Marcus Pierson, MD: Cooperation

Pursuing Perfect Healht Care in Whatcom County, WA

This is a high level view of our project plan. Details will be forthcoming in various media and arenas. The project officially begins June 1 though much work has been going on at many levels in the participating organizations.

Leadership Board Oversight
Use of Simulation Model to advocate for reimbursement changes
Complete Initial Staffing for Project
Staff Training
Creation of Curriculum and Documentation of Training provided all staff
Measurement
Information Technology Work on Infrastructure
Medication Hand-offs Work
Communication and Transparency (extraordinary openness) Infrastructure Complete
Diabetes Pilot Work Plan
Integrate Care Managers into the Clinics and Virtual Care Team
Congestive Heart Failure Pilot Work Plan
Hospital Related Changes to Support Chronic Care Model
Living With Chronic Illness Program Expansion
Idealized Design of Clinical Office Practice Completed for Pilots
Develop Evidence Based Medicine strategy and approach
Develop an approach for early adopters outside the grant

Communication and Transparency Infrastructure

The Pursuing Perfection grant encourages, develops and requires Transparency. Extraordinary openness. In order to accomplish this level of openness we have the following project goals in front of us. Several are underway, even before the grant begins, June 1.

Communication Plan Developed
Establish Communication Team
Identify current technology to support internal/external communication on Project Activities
Test Technology with this Workplan
Attempt to connect all sites participating across the country and in Europe with simple userfriendly web tools for communication. More later.
Quarterly Community Forums Planned
Extranet Web Site for Pursuing Perfection Started. More soon.
Videos Developed
Speakers Bureau Developed
Experiment with RadioLand as long term communication solution
Quarterly Community Forums

We will soon Complete the Initial Staffing for Project

For this project to truly be succefful, these typse of staff positions will need sustainable funding. A daunting thought for a cottege industry. It's a system. The only question is whether the stakeholders can create infrastructure to support a system.

Recruitment and Hiring of Project Staff (Data Analyst, Project Manager, Project Coordinator)
Hire Grant Writer
Recruitment and Hiring of information technology staff (Web Content/patient Education; Programmers)
Recruitment and Hiring of Team and Process Improvement Facilitator and Organizational Development (OD)
Recruitment and Hiring of Care Managers
Consultants and Contractors may be hired

We will use Simulation and System Models to understand and advocate for reimbursement alignment

Our task list includes the following:

Engage the other grantees in system dynamics effort, sharing knowledge with them as it accumulates
Follow up on HBOC Offer
Develop a contract with System Dynamics folks
Scoping Meeting in June.
Identify community business participation
Week long SYS Dynam meeting with the local Systems Team
Conduct community data analysis and costing for diabetes and CHF
Identification and contact with employers and community resources for support
Identification and contact with payors, national representatives for support in change in reimbursement model

