Transcript Document

Community Partner
Indianapolis
Discovery
Network for
Dementia
Clinician
7/18/2015
Researcher
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IDND Website
www.indydiscoverynetwork.com
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Objectives
1. Review the organizational structure of IDND
2. Get feedback on
1. members’ participation into the IDND
2. IDND website
3. Discuss IDND decision making process
4. Discuss the next steps:
1. Business plan:
1. Staff support
2. Member Need Assessment
3. Minimally Standardized Approach
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What do I know?
• The Path to a successful IDND is
– Brutal
– Almost Impossible
– Full of obstacles
• But, I will not give up until I reach age 85!
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Changing Environment
Physician
Pharmacist
Nurse
HCS Performance,
Reputation, Culture
Allied Health
Administrator
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Patient
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Complex Adaptive System
• An open, dynamic, flexible, adaptive, and complex
network
• The system is Complex due to
– Its numerous interconnected, semi-autonomous,
competing, and collaborating members.
• The system is adaptive due to
– Its capability of learning from its prior experience
– Its flexibility to change its members connecting
patterns to fit better with its surrounding
environment.
Holden LM. Complex adaptive systems: concept analysis. Journal Article] Journal of Advanced Nursing. 52(6):651-7, 2005 Dec.
Litaker et al. Using complexity theory to build interventions that improve health care delivery in primary care. [Journal Article] Journal of General Internal Medicine. 21 Suppl 2:S30-4, 2006 Feb.
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Characteristics of
Complex Adaptive System
• Emergent behaviors as opposed to
predetermined ones
• Self-organized controls instead of
hierarchical, pyramid-based, and central
controls
Holden LM. Complex adaptive systems: concept analysis. Journal Article] Journal of Advanced Nursing. 52(6):651-7, 2005 Dec.
Litaker et al. Using complexity theory to build interventions that improve health care delivery in primary care. [Journal Article] Journal of General Internal Medicine. 21 Suppl 2:S30-4, 2006 Feb.
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The 9 Principles of Introducing Change
in a Complex Health Care System
1.
View your system through the lens of complexity.
2.
Build a good enough vision with minimum specifications
3.
Lead from the edge by balancing data and intuition, planning and acting,
safety and risk.
4.
Foster the "right" degree of information flow, diversity and difference,
connection among agents, power differential, and anxiety.
5.
Uncover and work with paradox and tension.
Paul E Plsek. Working Paper: Some Emerging Principles for Managers of Complex Adaptive Systems (CAS). Paul E. Plsek & Associates, Inc. Uploaded to Internet 5 November 1997.
http://www.directedcreativity.com/pages/ComplexityWP.html#CAS.
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The 9 Principles of Introducing Change
in a Complex Health Care System
6.
Go for multiple actions at the fringes, let direction arise.
7.
Listen to the informal relationships, gossip, rumor, and hallway
conversations that contribute significantly to the individuals’
perceptions about their surrounding environment and their
subsequent actions.
8.
Allow complex systems to emerge out of the links among simple
systems that work well and are capable of operating
independently.
9.
Build a community of members who collaborate, create, learn and
compete
Paul E Plsek. Working Paper: Some Emerging Principles for Managers of Complex Adaptive Systems (CAS). Paul E. Plsek & Associates, Inc. Uploaded to Internet 5 November 1997.
http://www.directedcreativity.com/pages/ComplexityWP.html#CAS.
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Reflective Adaptive Process
• A practical method for using CAS principles to build a
local “Think-Tank” responsible of introducing an
acceptable, locally matched, flexible and effective
change in a health care system.
• The RAP team uses external or internal facilitators
who encourage the system diverse members to select,
adopt or create local processes to
– solve the system problem
– enhance the system performance
– guide the system respond to its surrounding environment
• RAP has five guiding principles that offer a focus
without prescribing specific actions; and improve the
system’s ability to adjust and survive uncertainty
• RAP is the second generation of CQI
Stroebel et al. How complexity science can inform a reflective process for improvement in primary care practices. Joint Commission Journal on Quality & Patient Safety 2005;31:438-46.
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RAP Principles
•
“Vision, mission, and shared values are fundamental in guiding
ongoing change processes in a complex adaptive system”.
•
“Creating time and space for learning and reflection is
necessary for complex adaptive system to adapt to and plan
change”.
•
“Tension and discomfort are essential and normal during CAS’s
change”.
•
“Improvement teams should include a variety of system’s
agents with different perspectives of the system and its
environment, including patients”.
•
“System change requires supportive leadership that is actively
involved in the change process, ensuring full participation from
all members and protecting time for reflection.”
