 65.0 68.3 72.4 76.4 78.0 80.5 82.1 83.7 85.2 86.8 87.6
Goal 90 90 90 90 90 90 90 90 90 90 90 90 90
# all patients 123 123 123 123 123 123 123 123 123 123 122 121 121
Oct 04
Nov 04
Dec 04
Jan 05
Feb 05
Mar 05
Apr 05
May 05
Jun 05
Jul 05
Aug 05
Sep 05
Oct-01
Foot Exam-Chinatown Pub. Hlth. Ctr.
0102030405060708090
100
% P
atie
nts
w/ F
oot E
xam
% w/ Foot Exam 4.6 21. 22. 33. 41. 50. 51. 60. 65. 73. 81. 80. 80.
Goal 90 90 90 90 90 90 90 90 90 90 90 90 90
# all patients 152 152 152 152 148 146 142 139 139 139 139 131 130
Oct 04
Nov 04
Dec 04
Jan 05
Feb 05
Mar
05
Apr 05
May 05
Jun 05
Jul 05
Aug 05
Sep 05
Oct 05
Highlights
Self-Management Goal -Siver Ave. Fam.Hlth. Ctr
0102030405060708090
100
% o
f Pat
ient
s w
/ SM
Goa
l
% SM Goal 18. 18. 18. 22. 32. 38. 39. 41. 42. 44. 64. 64.
Goal 70 70 70 70 70 70 70 70 70 70 70 70 70 70 70
# all patients 82 83 83 83 83 83 78 78 75 75 75 75
Oct 04
Nov
04
Dec
04
Jan
05
Feb
05
Mar
05
Apr 05
May
05
Jun
05
Jul 05
Aug
05
Sep 05
Oct 05
Nov
05
Dec
05
13 participate in group visit
Self-Management Goals – 8 Teams
All 8 showed improvement!
Self-Management Goals-Chinatown Pub. Hlth. Ctr.
0102030405060708090
100
% o
f Pat
ient
s w
/ SM
Goa
l
% SM Goal 0.0 0.0 0.0 0.0 16. 26. 34. 38. 39. 51. 63. 67. 68.Goal 50 50 50 50 50 50 50 50 50 50 50 50 50# all patients 152 152 152 152 148 146 142 139 139 139 139 131 130
Oct 04
Nov 04
Dec 04
Jan 05
Feb 05
Mar 05
Apr 05
May 05
J un 05
Jul 05
Aug 05
Sep 05
Oct 05
Highlights
A1c Tests – 9 Teams
5 showed improvement
1 already at goal and sustained
LDL Test - Richmond Hlth. Ctr. - Contra Costa
0
10
20
30
40
50
60
70
80
90
100
% P
ts. w
/LDL
pas
t 12
mnt
hs
% w / LDL Test 63.4 71.5 69.1 74.8 78.0 79.7 78.9 81.3 80.5 77.2 81.1 80.2 79.3
Goal 90 90 90 90 90 90 90 90 90 90 90 90 90 90
all patients 123 123 123 123 123 123 123 123 123 123 122 121 121
Oct 04
Nov 04
Dec 04
Jan 05
Feb 05
Mar 05
Apr 05
May 05
Jun 05
Jul 05
Aug 05
Sep 05
Oct-01
Nov-01
LDL Test – 9 Teams
5 showed improvement
A1c Test-Santa Clara Valley Medical Center
0102030405060708090
100%
t Pts
. w/A
1c T
est
% w/2 tsts w/in yr.≥3mnths apart
7.5 57.5 63.5 67.9 82.5 81.3 81.3 74.6 78.2 77.8 78.6 78.6
Goal 90 90 90 90 90 90 90 90 90 90 90 90 90
# all pts 252 252 252 252 252 252 252 252 252 252 252 252
Oct 04
Nov 04
Dec 04
Jan 05
Feb 05
Mar 05
Apr 05
May 05
Jun 05
Jul 05
Aug 05
Sep 05
Oct 05
HighlightsBP Control-Arrowhead Reg. Med. Ctr.
0
10
20
30
40
50
60
70
80
90%
of P
atie
nts
with
BP<
130/
80
% BP Control 20.4 21.1 21.4 19.7 18.8 18.3 19.0 20.5 25.0 31.3 29.5 33.7
Goal 40 40 40 40 40 40 40 40 40 40 40 40
# w /BP value 113 114 117 117 117 120 121 117 116 115 112 104
Oct 04
Nov 04
Dec 04
Jan 05
Feb 05
Mar 05
Apr 05
May 05
Jun 05
Jul 05
Aug 05
Sep 05
Oct-01
BP Control-San Mateo Med. Ctr.
