Presentation title. Better Health Care For Greater Cleveland Learning Collaborative March 5, Ron Adams, MD Regional Chief Internal Medicine

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1 Better Health Care For Greater Cleveland Learning Collaborative March 5, 2010 Presentation title Ron Adams, MD Regional Chief Internal Medicine SUB TITLE HERE

2 Prevent Heart Attacks and Strokes Every Day PHASE How To Increase High Risk CVD Patients on Presentation title SUB TITLE HERE Beta Blockers, Lisinopril, Aspirin, Lipid Lowering RX BALL

3 Background Heart disease and stroke are the leading causes of death in the United States. Although most cardiovascular disease (CVD) is preventable, proven prevention approaches are not being adequately applied in clinical practice. Elias Zerhouni, MD, Director, National Institutes of Health, April, 2004

4 Cholesterol Management For Patients With Cardiovascular Conditions LDL-C Screening The percentage of Commercial members age who were discharged with a diagnosis of acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA) or who had a diagnosis of ischemic vascular disease (IVD) and had an LDL-C screening

5 Cholesterol Management For Patients With Cardiovascular Conditions LDL-C Controlled The percentage of Commercial members age who were discharged with a diagnosis of acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA) or who had a diagnosis of ischemic vascular disease (IVD) and had an LDL-C screening controlled (less than 100 mg/dl).

6 Persistence of Beta-Blocker Treatment After A Heart Attack The percentage of Commercial members age 18 and older who were hospitalized with a diagnosis of acute myocardial infarction (AMI) and who received persistent betablocker treatment for 6 months after discharge.

7 Controlling High Blood Pressure The percentage of Commercial adults age who were identified as hypertensive, who were continuously enrolled during the measurement year, and whose blood pressure is adequately controlled (less than 140/90 mm Hg).

8 Comprehensive Diabetes Care Hemoglobin A1c (HbA1c) Tested The percentage of Commercial members age who were identified as diabetic (Type 1 and Type 2), who were continuously enrolled during the measurement year, and who had a Hemoglobin A1c test performed during the measurement year

9 Comprehensive Diabetes Care Hemoglobin A1c (HbA1c) Poorly Controlled The percentage of Commercial members age who were identified as diabetic (Type 1 and Type 2), who were continuously enrolled during the measurement year, and whose Hemoglobin A1c test performed during the measurement year was poorly controlled (greater than 9.0%).

10 Comprehensive Diabetes Care LDL-C Screening The percentage of Commercial members age who were identified as diabetic (Type 1 and Type 2), who were continuously enrolled during the measurement year, and who had an LDL-C test performed during the measurement year.

11 Comprehensive Diabetes Care LDL-C Controlled <100 mg/dl The percentage of Commercial members age who were identified as diabetic (Type 1 and Type 2), who were continuously enrolled during the measurement year, and whose LDL-C test performed during the measurement year was controlled (less than 100 mg/dl).

12 Comprehensive Diabetes Care Kidney Disease Monitored The percentage of Commercial members age who were identified as diabetic (Type 1 and Type 2), who were continuously enrolled during the measurement year, and who had a screening for nephropathy or evidence of nephropathy during the measurement year.

13 Comprehensive Diabetes Care Blood Pressure Control The percentage of Commercial members age who were identified as diabetic (Type 1 and Type 2), who were continuously enrolled during the measurement year, and who had a blood pressure of <130/80 mm hg during the measurement year.

14 Comprehensive Diabetes Care Blood Pressure Control The percentage of Commercial members age who were identified as diabetic (Type 1 and Type 2), who were continuously enrolled during the measurement year, and who had a blood pressure of <140/90 mm hg during the measurement year.

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16 Why Focus On Heart Attacks & Strokes in DM? $M 5.1 Heart Attacks, Stroke No Cal 1996 costs of DM Complications 2.4 Kidney Disease Sugar control Coma Amputation Blindness

17 What to do: The Consensus Phase By 1990 s Evidence emerged that lowering cholesterol decreased heart attacks & strokes The 1995 program: Treat all eligible patients who came to clinic with niacin $2,000 less than statins Nurse Practitioners to make calls to do 6 titrations Tested cholesterol every 3 months to address adherence

18 Consensus Phase Results Evaluated by Archimedes medical-economic model NO effect on Heart Attacks Treating low risk patients ( worried well ), Avg 7% five yr CVD risk Titrations didn t work 1 per patient accomplished when 6 were needed Benefit/Savings No benefit therefore no savings Cost of tests exceeded savings from using nurse practitioners Lessons: Treating low risk patients is not effective Titrating is very difficult in our system Testing is expensive and didn t lower heart attacks & strokes

