Making the Montefiore Medical Group Health Disparities Collaborative

Making the Montefiore Medical Group Health Disparities Collaborative Work at Montefiore Medical Center The MMG HDC Team Bronx CREED September 30, 2005 In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

This is NOT “Zach’s Diabetes Thing” n n Coordinated effort on the part of a lot of folks. This afternoon: • • Eleanor Larrier Introduction Me Introduction Nandini Deb: Clinical Information Systems Jennifer Klein: Diabetes Education CFCC: Judy Leuchter, Peer Educators FHC: April Evangelista, Health Ed PDSA WB: Sean Misciagna, M. D. , FM Resident Nutrition: Helen Persovsky In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

“We don’t just talk about reducing health disparities. . we reduce ‘em!” In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

So. . . how do we reduce health disparities? ‘THE COLLABORATIVE MODEL” What’s so great about that model? In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

OLD QI METHODOLOGY n “Swoop and Poop” Do everything to everyone all at once. n Punish whoever doesn’t have good scores. n Create simplistic and token responses to real problems. n In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

REAL PROBLEM n Health care worker lack of comprehensive understanding of the dimensions of pain, pain control, addiction, emotional response to pain and end of life issues, etc. n Patients feel too much pain in the hospital, report being ignored, addicts turned away from pain treatments, etc. In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

THE “SOLUTION” TO THESE COMPLEX AND MULTIDIMENSIONAL, REAL PROBLEMS: In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Collaborative Philosophy and Method Fix what is wrong, help clean the mess yourself. n Tests of change on small populations, then “SPREAD” to everyone - GRADUALLY n Realize that making mistakes is part of the process. Without mistakes no one learns. n Share senselessly, steal shamelessly n In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Chronic Care Model n Can be applied to all chronic conditions: • • Asthma Depression Hypertension Coronary Artery Disease HIV Diabetes Domestic Violence Emergency Preparedness In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Six Elements of the Chronic Care Model n Medical Information Systems • the registry • populated progress note n n n Self-Management (e. g. , classes, health educators) Community (e. g. , salsa classes) Delivery Systems Design (e. g. , planned visit) Decision support (listserv guidelines) Organization of Health Care (spread to MMC) In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

PDSA Plan, Do, Study, Act n Disciplined, results oriented method of group discussion. n Topic tracking and adherence. n Track progress. n Learn from failures. n Over and over again. n In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Collaborative Sponsorships of Montefiore Medical Group • Bureau of Primary Healthcare/National Collaborative • New York City Department of Health: Spread Collaborative • Academic Chronic Care Collaborative (ACCC by American Association of Medical Colleges) In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

What is the National Diabetes Collaborative? Made up of hundreds of health centers from all over the country Northeast Cluster In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

That’s all very special, so tell me, how do you get collaborative stuff going? n Get blessed. • Great leaders, great support, wonderful energy, motivated people. • Where do they come from? • We pick them out. n n Do something good with no money. Then write about it and present it to everyone every chance you have. Get money. “Salvador Dali: With Gold You Get Gold. ” Get going. Getting going is easy, thinking about getting going is hard. Keep going (THE VERY HARDEST PART!) In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

What were goals in first year for MMG HDC? 1. 2. 3. 4. 5. 6. Identify successes of FHC. Spread to CHCC, CFCC and WB in Diabetes Establish working teams. Determine key measures for all sites. Establish uniform/compatible data collection system for registry. Identify key measures needing improvement and begin interventions. In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Goal #1 Spread to CHCC, CFCC and WB in Diabetes In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Montefiore Medical Group Health Disparities Collaborative FHC (DM) CHCC (DM) WB (non 330) DM CFCC (DM) Bronx Community Health Network Sites In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Goal 2. 0 n Create centralized working group/leadership team: • • Facilitate, supervise, train, develop the sites. Coordinate allocation of resources. Plan for future Communicate with larger Collaborative organizations. In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Montefiore Medical Group: Health Disparities Collaborative Senior Leadership n n n Jon Swartz, M. D. , Senior Leader Arnel Tirado, Senior Leader Victoria Gorski, Senior (Academic Leader) Jennifer Klein, Director, Health Education Nandini Deb, Information Specialist Arthur Blank, Ph. D Eleanor Larrier and Celia Alfalla, M. D. , Bronx Community Health Network Rita Louard, M. D. , Joel Zonszein, M. D. , Endocrine Clyde Schecter, M. D. , Research Helen Persovsky, Nutritionist Zach Rosen, M. D. , Project Director In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Bronx Defeat Diabetes Project (BDDP) n Bronx Community Health Network (Eleanor Larrier and Celia Alfalla) • Obtained $3 M grant/3 years for community based initiatives – Diabetes Educators, Peer Educators, Diabetes Training, Specialty Care, etc. In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Goal #2. 1 Establish working teams. In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

