Let’s all work towards Improving Patient Care “ Indian Health Medical Home”

1. Let’s all work towardsImproving Patient Care “Indian Health Medical Home” George J.Ceremuga, DO, FAAFP CDR, USPHS Director Emergency Department and Inpatient Services Cheyenne River Sioux Service Unit Eagle Butte, SD 57625 george.ceremuga@ihs.gov

2. Acknowledgements: • CAPT Ty Reidhead, MD • CAPT Kelly Acton, MD,MPH,FACP • Dr Ann Bullock, MD • Dr Peter Ziegler, MD • LCDR Michelle Jesse, RN,BSN,MPH

3. Learning Objectives: • Understand the Improving PatientCare (IPC) model (formerly ChronicCare Initiative), past present and future • Discuss implementation challenges and successes at the Service Unit level • Discuss the effectiveness of the IPC model with clinical outcome data

4. “What must underlie successful epidemics, in the end, is a bedrock belief that change is possible…” Malcolm Gladwell- The Tipping Point

6. We are the “Champions”…..

7. IHS needs to be the care Indian people choose when they have many choices. Dr. RoubideauxNational Combined Councils Meeting

8. IHS Priorities • To renew and strengthen the partnership with Tribes and improve the tribal consultation process. • To bring reform to the IHS in the context of national health insurance reform. • To improve the quality of and access to care. • To have everything we do be as transparent, accountable, fair and inclusive as possible.

9. What matters to patients/families? “The care they want and need, when they need it” • Timely and effective access to care • Reduced waiting times • Helpful, specific, relevant information from their provider • Welcoming environment (customer service) • Safety

10. What matters to the clinician? • Information at the point of care • Summaries, Clinical Notes, Consultant Notes • Medication lists, Patient Data • EHR working for the patient/provider, not the other way around • Safety • Professional Satisfaction->“Customer Service”?

11. How Good Are We in the IHS? 2008 National Summary – Performance Measurement: Improving Healthcare for AI/ANs

12. Chronic Care Initiative = Improving Patient Care • Process to address chronic care • Practical, supportive, population and evidence based • Interactive between informed patients and health care team • Prepared and pro-active

13. Improving Patient Care (IPC) 12/04 9/05 2/06 Fall 06 1/07 3/06 Chronic Disease Management Strategic Plan Finalized Kickoff of “Chronic Disease Management Initiative” First meeting of Chronic Disease Workgroup IPC Teams Chosen IHS/IHIInitial Meeting Expert Meeting What Does the Indian Health System Need to Address Chronic Disease? “Addressing chronic care as a group would pose significant challenges… requiring an entire system redesign” IHI are… • Experts in: • Looking at systems of care • Improvement • Execution • Advisors IHI is not… • Experts in Indian Health System • Directing our work

14. Innovations in Planned Care (IPC) • Learning and innovation arm of the Improving Patient Care Model • Began in 2006: IHS and Institute of Health Care Initiatives partnership • Transform the IHS system of care • Utilize the Chronic Care Model by the McColl Institute for Health Care Innovations: used internationally

15. Virtual LS 2 Virtual LS 5 LS 4 & Site Visit Improving Patient Care 12/04 9/05 2/06 Fall 06 1/07 3/06 Chronic Disease Management Strategic Plan Finalized Kickoff of “Chronic Disease Management Initiative” First meeting of Chronic Disease Workgroup IPC Teams Chosen IHS/IHIInitial Meeting Expert Meeting IPC IPC2 2/07 –1/09 10/08 – 3/10 IPC2 10/08 – 3/10 Virtual LS 5 We are here…

16. Improving Patient Care Transitions IPC2 IPC1

17. Foundational Work Indian Health Medical Home(IPC3 Collaborative) Lessons learned from IPC2 to lay the foundation for the Indian Health Home I/T/U Facilities February 2012 October 2010 Improving Patient Care Quality and Innovation Learning Network Design to meet interested IPC2 Teams’ needs IPC2 Facilities Begin July 2010 Foundations SeriesA system-wide forum for web-based sharing of Best Practices

18. Indian Health Medical Home • Access and Continuity • Every patient has a relationship with a provider and care team, and has consistent and reliable access to that provider and care team. • Care Centered on the Patient and Family • Health programs design their services to put the patient and family at the center of care, to provide great customer service and to support them as they strive toward wellness. • Care Team • Everyone works in a coordinated way as members of highly functioning teams meeting the needs of the patient. • Community Focus • Renew and strengthen partnerships with Tribes and community-based services, and the culture or cultures of the Tribe(s) are integrated into the organization & delivery of care. • Quality and Transparency • Everyone in the system has the skills and tools for making improvement, and uses measurement and data to build better care.