19 Next step: Risk Stratification Phase To find high-risk patients Initiated population-based cholesterol screening Rapidly increased to ~80% tested in 2 years To increase efficacy: Added Lovastatin treatment (not yet generic)

20 Risk Stratification Phase Archimedes Results Still no drop in heart attacks and strokes MI s /1000 DM members MI s /1000 DM members, Why? Many with high cholesterol tests & hi risk were not treated! Lessons: Testing still did not decrease events To start meds, the program needs to focus on starting meds Treating cholesterol alone won t decrease heart attacks and strokes Program modeled: Statins were high cost and lower LDL but little drop in heart attacks and strokes

21 Back to Basics: What Causes a Heart Attack? Lipid Lowering Med Aspirin 21 Lisinopril [BP lowering] cracks `

22 What Prevents Heart Attacks and Strokes? % Prob CVD death, MI or Stroke -9% Aspirin Lisinopril Lovastatin -19% -29% -39% -49% -59% -69% -79% -89% -99% -25% -25% Anti-Platelet Trialists HOT HOPE EUROPA -30% 4S HPS Yusuf, S. Lancet 360: July 6, 2002

23 Efficacy of Multiple Risk Factor Intervention in High-Risk Subjects (Type 2 Diabetes with Microalbuminuria): Steno-2 Patients Reaching Intensive- Treatment Goals at Mean 7.8 y, (%) P=0.06 Glycosylated hemoglobin <6.5% Intensive Therapy P<0.001 Cholesterol <175 mg/dl P=0.19 Triglycerides <150 mg/dl Conventional Therapy P=0.001 Systolic BP <130 mm Hg Gæde P et al. N Engl J Med 2003;348: Copyright 2003 Massachusetts Medical Society. All rights reserved. P=0.21 Diastolic BP <80 mm Hg

24 Composite Endpoint of Death from CV Causes, Nonfatal MI, CABG, PCI, Nonfatal Stroke, Amputation, or Surgery for PAD: Steno-2 Primary Composite Endpoint (%) P=0.007 Hazard ratio = 0.47 (95% CI, ; 0.73; P=0.008) Conventional Therapy Intensive Therapy Months of Follow-up Gæde P et al. N Engl J Med 2003;348: Copyright 2003 Massachusetts Medical Society. All rights reserved.

25 Model of the Outcomes Phase: A.L.L. Systematic implementation in all pts with: Diabetes (age 55yo) or Cardiovascular disease (prior heart attack or stroke) To insure they are offered daily dose of: Aspirin mg Lovastatin 40mg Lisinopril 20 mg

26 Archimedes Modeling of A.L.L. & A1C in Diabetes : Effect on Morbidity & Mortality Average annual risk of various events Nothing HbA1c control ALL % Decrease MI Stroke ESRD Blind Dying

27 How We Increased Efficacy and Efficiency Identify high-risk with minimal testing: Diabetes (age 55yo) or history of heart attack or stroke Simplify implementation and cut costs: Eliminate titrations No change on effect of medications Less visits and testing

28 Would generic meds be good enough? Benefits & Costs of Statin Rx: Diabetes Low Risk Population* $135, Lova 40 lova 80 atorva 80 $3,000 $12,000 lova 40 lova 80 atorva 80 life-yrs gained *Pt has DM but Fram 10 yr risk <23% cost/yr life gained

29 Compare Costs of ALL Vs Usual Care costs of usual vs efficient care Usual "Efficient" ASA $ mod dose/str statin $ mod dose/ ACEI $ Med Tot $ 1,010 $ 95 Visits 50/visit $ Calls 20/call 20 Labs 40/lab $ sum $ 1,370 $ 205

30 A.L.L. reduces cost in patients with diabetes $6,000 Annual cost per person $5,000 $4,000 Savings start at $300/m, average $600/m $3,000 $2,000 $1,000 $0 Nothing ALL HbA1c Years after start of program

31 Did we do it and did it work? 170, ,000 47,000 Total Elig ALL 2004 No util 2005&6 Low util Hi util 21,000 Members *90,000 patients from No Cal ( PHASE program), remainder of patients from So Cal. MPR=Mean Possession Ratio

32 The effect per group was significant Reduction in Heart Attacks & Strokes/1000 pers/yrs Even 1 day of 5 utilization was significant But taking it 2/3 of the time was much more beneficial Low Util High Util 32

33 Archimedes Planned Outcomes Phase : A.L.L. medications prescribed to a large number of patients Heart attacks and strokes significantly decreased Costs of meds were contained using A.L.L.

