Guideline Implementation: Opportunities & Challenges Tisa Vorce RRT, MA Michigan Department of Community Health VorceT@michigan.gov 517.335.9463 AIM Partnership Forum May 31, 2012
Guidelines Available Guidelines Used Lack of awareness Lack of familiarity Lack of agreement Lack of self efficacy, time Lack of outcome expectancy Inertia of previous practice Barriers pediatricians face when using asthma practice guidelines. Arch Pediatric Adolescent Med 2000 Jul;154(7):685 93.
Guideline Implementation Panel (GIP) Report Key Messages Use inhaled corticosteroids to control asthma. Use written asthma action plans to guide patient self management. Assess asthma severity at the initial visit to determine initial treatment. Assess and monitor asthma control and adjust treatment if needed. Schedule follow up visits at periodic intervals. Control environmental exposures that worsen the patient s asthma.
Program developed by AIM Project Team, including asthma and practice redesign experts Goal: to help clinicians make diagnosis and care decisions based on the EPR 3 asthma guidelines, and incorporate these tools into their everyday practice Development and dissemination funded by National Asthma Control Initiative (NACI) Now available for distribution and implementation in any primary care practice
Asthma Guideline Implementation Steps & Tools (GIST) A provider education and practice redesign project by the Michigan Department of Community Health based on the 2007 NAEPP Asthma Guidelines. GIST makes it easier for primary care clinicians to use the asthma guidelines in their everyday care of patients with asthma. Visit GetAsthmaHelp.org/GIST for more information. Questions About Your Breathing or Asthma Control Test Given prior to seeing clinician Gets Questions form if being seen for respiratory complaints history and symptom questionnaire ACT form for returning asthma patient, patient control assessment Asthma Diagnosis Tool or Asthma Patient Follow Up Tool Patient with clinician, who uses: Diagnosis form if patient in for respiratory complaints diagnoses/rules out asthma, finds severity level if asthma, step care started Follow Up form for returning asthma patient finds control level, steps up, down or maintains as needed Stepwise Approach to Managing Asthma Asthma Action Plan, Ed & Meds Use Stepwise Approach to find medication needs, management approach Opportunity for patient ed about asthma triggers, meds, barriers, etc. Patient receives prescription(s) and Asthma Action Plan No specified AAP for GIST, many good ones available at GetAsthmaHelp.org Evaluate, improve system, repeat Monitor progress by tracking these or other outcomes: number of asthma patients in practice number (or %) of asthma patients with current asthma action plan number (or %) of asthma patients with control assessment at last visit number (or %) of asthma patients with appropriate prescription of ICS
Action Plans, Medication & Education Important! GetAsthmaHelp.org/GIST Asthma Action Plans, medication handouts and educational information Tools and resources for GIST implementation
2011 Two Pilot Practices Learned a lot about how practices work Saw improvements in one practice had motivated physician champion, committed office manager, experience in QI activities The other failed to implement effectively no improvement. Physician not a champion, office manager tried to do it all, staff not motivated to change Both had EMR issues
Implementation Challenges For both practices Peak flow based AAP Implementing practice now using UM AAP Getting all the clinicians on board Implementing physician champion able to use outcome measures to gain buy in For the practice that implemented GIST Juggling forms who gets what when? Use ACT score to indicate need for Follow Up Tool at nonasthma visit EMRs
Subjective Feedback A little time consuming if patient came in frequently learned how to adapt system to handle that Docs don t like to be told what to do but easier to sell GIST because just like NIH guidelines See difference in practice behavior, not just in reporting Measurement was a real wake up call AAP can be important opportunity to learn how patient actually handles asthma symptoms
GIST Champions Project Provided small incentives to physician champions to promote GIST and asthma QI in 5 new primary care practices for 6 months Staff and clinician trainings Started some QI activities, ACT EMR challenges
Lessons Learned Commitment from all staff, need physician champion Emphasize practice review of data with implementation Must have useful/beloved AAP Practice must be committed to routine, not just episodic asthma care Changes may need to be in baby steps Importance of EMR and difficulty of EMR Need for implementation resources: always growing at GetAsthmaHelp.org/GIST
Next Steps Need help promoting GIST how can you help? GIST in EMRs GIST in physician specialty accreditation Find funding for next steps
Why Asthma?
Asthma QI Targets: Severity and control assessments ACT to assess asthma control Prescription of inhaled steroids Use of asthma action plans Educational sessions
Outcomes ACT use has improved to 50% target was 75% Educational sessions were successful, well liked
Challenges System factors Personnel factors Physician factors Patient factors
System factors
Personnel factors
Physician factors Residents and faculty were not aware of the new guidelines Only one slot for grand rounds for resident education Resident schedules on different days Lack of continuity affecting medical records
Multiple responsibilities My project not our project Fellowship + SOBRAP + GIST Regular duties
Patient factors No planned visits Multiple medical problems to address in single visit Asthma a door knob complaint Not enough numbers acts of God?
Educational sessions
Next steps Every journey begins with a small step
Thank You