Chronic Disease Management:Driving Quality Improvement in

Primary CareAugust 1, 2008

Jan Norman, RD, CDEWashington State Department of Health

Quality Improvement Initiative

• Aimed at primary care providers

• Focus on prevention-based care

• Redesigns care delivery to deliver population-based care

The IOM Quality report: A New Health System for the 21st Century

http://www4.nas.edu/onpi/webextra.nsf/web/chasm?OpenDocument

The IOM Quality Report:Selected Quotes

• “The current care systems cannot do the job.”

• “Trying harder will not work.”• “Changing care systems will.”

A Framework for System ChangeED

UC

ATI

ON

COMMUNICATIONC

OO

RD

INA

TION

Consumer Purchasers

Providers Health Plans

CONFIDENTIALITY

Collaborative MethodsIHI

Breakthrough Process Planned

Care Model

Model for Improvement

Collaborative Process

Select Topic

Planning Group

Identify Change

Concepts

Participants

Prework

LS 1

P

S

A DP

SA D

LS 3LS 2

SupportsE-mail Visits Web-site

Phone Assessments

Senior Leader Reports

Outcomes Congress

A DP

S

(13 month time frame)

Community Resources and Policies

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

Functional and Clinical Outcomes

Health SystemHealth Care Organization

DeliverySystemDesign

Decision Support

ClinicalInformation

Systems

Self-Management

Support

Chronic Care Model

What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

Act Plan

Study Do

The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. G. Langley, K. Nolan, T. Nolan, C. Norman, L. Provost. Jossey-Bass Publishers., San Francisco, 1996.

History 1999 to 2008

Oct 1999 – Nov 2000 Diabetes 17 Teams

Feb 2001 – Mar 2002 Diabetes 28 Teams

Nov 2002 – Nov 2003 Diabetes 30 Teams

Jun 2004 – June 2005 Diabetes & Heart Disease 40 Teams

Feb 2006 – Mar 2007 Diabetes & Heart Disease 28 Teams

Collaborative vs Non Collaborative (DMI, DMII, Spread vs Non Collab)

77% 76%

53%

80% 80%

60%

49%

74%

62% 63%

43%

30%

17%

31%

76%

91%91%

45%

83%91%

71%

35%

0%10%20%30%40%50%60%70%80%90%

100%

CollabNon Collab

Washington State Collaborative 5 Diabetes Results

* Percent with average blood sugar < 150

Tacoma Spokane

Large, urban or for profit clinicsCommunity, rural or IHS clinics

Seattle

Washington State Collaborative Graduates

May 2008 – May 2009

• Adult topics– Diabetes– Depression– Asthma

• Pediatric topics– Asthma– Overweight prevention– Medical Home

• Partnership with Medicaid

• 33 teams• $5,000 stipend plus

incentive money for achievements

• Practice coaches• Target practice with

<5 providers

Policy Changes

• Medicaid established code to pay for group visits for diabetes and asthma

• Medicaid and BlueShield expanded diabetes education to all MD offices

• Uniform waived co-pay for Collaborative patients preventive visits

Key to Sustainability of Collaborative Outcomes

• “Quality improvement must be addressed on multiple fronts, just one of which is finding a way to build financial rewards for quality improvement into healthcare financing.”

Key to Sustainability of Collaborative Outcomes

• “Many plans and providers indicate a willingness to pursue such changes, but their efforts will depend on the support and commitment of the ultimate financiers of health care – government and private employers.”

2ESSB 5930 2007Governors Blue Ribbon

Commission Bill• Expand Medicaid to implement a

medical home for all aged, blind and disabled clients

• Direct DOH to provide primary care training in chronic care management

• Design a reimbursement plan to reward quality

ESSHB 2549 - 2008•Implement a Collaborative on

Medical Home•Redesign the funding to pay for the implementation of Medical

Home

Support tools for moving ahead

• AcademyHealth/Commonwealth Fund State Quality Improvement Institute

• Primary Care Coalition• WSC Advisory Committee• National Committee for Quality Assurance

Physician Recognition Program• Consensus definition of Medical Home

across provider groups

What is a Medical Home?

The patient-centered medical home is a model for care provided by Primary Care practices that seeks to strengthen the provider-patient relationship by replacing episodic care based on illnesses and patient complaints with coordinated care and a long-term healing relationship.