Chronic Care on a Dime Asthma Management Chronic

Chronic Care on a Dime: Asthma Management Chronic Care on a Dime: Engaging Providers to Use Asthma Management Plans in an EMR Franklin Square Family Health Center Family Medicine Residency Kristin Clark, MD and Netra Thakur, MD FHC Team: Harsha Bhagtani MD, Claire Bossle RN, Timothy Iannone MD, Matthew Reetz DO Spring STFM 2009 Peer in Progress Ó copyright Med. Star Health, 2008 © copyright Med. Star Health, 2008 1

Chronic Care on a Dime: Asthma Management FHC • September 2007 Family Health Center (FHC) – 90 total asthma visits with 11 (13%) asthma management plans – 44 acute asthma visits with 3 (7%) asthma management plans – 46 non acute visits with 9 (20%) asthma management plans • This same month there were 262 FHC patients seen in the ER with asthma • Several events led to choosing asthma as focus • EMR go live July 2007 • Acute visits are defined as patients presenting with cough, shortness of breath, chest tightness, wheezing as defined in the NBLHI guidelines. Spring STFM 2009 Peer in Progress Ó copyright Med. Star Health, 2008 © copyright Med. Star Health, 2008 2

Maine Medical Chronic Care on a Dime: Asthma Management Acad Med. 2007; 82: 161– 167. Spring STFM 2009 Peer in Progress Ó copyright Med. Star Health, 2008 © copyright Med. Star Health, 2008 3

Chronic Care on a Dime: Asthma Management Maine Medical Spring STFM 2009 Peer in Progress Ó copyright Med. Star Health, 2008 © copyright Med. Star Health, 2008 4

Chronic Care on a Dime: Asthma Management Project Goals • 90% of patients seen with acute asthma will have a documented asthma management plan • 90% of patients seen with acute asthma and diagnosed with persistent asthma will be on an anti-inflammatory medication • 90% of visits for acute asthma will have documentation of short acting Beta agonist use over the last 12 months Spring STFM 2009 Peer in Progress Ó copyright Med. Star Health, 2008 © copyright Med. Star Health, 2008 5

Chronic Care on a Dime: Asthma Management Initial Interventions • • Project kick-off meeting (Oct 4, 2007) EMR training on asthma templates (Oct 11 -12) CMA training during monthly meetings Education to residents and attending physicians with a case based presentation (Nov 29) • Weekly operation meetings with nurses, PA, residents • Workshop on asthma with hands on training: – prescribing and teaching patients to use spacers – getting a peak flow Spring STFM 2009 Peer in Progress Ó copyright Med. Star Health, 2008 © copyright Med. Star Health, 2008 6

Chronic Care on a Dime: Asthma Management Interventions: Provider Self Audit METRIC tool • Provider self audit on continuity patients • Served as an intervention • Free, online access for auditing with results provided to an individual practice comparing them to practices nationally • Standard audit tool available for Family Medicine re-certification Spring STFM 2009 Peer in Progress Ó copyright Med. Star Health, 2008 © copyright Med. Star Health, 2008 7

Chronic Care on a Dime: Asthma Management Feedback Intervention • Individual results compare to group • Providers discussed their barriers • • Not enough time Patients do not need it/appreciate it/use it Not my patient not my job Not enough clinical information on a first visit providers overall felt that patients need to be stable for an AMP to work • What is the point of an AMP without a peak flow • Unable to use AMP on EMR or find any staff who could • Physicians did not believe the data • We did not win hearts and minds of residents and attendings! PA/NP very successful • We did have the opportunity to provide resident individual compared to group data Spring STFM 2009 Peer in Progress Ó copyright Med. Star Health, 2008 © copyright Med. Star Health, 2008 8

Chronic Care on a Dime: Asthma Management Results Spring STFM 2009 Peer in Progress Ó copyright Med. Star Health, 2008 © copyright Med. Star Health, 2008 9

Chronic Care on a Dime: Asthma Management Results: Asthma Visits FHC Asthma Visits Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Acute Asthma 44 47 48 46 27 23 27 Non Acute Asthma 46 66 63 70 70 73 70 All Asthma Visits 90 113 111 116 97 96 87 Spring STFM 2009 Peer in Progress Ó copyright Med. Star Health, 2008 © copyright Med. Star Health, 2008 10

Chronic Care on a Dime: Asthma Management Next Intervention Chronic Care Model (CCM) • CCM programs focus on 4 concurrent strategies: – Patient self-management support – Practice teams to achieve clinical and behavioral management – Disease support – A well-designed clinical information system. www. IHI. org/topics/chronicconditions/allconditions Spring STFM 2009 Peer in Progress Ó copyright Med. Star Health, 2008 © copyright Med. Star Health, 2008 11

