Quality Improvement Lessons for Workers Compensation Quality of

Quality Improvement: Lessons for Workers’ Compensation Quality of Care Linda Rudolph, MD, MPH Medi-Cal Managed Care Division CA Department of Health Services May 1, 2003

What Do We Want? Quality • “The degree to which health services for individuals and populations increase the likelihood of desired patient outcomes given the current state of knowledge” IOM, 1990 • The extent to which health services meet their aim – improving health.

What Do We Want? (DWC Focus Groups) • • • accessible competent state of the art caring trusting • • • patient-oriented patient-selected reasonably priced coordinated continuous DWC, Improving the QOC for Injured Workers, 2001

What Do We Want? (Institute of Medicine) • Safe • Effective • Efficient • Timely • Patient Centered • Equitable IOM, Crossing the Quality Chasm, 2001

What Do We Have?

What Do We Have? • • Distrust Poor access to specialists Delays in care Fragmentation and lack of continuity Care not patient-centered Inefficient and ineffective care No accountability Improving the Quality of Care for Injured Workers: Focus Group Discussions. DWC. 2001

“Every system is perfectly designed to produce the results that it does achieve. ” (Berwick/Batalden)

What can we do? • Accountability • Improvement

Accountability • • Policies and contracts Monitoring Measurement Reporting

You can’t fatten a calf by weighing it…. Palestinian proverb

Improvement A systematic program for taking a system from one level of performance to a higher level of performance

Low Back Pain • ¼ w. c. claims • 1/3 w. c. costs

What Do We Have? • Care highly variable • Care inconsistent with guidelines • Patient outcomes poor

Theory of Change • Will • Ideas • Execution/supporting change

Low Back Pain = Chronic Illness

Care Model for Worker Health (adapted from IHI/Dr. Ed Wagoner)

Resources and Policies • Resources to support injured workers and providers are easily accessible • Insurers, State agencies, employers, and health care providers: – coordinate and partner with each other around worker and injured worker needs – promote and offer evidence-based effective interventions and programs • System incentives are aligned for policy (adapted from Institute for Healthcare Improvement’s Breakthrough Series Collaborative: Improving Care for People with Chronic Conditions. E Wagoner, and NICHQ)

Health and W. C. System • Specific goals for prevention and care management are part of the strategic and business plan. • Senior leadership is committed to meeting the needs of injured workers. Encourage coordination among primary care and occupational medicine care • System has adopted an effective performance improvement model. • Incentives support these organizational goals. (adapted from Institute for Healthcare Improvement’s Breakthrough Series Collaborative: Improving Care for People with Chronic Conditions. E Wagoner, and NICHQ)

Self-Management Support • Emphasize worker’s active and central role in managing illness • Resources available to increase patient knowledge, confidence, and skills • Workers assisted in setting shared goals • Workers have access to peer support • Workers assisted in improving communication with providers about health care. (adapted from Institute for Healthcare Improvement’s Breakthrough Series Collaborative: Improving Care for People with Chronic Conditions. E Wagoner, and NICHQ)

Decision Support • Evidence-based guidelines and protocols integrated into practice systems • Integrated expertise (occ med, specialists, mental health, w. c. , workplace) • Care team works to maximize cooperation, continuity, and patient outcomes • Use of modalities proven to change practice behavior (adapted from Institute for Healthcare Improvement’s Breakthrough Series Collaborative: Improving Care for People with Chronic Conditions. E Wagoner, and NICHQ)

Delivery System Design • Practice anticipates problems, provides services to maintain QOL and function • Roles/responsibilities of team members defined, appropriate training provided • Systems designed for regular communication and f/u (adapted from Institute for Healthcare Improvement’s Breakthrough Series Collaborative: Improving Care for People with Chronic Conditions. E Wagoner, and NICHQ)

Clinical Information System • Registry of patients in need of services maintained • Reminder system used for patients and care team • Information system provides regular feedback to care team • System allows for care planning (adapted from Institute for Healthcare Improvement’s Breakthrough Series Collaborative: Improving Care for People with Chronic Conditions. E Wagoner, and NICHQ)

Model for Improvement

Aims • • Reduce plain x-rays Reduce opiate prescriptions Increase patient self-management education Increase availability of modified work

From Aim to Improvement • • Define measures (process, outcome) Barrier analysis Identify available interventions Identify target population Outreach Implement interventions: Did it work? Start again!

Quality Improvement Collaboratives • • • Medi-Care Medi-Cal Pursuing Perfection/Rewarding Results CPCA (HRSA) DHS CCHRI