Clinical Care Improvement System

Mark Murray, MD, MPAMark Murray & Associates

System Elements

Organization of Healthcare System– clinical care management programs can be more

effective if the overall system (organization) in which care is provided is oriented and led in a manner that allows for a focus on clinical care

Delivery System– delivery system design, based on an

understanding of the fundamental dynamic of balancing demand to supply is critical for success in optimizing clinical care

System Elements (cont’d)

Community Linkages– linkages between the health delivery system (or

provider practice) and community resources play important roles in the management of clinical care

Organization of Healthcare system

Leadership with a clinical perspective Develop will Integration of clinical quality into

performance and business plans Commitment of leadership to lead

Organization of Healthcare System: change strategies

Leadership Commitment to Improvement of Clinical Care

Clearly Articulated Goals Around Clinical Care Measurement Commitment Incentives Based on Quality of Clinical Care Agreements that Facilitate Care Coordination

Within and Across the Organization

Delivery System

Planned care for every encounter “Opportunistic” care Proactive care No wait culture Balance demand and supply for all services Right person, doing right work, right away

Delivery System: change strategies

Access Commitment—No-Wait Culture Commitment to Panel Management and

Continuity Activated Practice Teams with Strong

Leadership on Teams Clinical Care Teams with Clarified Roles Delivery System that Plans for Care

Community Linkages

Identify community resources Mobilize these resources Integrate the resources

Community Linkages: change strategies

Linking Patients to Outside Resources Partnerships with Community

Organizations

Practice Elements

Self-Management– can help patients and families cope with the challenges of

living with and treating clinical conditions both “acute” and “chronic,” and reduce complications and symptoms

Decision Support– effective clinical condition management programs assure that

providers have access to evidence-based information necessary to care for patients—decision support. Includes evidence-based practice guidelines or protocols, specialty consultation, provider education, and activating patients to make provider teams aware of effective therapies

Practice Elements (cont’d)

Clinical Information Systems– timely, useful information about individual patients and

populations of patients with clinical conditions is a critical feature of effective programs, especially those that employ population-based approaches

Self Management

Empowerment Occurs in an environment of reliability and

trust Won’t happen unless there is linkage to a

specific provider Requires a plan

Self-Management: change strategies

Patient Involvement in Care Choices System for Patient Support Strategies,

Including Assessment, Goal-Setting, Action Planning, Problem-Solving and Follow-up

Options for Effective Behavior Change Interventions and/or Peer Support

Decision Support

Information available at the right time and place, just in time

Proactive Population based Requires embedded guidelines Guidelines inform the “Registry” design

Decision Support: change strategies

Use of Evidence-Based Guidelines or Pathways

Linkage with Specialists Through Service Agreements, Focused Education Efforts and Consultation Opportunities

Provider Continuing Education for Clinical Care

Involvement of Patients in Guideline Participation

Decision Support (cont’d)

Pre-visit Preparation and Planning, Including “Screening” and “Huddles”

Customized Treatment Plans for Challenging Situations, Including the Development of Case Management

Clinical Information Systems

Provide ongoing summary of clinical interaction for individual patients and for the population of patients

Provides information for proactive intervention both for the population and prior to the clinical visit

Allows view of “exceptions” Monitors performance of individuals Provides performance feedback

Clinical Information Systems:change strategies

Identification of Practice and Individual Clinical Profile from the Practice and Individual Panels

Identification of Patients with Targeted Conditions and Entry into “Registry”

Pre-Visit Signals or Prompts and Planned Response for Patient Needs

Population Signals and Planned Response for Patient Needs from the Panels

Measurement and Monitoring of Care