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Decision Support: More Than Guidelines Winston F. Wong, M.D., M.S. The Care Management Institute Kaiser Permanente CAPH CCLC November 2, 2004 ICIC Website: http://www.improvingchroniccare.org Chronic Care Model Community Resources and Policies SelfManagement Support Informed, Activated Patient Health System Health Care Organization Delivery System Design Productive Interactions Decision Support Clinical Information Systems Prepared, Proactive Practice Team Functional and Clinical Outcomes Decision Support Systems • A process for incorporating guidelines, education, expert advice and practice aids into routine clinical practice NCQA Decision Support • Embed evidence-based guidelines which describe stepped-care into daily clinical practice. • Integrate specialist expertise and primary care. • Use proven provider education methods. • Share evidence-based guidelines and information with patients to encourage their participation. Knowledge Management…One Approach What Works & What Doesn’t? • Meta-analysis of 99 trials, 160 interventions designed to change physician behavior – – Effective change strategies • Provider reminders • Patient-mediated interventions • Outreach visits (academic detailing) • Opinion leaders • Multifaceted interventions – Less Effective • Audit with feedback and educational materials – Not Effective • Formal CME conferences or activities, without enabling or practice-reinforcing strategies. • Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance. A systematic review of the effect of continuing medical education strategies. JAMA. 1995 Sep 6;274(9):700-5. What is evidence-based medicine? Evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. -David Sacket, BMJ 13 Jan 1996 What is evidence-based medicine? • Evidence-based medicine is an approach to health care that promotes the collection, interpretation, and integration of valid, important and applicable evidence. • The best available evidence, moderated by patient circumstances and preferences, is applied to improve the quality of clinical judgments. McMaster University What is evidence-based practice? • Efforts made to base clinical & other healthcare decisions on the best available evidence • Evidence is critically appraised & synthesized • The evidence synthesis is adapted to assist providers & patients in making decisions about specific clinical conditions. Embed evidence-based guidelines into daily practice Clinical Practice Guidelines • Clinical guidelines are systematically developed statements to assist practitioners and patients in choosing appropriate healthcare for specific conditions. -The Institute of Medicine Clinical Practice Guidelines Efforts to distill a large body of medical knowledge into a convenient, readily usable format. - Eddy. The challenge. JAMA 1990;263:287-290 The purpose of clinical practice guidelines GAP Current Practice Current outcomes Health status Satisfaction Cost Utilization Optimal Practice Optimal Outcomes QUALITY A quality gap persists: “…on average, Americans receive about half of recommended medical care processes.” — McGlynn, et al, NEJM, 6/26/03 Function Type of Care # of Indicators Overall care Preventive Acute Chronic Screening Diagnosis Treatment Follow-up NEJM 348:26, Rand study 439 38 153 248 41 178 173 47 % Recommended Received 54.9% 54.9% 53.5% 56.1% 52.2% 55.7% 57.5% 58.5% IOM: “What is perhaps most disturbing is the absence of real progress toward restructuring health care systems to address both quality and cost concerns, or toward applying advances in information technology…” Need for Information at the Point of Care Clinicians carry frequently used information resources with them Information systems goal: Empty the lab coat pocket Evidence-based Practice • Begin with NIH Guidelines – all team members should be familiar • Identify thought/opinion leaders – within your organization and outside – systematic literature review – organized learning within organization Steve Simpson, MD Kansas University Stickies were ubiquitous Labels with patient Information and pre-visit summaries are also used as reminders Evidence-based practice, cont. • Customize guidelines to your setting • Embed in practice: able to influence