An Extension Program for Primary Care James W. Mold, MD, MPH Department of Family and Preventive Medicine University of Oklahoma Health Sciences Center
Disclosures and Disclaimers • As the vision I’m going to present becomes reality, I plan to obtain funding from a variety sources to participate in its development. • However, at present I have no financial conflicts of interest to report.
The Patient Protection and Affordable Care Act of 2010 • 2074 pages; 9023 Sections • Section 5405: Primary Care Extension Program • Section 3502: Establishing community health teams to support the patient-centered medical home • Section 4201: Community transformation grants • Section 5403: Interdisciplinary, community-based linkages
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The Oklahoma Physicians Resource/Research Network (OKPRN) • Founded in 1994 as joint project of the OAFP and the OU Department of Family Medicine • 220 primary care clinicians in 140 separate practices throughout Oklahoma • 501c3, not-for-profit charitable organization • Contracts with the OU Department of Family and Preventive Medicine for administrative and methodological support • So far, > $5 in external funding to support network projects
OKPRN Mission To improve the primary health services available to Oklahomans by developing and sharing resources and conducting relevant practice-based research.
OKPRN Clinical Studies • Use of e-mail and the internet by primary care patients in Oklahoma • Epidemiology, prognosis, and management brown recluse spider bites • Prevalence, causes, and consequences of night sweats • Prevalence and consequences of peripheral neuropathy in older primary care patients • Reasons older Oklahomans change primary care physicians • Reasons primary care clinicians don’t always follow ADA guidelines for BP control in diabetic patients • Natural history and management of poison ivy
The QIO keeps sending me performance reports showing how bad I am doing. That really doesn’t help me. If they would just tell me who is doing it well, maybe I could call them and find out how they do it. Mark Gregory, M.D. Okarche, OK circa 1999
Best practices Research • Almost every primary care clinician has discovered something that other clinicians would like to know about. (We are all researchers.) • Identification, description, and combination of the most effective and efficient principles, techniques, and scripts being used effectively/efficiently in practice
Best Practices Projects • Pneumonia vaccinations • Management of lab test results • Management of patients with diabetes mellitus • Management of prescription refills • Reduction and management of no-shows • Delivery of adult preventive services • Maximizing rate and quality of well child care • Helping patient lose weight and keep it off
Delivery of Preventive Services • Recall and reminder system (PSRS) • Standing orders • Wellness visits • Prevention nurse • Case management - outreach • Wellness portal (personal health record) • Health risk appraisal tool
Implementation of Innovations in Primary Care Research Results and Local Best Practices Academic Detailing Performance Feedback Facilitation Practice Enhancement Assistant IT Support Local Learning Collaboratives
Challenges • Little infrastructure other than in OKPRN and other networks or large health systems • Expensive • Time • Travel • Disconnected • Availability of assistance may not correspond with readiness to participate • Too little long term follow-up and reinforcement • Non-strategic • Involved practices may not be “opinion leaders” so innovations may not diffuse optimally
“Innovations” Awaiting Broader Dissemination and Implementation • Collaborative care models involving primary care and mental health care • Care management embedded within primary care • Open access scheduling • Cluster and group visits • E-visits, e-consultations, HIE, and telemedicine • Home sleep testing • Automated and internet-based support for healthy behaviors and chronic disease management • Health risk appraisal – directed preventive services
Clinical Knowledge and Skills that Need Broader Dissemination • Diagnosis and management of chronic hepatitis B and C • Recognition, diagnosis, and management of obstructive sleep apnea • Cognitive screening and diagnosis of cognitive problems • Office pulmonary function testing • Aggressive management of congestive heart failure • Diagnosis and management of urinary incontinence • Management of chronic pain patients • Management of morbid obesity
Cooperative Extension • 1796: George Washington proposed an office to promote evidence-based farming • 1810: First agricultural journals • Few farmers read them • 1862: Land-Grant College Act • Enrollment slow • Farmers thought their children could learn better by doing than by studying, and they were needed on the farms • Little to teach because little relevant science; mostly taught farm operations • 1882: Hatch Act established funding for “experimental farms” • Local in order to conduct experiments under local conditions • Exposed students to research and researchers to local farmers