Chronic Care on a Dime: Asthma Management Planned Visit for Asthma • Pre-Visit – Identify patients who are coming for acute asthma visits (asthma exacerbation) – Staff collect information • Visit – Provider in role to provide medical management – Provider to identify self management goal – Document AMP • Registry – All Billing sheets flow to “Chart Checkout” – Chart checkout sends e-chart to Asthma CMA who updates the registry – Asthma CMA sends chart to provider to do post visit with comments as to what is missing – Asthma CMA ensures that children have a copy of the AMP at their school • Post Visit – Continuity provider calls their patient to see if they followed up their self management goal and are using the AMP • Goal set for 10 patients to go through the cycle Spring STFM 2009 Peer in Progress Ó copyright Med. Star Health, 2008 © copyright Med. Star Health, 2008 12

Chronic Care on a Dime: Asthma Management FHC DASHBOARD- AMP in Acute Visits 2008 -2009 N=31 AMP=20 Spring STFM 2009 Peer in Progress Ó copyright Med. Star Health, 2008 © copyright Med. Star Health, 2008 13

PRE VISIT Chronic Care on a Dime: Asthma Management If positive check what is positive. If negative check all and click to insert text and type “NO” in front of risk factor sentence in text box. See arrow below. Spring STFM 2009 Peer in Progress Ó copyright Med. Star Health, 2008 © copyright Med. Star Health, 2008 14

Chronic Care on a Dime: Asthma Management Conclusions • FHC determined the focus needed to be on continuity – Allow the EMR time to evolve – Focus on one disease at a time seems disjointed when continuity was problematic • FHC will work toward quality measurements as are all academic health centers Spring STFM 2009 Peer in Progress Ó copyright Med. Star Health, 2008 © copyright Med. Star Health, 2008 15

Chronic Care on a Dime: Asthma Management Spring STFM 2009 Peer in Progress Ó copyright Med. Star Health, 2008 © copyright Med. Star Health, 2008 16

Chronic Care on a Dime: Asthma Management Lessons Learned • • Create partnerships. . Assess strategies mid-cycle. Be patient. Communicate often with everyone! Listen to those around you. Align your vision with that of the institution. Throw your rocks in the water one at a time! Slow down. Ihi. org/topics/chronicconditions/asthma/improvementstories/reduci Spring STFM 2009 Peer in Progress ngasthmahospitalizationsandemergencyroomvisits. htm Ó copyright Med. Star Health, 2008 © copyright Med. Star Health, 2008 17

Chronic Care on a Dime: Asthma Management • END Spring STFM 2009 Peer in Progress Ó copyright Med. Star Health, 2008 © copyright Med. Star Health, 2008 18

Chronic Care on a Dime: Asthma Management Spreading Through the Continuum • • • Presented at Med. Star Best Practice Committee Presented to Honeygo Pediatrics GME as a Driver for Clinical Excellence NESTFM Regional Poster Presentation Submitted to present at national STFM conference • The registry is being revamped to create an audit tool to align with FSH quality improvement initiatives Spring STFM 2009 Peer in Progress Ó copyright Med. Star Health, 2008 © copyright Med. Star Health, 2008 19

Chronic Care on a Dime: Asthma Management Next Interventions • Medical Home and continuity with planned visit • Create a ground swell among resident physicians – Proactive Audits – Measured patient experience data • Do you understand your medications? • Was your care perfect today? – Make results visible • Prepare office to use Centricity Registry Spring STFM 2009 Peer in Progress Ó copyright Med. Star Health, 2008 © copyright Med. Star Health, 2008 20

Chronic Care on a Dime: Asthma Management Personal Medical Home • • • A personal physician Physician-directed medical practice A whole-person orientation Coordinated care, quality and safety Enhanced access A system of payment that reflects the added value of a patient-centered medical home Spring STFM 2009 Peer in Progress Ó copyright Med. Star Health, 2008 © copyright Med. Star Health, 2008 21

Chronic Care on a Dime: Asthma Management Applications of this Project • Med. Star can use this registry as part of Centricity • Med. Star practices can institute planned visit for chronic disease management into their practices • Peter Basch, MD and Michael Dwyer are discussing creating a nurse visit (our pre-visit) • Increase knowledge in Residencies through STFM presentation (and Med. Star through CIC) – Chronic Disease management – Registry (point is to track all patients with asthma- we were discouraged) – Self management goals by patients • FSH is working toward becoming an asthma certified hospital in pediatrics Spring STFM 2009 Peer in Progress Ó copyright Med. Star Health, 2008 © copyright Med. Star Health, 2008 22

Chronic Care on a Dime: Asthma Management Addendum • The following slides are additional information Spring STFM 2009 Peer in Progress Ó copyright Med. Star Health, 2008 © copyright Med. Star Health, 2008 23