34 Potential Next Steps Using Iterative Modeling could include Hypertension: Adding the next medication class is 5x more powerful than titrating 2 meds control 60%, 3 meds control 80% start one generic combination of two medications (prinzide) Add 3 rd drug (amlodopine) if needed In any field Could you do iterative modeling for the top 10 most expensive diseases while applying the principles of efficacy and efficiency?

35 CMI Guidelines for ALL Meds ALL meds: Aspirin > 40 yrs. Use daily unless contraindicated (80 mg) ACE/ARB In normotensive with DM + microalbuminuria > 55 with 1or more CV factors, (TC > 200 mg/l, HDL < 35, HTN, Microalbuminuria or current smoker) Statin Age 40 80, Statin use recommended if TC >135, (lovestatin 40 mg.) Age < 40 - DM + CAD = Statin Age >80 DM + no CAD, = Shared Decision DM + CAD, = Statin

36 Goals To develop an integrated model of care that will prevent duplication of services To address Clinical Strategic Goals ( CSG ) at the primary care physician practice level To improve member satisfaction by strengthening primary care physician bonding To foster patient engagement, self management, and behavior modification

37 OBJECTIVES Generate an office visit when indicated Develop a rapport with the patient Create an environment of trust Incorporate the patient into the care planning

38 Who Are the Participants? The Patient The Primary Care Provider Advance Practice Nurse RN Care Managers Pharm.D Population Care Coordinator Nutritionist LPNs MAs Health Connect Point System Laboratory Services Pharmacy Services

39 Getting to the Point! The Care Management tool that provides intelligence It Identifies and Risk Stratifies Kaisers chronic condition population it is used to strategize and plan outreach efforts (it is an outreach tool) a list generator which generates a list of patients based on user focus To help improve care of patients with the listed conditions: Congestive heart failure (CHF) Coronary artery disease (CAD) Chronic kidney disease (CKD) Cardiovascular disease (CVD) Diabetes Asthma Hypertension Panel

40 Where to go and get the information

41 Drilldown Summaries Has two views Drilldown View Patient Summary View Region Area/Medical Center Clinic/Facility/MOB Department Specialty PCP

42 Risk Stratification Very High Risk PCP, PCm, NP High Risk PCP, PCM, NP Moderate Risk Low Risk PCP, Pharm.D, RN Care Manager PCP

43 POINT Population Care Management will pull up patient registry list PCM identifies high risk patients and highlights care gaps PCM uses Care management tool and Performance management tool

44 Outreach Identification of target group POINT Clarity Orders entered (lab, screenings) Letters Batch letters sent Missing labs, missing screenings, new Dx Currently 10 different letters, over 50,000 per yr. Follow-up Calls

45 Sequence of Patient Targets for Risk Groups Focus on the ALL Therapies Focus on Glycemic Control Focus on Hypertension Assess if Patient Eligible for Automatic Self- Titration or supervised TTT Nutrition Support, Diabetes Education Ophthalmology, Immunizations, Podiatry

46 Primary OUTCOME Goals are Simple as 1,2, 3 Change in SBP Monthly until SBP< 130 Target LDL <100 in two months Target A1c <7 in three months

47 Hypertension Beginning January 15, 2008, the RN Care Managers will no longer be solely responsible for hypertension monitoring. The LPN treatment nurse will add this to their daily responsibilities. The LPN treatment nurse will have a schedule which will include ten minute appointments for blood pressure monitoring for patients with a diagnosis of hypertension or when unconfirmed hypertension is suspected

48 Dedicated Time For RN & PCP High Risk: 20 to 40 minutes per week allotted depending on the volume Fifteen patients will be reviewed monthly by the PCP, Population Care Manager, APN/PA over a forty minute interval Moderate Risk: Twenty patients will be reviewed monthly by the and PCP over a forty minute interval between RN Care Manager and PCP. Times to be determine by PDSA Cycle

49 Prior To Office Visit Patient registry list will be generated Care gaps will be highlighted Appropriate labs, testing, etc. will be completed prior to the office visit The physician will have access to that information prior to the office visit

50 Proposed Decentralized Roles Primary Care Physician RN Care Managers Primary Care Team

51 Primary Care Physician Linked specifically to RN, LPN, or MA in the primary care module Reviews suggested care plan from Population Care Management Signs off or modifies care plan Patients are risk stratified per the POINT criteria Hands off to appropriate extender who communicates / executes on the plan

52 RN Care Managers Linked specifically to the physicians in the primary care module Receives patient list from Population Care Management Reviews and carries out plan of care approved by physician Involved with patient care as needed Interacts with patient on telephone Coaching and education

53 Primary Care Team Each physician has support staff HCT supported by RN care manager on primary care module LPN can enter lab orders, etc MA, clerks, or LPN can schedule appointments, etc

