Favoriser le changement et la performance grâce aux indicateurs de qualité
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1 Favoriser le changement et la performance grâce aux indicateurs de qualité Pascal Briot Direction médicale et qualité Direction des finances +41 (0) novembre 2017
2 Agenda 1. Application du «chronic care model» à Intermountain Healthcare: «personalized care» 2. Utilisation d outils informatiques et d indicateurs pour améliorer la prise en charge des patients souffrants d asthme 3. «Team Based Care» et son application à la prise en charge des patients complexes: indicateurs et résultats
3 Remerciements Les informations, données et chiffres contenus dans cette présentation sont la propriété d Intermountain Healthcare. Tous mes remerciements à Intermountain Healthcare, son Institut for Healthcare Delivery Research, son programme clinique Primary Care et en particulier son directeur médical Dr Wayne Cannon et son directeur pour Mental Health Integration Dr Brenda Reiss-Brennan.
4 Constat
5 Chronic Care Management Model 1. Community Resources and Policies 2. Health System Health Care Organization 3. Self-Management Support 4. Delivery 5. Decision 6. Clinical System Support Information Design Systems Informed, Activated Patient Productive Interactions Prepared, Proactive Practice Team Improved Outcomes Wagner, E.H. Chronic Disease Management: What Will It Take to Improve Care for Chronic Illness? Effective Clinical Practice 1998; 1:2-4. Permission to reproduce model image granted from American College of Physicians (ACP), July 7, 2006.
6 Care Management Processes in Physician Organizations (N = 1,040) Process Diabetes Asthma CHF 1. Case management 39.7% 39.7% 43.4% 2. Feedback to physicians Disease registries Clinical guidelines with reminders Average Practices using all Casalino, L. et al. (2003). External incentives, information technology, and organized processes to improve health care quality for patients with chronic diseases. Journal of the American Medical Association.
7 INTERMOUNTAIN HEALTHCARE : Management of complex chronic disease in primary care (Personalized Primary Care) Total Population with Chronic Disease (e.g. Asthma) 2/3 1/6 1/6 Primary Care Physicians (General Internists and Family Practice Physicians) Adult Medical Specialists * Medical Assistant Generalist Care Manager & Mental Health Clinician Specialist Care Manager and Other Support Staff Mental & Whole Health Integration (MHI) * Allergy Cardiology Dermatology Endocrinology Gastroenterology Nephrology Neurology Physiatry Psychiatry Pulmonology Rheumatology
8 Aperçu d Intermountain Healthcare employés: siège est à Salt Lake City, 5,5 milliards d euros de revenus (2015) Créé en 1975, lorsque l église des Mormons fait un don de ses 15 hôpitaux à la communauté Hôpitaux (1975) 22 hôpitaux médecins affiliés lits 41% des hôpitaux de l'utah, 44% des lits, 54% des admissions Groupes Médicaux (1994) 185 cliniques (centres ambulatoires pluridisciplinaires) médecins employés Gestion de la santé de la population (2015) Responsabilité partagée Soins primaires personnalisés Bien être / mieux vivre Assurance HMO SelectHealth (1983) 800,000+ assurés ~ 23% du marché
9 INTERMOUNTAIN HEALTHCARE : Mental & whole health integration structure
10 IH essential elements for integration 1. Leadership and culture: Champions establishing a core value of accountable and cooperative relationships 2. Workflow: Engaging patients on the team and matching their complexity and need to the right level of support 3. Information system: EMR, EDW, registries, dashboard to support team communication and outcomes feedback 4. Financing and operations: projecting, budgeting and sustaining team FTE to measure the ROI 5. Community resources: community partner to help engage population in sustaining wellness
11 Tools to facilitate the work of the healthcare professionals Care Process Model
12 Summary report for physician and patient 1. General Patient status information 2. Disease Specific information 3. Process and Outcomes measures 4. Recom mendations
13 Primary Care Clinical Program Website
14 Physician level summary data
15 Patient Detail Report
16 Medical Director Report