MMG HDC Multidisciplinary Work Teams • Administrative Director • Medical Director • Physician Champion • Nurse or Nurse Manager • Diabetes Educator • Peer Educator In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Montefiore Family Health Center The Bronx Diabeaters: q q q Ibis Castro, Health Educator, MFHC Jose Delgado, Associate Director, MFHC Wayne Joseph, MD, Attending, MFHC Zach Rosen, MD, Medical Director, MFHC April Evangelista, Diabetes Educator In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Williamsbridge Family Health Center “The Sugarbusters” • • • Sandra Barnaby, R. N. Noel Brown, M. D. Joanne Dempster, M. D. Blanche Doati Victoria Gorski, M. D. Danette Ortiz Staff Nurse Medical Director Team Leader Associate Director Academic Leader Front desk supervisor (day-to-day leader) In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Comprehensive Family Care Center (CFCC) n n Medical Director Physician Champion Team Leader Team Members Marta Rico, MD Chris Meserve, MD Carol Lau, FNP, Associate Director Carmen Cintron. Lopez, Assistant Administrator Joanna White, Administrative Nurse Manager Judy Leuchter, Health Education Manager Bobbie Jamison, Health Educator Jennifer Sanchez, PECS data entry Estelle Vargas, LCSW In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

CHCC Team Joe Deluca, M. D. , Team Leader and Physician Champion n Jennifer Santiago-Rivera Health Educator n Donna Wade, Nurse Manager n Erwin Duran, Data Entry n Carmen Guerra , Nurse n In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Goal #3: Determine key measures for all sites. In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Goal Shared Core Measures <8% Average Hgb. A 1 c 70% % of patients with BP< or = 130/80 70% % of patients with an LDL <100 90% % of patients who have had pneumococcal vaccine 90% (90% % of patients with documented LEAP foot exam in the past 12 months % of patients receiving annual flu shots) 90% % patients on aspirin (or other anti-coagulant) 70% Signed self management contract in chart In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Other measures Smoking n Passive smoking (asthmatics) n Nutrition n Exercise n. . . n In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Goal #4 Establish uniform/compatible data collection system - Registry In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Goal #5 Identify key measures needing improvement and begin PDSA’s In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

FHC: Percent of DM Patients with Pneumococcal Vaccine (10 years) PDSA Latest Data as of September 1, 2005 In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

FOOT EXAM PDSA (s) 1. 2. 3. 4. 5. From registry get print out of all charts without pneumovax. Pull charts and have provider review (some charts didn’t have it recorded but had pneumovax given). Put yellow stickies in charts without pneumovax. Combine fluvax and pneumovax forms. Etc. etc. In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

So where’s the data? In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

DM Collaborative: Key Measures By Site May 2004 – May 2005 Note: Data from FHC and WB are for patients with Pneumococcal Vaccine in the past 10 years In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

FHC: Number of Patients in Registry Latest Data as of September 1, 2005 In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

FHC: Average Hb. A 1 c for DM Patients Latest Data as of September 1, 2005 In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

FHC: Percent of DM Patients with One Hb. A 1 c (12 months) Latest Data as of September 1, 2005 In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

FHC: Percent of DM Patients with Last Hb. A 1 c >=9. 5 Latest Data as of September 1, 2005 In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

FHC: Percent of DM Patients with BP <=130/80 Latest Data as of September 1, 2005 In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

FHC: Percent of DM Patients with LDL <100 (of DM patients with Lipid Screen) Latest Data as of September 1, 2005 In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

FHC: Percent of DM patients with SM Goal (12 months) Latest Data as of September 1, 2005 In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

FHC: Percent of DM Patients with Daily Aspirin Use Latest Data as of September 1, 2005 In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

FHC: Percent of DM Patients with Foot Exam (12 months) Latest Data as of September 1, 2005 In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

FHC: Percent of DM Patients with Retinal Exam (12 months) Latest Data as of September 1, 2005 In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