Cooperative Extension • 1889: Dept of Agriculture began issuing Farmers’ Bulletins and the Yearbook of Agriculture; experimental farms issued research and “popular” bulletins • Publications reached small proportion of farmers, many of whom distrusted “book farming” • 1880 -1911: Establishment of “farmers institutes” and “mobile institutes” to reach more farmers • 1906: S. A. Knapp (Terrell, TX) hired the first county extension agent to demonstrate evidence-based methods and spread them throughout the county through personal relationships and direct assistance Rasmussen WD. Taking the University to the People, Iowa State University Press, 1989 Gawande A. Testing, Testing. In The New Yorker, Dec 14, 2009
The Importance of Local Control • Health and health care improvement initiatives are more likely to be successful if they are managed locally. • Local challenges • Local resources • Local relationships • Local personalities and politics • Centralized QI efforts are inefficient and largely ineffective. • Performance reports, admonitions, and printed guidelines that go in the circular file
Primary Care Extension 1. Quality Improvement/Practice Transformation 2. Patient-Centered Medical Home 4. Health Improvement Coalitions 3. Accountable Care organizations 5. Research and Development Engines PBRN CBPR Primary Care Parks & Recreation Extension Center Mental Health University/AMC Public Health Care Coordination Hospital Schools Sub- specialists Payers
Community Cohesiveness and Priorities External Research Resources and Policies Evidence-Based Knowledge Population Health Mission Rules of Engagement Advisory Board Needs Assessment Education/Training Rewards/Incentives Fiscal Entity (e.g. 501c3) Coordinating Center Prioritization Education/Training Rewards/Incentives Longitudinal Respectful Prepared Proactive Research Team Informed Activated Community Productive [push-pull] Interactions Relationships Community Test Sites Dissemination/Implementation Infrastructure Improved Population Health
Funding • Stable infrastructure funding • Federal government (?also state, local govt.?) • Insurance companies • Miscellaneous (contributions, local industries, etc.) • Project-specific funding • Public health (CDC, OSDH, etc.) • Dept. of Defense (preparedness, surveillance, obesity, etc.) • Foundations (demonstration projects) • Research (NIH, AHRQ) • Manpower development (HRSA, etc.)
Plenty of Project-Specific Funding Few Receptor Sites
Care Management • When Medicare decided to fund 15 care management experiments across the country, they chose not to collaborate with primary care practices. • Instead, they funded private care management companies (e.g. Life Masters). • Largely because of the lack of integration with primary care, 13 of the 15 the experiments failed to improve quality or reduce cost
Preparing for Pandemic Influenza • In 2006 and 2007, the CDC distributed around $200 million to state departments of health to prepare for pandemic influenza. • Guidelines and toolkits were prepared to help primary care practices. • However, practically none of the money and no assistance made it into primary care offices where most of the action will take place in an epidemic.
Dissemination/Implementation of Asthma Guidelines • We recently received a $1.7 million grant from the National Heart, Lung, and Blood Institute to study ways to implement their most recent asthma guidelines in 48 practices in Oklahoma and western New York. • We have received more than $8 million in grants and contracts for similar projects (limited mainly by manpower to write grant applications and run projects).
Evidence for “Traction” • Payer and Academic Health Center Initiatives • Community Care of NC (Medicaid and Medicare) • Oklahoma Health Access Networks (Medicaid) • Vermont’s Community Health Boards (all payers) • The Health Extension Program in New Mexico • NIH Clinical and Translational Science Awards • Health Information Technology Extension • Oklahoma Foundation for Medical Quality • U.S. Senate health care reform legislation • $120 million proposed funding for “Primary Care Extension” • 10 states initially plus planning grants
HIT Extension and HIE • American Recovery & Reinvestment Act of 2009 • Health Information Technology Extension (HITECH) • Oklahoma Foundation for Medical Quality • State Level Health Information Exchange • OK Health Information Exchange Trust
Health Information Exchange 501c3 501c3 501c3 501c3 HIE HIE HIE HIE Statewide HIE Backbone HIE HIE HIE HIE 501c3 501c3 501c3 501c3 HIT Decision Support Applications
References • Grumbach K and Mold JW. A health care cooperative extension service: Transforming primary care and community health. JAMA 2009; 301(24): 2589-2591 • Scutchfield FD. The cooperative medical extension program: Translation of medical best practices to practicing primary care providers. Am J Prev Med 2009; 37(4): 374-376 • Kaufman A, Powell W, et al. Health extension in New Mexico: An academic health center and the social determinants of disease. Ann Fam Med 2010; 8(1): 73-81 • Weil A and Scheppach R. New roles for states in health reform implementation. Health Affairs 2010; 29(6): 1178-1182 • Abrams M, Schor EL, and Schoenbaum S. How physician practices could share personnel and resources to support medical homes. Health Affairs 2010; 29(6): 1194-1199 • Steiner BD, Denham AC, Ashkin E, Wroth T, and Dobson LA. Community care of NC: Improving care through community health networks. Ann Fam Med 2008; 6(4): 361-366