Stroebel
et al. How complexity science can inform a reflective process for improvement in primary care practices. Joint Commission Journal on Quality & Patient Safety 2005;31:438-46.
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WHY Do We Need IDND?
•
•
•
•
Present in 3-11% of persons ≥ 65
Present in 25-47% of persons ≥ 85
Mean survival > 8 years (chronic disease)
Contribute 11% of all years lived with
disability by people ≥ 60.
• Lead to an annual societal cost of $100 billion
–
–
–
–
–
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Long-term residential care
Lost of CG productivity
CG health care utilization
Acute care needs and complication
Impact on other diseases’ management
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Boustani et al, 2003
WHY Do We Need IDND?
Million
12
10
8
mild
6
severe
4
total
2
0
No Trx
Delay
Slow
Combined
Projections of AD prevalence based on three models of the effects of
significant therapy advances introduced in 2010
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Sloane et al, Ann Rev PH 2002
Ambulatory Dementia Care
in The Real world
HCS 1
Com-Res
PCP
PCP
PCP
PCP
PCP
PCP
MCP
WHY Do We Need IDND?
PCP
HCS 3
MCP
PCP
MCP
HCS 2
PCP
PCP
PCP
Com-Res
PCP
Com-Res
HCS: Health Care System
PCP: Primary care practice
MCP: Memory care practice
Com-Res: Community Resource
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R-I: Research
Infrastructure
D-Cx: Discovery Culture
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WHY Do We Need IDND?
Memory Care Practice
100
90
80
70
dementia
64
CIND
60
50
other mental
disorders
Normal
40
30
22
20
10
9
5
100
90
80
70
60
50
40
30
20
10
0
AD
VaD
63
Mixed AD+
12 15
6
ETOH
Dementia
Other dementia
4
0
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Boustani et al, Annals of IM 2003
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WHY Do We Need IDND?
Primary Care Practice
70
80
60
70
60
50
50
40
AD
VaD
D e m e nt ia
40
C IN D
N o rm a l
Mixed AD+VaD
30
Other
30
20
20
10
10
0
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0
dementia type
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Boustani et al, JGIM 2005
WHY Do We Need IDND?
• Unrecognized cases
– 60% in acute setting; 80% in primary care
• Receive definitive Anticholinergics
– 22% in acute setting; 26% in acute setting
• Receive ChEIs
– < 5% in acute setting; < 10% in primary care
• Receive Psychotropics (no FDA indication)
– > 25% in acute setting; ~ 25% in primary care
• ER or hospitalization in the last 6 months
– Pt 38%; CG 24%
• CG PHQ-9 score: 4.4
• Pt’s with BPSD: 80%
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Schubert et al, JAGS 2006;
Boustani et al, JAGS 2005; Boustani et al, JAGS 2006
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WHY Do We Need IDND?
PREVENT system
100
90
80
P=0.002
P=0.007
80
71
70
60
55
50
P=0.029
I
UC
45
43
40
30
28
P=NS
20
P=NS
13
10
10 10
7
0
% NPI > 4
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% ChEI
% SSRI
% AP
% Hypnotic
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Callahan, Boustani et al, JAMA 2006
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WHY Do We Need IDND?
PREVENT System
• NNT = 3.7
• Each 1 point decline in
NPI = $250-$400 in
health care expenses.
• PREVENT reached 5 NPI
point improvement =
$1250-$2000.
• Improvement in CG
stress.
8
P=0.003
6
4
P=0.012
2
I
UC
0
-2
-4
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change in
CG Stress
NPI
NPI
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Callahan, Boustani et al, JAMA 2006
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WHY Do We Need IDND?
Caregiver Focus:
-Problem solving skills
-Counseling
-Respite care
-Support group
Coordinate and Deliver
Primary Care Clinician:
-detect and treat delirium
-detect and treat BPSD
-Enhance cholinergic system by
-Prescribe ChEIs
-Discontinue Anticholinergic
Dynamic
Feedback
Dynamic
Feedback
Clinical
Liaison
Expert Team:
-Geriatrician
-Social Psychologist
-GeroPsychiatrist
Coordinate and Deliver
General Environmental Modification:
-Medication adherence support
-Home safety assessment
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Time
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WHY Do We Need IDND?
How Can We Implement PREVENT
/ Research Findings In The Real World?
Do We Have The Research Infrastructure
(the LAB) To Test the Implementation of
PREVENT?
Are We Ready for the Next Generation of
CQI?
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WHY We Need IDND
• The IOM identified sub-optimal health care
quality, compromised patient safety, and waste
in our current health care system.
