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Challenges of Sustaining, Scaling, and Spreading Innovations in Cardiovascular Care. AHRQ Annual Meeting Session 34, Track C Sept. 10, 2012. Session Goals. To share two heart health innovations from the Health Care Innovations Exchange

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challenges of sustaining scaling and spreading innovations in cardiovascular care

Challenges of Sustaining, Scaling, and Spreading Innovations in Cardiovascular Care

AHRQ Annual Meeting

Session 34, Track C

Sept. 10, 2012

session goals
Session Goals
  • To share two heart health innovations from the Health Care Innovations Exchange
  • To consider how organizations might explore adoption of these and similar innovations
heart health focus
Heart Health Focus
  • National Quality Strategy
    • Promoting the most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease
  • Million HeartsTM Campaign
    • National initiative to prevent 1 million heart attacks and strokes over five years.
    • millionhearts.hhs.gov
agenda
Agenda
  • Introduction
    • Judi Consalvo, AHRQ
  • Language Concordant Health Coaches Innovation
    • Hali Hammer, San Francisco General HospitalFamily Health Center
  • Heart360® Innovation
    • David Magid, Kaiser Colorado
  • Activity: How Can I Implement This Innovation?
    • Veronica Nieva, Westat
what is the health care innovations exchange
What Is the Health Care Innovations Exchange?

Goal:

To accelerate sharing of innovations and online tools to improve health care services and reduce health care disparities.

Components of the Exchange:

The Web site: innovations.ahrq.gov

Learning and Networking Activities

what is the health care innovations exchange1
What Is the Health Care Innovations Exchange?

Web site features profiles of successful and attempted innovations and practical tools

Service Delivery

Policy

Learning and Networking

Webinars

Meetings to promote spread

Videos

the innovations exchange
The Innovations Exchange
  • Visit our Web site: innovations.ahrq.gov/
  • Follow us on Twitter: #AHRQIX
  • Send us email: info@innovations.ahrq.gov
health coaches as members of the health team

Health Coachesas Members of the Health Team

Hali Hammer

San Francisco General Hospital,

Family Health Center

san francisco general hospital family health center
San Francisco General HospitalFamily Health Center

Hospital-based full scope family medicine clinic

Part of the San Francisco Department of Public Health’s primary care network

Participating in access and quality improvement initiatives as part of the 1115 California Medicaid Waiver (CMS Incentive Program), which ties federal funding to milestones, including PCMH standards (team-based care, clinical outcomes)

10,700 patients served; 1500+ adults with diabetes

50,000+ patient visits per year

Teaching clinic: 41 family practice residents and many medical and nursing students

Diverse patient population

42% Latino, 26% Asian, 14% Caucasian,

12% African American

51% Medicaid, 33% uninsured (almost all enrolled in Healthy San Francisco), 15% Medicare

31 different languages spoken

48% English, 30% Spanish, 9% Cantonese/ Mandarin

description of health coaching at the sfgh family health center
Description of health coaching at the SFGH Family Health Center

Health Coaches are members of the health care team who provide self-management support to a stable panel of patients with chronic illness (in our setting, primarily diabetes).

Health Coaches:

  • are language-concordant with all their patients
  • are trained in motivational interviewing, panel management, diabetes basics, and medication adherence
  • work collaboratively with a patient’s Primary Care Provider, unlike promotoras or community health workers in other settings
  • are primarily in the job classification “Health Worker,” but may also be Medical Assistants, pre-medical students, trained peers.
description of health coaching at the sfgh family health center1
Description of health coaching at the SFGH Family Health Center

The Health Coach role includes:

Self management support

supporting their patients to have the knowledge, skills, and confidence to become active participants in their care

Bridge

clarifying information provided by the provider, pharmacy, or insurance company

bridging cultural/ linguistic gaps

Clinical continuity

following patients who are in their continuity panel, with a goal to maximize continuity between patient and health coach

Emotional support

language- and often cultural-concordance enhances trust and engagement in learning how to self-manage the chronic illness

Clinical Navigation

Health Coaches may be more accessible because they are in clinic every day and can be the primary clinic contact person for patients throughout the week

help with making and keeping appointments, accessing pharmacy and other services

costs associated with health coaching
Costs associated with health coaching

Health Coach program cost considerations

Salary ($58,000 per year in our setting, which is 44% of an RN)

A full time Health Coach can manage a patient panel of 200 patients

Physician or Nurse Practitioner supervision (approximately 5% time)

Training costs (6-8 sessions)

Must consider how Health Coaches are assigned and interface with other members of the care team (i.e. case managers, social workers)?

factors to consider in the business case for health coaching
Factors to consider in the business case for health coaching

Who provides self-management support and education in a traditional primary care visit? What is the most cost-effective and efficient way to provide this important component of chronic illness care? Health coaching may be the answer.

