Care by design magill retrospective mixed methods analysis sep 21 2011
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a look back of a decade of build PCMH level care at the university of Utah.
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Care by design magill retrospective mixed methods analysis sep 21 2011
- 1. Retrospective Mixed Methods Analysis of Practice Transformation Michael K Magill, MD Professor and Chairman Department of Family and Preventive Medicine University of Utah School of Medicine and Community Clinics AHRQ Grants # HS019136-01 (TPC) HS20106-01 (ARRA-SSCM)
- 2. Interdisciplinary Team Julie Day, MD University of Utah Community Clinics JaeWhan Kim, PhD School of Medicine, Dept of Family & Preventive Medicine Annie Sheets Mervis, MSW University of Utah Community Clinics Debra L. Scammon, PhD David Eccles School of Business, Dept of Marketing Andrada Tomoaia-Cotisel, MPH, MHA School of Medicine, Dept of Family & Preventive Medicine Norman J Waitzman, PhD College of Social and Behavioral Science, Dept of Economics
- 3. Visits: 300,000+ Active patients: 157,000 11 Community Clinics
- 4. University of Utah Community Clinics Clinic Year Opened Total Providers Primary Care Providers Visits Per Year (FY09) Madsen 1975 6 5 18,970 Greenwood 1976 17 10 54,475 Redwood 1985 20 10 93,110 Westridge 1988 7 6 29,208 Parkway 1989 6 5 19,488 Sugar House 1996 10 9 20,344 Stansbury 1999 7 6 24,145 Redstone 2001 7 5 26,309 South Jordan 2003 3 2 11,359 Centerville 2007 4 4 8,044
- 5. Care by DesignTM • Appropriate Access – 2003 • Balance supply and demand of visits • Standardized schedules • Care Team – 2004 • Expanded MA role • Providers and MAs working in teams • EMR tools • Planned Care – 2006 • Pre-visit planning • Registries • Labs prior to visit
- 6. Retrospective Analysis: Qualitative Aims AHRQ Grant # 1R18 HS019136-01 Transforming Primary Care Aim Method Document and measure the transformation • Archival Search Determine impact on the experiences and satisfaction of providers, staff and patients • Provider and Staff Surveys • Provider and Staff Interviews • Patient Satisfaction Survey • Patient Focus Groups Explore organizational & contextual factors • Clinic Environmental Audit • In-Clinic Observations Assess in depth how the transformation was implemented • Archival Search • Leadership Interviews • Provider and Staff Interviews
- 7. Care by DesignTM • Appropriate Access – 2003 • Balance supply and demand of visits • Standardized schedules • Care Team – 2004 • Expanded MA role • Providers and MAs working in teams • EMR tools • Planned Care – 2006 • Pre-visit planning • Registries • Labs prior to visit
- 8. Qualitative Data: Care Teams 8 Component Type of Information Gathered Archival search • when/how the care team was rolled out Clinic Environmental Audit • size of clinic, team composition, patient volume, presence of specialists In-clinic observations • feeling in the clinic, background info Employee Interviews • personal experience with implementing care team + experimenting with local adaptations: how + why Leadership interviews • personal experience with leading the care team roll out + managing the evolution: what + why Provider & Staff Survey • trends in team development, employee burn out, organizational culture Patient Sat. Surveys • patients’ satisfaction with visits Patient Focus Groups • changes noticed and patient perspective
- 9. Care Team Structure & MA Role CBD Care Team Model Variations Traditional Model Team Members: • Providers • MAs
- 10. “Care Team” • 5 MAs: 2 Providers • Working together • Doing it all! MA specialists • (V1): 1 MA phlebotomist does all draws • Others are 5 MAs :2 Providers • (V2): 1 MA rooms patients + 1 MA scribes in the room : 1 Provider Clinic- wide team • All of the MAs are in one pool • Room patients in a rotation • Outside visit work done in between Hybrid Traditional Model • 1 MA : 1 Provider • Variation – 2 MAs : 1 Provider Team Members: • Providers • MAs Care Team Structure & MA Role • (V1): 5 MAs : 2 Providers for patient visits, but • 2 MAs: 1 Provider for outside visit work • (V2): 5 MAs : 2 Providers, but • 1 “primary” MA : 1 Provider
- 11. Example of Insights from Quantitative Research Clinic Culture An illustration of possible explanations for the observed differences in implementation of Care Teams
- 12. Organizational Culture Assessment Instrument: “Competing Values” Quinn, Rohrbaugh: http://www.ocai-online.com/
- 13. Greenwood
- 14. Parkway
- 15. Redstone
- 17. Organizational Culture In Community Clinics
- 18. Aim Method Document and measure the transformation and impact on the quality of patient care delivery • Clinical Data • CBD Implementation Determine impact of the transformation on cost to the clinics • Operational Data Determine impact of transformation on overall costs of healthcare services, including direct costs to patients • Centers for Medicare & Medicaid Services Data • Utah All Payer Claims Database Retrospective Analysis: Quantitative Aims AHRQ Grant # 1R18 HS019136-01 Transforming Primary Care