54 Pharmacy I. Medication management II. Telephonic outreach LDL greater 100 A1C less 10 No hypertension outreach

55 Advanced Practice Nurse Predominately high risk population Assesses medical condition Determines treatment plan Medication management Provides intensive follow up for medication adherence and compliance to treatment plan

56 Collaborative Time High Risk: 20 minutes per week allotted per Provider Fifteen patients will be reviewed monthly by the PCP, Population Care Manager and APN Moderate Risk: Six patients will be reviewed daily over a twenty minute interval between RN Care Manager and PCPs (30 pts reviewed per week). Providers Schedules blocked off for this time

57 Population Care Management and Prevention Outreach Clinical Gaps HEDIS (A1c, LDL, URINE PROTEIN, ALT, CREATINIEN, POTASSIUM medications, annual eye exams, etc. ) Prevention Cancer Screenings ( PAP, Mammograms)

58 Population Care Management and Prevention Data Analysts Generates lists for targeted populations Generates standardized reports HEDIS CMI reports Project metrics (Complete Care) Facility and team reports

59 PHASE Population DM Diabetes CAD Coronary Artery Disease CVA Cerebrovascular Accident or TIA Transient Ischemic Attack AAA Abdominal Aortic Aneurysm PAD Peripheral Arterial Disease CKD Chronic Kidney Disease age 50 and GFR 30 or GFR 30-60, plus proteinuria

60 Impact of PHASE Medications Antiplatelet Statin Ace Inhibitor Beta Blocker Risk Reduction in CV Events 22% 28-37% 23% 24%

61 Impact of PHASE Lifestyle Changes Risk Reduction for CV Events Tobacco Cessation Physical Activity Healthy Eating Weight Management 36% 20-24% 10-75% Improves multiple risk factors

62 CAD Progress CAD patient population is risk stratified for care as follows: ( a ) Very high and high --- Pharmacy ( b ) Moderate and low CAD with or without hypertension --- Nurse Practitioner ( c ) Moderate and low CAD with Diabetes with or without hypertension --- RN Care Manager All risk stratifications will have Outreach conducted by Population Care Management Outreach to begin in June by Population Care Management for those CAD patients with no LDL lab results

63 Proven Preventive Therapies 4 Drug Interventions Antithrombotic Medication Treatment with Aspirin mg daily for all PHASE patients unless contraindicated If contraindicated, use of clopidogrel is recommended Lipid Lowering Medications Treatment with statin is recommended even if LDL-C is <100 mg/dl ACE Inhibition Treatment with ACE inhibitor long-term unless contraindicated Beta Blockade Treatment with a beta blocker for members with CAD, PAD, and AAA unless contraindicated

64 Proven Preventive Therapies Controlling 3 Risk Factors Blood Pressure BP 129/79 mm Hg for patients with heart failure, chronic kidney disease (renal insufficiency or proteinuria), and diabetes, CAD, PAD, AAA, and CVD Lipids Statin dose sufficient to bring LDL-C levels < 100 mg/dl Statin recommended even if baseline LDL-C is < 100 mg/dl Blood Glucose Control HgA1c 7.5 is optimal for members with diabetes

65 Proven Preventive Therapies 4 Lifestyle Changes Tobacco Cessation Smoking cessation should be a primary target in the clinical strategy Physical Activity Regular, moderate physical activity is recommended for all patients Healthy Eating Recommend a diet rich in fruits, vegetables, legumes, nuts, whole grains, and n-3 polyunsaturated fat Weight Management Weight management reduces multiple risk factors

66 Medication Initiation and Shared Decision-Making Most members need 3-4 PHASE meds Many already on 1-3 medications Most will need 1-3 more medications Less focus on Clinician Prescription More emphasis on Member Adherence Member acceptance key to success

67 Lessons Don t lose focus on the desired outcome e.g. drop in heart attacks & strokes, not Chol Focus on what will get you there e.g. ALL medications Make it cheap and simple to implement Consider iterative modeling to evaluate and test each phase

68 Inputs Strategies Logic Chain of Impact Registries Population Care Information Technology Resources Problem with: Large population impact Evidence based solution Senior Sponsors Planning and Monitoring Team Project oversight and funding Refine problem/develop Action Plan Develop SMART Goals Develop Impact Logic Chain Assign Accountability Periodic report Frequent report Long term Example: Sustained 90th percentile HEDIS performance on A1c control Medium term Example: Outreach call process integrated into population care workflow Implementation Team Implementation Carry out action plan Feedback and correction until target is achieved Generate progress reports PDSA Very frequent report Short term Set SMART goals Example: 1 RN makes 5 new and 10 follow up outreach A1c control calls per day Efficient effective workflow identified and documented