Leadership to Change Healthcare

Pursing Perfection (PP) Leadership Board Oversight

Recruitment of Additional Members
- We started with the leaders of the provider groups, added the leaders of the payer groups (Group Health and Regence. CHPW (Community Healht Plans of Washington) plans to join soon.
- We plan to invite WA State Medicare (DSHS) and Medicare (CMS) to join in the ldiscussions and modeling for alignment of payment with improved care processes. This work begins in July and shold conclude by January.
Ongoing Measurement of Team work
- The Institute of Health Care Improvement is leading all of the grantees to find measures that are common between the participants across the nation. The goal is for us to benchmark ourselves and raise the bar on quality of healht care we deliver.
- Locally we have experience in measuing patient-centered satisfaction with healthcare, healthcare functional status outcomes, and "teamness", a proxy for cooperation. We will share that knowledge and experience with the others.
Assessment of development needs
- We are hiring staff with skills in organizational development, education, and human relations. These folks will help us determine where we will want to increase our knowledge and skills, to make patient-centered care a reality by the end of this pilot project in less than two years.
Develop Strategy to engage CMS and Medicaid
- As noted above, we have a plan and strategy to collaboratively develop a deep understanding of the local health care situation including the patients' and payers' concerns. We plan to get all the key skakeholders at the table late summer and fall to model ideal health care for thoses with diabetes and congestive heart failure in Whatcom County. We sincerely hope that a coherent demonstration project can be crafted between the providers, patients, and payers; especially Medicare--since much of the cost of chronic care is paid by Medicare.
Initial Training of Board
- The existance of a board of professional leaders working together to create a system of care that supports the Institute of Medicine's (IOM) CHROSSING THE QUALITY CHASM report is exciting and represents a paradigm shift in focus and system building.
- We will try to support this group so that they are the most effective team with the best ideas and models to support such dramatic change in and amoung their organizations. More later.
We have engaged Kristin Crosby to orient us to Medicare realities
- Kristen Crosby is the medical director of Olympic Healthcare, a division of Sterling Insurance. Olympic is the largest provider of Medicare supplemental insurance in the country. Kristen is helping us understand the workings and relationships needed for collaboration with Medicare.
Development of strategic community-wide plan
- For this pilot to meet its aims, it must begin to engage the entire community and provide a sustainable vehicle for the full development of the Six Aims of the IOM report Crossing the Quality Chasm: safe, effective, patient-centered, efficient, timely, equitable care. This level and direction of change will require ongoing system building. This is one of the key responsibilities of this PP Board.

Site map?. We need something akin to a site map for Whatcom PP that show what and who a user can link to.

Searching strategies.

Searching appropriately,

Our next big challenge is to get a search engine in our implementation of Radio and Manilla so that it does what the customer would expect: search the current author's category, the current author's entire web site, the entire Whatcom Community’s category or all local Radio PP sites, and then the WWPP by the same aggregates.

One would also want to be able to search by any combination of organizations, categories, and authors.

This represents design perspective as well as a search strategy.

Medication System, measure related to quality.

Common Measures: Medication System

1. Adverse Drug Events (ADEs) per 1000 doses (safety)

2. Therapeutic Range (effectiveness)

3. Cycle time to medication for certain medication (timeliness)

Site map?

We need something akin to a site map for Whatcom PP that show what and who a user can link to.

Searching strategies

Searching appropriately,

One would also want to be able to search by any combination of organizations, categories, and authors.

This represents design perspective as well as a search strategy.

WA state medical reimbursement.

Rewriting WA State medical reimbursement to support new models of care..

From: Anderson, Nancy, Dr. (MAA) [mailto:ANDERNA@dshs.wa.gov]

Sent: Monday, May 13, 2002 10:49 AM

To: Kevin Little

Cc: 'James W. Stout'

Subject: RE: [asthma] FW: [btscollege] Re: Asthma group visits

Medical Assistance (the Washington State Medicaid Administration) is in the process of writing billing instructions for group clinical visits, led by an MD or ARNP, that are specific for diabetes and asthma.

We've written various drafts of the instructions, but all include:

1. review of records/labs/etc by the clinician prior to the visit;

2. Group discussion devoted to a clinical issue;

3. Some question/answer time;

4. Routine review for all (most can be done in a group setting) and short individual visits as necessary

We will allow four one hour modules per year, which can be grouped together and billed as more than one module at one time. We will not allow billing for another e/m code the same day for the same diagnosis. We will allow those clients who have both diabetes and asthma to get clinical visits for each diagnosis (ie 8 one-hour visits a year, 4 for each disease). I'm hoping that we'll begin reimbursement June 1 (but with various bureaucratic issues, probably wouldn't make a bet). We also have a separate pilot project for asthma education with one clinical site, which is an individual contract. These visits are let by an asthma educator and are modeled after the diabetes education that we already reimburse.

Nancy Anderson MD MPH

Medical Epidemiologist

PO Box 45506

Olympia WA 98504-5506

360-725-1567 (v)

360-664-3884

High Level model of Whatcom Co, Pursuing Perfection approach. Key Components of Whatcom Consortium's approach to Pursuing Perfection in Healhtcare.