real time decision-making Flow sheets with prompts Decision rules in EMR Share with patient Reminders in registry Standing orders • Have data to monitor care Attributes of Good Guidelines • Clear definition of condition and population • Exceptions are described • Evidence summaries are available with links to key articles • Clinical actions for stepped-care are clearly stated • “Nice-to’s” that are not evidence-based are omitted • Regularly updated to incorporate new data http://pkc.kp.org Stepped Care • Often begins with lifestyle change or adaptation (eliminate triggers, lose weight, exercise more) • First choice medication • Either increase dose or add second medication, and so on • Includes referral guideline Population Management Concept Patients with diabetes can be segmented into three care levels based on needs. Level 3 Patients are complex. High inte nsity manageme nt of the patient’s care is re quir ed. Intensive Management Level 2 Assisted Care • Car e Mgmt Pr ograms: – Group Visits – one-on-one F/U Patients are in poor metabolic control and may be nef it from participation in a short term c are m ana gem ent program where they learn self care skills Level 1 Self Management • Diabete s: The Basics • Living W ell with Diabe tes • SMBG Prevention & Wellness Overvi ew Patients can be supporte d by routine APC team care but ma y nee d self manageme nt basic educa tion Prevention and wellness are the foundation of basic care. 4 D ia be te s Po pu la tio n Ma na ge me nt Diabetes Population Management Program 2003 Level 3 Intensive Care • C omple x m edica l is sue s • Ps yc ho-soc ial bar rie rs t o s elf-m ana gem e nt Endoc Endocrinologis rinologist/Dia t/Diabetologist betologist C Cas asee Ma Manage nagerr Conf Confirms irms diagnosis diagnosis Ident Identifies ifies co-m co-morbidit orbidities ies Coaches Coaches members members in in crisis crisis Manages Manages access access to to specialty specialty and and EED D care care Optim Optimizes izes m medi edicati cation on regim regimen en Ment ors Case & Care Managers Ment ors Case & Care Managers Coordinates Coordinates care care across across continuum continuum Level 2 Care Management Ou Outre treaach ch && tria triage ge • ED vis its • H ospita liza tion • H gA1 c > 8.5 % • Mic roa lbum in > 3 0 Week 2 Intak e V is it One-to -One Office Visit Risk reduction Goal settin g Group A ppt. Assessme nt Care Mana ger Beha vi orist Die ti tia n Mon thl y •H •HTN, TN, Dy Dysli slipi pide demi miaa (L (LDL DL>10 >100) 0) Tre Treatme atment nt aaccor ccordi ding ng to to pro protoco tocolsls •Be •Beha havi vior or ch chan ange ge/mo /motitiva vatition on •R •Rei einfor nforce ce se self-m lf-man anag agem emen entt ski ll s ski ll s HTN,/ Dyslipi demia •Pa •Patie tient nt rretur eturns ns to to LLeve evell 11 Group A ppt Monthly Cli nical /be havio ra l in terven tio ns Care Mana ger Beha vi orist Die ti tia n As need ed Level 1 Self Care • D ia bet es is well c ontrolled • Me m ber pr ac tice s e ffe ctiv e s elf-c ar e DM care path 2003 Mon ths 2-6 •Pri •Prior oritize itize CV CV rrisk isk fa factors ctors:: Any of above WITH • Week 1 Liv Living ing W W ell ell with with D ia bet es D ia bet es Cla Class ss and and others others Educ Educationa ationall R Res esourc ources es Heal Healthwise thwise Handbook, Handbook, KP KP Onli Online ne Pr Prima imary ry Ca Care re Tea Team m Revi Reviews, ews, ad adjusts justs medi medica catitions ons Reg Regular ular screeni screening ng tests tests Rei Reinforces nforces self-manag self-management ement Tele phone Follow- up Vis it s (1:1 Of fice V isi t as needed ) Yes We Can Stratification Model LEVEL 4 Intensive Case Management Intensive Case Management Child with poor asthma control and Family in need of self-management skills and Highly complex and unstable social/psychosocial criteria LEVEL 3 Moderate Case Management by Yes We Can Asthma team Basic Case Management by Yes We Can Asthma team Self-Management Support by Primary Care Moderate Case Management Child with poor asthma control and Family in need of self-management skills and Moderately complex and unstable social/psychosocial issues LEVEL 2 Basic Case Management Child with poor asthma control Family in need of self-management skills