The 20-Minute Medicare Visit

1. The 20-Minute Medicare Visit David B. Reuben, MD Archstone Foundation Chair and Professor David Geffen School of Medicine at UCLA

2. Overview of Talk • What’s the problem here? • Fixing the problem • Changes you can make on Monday • Longer term practice redesign changes • An example of practice redesign • Does practice redesign work? • Learning more

3. The Problem Physicians are unable to provide high quality of care for conditions affecting older persons within the context of busy primary care practices.

4. Health care quality for vulnerable elderly • Assessing Care of the Vulnerable Elderly (ACOVE) project • identified elders at increased risk for death or functional decline, • created quality indicators based on literature review and expert panel for 22 conditions

5. ACOVE results • Overall, 55% of Quality Indicators passed • Compliance for geriatric conditions was worse than for general medical conditions (31% versus 52%) • Care for specific conditions varies greatly • Stroke 82%; end-of-life care 9% Wenger NS et al. Ann Int Med 2003

6. Barriers to good health care • Insufficient cognitive capacity • Not enough time • The health care system isn’t a system • Rewards are wrong

7. Insufficient cognitive capacity • Too much to know • During 2001, the US National Library of Medicine added more than 12,000 new articles per week to its on-line archives • To maintain current knowledge, a general internist would need to read • 20 articles per day • 365 days per year • Shaneyfelt TM. JAMA 2001; 286:2000-2601

8. Insufficient cognitive capacity • Too much to know • Too much to remember • Heart failure management • 10 ACEIs • 7 ARBs • 3 Beta-blockers • 2 aldosterone antagonists • All with different starting and target doses

9. Not Enough Time • Assuming • practice size 2500 patients • age and chronic disease distribution of US population • following guidelines for 10 chronic diseases • Would take 10.6 hours per day! • Plus time for management of other problems. • Ostbye, Ann Fam Med 2005; 3:209-214.

10. The Health Care System isn’t a System • Duplication • Reordering tests rather than looking for results • 34% sometimes or often • Unavailability of needed clinical info • 72% sometimes or often Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. 2005

11. The Health Care System isn’t a System • Behind the times • In 2006, only 12.4% of offices had EMRs that had: • Computerized orders for prescriptions and tests • Test results and clinical notes • Source: NAMCS 2007 • In 2007-2008, only 4% of offices had above plus electronic decision support systems. • Source: DesRoches N Engl J Med. 2008 Jul 3;359(1):50-60 • But 73% use IT for electronic billing • Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. 2005

12. The Wrong Reward System • Productivity is most important factor in determining income • Having more time to spend with patients is best method for improving quality • Over half believe that providing higher quality of care often/sometimes means less income Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. 2005

13. Fixing the Problem • Ground rules • Run a more efficient practice • Things you can do on Monday • Longer term changes: practice redesign

14. Ground rules (assumptions) • Follow-up visit cannot take more than 20 minutes • General medical care cannot be compromised • No electronic medical record • Office staff can provide some help

15. Run a More Efficient Practice 1) Delegate data collection

16. Physician-Patient Encounter $$$$ Out-of-Office Preparation Office Visit $$ $ • Reduce time but increase effectiveness/efficiency of the inner circle • Always push to outermost possible circle whenever possible

17. Delegation to Patients • Pre-visit questionnaires • Initial • Follow-up

18. Pre-visit Questionnaire 1. Past medical history- Current medications- Drug allergies- Surgical & medical hospitalization- Social history (habits, sociodemographics)- Preventive services, including lifestyle 2. Home safety checklist 3. Advance Directives

19. Pre-Visit Questionnaire • Specific questions on: • Vision • Hearing • Dentition • Falls • Urinary incontinence • Nutrition • Depressive symptoms • Functional status

20. Follow-up Questionnaires • General • 2 most important issues • Mini-ROS • Other doctors they have seen • Medications • Condition-specific • Keeps issues on the table • Monitors adherence and response to treatment • Prompts asking questions about next steps