FHC: Percent of DM Patients with Microalbumin Screen (12 months) Latest Data as of September 1, 2005 In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Moving Forward: Goals for MMG HDC Diabetes n n n ABC’s improvement. Selected Targeted Population Parameters for MMG HDC (e. g. self-management scores) Selected Targeted Population Parameters by site (e. g. LEAP at FHC) Incorporation of MIS into MMC CIS Monte Home Care Collaboration Build on Peer and Health Educator gains. In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Clinical Information Systems DM Collaborative Core Team: Dr. Jon Swartz, Dr. Zach Rosen, Arthur Blank, Jennifer Klein In response to the Montefiore Quality Council, this information isand provided under Section 2805 -m of the New York Nandini Deb Public Health Law.

CIS currently used: n CVDEMS - Cardiovascular and Diabetic Electronic Management System - Microsoft Access Based Program n PECS - Patient Electronic Care System - Microsoft Access Based Program In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Montefiore Medical Group Health Disparities Collaborative FHC CHCC CFCC WB CVDEMS PECS CVDEMS In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

CVDEMS Data Capturing Process: FHC AS MODEL Data Collection: n At each visit, Nurses print out CVDEMS form with last encounter data and demographic information of the patient n Providers update form at current visit—CVDEMS form gets into chart n EHIT generates weekly encounter list at FHC (~100/week) In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

CVDEMS Form In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

CVDEMS Data Capturing Contd. Data Monitoring n Semi-annual generation of list of all patients with no visits in the last 6 months, given to Health Educators for outreach n Annual pruning of patients with no visits in the past year (after outreach attempted) n Bi-yearly reassignment of Providers/matching Providers with patients n Data quality checks—random sample of 5% charts reviewed to assess validity, reliability and completeness of data In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Data Capturing Contd. Bi-weekly CVDEMS automatic lab data transfer to CVDEMS and PECS for FHC, WB, CFCC and CHCC: n Tuesday: Program identifies all patients who had labs done in the last two weeks n Wednesday: Program dumps all labs for the identified patients n Wednesday: Lab results are sent back to the sites In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Monthly Reports n Monthly report generation: - Registry Summary Report - Provider Report In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Registry Summary Report In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Provider Report In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Key Measures by Site Reporting Period: May 2004 -May 2005 In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Our Persistent Challenges n CVDEMS and PECS rigidities n CVDEMS forms not completely filled out n Problems due to manual data entry n Resource constraints at the sites n System crashes—very painful! In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Our Successes n Structured monitoring of data n Automatic lab data transfer for all the sites n Monthly Reports for FHC, WB, CFCC and CHCC In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Our Plans for the Future n Montefiore CIS system with Provider entry of data n Chronic Disease Management Screen—with capabilities to present the entire history of the patient. n How to use this data repository to ask research questions? In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Acknowledgements n Each and everybody who has worked and currently working with the DM Collaborative n Special thanks to Jasmine Smith, Erwin Duran and Jennifer Sanchez — our data support personnel n Nadav Tanners (Having fun at Yale!) n Yan Chai — DFSM Data Manager In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

SELF-MANAGEMENT In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Patient Self-Management n Patients already self manage • All patients make decisions and engage in behaviors that affect their health. • They are in control. • They decide on what health behaviors they will or will not engage in. In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Traditional vs Collaborative Care n Shared expertise Shared responsibility n Provider as expert n n Provider is principle caregiver and problem solver Provider gives instructions to n Patient sets goals be complied with n n Behavior is externally n motivated n Provider identifies problem Provider solves problemsn Internal Motivation Patient identifies the problem Patient is taught problem solving skills In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Self-Management Education Based on Self Efficacy Theory (Self Confidence) n Emphasizes n • Problem Solving • Decision making • Confidence building n Goal Setting In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