• The IOM recommended the need for
– system thinking
– integrated, productive, locally sensitive collaboration
among the local community, health care systems and
research organizations.
• The IOM recs will ensure safe, effective, patientcentered, timely, efficient, and equitable 21st
century American health care system.
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IDND VISION
• The Vision of the Indianapolis Discovery
network for Dementia is to become the
international authority in unifying clinical
care and clinical research in dementia;
thus, decreasing the global burden of
dementia for future generations.
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IDND Mission
• Building a local, diverse, and sustainable “ThinkTank” of health care providers, clinical
researchers, and community advocates who are
dedicated to enhancing the quality of life and
care of individuals with Dementia. This local
interdisciplinary network would
– (a) facilitate conducting dementia implementation
research activities that meet the local research,
clinical, and community needs;
– (b) promote a culture of discovery, cooperation, and
team work among its diverse members; and
– (c) disseminate knowledge and innovations in
dementia care.
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IDND Values
• The members of the Indianapolis Discovery
Network for Dementia value excellence,
cooperation, creativity, and integrity in dementia
care. The network’s members value the role of
clinical research as a tool to enhance the quality
of life for individuals suffering from dementia.
They strive to create an environment that
facilitates information exchange among diverse,
autonomous, and collaborative individuals.
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From Discovery to Delivery
Epidemiology
Basic science
Lab
Clinical
Observation
Promising
Intervention
Clinical trial testing
Approved
Intervention
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System and Provider
Implementation
Post-Marketing
testing
Implementation
Research
IDND
Guideline
Development
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IDND Structure
Com-Res
R-I
D-Cx
PCP
PCP
PCP
PCP
PCP
MCP
R-I
D-Cx
R-I
D-Cx
MCP
PCP
PCP
MCP
PCP
Com-Res
PCP
PCP
PCP
R-I
D-Cx
PCP
Com-Res
PCP: Primary care practice
MCP: Memory care practice
Com-Res: Community Resource
R-I: Research Infrastructure
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D-Cx: Discovery
Culture
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Ambulatory Care for
Older Adults
Pt’s Home
Checking –In at the Clinic
Pt-Clinician Interaction at
the Acute Care Setting
Waiting Area
Pt-MD Interaction
At the Clinic
Checking-Out
Pt-Clinician Interaction at
the Long-term Care Setting
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Pt’s Home
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Research Infrastructure & Discovery Culture
• R-I:
– Minimum Standardized Approach
– Practical & Electronic Data Collection
–
–
–
–
–
Protocol Development
IRB Submission
Recruitment Methods
Formative Evaluation
Publication support
• D-Cx:
– Reflective Adaptive Process
– Consultancy rounds
– Story telling
– Appreciative Inquiry
– Quarterly meeting
– Annual summit
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IDND Big Challenge
• Integrating implementation research within
the real world with no
– Disruption of the clinical flow
– Addition of time to clinicians
• Supporting the real World Dementia care
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Senior Advisory
Board
Community Outreach
Board
IDND Steering Committee
Educational Committee
Research Committee
IDND Staff
Clinical Practices Committee
Discovery Committee
Public Relation Committee
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IDND Steering Committee
IDND Director of
Operations
Member Representative
IDND Director of
Research Activities
Primary Care Practice
Representative
IDND Director
of
Administration
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Memory Care Practice
Representative
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Senior Advisory Board
PhRMA
Representative
Healthcare System
Leadership
Foundation
Representative
St. Vincent Hospitals
Wishard Hospital
Clarian Hospitals
Community Hospitals
* up to 10 members
St. Francis Hospitals
Other
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Community Outreach
Board
Patient and Caregiver #2
Indiana Minority
Health Coalition
Alzheimer’s Association
Patient and Caregiver #1
CICOA
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IDND Steering
Committee
Public Relations
Committee
Educational Committee
 Annual Conference
 CME Activities
 Community Advocacy
and Relationships
 Media Relationships
Discovery Committee
 Bi Monthly Meeting
 Implementing Research
Clinical Practices Committee
 Minimum Standard Approach
 Process of Care
 Patient Referral Network
Research Committee
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 Research Products
 Improving, Facilitating and
Implementing Research
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IDND Decision Making Process
• Steering Committee with advise from
– Senior Advisory Board
– Community Outreach Board
– IDND members
• IDND various committees with advise from
– Steering committee
– IDND members
• IDND members directly
• Other methods?
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IDND Next steps
•
•
•
•
Filling today survey
Involve with the IDND website.
Spring Annual Conference
Business plan:
– IDND members Need Assessment
– Minimally Standardized Approach
• Other steps
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