22. Delegation to Patients • Pre-visit questionnaire • Initial • Follow-up • Lists • Diaries

23. Delegation to Office Staff • Screening/Case identification • History gathering • Following up on triggers • Medications/allergies • Enhanced vital signs/physical exam • Orthostatic blood pressure readings • Visual acuity testing • Patient education

24. Run a More Efficient Practice • ) Delegate data collection • ) Minimize data recording time • Dictation • Templates • Computerized medical records

25. Strategies for Savings Time in Clinical Practice 3) Keep information needed for decision-making readily available • Pocket guides • PDA programs • Useful books • Computer retrieval system • ) Delegate plan execution • Network of health professionals • Health educators

26. Longer Term Practice Redesign Changes • To improve care, change must focus on three key levels • patient • provider • practice • Must fundamentally change the office visit • Does not need to be expensive

27. Practice Redesign (ACOVE-2) • Case finding (identification) • Delegation of data collection • Structured visit notes that lead physicians through appropriate care processes • Physician and patient education • Linkage to community resources

28. Case Finding • Several options • Telephone call prior to visit • Medical staff prior to placing patient in room • Pre-visit questionnaires in waiting room • Brief questions to identify bothersome incontinence, memory loss, and falls or fear of falling • Responses are given to provider at clinic appointment along

29. Structured Visit Note • History items and simple procedures (completed by office staff) • More detailed H & P, ordering tests (completed by physician) • Impression and plan (completed by physician)

34. Patient educational materials • Assembled for each condition • Readily available to the clinician to facilitate treatment • Community resources • Follow-up visit sheet

36. Decision Support-Physician Education • Small group educational sessions aimed at practical approaches • Written briefs that describe management of the condition

37. Flexibility • Must address all conditions using all components of the intervention • Flexibility in administration and content • Decide how much of the intervention is performed by staff rather than physicians • Can modify content and supporting materials

38. ACOVE-2 Medical Groups

39. Patient Characteristics

40. Quality Scores after Interventionfor Dementia, Falls & UI

41. Better Care as a Result of the Intervention • Falls • Perform fall exam (45% versus 12%) • Treat strength/gait problem (89% versus 58%) • Incontinence • Take history (36% versus 12%) • Use behavioral treatment first (33% versus 4%) • Dementia • Check blood tests (46% versus 25%)

42. Summary of main findings • A practice-based, low tech intervention can improve care for falls and incontinence. • The intervention’s effectiveness was only moderately effective.

43. Why wasn’t ACOVE-2 more effective? • Failure to delegate data collection? • Not enough recognition of inadequate practices with subsequent modification? • Not enough patient empowerment?

44. Recently Completed Practice Redesign Projects • Make intervention more powerful • Add quality improvement component • ACOVEprime (Atlantic Philanthropies-ACP) • Partner with community based organizations • ACOVE AD (Alzheimer’s Association) • Increase delegation to office staff • Nurse practitioner co-management of chronic conditions- (Hartford Foundation)

45. ACOVEprime • 5 Practice sites (intervention and control) • 2 conditions (Falls and UI) • Modified ACOVE-2 intervention • Variation in implementation • High versus low delegation to staff • EHR versus handwritten notes • Planned F/U visits to address conditions versus integrating into current visit

46. ACOVEprime Implementation • 6140 older persons aged > 75 y screened • 2884 (47%) screened positive • Staff were able to accommodate changes • Physician response was variable • Not enthusiastic about QI component • Liked falls more than incontinence • Logistic obstacles to planned F/U visits

47. ACOVEprime Results • Knowledge scores • Increased by 14.8% intervention versus 3.2%, in control group, p=0.007 • Confidence in managing falls and UI • mean change 0.64 on 5-point scale versus 0.10, respectively, p<0.05

48. ACOVEprime Quality Results • Results based on 1229 medical record abstractions • Falls: 11 quality indicators • Urinary Incontinence: 10 quality indicators

49. ACOVEprime Final Results

50. ACOVEprime Final Results