What would you like to do to improve your health? Monitoring Physical Activity You choos e Medications Coping Unhealthy Behaviors In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Self-Management Goal Setting n My Action Plan • • n n What Where When How often Barriers Problem Solving to overcome barriers Support needed to reach goal Confidence level In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Self-Management Goals Teaching Techniques n Facilitative n Participatory n Collaborative • Use of Motivational Interviewing techniques to elicit Self- Management Goals In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Self-Management Support at MMG Ø Ø Ø Educational Classes Group Medical visits Support groups Walking club Individual Sessions Cooking Classes Ø Ø Ø Waiting Room Talks Phone Contacts Salsa Classes Peers Support Community involvement In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Montefiore Comprehensive Family Care Center – Bronx Community Health Network (MMG-CFCC/ BCHN) 1621 Eastchester Road Bronx, New York 10461 In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Montefiore Medical Group Comprehensive Family Care Center About Us n n n n 75, 000 visits / year Internal Medicine, Pediatrics, & Ob. Gyn Residency Programs 60 atttending MDs 102 (48 IM, 31 Peds, 28 Ob. G)Residents Nurse practitioners, midwives Numerous other providers Total users 2004 – 18, 682 Of those 1042 (5. 6%) are patients w/Diabetes mellitus Demographics n n n Black/African-American 30% Hispanic/Latino 46% White (not H/L) 12% Unknown/unreported 11% Asian/Pacific Islander 1% Native Am/Alaskan Native. 02% Languages n English n Spanish In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

AIM AIM: Montefiore Medical Group – CFCC will redesign our care delivery system to maximize the health and quality of life for our patients with Diabetes mellitus, by assuring that they receive effective, evidence-based services, using a coordinated care plan. We will achieve this by implementing a comprehensive approach, using the components of the Chronic Care Model In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Self Management, highlights GROUP LEARNING n n Group Educational Series: English and Spanish Team presentation of learning sessions (Health Educator, Residents, Physician, Social worker and Nutritionist). Collaborative, interactive format Alumni lunches held once a month to re-visit self-management , education and problem solving issues GROUP ACTIVITES n n n Walking club twice a week, open to all CFCC patients Birthday Lunch Breakfast Club: pilot In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Self Management, cont. INDIVIDUALIZED GOALS n n n Individualized sessions at the end group to define self-management goals. Individual mini-sessions prior to provider visits consisting of diabetes education, nutritional counseling, and self-management goal setting. Individualized sessions with nutritionist. PEER SUPPORT n n n CFCC patients with diabetes trained as Peer Educators for Bronx Defeat Diabetes Project. We have 4 peer educators. Participation in all group activities. Waiting room contacts with ADA risk assessments completed. Development of peer patient panels to encourage compliance and supply support. Ongoing training in 1 -1 diabetes management education. Outreach activities within the health center and into the community. In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Montefiore Family Health Center 360 East 193 rd Street Bronx, New York 10458 In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Montefiore Medical Group Family Health Center About Us n n n 45, 000 visits / year Family Medicine Residency Program 18 Providers 16 Residents # Diabetic patients: 755 Demographics n n n Primary Insurance n Medicaid 39% n Self Pay 29% n Medicare BC/BS Empire 13% n Bronx Health Plan n GHI Black/African-American 30% Hispanic/Latino 41% White (not H/L) 13% Unknown/unreported 8% Asian/Pacific Islander 7% Native Am/Alaskan Native. 02% Languages n English n Spanish n Cambodian n Vietnamese n Other 56. 70% 36. 20% 5. 30% 1. 30% 0. 40% In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Self Management Highlight Diabetic referrals via Walkie Talkie n n GOAL: Coordinate efforts with 2 nd and 3 rd floor PCTs, Health Educators and Nutritionist to increase percentage of self-management goals set at FHC. ACTION: Individual health educator or nutritionist counseling sessions with diabetic patients pre/post provider visit. PROCEDURE: Use walkie-talkie between central locations: PCTs call health educator or nutritionist through walkie talkie once a diabetic is prepped. While waiting for the provider patient is then seen by the health educator or nutritionist in the exam room. RESULT: SUCCESS 8% increase in the percentage of self-management goals set from July until August at FHC. In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Resident Collaborative Involvement Thinking outside the box to improve community oriented primary care of chronic disease n Identifying community resources n • Care doesn’t just happen inside the clinic • Better understanding of pt’s social context • Contributing to the community and the bouquet of services that already exist n Looking to the future In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Nutrition In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Ways I Work With Patients One to One sessions n Group sessions n Setting self-management goals n Community Outreach n In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Teaching Methods Food models n Visuals n Power points n Food demonstrations n In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Challenges Scheduling follow-ups n Show up rates n Reminder calls n Follow up on self-management goals n In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.

Successes Cooking classes n Changes on patients Hg. A 1 C n Outreach lectures n In response to the Montefiore Quality Council, this information is provided under Section 2805 -m of the New York Public Health Law.