17 IH Board goals (for asthma in 2002) Primary Care Pulmonary-Allergy Development Team - ASTHMA- For all SelectHealth members with persistent asthma (as defined using HEDIS criteria) reduce the percent of patients who have a visit to an emergency department to < 13.10% (currently 13.6% and rising by 0.8% every year) The intent of this goal is to focus primarily on improving asthma care and thus quality of life and preserving normal lung function for patients with asthma. ER visits is a marker for poorly controlled asthma. We are also secondarily interested in decreasing ER visits both for cost reasons and also continuity of care and convenience issues. Référence: Dr Wayne Cannon, Intermountain Healthcare 2002 Board Goal for Primary Care Clinical Program
18 IH Board goals (for asthma in 2002) Référence: Dr Wayne Cannon, Intermountain Healthcare 2002 Board Goal for Primary Care Clinical Program
19 IH essential elements for integration 1. Leadership and culture: Champions establishing a core value of accountable and cooperative relationships 2. Workflow: Engaging patients on the team and matching their complexity and need to the right level of support 3. Information system: EMR, EDW, registries, dashboard to support team communication and outcomes monitoring 4. Financing and operations: projecting, budgeting and sustaining team FTE to measure the ROI 5. Community resources: community partner to help engage population in sustaining wellness Référence: Dr Brenda Reiss-Brennan, Intermountain Healthcare, Mental Health Integration Team Based Care, Office of Research 2016.
20 Work flow: Matching population to social and health needs Référence: Dr Brenda Reiss-Brennan, Intermountain Healthcare, Mental Health Integration Team Based Care, Office of Research 2016.
21 Information flow: Team message log Référence: Dr Brenda Reiss-Brennan, Intermountain Healthcare, Mental Health Integration Team Based Care, Office of Research 2016.
22 IH essential elements for integration 1. Leadership and culture: Champions establishing a core value of accountable and cooperative relationships 2. Workflow: Engaging patients on the team and matching their complexity and need to the right level of support 3. Information system: EMR, EDW, registries, dashboard to support team communication and outcomes monitoring 4. Financing and operations: projecting, budgeting and sustaining team FTE to measure the ROI 5. Community resources: community partner to help engage population in sustaining wellness
23 Linking data: cost and quality outcomes Référence: Reiss-Brennan B, Briot P, Savitz LA, Cannon W, Staheli R. Cost and quality impact of Intermountain s Mental Health Integration program [Impact sur les coûts et la qualité du programme d'intégration des soins pour maladie mentale d Intermountain Healthcare]. J Healthc Manag 2010;55(2):1-18.
24 Linking data: total savings for the insurance plan (SelectHealth) Référence: Reiss-Brennan B, Briot P, Savitz LA, Cannon W, Staheli R. Cost and quality impact of Intermountain s Mental Health Integration program [Impact sur les coûts et la qualité du programme d'intégration des soins pour maladie mentale d Intermountain Healthcare]. J Healthc Manag 2010;55(2):1-18.
25 IH essential elements for integration 1. Leadership and culture: Champions establishing a core value of accountable and cooperative relationships 2. Workflow: Engaging patients on the team and matching their complexity and need to the right level of support 3. Information system: EMR, EDW, registries, dashboard to support team communication and outcomes monitoring 4. Financing and operations: projecting, budgeting and sustaining team FTE to measure the ROI 5. Community resources: community partner to help engage population in sustaining wellness
26 Culture change overtime Référence: Dr Brenda Reiss-Brennan, Intermountain Healthcare, Mental Health Integration Team Based Care, Office of Research 2016.
27 Measuring change of culture overtime: IH MHI scorecard Référence: Dr Brenda Reiss-Brennan, Intermountain Healthcare, Mental Health Integration Team Based Care, Office of Research 2016.
28 Team performance towards routinization: progression of Team Based Care (TBC) in the IH delivery system Référence: Dr Brenda Reiss-Brennan, Intermountain Healthcare, Mental Health Integration Team Based Care, Office of Research 2016.
29 Team Based Care (TBC) results
30 Merci Référence: Dr Brenda Reiss-Brennan, Intermountain Healthcare, Mental Health Integration Team Based Care, Office of Research 2016.
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