Chronic Care on a Dime: Asthma Management Spring STFM 2009 Peer in Progress Ó copyright Med. Star Health, 2008 © copyright Med. Star Health, 2008 24

Chronic Care on a Dime: Asthma Management METRIC QUESTIONS • • • Does the chart reflect whether the frequency of the patient's daytime symptoms was evaluated in the past 12 months? Does the chart reflect whether the frequency of the patient's nighttime symptoms was evaluated in the past 12 months? Does the chart reflect the frequency of short-acting beta 2 -agonist inhaler use by the patient in the past 12 months? Does the chart reflect the frequency of acute attacks/exacerbations in the past 12 months? Does the chart reflect the frequency of missed or modified activities in the past 12 months? Is assessment of current control documented? Does the chart reflect what asthma medications were prescribed (including drug name, dosage and recommended frequency of use)? If the patient has persistent asthma, was a long-term control medication (inhaled corticosteroid or acceptable alternative treatment) prescribed? Does the chart reflect that the patient was asked whether medication(s) was/were taken as prescribed? Is the patient a regular smoker? If the patient presently smokes or recently quit, does the chart reflect that the patient was counseled to stop smoking (or encouraged to continue his/her cessation efforts) at the last visit? Does the chart reflect that possible triggers and allergens were discussed with the patient during at least one visit during the past 12 months? OPTIONAL: Does the chart contain an asthma assessment tool that was completed in the past 12 months 25 Spring STFM 2009 Peer in Progress Ó copyright Med. Star Health, 2008 © copyright Med. Star Health, 2008

Chronic Care on a Dime: Asthma Management Improving Care of Chronic Conditions • Locus of improvement and change should be the primary care office • Chronic care training programs important for residents • Challenge in current system that is geared toward acute care Starfield, Ann Fam Med 2003; 1: 8 -14. DOI: 10. 1370/afm. 1 Main, Ann Fam Med 2003; 1: 15 -21. DOI: 10. 1370/afm. 4 Spring STFM 2009 Peer in Progress Ó copyright Med. Star Health, 2008 © copyright Med. Star Health, 2008 26

Chronic Care on a Dime: Asthma Management Registry Revision 3 July 2008 Asthma Registry Key: 0 - No 1 -yes NA Not applicable NP Not Possible Visit Date Patient name DOB Age PMD Visit Doctor Baseline Meds include ICS (1/0) Spring STFM 2009 Peer in Progress Ó copyright Med. Star Health, 2008 © copyright Med. Star Health, 2008 What Dose (low, med, high) 27

Chronic Care on a Dime: Asthma Management Registry Revision 3 July 2008 Asthma Registry Key: 0 - No 1 -yes NA Not applicable NP Not Possible Patient name ED visits for asthma in last 12 months Hospitalization for asthma in last 12 months Steroid burst in last 6 wks Prior ICU Prior intubation Spring STFM 2009 Peer in Progress Ó copyright Med. Star Health, 2008 © copyright Med. Star Health, 2008 28

Chronic Care on a Dime: Asthma Management Registry Revision 3 July 2008 Asthma Registry Key: 0 - No 1 -yes NA Not applicable NP Not Possible Patient name Last Name, ini Classificati on of type of asthma is persistent? (1/0) If not already on ICS was it added? (1/0/NA) Is the patient a smoker? (1/0/NA ) If ready to quit advice or resource given? (1/0/NA) Patient not ready to quit? (1/0/NA) AMP? (1/0) AMP at school? Is medicine form at school? (1/0) Selfmanageme nt Goal? (1/0) 29 Spring STFM 2009 Peer in Progress Ó copyright Med. Star Health, 2008 © copyright Med. Star Health, 2008

Chronic Care on a Dime: Asthma Management Quality of Asthma Care Percent of Adults With Asthma, 2003: Maryland Compared to Benchmarks Spring STFM 2009 Peer in Progress http: //www. ahrq. gov/qual/asthmacare/asthmafig 4_2. htm. Source: Calculated from Behavioral Risk Factor Surveillance System (BRFSS) 2003 data. Ó copyright Med. Star Health, 2008 © copyright Med. Star Health, 2008 30

Chronic Care on a Dime: Asthma Management Chronic Care Model 5 Principles 1. First contact: Primary care provider 2. Continuous relationship with primary care provider 3. Comprehensiveness 4. Coordination 5. Accountability Spring STFM 2009 Peer in Progress Ó copyright Med. Star Health, 2008 © copyright Med. Star Health, 2008 31

Chronic Care on a Dime: Asthma Management Barriers • • EMR Residency training and conferences Multiple priorities Personnel Spring STFM 2009 Peer in Progress Ó copyright Med. Star Health, 2008 © copyright Med. Star Health, 2008 32