- 19. Quantitative Data Component Type of Information Gathered CBD Implementation • Use of EMR tools • Appointment availability • Continuity with PCP • Use of pre-visit planning tools and processes • Flow and processes of Care Team • Efficiency of visit/wait times Impact on Operations • Provider productivity • Financial performance • Patient population characterization Clinical Outcomes • Quality performance (chronic & preventive) • Patient, Provider, Staff satisfaction Cost of Care • Utilization and cost of care • CMS • Utah Population Data Base (UPDB) • Utah All Payer Claims Database (APCD) Gray = data analysis pending
- 20. 10% 20% 30% 40% 50% 60% 70% 80% 2003 2004 2006 2008 2009 Quality Measures Percent of Patients Receiving Recommended Care CAD* Preventive Care* Diabetes* Heart Failure* Note: Sample size=14 providers who had all measures in FY 2003, 2004, 2006, 2008, and 2009; *p≤0.05
- 21. 20% 30% 40% 50% 60% 70% 80% 90% 100% 2003 2004 2006 2008 2009 Patient Satisfaction Percent of Patients Reporting "Very Satisfied" Recommend provider* Explanation of what was done* Visit overall* Time spent with physician* Length of time waiting at office* Note: Sample size=16 providers who had all measures in FY 2003, 2004, 2006, 2008, and 2009; *p≤0.05
- 22. Overview of Quantitative Design: Link data from multiple sources to assess impact of transformation to CBD Cost & Utilization CBD Implementation Clinical Data Operations Data
- 23. Level of CBD Implementation: 2008 1.00 1.20 1.40 1.60 1.80 2.00 2.20 All elements
- 24. Examples of Correlation between CBD Implementation and Patient Satisfaction Patient Satisfaction CBD Implementation Measure 2008 Same Day Appointments Efficient Visit Length of time waiting at the office 0.61** 0.33* Time spent with the physician/health care professional you saw 0.20 -0.21 Explanation of what was done for you 0.14 -0.13 The visit overall 0.50** 0.20 Would you recommend the physician/health care professional to your friends and family? 0.34* -0.17 N=16 providers *p≤0.1, **p≤0.05
- 25. Correlation between CBD Implementation and Quality Measures CBD Implementation Measure 2008 Quality Measures Diabetes Coronary Artery Disease Preventive Care Seen by PCP last visit 0.60* 0.61* 0.57* Use of X-files by MA 0.33* 0.18 0.18 Best Practice Alerts 0.34* 0.26 0.29 After-Visit summary 0.23 0.18 0.11 Labs done prior to visit 0.54** 0.47* 0.36* N=14 providers with data across five years *p≤0.1, **p≤0.05
- 26. Impact of practice redesign • Quality improves • Continuity matters • Pre-visit planning and EMR reminders help • Patients notice • Access improves patient satisfaction • Level of implementation varies across clinics • Clinic culture impacts implementation • Culture is a critical factor in translational research
- 27. Future analysis: impact of redesign on… • Internal cost and productivity of clinics • Overall utilization • Total cost of care
- 28. Future: Internal Performance Analyses Cost & Utilization CBD Implementa- tion Clinical Data Operations Data • Provider productivity • Financial performance • Patient population characterization
- 29. Future: Cost and Utilization Cost & Utilization CMS, APCD CBD Implementa- tion Clinical Data Operations Data CMS Data • All Medicare Claims at individual level for Utah (2007+) • For the following: • Outpatient • Inpatient • Home Health • Nursing Home • Prescription Drug (Part D) •Linked to State Vital Statistics and facility data (Utah Population Database ) All Payer Claims Database (APCD) • Data elements: • Charges • Reimbursements • Utilization • For the following: • Outpatient, Inpatient, Rehabilitation • Prescription Rx • Linked to State Vital Statistics and facility data
- 30. Challenges in Assembling Cost, Utilization and Demographic Data • Gaining access • Navigating layers of documentation, requests, approvals (CMS) • Obtaining IRB and other database approvals • Building APCD platform as 1st user • Translating utility into usable research database • Creating files linkable at individual level • Linking data – hospital, ED, vital statistics
- 31. Challenges of Retrospective Mixed Methods Research • Timing of all the components • Recall isn’t perfect – current events color memory • Data used for operations differ from data required for research • IRB & HIPAA rules for linking PHI to operations and external data
- 32. Benefits of Mixed Method Research • Multiple components inform each other throughout data collection • Participant selection • Instrument development • Sequencing • Multiple components inform each other throughout data analysis • Convergent/consensual validation • Multiple components facilitate integration of different perspectives