HEART FAILURE PATHWAY IN LYON

JOURNEY OF A CLINICAL INTEGRATION PROGRAM

IN DEVELOPMENT

Collaboration FIC HCL-CERGAM-CoActiS- GATE LSE Intermountain Healthcare – Utah USA

Pascal Briot - QI Project Manager– Intermountain Healthcare Institute for Healthcare Delivery and Research

Valérie Buthion - Associate Professor in Managemant Sciences – CoActiS University of Lyon

Geneviève Derumeaux - Coordinator of the Heart Failure Clinical Integration Program of Louis Pradel Hospital –

HCL University of Lyon

Nora Moumjid – Associate Professor in Economics – GATE LSE University of Lyon

Alice Teil - Associate Professor in Managemant Sciences - Coordinator of the Research Project - CERGAM

University of Aix-Marseille

1 – Patent holder/Shareholder or member or employee of a

government organization

2 – Consultant or member of a scientific council

3 – Paid speaker or author/editor of articles or documents

4 – Manager of travel expenses, lodging, or conference/event

registration

5 – Principal Investigator of a research or clinical study

6 – Co-Investigator of a clinical study

DisclosuresHealth Industry Interests relevant to Presentation

MEDICARE costs versus Quality

Baicker, K and Chandra, A. Medicare spending, the physician workforce, beneficiaries' quality of care.

Health Affairs Web Exclusive 7 April 2004; W4-184-97.

Expenditure

Person= Episode

Personx

Processes

Episodex

Cost

Process

Economic efficiency and current incentives (Copyright Intermountain Healthcare,

Briot P. and Teil A.)

Productive

efficiency

Healthcare

allocative

efficiency

Public Health

Allocative

efficiency

IOM 2010 (US) Total expenses

expected to be

20% of GDP by

2017

+ iatrogenic

events

16% of total expenses due to

over-use of processess without

patient centered added value

Impact of

current

incentives on

healthcare

expenses

4 3 2 1

Impact of Intermountain clinical integration programs : Example Cardiovascular Clinical Program

ACE inhibitors for Heart Failure

•Compliance increased from 65% to 95% in 1 year

•Readmissions within 1 year reduced from 47% to 39%

•551 readmissions avoided per year

•331 lives saved per year

•$2.5 M reduction in healthcare expenditures

Heart Failure Pathway in Lyon: Develop optimal clinical pathway for patients

1.Gathering every health specialty around patients

2.Organizing processes around continuous clinical pathways

3.Developing patient registry for evidence based health care

4.Developing cooperation with medical home, other hospitals

and independent physicians

Heart Failure Pathway in Lyon: First Step (2010-2011)

•Organization of heart failure activity based on a general

clinical process (will be presented here)

•500 patients total and 10 new patients a week

•A need to

• Generalize the organization inside the HCL with an

administrative support

• Develop a full clinical pathway through clinical

integration

• Measure impacts of process change

� 3 months � 6 months � 12 months

- TTE- 6 WT- BNP- Education programme

- Clinical assessment- 6 WT- BNP- Education programme

- TTE- VO2 max- 6 WT- BNP- Education programme

� 3 months � 6 months � 12 months

- TTE- 6 WT- BNP- Education programme

- Clinical assessment- 6 WT- BNP- Education programme

- TTE- VO2 max- 6 WT- BNP- Education programme

Stable heart failureUnstable heart failureSevere HF (NYHA IV)Hospitalisation in intensive care unit

Dedicated consultation at one monthTTEBNP6WT

Ventricular support deviceTransplantation

Out-patient clinic : 1 day« Identity Card of the patient »

- VO2max- 6 WT- TTE- BNP- Proposal of the Education programme

In-patient clinic : 2 days« Education programme+ Rehabilitation test »

Out-patient clinic : 1 day« Identity Card of the patient »

- VO2max- 6 WT- TTE- BNP- Proposal of the Education programme

In-patient clinic : 2 days« Education programme+ Rehabilitation test »

Therapeutic optimisation

Clinical microsystem

Multidisciplinary team working together

Clinical and business aims

Care process model implementation with

measurement system

Integrating Patient education and preferences

Information system

Embedded in clinical work process for

shared medical decision support

Longitudinal studies of process change and

its impacts

Continuous feedback of information to the

front line for continuous improvement

Managerial support

Leadership and staff and team focus

Resource allocation when needed based

on the relationship between clinical

outcomes and financial outcomes

Organizational learning and

culture

Development and regular update of guidelines

Decision support tools

Collective decisions and assessment

Professional education

Interdisciplinary training programs (ATP-peer

training in situ)

Conditions of

Clinical

and Organizational

Integration along

care pathways

Alignment

Alignment

Ali

gn

me

nt

Alig

nm

en

t

En

viro

nm

en

t inte

rface

s

Fundamental Knowledge integration

Review of

fundamental

knowledge

Review of

fundamental

knowledge

Design of protocols

and Data need

Design of protocols

and Data need

Development and tracking

of indicators (process,

service, outcomes)

Development and tracking

of indicators (process,

service, outcomes)

Implementing a

continuous feedback of

information to the

providers

Implementing a

continuous feedback of

information to the

providers

Organizational infrastructure

Implementation of

the protocols

Implementation of

the protocols

Management support

•Clinical Decision support

tools

•Training/Education

Management support

•Clinical Decision support

tools

•Training/Education

Culture

•Leadership

•Accountability

•Transparency

Culture

•Leadership

•Accountability

•Transparency

Implementing a continuous

feedback of information of

performance (clinical and

organizational)

Implementing a continuous

feedback of information of

performance (clinical and

organizational)

Information system needed

Collection of

meaningful data

embedded in

workflow

Collection of

meaningful data

embedded in

workflow

OutcomesOutcomes

Compliance

to the

protocols

Compliance

to the

protocols

Continuous

feedback of

actionable

measures

Continuous

feedback of

actionable

measures

Culture and

satisfaction

Culture and

satisfaction

RMOUNT

AI

N’

S

INFO

RMAT

ION

SY

ST

E

Episode of Care

DiagnosisHealth NeedPatient

PerceptionProcedure

Results &

Outcomes

Outpatient LABInsurance

Claims

Satisfaction

Survey

FinancialsPharmacy Radiology

Enterprise Data Warehouse

Not all data sources are shown...

HospitalElectronic

Medical/H

ealth

Record

« We can manage only what we can measure »: the right

Information is key, embedded in the work flow with continuous

actionable feedback

Billing and

Payment

Claims

Processing

Quality of

clinical processes

Patient centered

outcomes

First charts will be produced at the end of 2012

JAN - JUIN JUILLET - DEC

MESURE Non-Filiere Filiere Non-Filiere Filiere

Processes 33,0% 36,8% 37,0% 58,0%

Service (Likert 0 - 5) 3,0 4,5

Clinical outcome (re-

admission rate)

after 1 mont 10,0% 8,0% 9,0% 6,0%

after 6 months 22,0% 18,0% 24,0% 14,0%

after 1 year 44,0% 42,0% 42,0% 35,0%