Family Community

Assessment of medication

adherence, education, self-

management support, phone

follow-up (between-visits)

Review of symptoms,

diagnosis, medications,

addressing urgent problems

Patient

Post-visit

Visit

Pre-visit

Provider

Health

Coach

Team huddle or other communication

Communication about medical and psychosocial

issues, goals of care, medication problems

factors to consider in the business case for health coaching1
Factors to consider in the business case for health coaching
  • The business case for Health Coaching relies on showing that it decreases long-term complications, hospitalizations, and emergency department use.
  • Self-management support does improve health outcomes in patients with chronic illness.
  • So, the question for health care organizations is: who should provide the self-management support?
  • The answer is based on the payer mix for the organization, as well as staffing costs.
  • In our organization, Health Coach salaries are approximately 36% of physicians and 44% of registered nurses.
  • Health coaching can be done effectively by a non-licensed, trained member of the staff under appropriate supervision.
lessons learned in scaling and spreading
Lessons learned in scaling and spreading
  • Health coach resources should be allocated to patients at highest risk of poor outcomes if they are not able to self-manage their chronic illness. In our setting, we targeted diabetic patients with hgbA1c > 8.
  • Highest risk patients may also be most in need of emotional support: Health Coaches must be trained to place limits on patients so that coaching is possible.
  • Communication, a patient’s perception of access, and self-management education are best provided by trained staff who speak the patient’s language.
  • Other health coaching models which use RNs include the added roles of medication adjustment by protocol and symptom assessment; we prioritize self-management support and medication adherence education, which can be provided by an unlicensed coach.
plans for scaling and spreading
Plans for scaling and spreading

Capitation (instead of fee-for-service reimbursement) allows providers to prioritize outcomes and satisfaction. As reimbursement is increasingly tied to improved patient outcomes, team-based approaches to chronic illness care will be feasible for more organizations.

Primary care workforce issues have also shed light on the increasing pressures and low job satisfaction among a decreasing pool of primary care providers. Engaging other members of the team to take on time-consuming, non-medical tasks, such as self-management support, may improve satisfaction and make primary care more sustainable.

With funding incentives through the CMS Incentive Program / Medicaid Waiver, we will be able to expand health coaching if we continue to show improvement in patient care and access.

heart360

Heart360®

David J. Magid

Insitute for Health Research

Kaiser Permanente Colorado

rates of hypertension control in the u s are low
Rates of Hypertension Control in the U.S. are Low
  • Benefits of hypertension therapy
    • 25% reduction in heart attack
    • 40% reduction in strokes
    • 50% reduction in heart failure
  • NHANES (2005-2008)
    • Treatment 70%
    • Control 46%
focus groups kaiser colorado clinics
Focus Groups Kaiser Colorado Clinics
  • Controlling my BP is critical
  • Office visits are inconvenient and time-consuming
  • Using a home BP cuff is appealing
slide23

Research Question

For patients with hypertension, is a clinical pharmacy specialist-led Heart360®home BP monitoring program (HBPM) more effective than usual office-based care?

study population
Study Population

Uncontrolled HTN

Usual Care

HBPM-Heart360®

Initial visit

Initial visit

Referral

To PCP

Home BP monitoring

  • six month follow-up visit
hbpm patients had superior 6 month bp control
HBPM Patients Had Superior 6-month BP Control

57%

37%

Usual Care

HBPM

RR = 1.5 (1.2-1.9); p < 0.001

slide29

Heart360® HBPM Group Had a Greater Drop in Systolic BP

Usual Care

HBPM

Mean BP drop (mm Hg)

P <0.001

heart360 hbpm patients reported greater satisfaction with care
Heart360® HBPM Patients Reported Greater Satisfaction with Care

Very to Extremely Satisfied

P <0.001

what are the cost implications for heart360 hbpm
What are the cost implications for Heart360® HBPM?
  • Intervention Costs
  • CV Events Prevented
  • Cost of Events Prevented
implementation barriers
Implementation Barriers
  • Cost of BP cuffs
  • Need for computer and internet
  • Capitation vs. Fee for Service
translation to routine practice a tale of two regions
Translation to Routine Practice: A Tale of Two Regions

KaiserColorado

KaiserSouthernCalifornia

kp colorado
KP Colorado
  • Enthusiastic response to presentations to health plan leaders and stakeholders
  • Initially little movement towards adoption in routine clinical practice
    • Turnover in clinical champion
    • Change in organizational priorities
    • Limited bandwidth
    • Lack of sponsorship
  • Director of Pharmacy Department stepped forward to sponsor rollout
    • Currently working toward broader implementation
kp southern california
KP Southern California
  • Enthusiastic response to presentations to health plan leaders and stakeholders
  • Movement towards adoption
    • Stable clinical champion - > 20 years
    • Organizational priority – improve efficiency
    • Sponsorship by Associate Medical Director
  • Current Plans
    • Pilot at 2 medical centers
    • Subsidize cost of cuff, consider BP cuff library
    • Existing infrastructure to support rollout
lessons learned
Lessons Learned
  • Clinical champion
  • Sponsorship
  • Organizational priorities
  • Bandwidth
activity
Activity

How Can I Implement This Innovation in My Organization?