0
10
20
30
40
50
60
70
80
90
% o
f Pat
ient
s w
ith B
P<13
0/80
% BP Control 23. 24. 22. 21. 25. 27. 27. 31. 32. 34. 35.
Goal 40 40 40 40 40 40 40 40 40 40 40 40 40
# w /BP value 64 114 111 107 107 106 108 105 105 105 103
Oct 04
Nov 04
Dec 04
Jan 05
Feb 05
Mar 05
Apr
05
May 05
Jun 05
Jul 05
Aug 05
Sep 05
4-Oct
BP Control – 9 Teams
4 showed improvement
1 already at goal and sustained
HighlightsLDL Control-San Mateo Med. Ctr.
0102030405060708090
100%
of P
atie
nts
wi/
LDL<
100
% LDL Control 45. 47. 48. 50. 51. 54. 55. 57. 57. 60. 59.
goal 70 70 70 70 70 70 70 70 70 70 70 70
# w /LDL w /in yr 109 103101 97 94 94 98 102 100 99 97
Oct
04
Nov 04
Dec
04
Jan
05
Feb 05
Mar
05
Apr
05
May 05
Jun
05
Jul 05
Aug 05
Sep
05
4-Oct
LDL Control - Richmond Hlth. Ctr. - Contra Costa
202530354045505560657075
% o
f Pat
ient
s w
i/ LD
L<10
0
%w /LDL Control 29.529.5 27.132.6 31.333.743.3 43.046.5 48.450.552.6 58.3
goal 50 50 50 50 50 50 50 50 50 50 50 50 50 50
# w /LDL w /in yr 78 88 85 92 96 98 97 100 99 95 99 97 96
Oct 04
Nov
04
Dec 04
Jan 05
Feb 05
Mar 05
Apr 05
May
05
Jun 05
Jul 05
Aug 05
Sep 05
Oct-01
Nov-01
LDL Control – 9 Teams
4 showed improvement
LDL Control-Santa Clara Valley Medical Center
0102030405060708090
100
% P
ts. w
i/ LD
L<10
0
% w/Control 37. 41. 40. 37. 41. 44. 45. 47. 72. 76. 63. 64.
goal 55 55 55 55 55 55 55 55 55 55 55 55 55
# w/LDL w/in yr 197 196 189 226 188 184 210 196 170 172 176 171
Oct 04
Nov
Dec
Jan
Feb
Mar
Apr 05
May
Jun
Jul 05
Aug
Sep
Oct 05
HighlightsAverage HbA1c- SFGH Family Health Center
56789
101112131415
Oct04
Nov04
Dec04
J an05
Feb05
Mar05
Apr05
May05
J un05
J ul05
Aug05
Sep05
Ave
rage
HbA
1c
Average HbA1c-Richmond Hlth. Ctr. - Contra Costa
6.56.66.76.86.9
77.17.27.37.47.57.67.77.87.9
88.18.2
Ave
rage
HbA
1c
A1c Control – 9 Teams
Average < 7: 2 showed improvement
% < 7: 3 showed improvement
A1c Control-Santa Clara Valley Medical Center
0102030405060708090
100
% P
ts. w
/A1c
≤7
%≤7 27.3 36.9 43.3 41.9 44.5 46.7 48.0 42.4 43.6 53.5 47.3 48.1
goal 60 60 60 60 60 60 60 60 60 60 60 60 60
# w / A1c 238 203 231 246 229 227 221 224 225 215 222 214
Oct 04
Nov 04
Dec 04
Jan 05
Feb 05
Mar 05
Apr 05
May 05
Jun 05
Jul 05
Aug 05
Sep 05
Oct 05
Challenges to Improving Chronic Care in Challenges to Improving Chronic Care in Public Hospitals & Health SystemsPublic Hospitals & Health Systems
• No reimbursement for non-physician care• Information systems not geared for tracking
chronic care patients• Chaotic, overstressed primary care clinics• Patients with limited English & low health literacy• Difficulty changing job descriptions of clinic staff• Bureacracy• Delivery system geared toward acute illness
Public hospital Systems Can Have the Most Impact on Disparities in Chronic Care
• Health disparities: patient population is 78% people of color, predominantly low-income
• Comprehensive systems of care: potential to improve along continuum of care
• Training next generation of health care professionals