ImproveCareNow Collaborative Chronic Care Network
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1 ImproveCareNow Collaborative Chronic Care Network Peter A. Margolis, MD PhD Richard B. Colletti, MD NIH NIDDK R01DK AHRQ R01HS AHRQ U18HS ImproveCareNow Network Care Centers
2
3 .5 x.5 =.25
4 Learning Healthcare System Patients and providers work together to choose care based on best evidence Drive discovery as natural outgrowth of patient care Ensure innovation, quality, safety and value All in real-time
5 Network-Based Production Yochai Benkler, The Wealth of Networks
6
7 Percent of Patients in Remission Crandall, Margolis, Colletti et al Pediatrics 2012;129:1030
8 Network Organization ImproveCareNow, Inc Clinical hub Cincinnati Children s Anderson Center for Health Systems Excellence C3N Project Accelerator Budget ImproveCareNow operating costs supported by fees -$1,000,000/year Center costs - $35-100,000/year Research and innovation - $2 mil/year Limited commercialization funds Care Centers Patients
9 How do you create network-based production for health? 1. Focus on outcome 2. Build community 3. Effective use of technology 4. Learning system System science, QI, qualitative research, clinical research
10 Building community Compelling purpose Core leadership patients, clinicians, researchers Sharing stories Many ways to contribute Jill Plevinsky, Chair, PAC
11 Effective use of technology Example: Data Collection
12 Data capture at clinical visit
13 Enhanced Registry Data-in-once Automate chronic care processes Measure performance for QI and learning Generate high quality data Create new knowledge at three levels care center, population and individual level John Hutton, MD; Keith Marsolo, PhD; Charles Bailey, MD; Christopher Forrest, MD, PhD; Marshall Joffe, MD, PhD; Wallace Crandall, MD; Mike Kappleman, MD, MPH; Eileen King, PhD
14
15 04/07 08/07 12/07 04/08 08/08 12/08 04/09 08/09 12/09 04/10 08/10 12/10 04/11 08/11 12/11 04/07 08/07 12/07 04/08 08/08 12/08 04/09 08/09 12/09 04/10 08/10 12/10 04/11 08/11 12/11 Performance Report - QI Key Measures Monthly Report December 2011 Advanced Track All Sites Performance (score, goal, n) 1. Remission rate 10 (76%,, n=2435) Steroid free 10 remission rate 6 (72%, 76%, n=2424) Sustained remission 10 rate 6 (57%, 45%, n=1352) Off prednisone 10 (91%, 95%, n=2542) Satisfactory nutritional 10 95% status 9 (9, 9, n=2615) 85% 75% 6. Satisfactory grow th 10 95% status 9 (93%, 9, n=1851) 85% 75% 10 7.Complete documentation bundle 6 (94%, 95%, n=502) Documented visit in last 6 months (79%,, n=3031) 9. Starting thiopurine and TPMT measured (67%, 9, n=6) 10. Thiopurine dose according to Model Care (75%,, n=509) TGN level measured according to Model Care (17%, 75%, n=12) 12. Infliximab initiation and prior PPD or chest X-ray 3-month moving average (79%, 95%, n=34) 13. Infliximab dose according to Model Care (95%, 95%, n=535) 14. Infliximab trough level measured (55%, 75%, n=11) Methotrexate dose >= 10 mg/square-meter/w eek (91%, 95%, n=65)
16 Re-design Care - Care Center Level Studies Treatment Combination Pre-visit Planning Population Management Self- Management Support % in Remission Site Site Site Site Site Site Site Site
17 Comparative Effectiveness Research Population Level Probability Probability Clinical Remission Steroid-free Remission Simulated Trial Treatment Control Treatment Control Cumulative Probability of Achieving Remission with Biologic Therapy vs. controls for patients with moderate/severe pediatric Crohn s disease Chris Forrest, MD, PhD, Charles Bailey, MD, Marshall Joffe, MD, PhD. Univ of Pennsylvania Number of Weeks Number of Weeks
18 10/1 10/2 10/2 10/2 10/2 10/2 10/3 11/2/11 11/4/11 11/6/11 11/8/11 11/1 11/1 11/1 11/1 11/1 11/2 11/2 11/2 11/2 11/2 11/3 12/2/11 12/4/11 12/6/11 12/8/11 12/1 12/1 12/1 12/1 12/1 12/2 12/2 12/2 12/2 12/2 12/3 1/1/13 1/3/13 1/5/12 1/7/12 1/9/12 1/11/12 1/13/12 1/15/12 1/17/12 1/19/12 1/21/12 1/23/12 1/25/12 1/27/12 1/29/12 1/31/12 2/2/12 2/4/12 2/6/12 2/8/12 2/10/12 2/12/12 2/14/12 2/16/12 2/18/12 2/20/12 Personalized Care 19 yr. old with Crohn s colitis Colectomy with ileo-anal anastomosis (10 yrs) Chronic diarrhea, nocturnal stools, fatigue, poor quality of life Current medications: Infliximab & PRN imodium Infliximab Nocturnal (I chart) PT sick, took amoxicillin 12/9-12/16 PT sick, took Augmentin 1/25-2/1 Heather Kaplan, MD, MPH, Jeremy Adler, MD, MPH, Shehzad Saeed, MD, Ian Eslick, MS, Lloyd Provost, MS, Tom Nolan, PhD, Peter Margolis, MD, PhD
19 MyIBD.c3nproject.org
20 What s Next? Inter-visit Planning Mentoring Community Building/Organizing Passive Patient Reported Outcomes Lisa Opipari, PhD, John Chaffins, David Fore, Michael Seid, PhD, Keith Marsolo, PhD, Tania Moon, Jill Plevinsky
21 Collaborators
22 Be part of the solution Help test patient-engagement interventions using network as lab Better outcomes and lower costs Kauffman Foundation Health Network Trust Project Be part of the scale up 10,000 more in remission Be part of the scale out Adults with IBD Another disease Accelerate Technology strategy and partnerships
23
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