IPIP Kick-Off!

1. IPIP Kick-Off! January 16, 2007 Monroe Center Greenville, NC

2. Welcome • Thank you for contributing to IPIP • Get to know the other teams • Share senselessly and steal shamelessly • Make us work for you tonight

3. Introductions • Steve Willis MD • Executive Director, Eastern AHEC • Chuck Willson MD • Medical Director of Community Care Plan of Eastern Carolina (CCPEC)

4. Let us know… • Your Practice Name • Are you measuring Diabetes or Asthma? • What are you looking to get out of IPIP?

5. Improving Performance in Practice Warren P. Newton, MD, MPH Greenville, NC January 16, 2007

6. Objectives • Introduce briefly the Improving Performance in Practice (IPIP) project, and your role in it • Summarize IPIP methods and rationale • Describe how it will work– expectations, timeline and reimbursement

7. IPIP: Why? The Quality Chasm About half the time, interventions that we all agree should happen don’t, no matter what the problem or setting

8. IPIP: A National Initiative American Board of Medical Specialties American Academy of Family Physicians American Academy of Pediatrics American Board of Family Medicine American Board of Pediatrics Plus American College of Physicians American Board of Internal Medicine …funded by the Robert Wood Johnson Foundation and the CDC

9. IPIP: The Vision • Radical transformation of office care with improvement of management of chronic disease and access to care • All Primary Care Disciplines—Family Medicine, Pediatrics, General Internal Medicine—across the whole state • New approach to CME and linkage to Maintenance of Certification Part IV • Pilot with Asthma and Diabetes in North Carolina and Colorado

10. IPIP in North Carolina • Focus is providing help for doctors to transform their practice • Partnership of CCNC and AHEC; other partners: NCAFP, NCPS, NC cACP and NCMS, with NC Department of Public Health, CCME (MRNC) • Pilot: CCPEC/Eastern AHEC/Pitt Co HD and Access II Care/MAHEC/Henderson Co HD

11. IPIP Methods Overview • Focus is on providing help for doctors change their practices rapidly • Quality Improvement Coaches • Data Collection and Reporting • Learning Networks

12. What is the evidence? Organized systems of care have resulted in profound improvements • Northern New England Cardiovascular Group • End Stage Renal Disease Network • Children’s Oncology Group • Eight fold increase in survival for patients with ALL • Vermont Oxford Network (neonatology) • NHS primary care collaborative • Cystic Fibrosis Collaborative (ongoing)

13. Adequacy of Hemodialysis Sehgal A, JAMA 2003;289:1996-1000

15. Asthma Management Wroth TH, Boals JC NCMJ 2005;66(3):218-220

16. IPIP in North Carolina How will it work for you?

17. IPIP Overall Goal Dramatic and sustained improvement in quality of care of asthma and diabetes

18. IPIP will provide you with • QIC to work with you on all aspects of practice redesign • Help with setting up data systems • Tools for changing your practice • Comparisons to other practices, with opportunity to learn from them • CME and MOC IV credit • Some financial support

19. What IPIP wants from you • Identification of a team from your practice to champion change • Participation in kick-off meeting • Submission of baseline and regular data • Frequent small changes in your practice, with tests of change • Participation in activities of learning network

20. IPIP Timeline 12/06-2/07—develop data systems, kick off meeting, submit baseline data 3/07-10/07—learning network phase 1 begins; submit regular data and record changes in practice; participate in learning network activities 10/07 onward—transition to phase 2, with new focus of interest

21. IPIP Reimbursement • Initial $1000 after identification of clinical improvement team, attendance at kick-off meeting and beginning submission of baseline data • Second $1000 after submission of baseline and six months of data and participation in network activities. • CME will be provided for ongoing activities

22. IPIPA Vehicle for Leadership • Help us learn how to help other doctors across the state to transform their practice and respond to pay for performance initiatives • Pilot the Governor’s Quality Initiative • Help push reimbursement reform for quality and the role of the medical home

23. Ups and Downs of Improvement Darren DeWalt, MD UNC General Internal Medicine

24. Outline • Getting started • Improving data management • Involving the providers • Using a registry to improve care • Expanding the use of the registry

25. UNC General Internal Medicine Practicecirca 1999 • 75 resident and faculty physicians • ½ day per week to 5 days per week • Individual care often good, but uncoordinated • Limited access to providers • Limited diabetes education/other illness self-management support • Patient barriers often not addressed because of limited time, skills, resources

26. Getting Started • Interest in improving chronic illness care • Improve access to self-management education • Reduce variation in practice • Ensure adherence to guidelines

27. Data Entry • All manual entry in beginning • Slow transition to connect with health system information technology

28. Randomized Controlled Trials Planned care versus Usual care • Diabetes • Lower A1C • Lower BP • More prescribing of aspirin *Rothman et al. American Journal of Medicine 2005, 118:276-284. **DeWalt et al. BMC Health Services Research 2006, 6(1):30

29. Problem of Scale-Up • Diabetes trial had 230 patients • We care for ~1600 patients with diabetes • Needed to engage all staff of clinic

30. Needed Innovations • Decision support (case management not available on scale-up) • Automation of guidelines (ordering needed tests)

31. Managing Information at the Visit • Patient profile—all the information needed for a given patient • Useful for the nurse or other care assistant • Decision support tool for clinicians • Addresses specific concerns the physician should address

32. Patient Profile

33. Patient Profile

34. Patient Profile

35. Patient Profile

36. Patient Profile

37. Decision Support

40. Re-implement automated Front desk fidelity

41. Front Desk Process • List of patients with diabetes • Whether or not labs need to be drawn • I had patients that needed labs that were not getting triaged appropriately • Looked at front desk logs

42. Front Desk Logs • About 60 patients with diabetes/week • 30 needed a lab drawn • Only 15 had it drawn (50%)

43. Pizza for 90% Fidelity • 25/33 = 75% No pizza • 34/36 = 94% PIZZA

44. Re-implement automated Front desk fidelity

46. Continue to Evolve • Monthly review of run charts and PDSAs • Quarterly “all-hands” meeting • Working on several different projects (diabetes, advanced access, anticoagulation, chronic pain management, colon cancer screening) • Giving out awards to clinicians…

47. Summary • Improvement work different from research • Need to engage all members of staff • When results slow, examine parts of the process • We continue to make changes and to take on new projects • Improvement isn’t about arriving, it is about changing and optimizing

48. What Now? • Improving total cholesterol measurement, but how do we get LDL measurement up?

49. Another Example If Needed