Relatively stable social/psychosocial issues LEVEL 1 Self-Management Support Child with relatively well controlled asthma Family has self-management skills Relatively stable social/psychosocial status Integrating Specialist and Primary Care Expertise Clarifying roles and working together Definitions • Referral: transfer of care • Consultation: one-time or limited time • Collaboration: on-going co-management Effective specialty-primary care interactions • When to consult – trouble making a diagnosis – specialized treatment – goals of therapy not met Adapted from material by Steve Simpson, MD Kansas University Using Consultants Effectively Make your consultants partners – 1st principle of partnership - communication – communication begins with you – ask a specific question – specify type of consult: ongoing (referral), one time only, duration of specific problem Steve Simpson, MD Kansas University Communicating • Telephone or in person • Letter • Letter with supporting objective data • e-mail • e-mail must be encrypted Steve Simpson, MD Kansas University Example of an agreement in place Primary Care 1. State that you are requesting a consultation 2. The reason for the consultation and/or question(s) you would like answered 3. List of any current or past pertinent medications 4. Any work-up and results that has been done so far 5. Your thought process in deciding to request a consult 6. What you would like the Specialist to do Source: HealthPartners, MN The agreement in place Specialty Care 1. State that you are returning the patient to primary care for follow-up in response to their consult request 2. What you did for the patient and the results 3. Answers to Primary Care Physicians questions in their consult request 4. Your thought process in arriving at your answers 5. Recommendations for the Primary Care Physician and educational notes as appropriate 6. When or under what circumstances the Primary Care Physician should consider sending the patient back to you Source: HealthPartners, MN Going beyond referral and consultation: integrating specialist expertise • Shared care agreements • Alternating primary-specialty visits • Joint visits • Roving expert teams • On-call specialist • Via nurse case manager Use proven provider education methods Beyond CME… Effective educational methods Interactive, sequential opportunities in small groups or individual training • Academic detailing • Problem-based learning • Modeling (joint visits) Effective educational methods • Build knowledge over time • Include all clinic staff • Involve changing practice, not just acquiring knowledge Result: better diagnosis, continuing care and guideline based care in children with asthma Evans et al, Pediatrics 1997;99:157 Share evidence-based guidelines and information with patients to encourage their participation. What is shared decisionmaking? • Patient and clinician share information with each other (clinician shares medical information, patient shares personal knowledge of illness and values) • Participate in a decision-making process • Agree on a course of action Sheridan et al Am Jrnl Prev Med 2004 Guidelines for patients • Expectations for care • Wallet cards • Web sites • Workbooks • Stoplight tools Example of a successful strategy: Adults with asthma • Developed a skill-oriented self-help workbook • Health educator session for 1 hour • Support group • Telephone calls RCT: better inhaler skills and use, decreased symptoms, less ER use. Bailey et al Arch Inter Med 1990;150:1664 Stoplight tools: patient guidelines Supporting the Patient Role What Does Work? Effectiveness of QI Interventions on Immunizations & Cancer Screening 12 10 8 6 4 2 0 High CI Odds Ratio 10.35 Pt. Reminders Pt. Educ. 2.62 Organizational Change 2.25 1.41 Pt Financial Incentives 1.43 Feedback • Low CI Interventions that increase use of adult immunization and cancer screening services: a meta-analysis. Ann Intern Med, 2002 May 7; 136(9):641-51. Stone EG, Morton SC, Hulscher ME, Maglione MA, Roth EA, Grimshaw JM, Mittman BS, Rubenstein LV, Rubenstein LZ, Shekelle PG. Important Web Addresses • PubMed – http://www4.ncbi.nlm.nih.gov/PubMed/ • Guidelines – http://www.guidelines.gov • NIH - http://www.nih.gov Contact us: •www.improvingchroniccare.org thanks