Pursuing Perfection Components in Whatcom County.

We will use this or a similar graphic on the home page of the future to guide users to the parts they are interested in. We will also add search capabilities by these categories... in the future, the near future I hope.

Cooperation and communication are related.

If we are to begin to cooperate/communicate with web logs we probably need some instruction in "reporting". I am thinking about getting a news paper reporter and some professor types from the university to help us learn to communicate in this style. I wonder if someone from the Weblogging community might not have some good ideas too.

Remote e-mail to your weblog (Radio site). I figured out how to send updates to my weblog from e-mail anywhere. That will come in handy. The only trick is that you need another dedicated e-mail account.

Stories or Weblogs. If our logs are to be navigable we either need to find a way to only present the top couple of lines and then link or expand OR use "stories" feature and link to those form a weblog.

Interactions the antidote for isolation. I am beginning to like this. The reason is that for a babble brain like myself it is an outlet in an otherwise isolated environment. I can see that the exchanges/interactions could become very rewarding in a purely selfish way. But, whatever rings your bell could result in music. [Bill Mahoney's Radio Weblog]

Medication Hand-offs from Hospital to Community.

From Mary Minniti, Project Manger of Pursuing Perfection and Carol Boston, Director of Clinical Quality for PeaceHealth:

Hi All:

As we move into implementation of our Pursuing Perfection Phase II effort, a number of work teams are being formed. We are blessed with a wonderful opportunity to focus some attention on the issue of medication safety and hand-offs now to get us started. Carol Boston will be leading a team to focus on improving the medication hand-offs between hospital and the community. The aim is to decrease medication list inaccuracy between venues for CHF patients. This project has been scoped and team members are being identified. Either Carol or myself will be contacting those potential members to confirm their ability to participate. As is the case with RWJ efforts, this team will launch quickly. Tentative first meeting is slated for May 9th from 7- 10 am and a follow-up the week of May 20th.

You are receiving this email as an FYI. We would appreciate your support in this effort and we will keep you informed of progress. Clearly, there are many things to do and unlike the work of the core team- to write a grant, transforming healthcare will take a much larger and expanded group. So core team members will not all be able to participate in all activities. However, by keeping communication lines open, we can ensure thoughts and ideas are shared. Stay tuned for details.

Feel free to share this with others as appropriate. Carol Boston is the lead and questions can be directed to her.

Thank You!
Mary Minniti, CPHQ, Project Manager

Patient ACTIVATION, the key to care planning and resource deployment.. From: Bill Mahoney [mailto:bilmah@telebyte.com]
Sent: Monday, May 06, 2002 9:49 AM
To: Minniti, Mary
Subject: Activated Patient

Hi Mary

As you know I have been working with Judy Hibbard's RWJ data trying to build a measure of how activated is a patient. I have a measure that makes good theoretical sense, is consistent with the research in this area and works quite well.

I just wanted to let you know what is available and what next steps I would suggest to complete this.

I will leave it at that and let you respond, but a few things:

All of this stuff (activated patient, patient-centered care, team development, culture of patient-centeredness, leadership, outcomes) is integrated around the central concept of patient-centeredness. And all of this is integrated with readiness to change, how change occurs and selg-perception theory (I can give you the model if interested).
The measurement of how much activation is the up front piece for every patient since this is what optimally serves as the information on which the care plan is built and the care team resources are allocated. Using this in this manner will result in the most effective use of resources and the most targeted care.
Perhaps it would be useful to meet with the teams (CHF, Diabetes, ?) and discuss this and other needs they think they have. I suspect there are reasonable and unknown needs.

Just some thoughts. Let me know your needs.

Bill

Chronic Disease Congress: September, Seattle, WA. You may want to attend a Seattle Congress on Chronic Diseases in September, 02.

Great Britian's Clinical Measures

Links to the Great Britians National Healht Service (NHS) national performance indicators.

Acute Care Hospital, measures related to quality.