20. IPC changes compared with other models of care referred to as a “Medical Home”

21. Improving Patient CarePilot Sites (IPC1) Eight Federal sites: • Gallup Indian Medical Center • Albuquerque Service Unit • Warm Springs Service Unit • Chinle Comprehensive Health Care Center • Wind River Service Unit • Sells Service Unit • Whiteriver Service Unit • Rapid City Service Unit • Five Tribal sites: • Indian Health Council, Inc. • Cherokee Nation Health Services • The Choctaw Health Center • Eastern Aleutian Tribe  • Forest County Potawatomi Health & Wellness Center • Urban program: • The Gerald L. Ignace Indian Health Center 

22. Improving Patient CareAdditional Sites (IPC2) Federal sites: (14) • Clinton Indian Health Center • Colville Indian Health Center • Fort Defiance Service Unit • Fort Peck Service Unit • Fort Yuma Health Center • Kayenta Health Center • Northern Cheyenne Service Unit • Phoenix Indian Medical Center • Red Lake Hospital • Ute Mountain Ute Health Center • Wagner IHS Healthcare Facility • Wewoka Service Unit • White Earth Health Center • Yakama Indian Health Service • Tribal sites: (8) • Chickasaw Nation Health System • Chief Andrew Isaac Health Center • Chugachmiut • Fort Mojave Indian Health Center • Oneida Indian Health Service • South East Alaska Regional Health Center • Swinomish Health Clinic • Cherokee Indian Hospital (Eastern) • Urban programs: (2) • Oklahoma City Indian Clinic • South Dakota Indian Health Center

24. Act Plan Study Do Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement?

25. Plan Do Study Act Aim: Goal to achieve Decrease turn around time for pts lab reports to provider at time of visit Plan: Registration clerks give lab order numbers to pts Prediction: decrease bottle neck and wait time for patients Do: Nursing staff report increase wait time bottle neck moved from Lobby to hallway Increased pt confusion

26. Plan Do Study Act Study: bottle neck did not improve test not successful Act: modify plan nurse prepare pt lab orders in advance and clerk to give to pt and instruct to go to lab

27. Let’s work together towards Improving Patient Care The Wewoka Service Unit Experience

29. Phase 1 • Leadership • - CEO drew us the “big picture” • Community forums • - Lack of participation

30. Phase 2 • Communication • Tribal Health Board updates • IPC agenda item for ALL events • Medical Home • Designated PCP • EHR • Screening template • Pre-visit planning • DM chart reviews • RN case management • iCare

31. Phase 3 • New employee orientation • FT IPC Coordinator • Spread team • Case management • Self-Management • Referral to CH programs • Successful SMS • Pt’s 36 lb weight loss!! • Behavioral Health integration?

32. Where we came from… • Extended wait times • Cycle times in excess of 2 hours • Numerous trips back & forth to lobby • Unsatisfied patients • c/o long wait times • Patients going elsewhere • Unnecessary processes • Low morale • Limited teamwork

33. Where we want to be… • Satisfied patients • Satisfied staff/high morale • Teamwork • Patient centered care • Our patients choose to come to us • What if they didn’t? • NO delays in care • Limited waiting • Elimination of unnecessary processes • Improved quality of care • Medical home for our People

34. What we’ve encountered so far… • Staff resistance • “This is the way we’ve always done it!” • “We can’t do it that way.. We tried it before and it didn’t work..” • “Administration doesn’t understand, just get through this, we’ll go back to the old way soon.” • Confusion • lack of communication

35. Challenges • Resistance to change • “new way” & “old way” • How do we know it is improvement? • Working at top of licensure • Microsystem change mid-project • Empanelment • IPC workload/deadlines • Division of duties • Reorganization of team June 2009 • Dedicated FT IPC Coordinator April 2010

36. Successes • Universal screening template/dialogue • Oklahoma Area wide soon • Utilization of our CAC • Administration support • Tremendous strides in IPC measures • 20 significant measures • 55% (11) above goal • 40% (8) improving • Consistent data reporting • Patient reports of improvement

37. Lessons Learned • Empanelment • Data quality • Garbage in/Garbage out • Persistence and communication!! • Unconscious PDSA’s • Sponsor Support • Benefit for patient care was clear • Realized the importance

38. From the mouths of patients.. • “I don’t know what you guys are doing up there, but I was in and out in no time the other day!” • “The changes your making are working, keep up the good work!” • “Quicker than in the past.” • “Nurse & Dr. Fried are very efficient & considerate.” • “I think the system has improved quite a bit.” • “Overall the clinic is improving and we are glad to see this.”

39. Empowerment Day 2009 DM Camp

40. IPC Results

41. 36% Empanelled 20% Empanelled % of Patients with a Primary Care Provider designated in CIS IPC1 Sites IPC2 Sites 421,800 Patients

42. The term “metabolic memory” is used to describe the phenomenon of cells remembering good control for long periods of time. This phenomenon is stored early in the course of diabetes, and glycemic control initiated prior to the onset of overt pathology has the most profound long-term impact. The persistence or progression of hyperglycemia-induced microvascular alterations during subsequent periods of normal glucose suggests that previous high or low glucose levels imprint their effects. “Metabolic Memory” .

43. Researchers concluded, “There may be many mechanisms, but whatever it is, the observation is true that a short period of intensive therapy seems to result in this long-term benefit.” “Metabolic Memory”

44. “The UKPDS showed the benefits of an intensive strategy to control blood glucose levels in patients with type 2 diabetes sustained up to 10 yrs after cessation of the randomized intervention. Benefits persisted despite the early loss of within-trial differences in A1C levels between the intensive-therapy group and conventional-therapy group – a so-called legacy effect.” Holman RH et al. NEJM 2008. 359: 1577-1589 The Legacy Effect: conclusions

45. Incidence rates of diabetes-related new ESRD by race, 1980 - 2007 Source: 2009 USRDS Atlas

49. Centered on the Patient and Family Access and Continuity Care Team Approach Community Focus Empowerment for Improvement IPC “Medical Home”