Team Based Care

Combining Team Based Care and Technology to Improve Quality and Transform Healthcare to Improve Blood Pressure Control Wednesday February 12th, 12 Noon

Improving Health for Populations & Communities

South Dakota Foundation for Medical Care Christopher H. Tashjian, MD, FAAFP HIT fellow using the EHR and practice innovations to increase participation in the Million Hearts Initiative and improve performance on the Million Hearts goal Chief Medical Advisor WHITEC

Active Decision to Improve Care

 We changed our overall thinking from: ◦ It’s a physician problem To ◦ It’s a team challenge

What does that mean?

 Physicians had to give up TOTAL ownership  ◦ ◦ ◦ ◦ Staff had to be trained to understand the problem Nurses Lab Care Co-ordinators Front Office

What does that mean? (Part II)

  My patients are my partner’s patients My partner’s patients are my patients  Every visit is a hypertension visit!

MU and MH built into the patient visit Continuous Quality improvement

Pre-Visit Registratio n Patient & Family Engagement Patient Intake Provider Visit Privacy & Security Check Out Post Visit

Continuous Quality improvement

Using basic EHR functionality and performing common tasks can meet MU and Million Hearts goals

Stages of Meaningful Use

Stage 1: Data capture and patient access Stage 2: Information exchange and care coordination Stage 3: Improved outcomes

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Million Hearts® Goal: Prevent 1 million heart attacks and strokes in 5 years

• • National initiative co-led by CDC and CMS Partners across federal and state agencies and private organizations

Heart Disease and Stroke Leading Killers in the United States

• • • Cause 1 of every 3 deaths More than 2 million heart attacks and strokes each year – – – – 800,000 deaths Leading cause of preventable death in people <65 $444B in health care costs and lost productivity Treatment costs are ~$1 for every $6 spent Greatest contributor to racial disparities in life expectancy Roger VL, et al. Circulation. 2012;125:e2-e220.

Heidenriech PA, et al. Circulation. 2011;123:933 –4.

Key Components of Million Hearts™ CLINICAL PREVENTION

Optimizing care

COMMUNITY PREVENTION

Changing the context

Focus on ABCS Health information technology Clinical innovations

TRANS FAT

Million Hearts – Provider Goals

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Clinical Prevention Optimizing Quality, Access, and Outcomes

• • •

Focus on the ABCS

Simple, uniform set of measures Data collected or extracted in the workflow of care Link performance to incentives

NQF#0064 NQF#0018 NQF#0075 NQF#0068 NQF#0028

Comprehensive Diabetes Care: LDL-C Control <100 mg/dL Controlling High Blood Pressure Ischemic Vascular Disease (IVD): Complete Lipid Profile and LDL-C Control <100 mg/dL Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention

Getting to Goal Intervention A

spirin for those at high risk

B

lood pressure control

C

holesterol management

S

moking cessation

Baseline

47% 46% 33% 23%

Target

65% 65% 65% 65% 12 Sodium reduction Trans fat reduction ~ 3.5 g/day ~ 1% of calories 20% reduction 50% reduction Unpublished estimates from Prevention Impacts Simulation Model (PRISM).

Clinical target

70% 70% 70% 70%

Low Tech

HIGH TECH

First Take Data from EHR and Export to Excel

Excel to Access Database

Generate Patient Lists

Use of Filters

Patient Scorecards

Provider Scorecards

Results!

 In just four years, Ellsworth Medical Clinic reported the following improvements in blood pressure control: ◦ Among patients with diabetes, hypertension control increased from 73% to 97% (2007–2011) ◦ Among patients with cardiovascular disease, ◦ BP control increased from 68% to 97% (2007– 2011) Currently as of December 2012 ALL patients with hypertension controlled at 90%

Current progress

Percentage (%) of Patients in Control by Category November 2013 Review Category BP Hgb A1c LDL ASA Tobacco In Control 95 74 85 100 82 Total Patients Percent 100 100 100 100 100 95.0% 74.0% 85.0% 100.0% 82.0% 52.0% Total Patients in Control August 2013 Review Category BP Hgb A1c LDL ASA Tobacco Total Patients in Control 52 In Control 99 Total Patients Percent 104 82 86 104 104 104 87 104 104 95.20% 78.80% 82.70% 100.00% 83.70% 57 100 104 55.00%

Saves 417 Hearts, 72 Legs & 745 Pairs of Eyes Each Year!

• 32,747 members with diabetes, in one health plan, in 2012 suffered 417 fewer heart attacks, 72 fewer leg amputations and 745 people did not experience eye complications compared to what would have happened to the same 32,747 plus members in 2000.

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For our Patients – We have a Million Hearts

This Year

River Falls is a Million Hearts Finalist!

The Difference it Makes – Ask our Patients!

It Takes Teamwork!

Join Us: Take the Pledge

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http://millionhearts.hhs.gov

Resources

• Vital Signs: Where’s the Sodium?

www.cdc.gov/VitalSigns/Sodium/ index.h®l

• Vital Signs: Getting Blood Pressure Under Control

www.cdc.gov/vitalsigns/Hypertension/ index.h®l

• Team Up. Pressure Down.

http://millionhearts.hhs.gov/resources/ teamuppressuredown.h®l

• Community Guide: Team-Based Care

www.thecommunityguide.org/cvd/ teambasedcare.h®l

• SDOH Workbook: Promoting Health Equity, a Resource to Help Communities Address Social Determinants of Health

www.cdc.gov/nccdphp/dach/chhep/pdf/SDOHworkbook.pdf

• Program Guide for Public Health: Partnering with Pharmacists in the Prevention and Control of Chronic Diseases

www.cdc.gov/dhdsp/programs/nhdsp_program/docs/ Pharmacist_Guide.pdf

• Data Trends & Maps

http://apps.nccd.cdc.gov/NCVDSS_D®

A Different Way to Look at Quality?

Previous simvastatin label

Avoid simvastatin with: Itraconazole Ketoconazole Erythromycin Clarithromycin Telithromycin HIV protease inhibitors Nefazodone Do not exceed 10 mg simvastatin daily with: Gemfibrozil Cyclosporine Danazol Do not exceed 20 mg simvastatin daily with: Amiodarone Verapamil Do not exceed 40 mg simvastatin daily with: Diltiazem Avoid large quantities of grapefruit juice (>1 quart daily)

New simvastatin label

Contraindicated with simvastatin: Itraconazole Ketoconazole Posaconazole (New) Erythromycin Gemfibrozil Clarithromycin Telithromycin HIV protease inhibitors Nefazodone Cyclosporine Danazol Do not exceed 10 mg simvastatin daily with: Amiodarone Verapamil Diltiazem (Note: These drugs are contraindicated with Simcor as Simcor is only available with 20 mg or 40 mg of simvastatin.) Do not exceed 20 mg simvastatin daily with: Amlodipine (New) Ranolazine (New) Avoid large quantities of grapefruit juice (>1 quart daily

What We Found

70,000 Total Patients in all 3 clinics Simvastatin Dose

20 40 80

Total Number

95 976 365

Amiodarone Amlodipine

8

241 Verapamil

13

Diltiazem

49

Other Itraco nazole

0

Ketoco nazole

2

Posaco nazole

0

Erythro mycin

1

Clarithr omycin

1

Telithro mycin

0

Nefaza done

0

Gemfi brozil

23

Dan azol

0

Be BOLD!

For More Information contact: Chris Tashjian, MD, FAAFP [email protected]

Ellsworth Medical Clinic 715-273-5041