Common Measures

1. Adverse Drug Events (ADEs) per 1000 doses (Safety)

2. Mortality rates (Effectiveness)

3. Readmissions (Effectiveness)

4. Time to treatment on presentation (Timeliness)

5. Functional status, Quality of Life (Patient centered)

6. Average cost per case (Efficiency)

7. Average length of stay (Efficiency)

8. Hours of diversion per month (Efficiency)

9. Patient satisfaction (Patient centered)

Access to Care, Measurements of. Common Measures

1. 3^rd next available appointment (effectiveness)

2. Total time for a visit (efficiency)

3. # of patients on a wait list to be assigned a primary care physician (effectiveness)

4. Percent of patients “highly satisfied” with appointment scheduling (patient centered)

5. Percent “no show” (efficiency)

Boston U. Sch. of Health Poligy to evaluate Pursuing Perfections Sites..

From: Fiorillo, John (Robert Wood Johnson Foundation)

Sent: Wednesday, May 15, 2002 3:13 PM

To: Bitting, Nancy J.

Subject: Pursuing Perfection Evaluation

To Pursuing Perfection Phase II CEOs

During prior meetings of the Pursuing Perfection grantees we've briefed you on the Foundation's plans to evaluate this program. We're happy to tell you that, after an excellent competitive process, we've selected a team composed of several national experts in health services research from the Boston University schools of management and public health to conduct the evaluation of Pursuing Perfection.

The team will be led by Dr. Martin Charns who, in addition to his role in the School of Public Health, is Director of the Management Decision and Research Center at the Veteran's Administration. Another key member of the team is Dr. Alan Cohen, Professor of Health Policy and Management at the School of Management. Dr. Cohen is a former Vice President for Research and Evaluation of RWJF. It is important that this team begin working with each of you as early in your implementation efforts as possible, so we have asked that they conduct initial site visits during June. A member of the evaluation team will be contacting you shortly to arrange a visit during which they would like to conduct initial interviews with key staff members. We realize that scheduling for June may require some accommodations in scheduling, but it's important that the team have an understanding of what you're trying to accomplish right from the beginning.

The Boston University team will be present at the May 29th meeting to introduce themselves and answer your questions about the evaluation.

We know you understand how important this evaluation is to building an understanding of how others may follow your example in pursuing perfection in health care. We also believe this team brings expertise to the overall effort that will enhance your ability to achieve your ambitious goals.

Sincerely,

John Fiorillo Linda Bilheimer

Senior Consultant Senior Research and Evaluation Officer , RWJF RWJF

6 Aims and 10 Simple Rules for more perfect heathcare, Institute of Medicine.

The key ideas behind this entire Institute of Medicine approach includes six goals:
1. Safe, 2. Effective (evidence based), 3. Patient-centered, 4. Timely, 5. Efficient, and 6. Equitable; and ten simple rules:

1. Continuous healing relationships
2. Customization
3. Patient control
4. Shared information
5. Evidence-based decision-making
6. Safety as a system property
7. Transparency
8. Anticipation of needs
9. Continuous decrease in waste
10. Cooperation among clinicians

Patient Centered care, the relationship between measruement and care team behavior..

Bill Mahoney begins the open dialogue on Patient Centered care when he posts:

Activated patientness is not a trait but a state. The state is created by the care team (in whatever form) providing patient-centered care. The only importance of patient traits is that they (e,g, locus of control, self-esteem, soci-economic status, location in the social structure) specify the probability of x level/type of patient-centered care activity resulting in y level of activation. The biggest barrier (if the focus groups done 2 years ago tell us anything) is not the patient, but the provider. Building patient-centered care (CCM's productive interactions) is identical to building team development (it is team development.....patient as full partner in the care team). The absolutely essential foundation of patient-centered care is the creation of team cohesiveness (see team measure) and this will require that providers redefine their role, the patient's role and the nature of the patient-provider relationship. My hypothesis is that few will be willing to go there and we may easily revert to blaming it on those noncompliant patients...an animal that does not exist. [Bill Mahoney's Radio Weblog]