CLINICIAN CALENDAR

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Tennessee Health Collaborative Program

Problem Statement

 

Heart disease and stroke are major health risks for Tennesseans. According to the report, “The Burden of Heart Disease and Stroke in Tennessee ” (2006), heart disease and stroke are the first and third leading causes of death in both the United States and Tennessee . Among Tennessee adults in 1996-2002, 27-30% report ever having physician–diagnosed Hypertension, with higher prevalence for black females in most years. Among Tennessee adults, 3.6% reported ever having a physician-diagnosed stroke, including 9% of black males in 2002. Six percent of Tennessee adults reported ever having a physician-diagnosed heart attack, with a higher prevalence for white males, and over 14,000 Tennesseans were hospitalized for myocardial infarction in 2002.

 

Cardiovascular disease alters the quality of life for many Tennesseans and places a huge burden on our health system. Nearly 20, 000 Tennesseans were hospitalized for stroke in 2002 while inpatient costs associated with diseases of the heart (primary diagnosis) among the general population increased from 1.4 billion in 1997 to 2.1 billion in 2002. This 50% increase translated to nearly 70,000 (40,000 elderly) Tennesseans admitted to hospitals for diseases of the heart in 2002. Cardiovascular diseases accounted for approximately 12% of all inpatient visits in Tennessee with over 14,000 Tennesseans hospitalized for myocardial infarction in 2002. The average length of stay for hospitalizations related to diseases of the heart is 5.1 days.

 

Altering modifiable risk factors can help prevent many people from developing diseases of the heart and stroke. Alarmingly, 9 out of 10 adult Tennesseans reported at least one risk factor in 2002, and nearly two-thirds reported two or more risk factors.

 

Health centers in Tennessee reported that 32,561 patients with Hypertension (ICD-9 codes: 401.xx-405.xx) received 71,403 visits in 2005 (Uniform Data Sets 2005). In addition, 9,179 patients were reported as having heart disease (ICD-9 codes 391.xx-392.xx and 410.xx-405.xx) and utilizing 4940 visits in the health center. Cardiovascular disease control and management remains a challenge in Tennessee health centers.

 

Mission

 

The Health Disparities Collaborative is an integrated and collaborative state-wide effort to eliminate disparities and improve delivery systems of healthcare to all individuals living in Tennessee under the care of Health Resources and Services Administration (HRSA) - supported Health Centers.

Strategic Goals of the Health Disparities Collaborative (HDC) program include:

1. Introduce and assist in the implementation of the Care Model and the Model for Improvement in Tennessee Health Centers that have appropriately filed an application to join the state HDC initiative.
2. Improve the systematic tracking and reporting of the improvements made by the Tennessee teams through improved quality management and reporting systems.
3. Develop improved community organizational resources and alignment of community activities of relevance to the Health Centers at the local, state, and national levels in order to improve the care delivered to all active patients of the Health Centers.
4. Help Health Centers prepare better for the evolving Health Information Technology market and the increasing data driven environment of pay-for-performance and other related activities for both individual patient care and population-based care.

 

The Tennessee Primary Care Association (TPCA) currently provides support to 17 Health Centers that are working to implement these models in their own organizations.

The equivalency will expand training opportunity to all currently untrained FQHC teams in Tennessee .

 

TPCA support includes:

• Technical support and staff trainings.
• Monthly feedback on HDC reports.
• Information Technology support as it relates to reporting expectations.

 

Aim

 

Improve standard of clinical care provided by Tennessee community health centers to ensure that all patients have quality, evidence-based care. The mission of the Tennessee Primary Care Association in undertaking the sponsorship of a state-based collaborative is to provide the TPCA membership an opportunity to align itself with the BPHC HDC initiative in a local environment. This program will lay the foundation for future quality improvement activities.

Learning goals:

•  Participants will:

•  Gain an understanding of the Improvement Model;

•  Be able to conduct a PDSA (Plan, Do, Study, Act) test of change;

•  Be able to identify the six components of the Care Model (Self Management, Decision Support, Clinical Information Systems, Delivery System Design, Organization of Health Care and Community) and align PDSA cycles with the appropriate components of the Care Model;

•  Be able to identify the required Key Measures of the Cardiovascular Collaborative and choose a minimum of one additional recommended measure:

•  Hypertensive patients with appropriate BP control (required)

•  CVD patients with 2 BPs in the last year (required)

•  Documentation of self management goals (required)

•  Patients with appropriate fasting lipid profile documented (required)

•  Patients with LDL cholesterol level treated to goal (required)

•  Aspirin or other antithrombotic agent use (required)

• Be able to understand how to integrate Diabetes care into Cardiovascular care;
• Be able to understand how Depression impacts the treatment and care of patients with chronic illness;
• Be able to access the HDC website as needed for additional information;
• Be able to identify minimum data elements required for entry in a patient registry system in order to track Key Measures.

 

Scope

 

The health collaborative faculty will work with participating teams to improve their cardiovascular disease management, with a focus on eliminating disparities in cardiovascular disease outcomes. This initiative will emphasize the implementation of current evidence-based cardiovascular disease care guidelines, especially in the areas of risk assessment/screening and self-management. Participants will include HRSA supported health center staff that have not previously received health collaborative training. Participating practices will have the opportunity to evaluate their provision of cardiovascular care as compared to recommendations within the areas addressed by current national guidelines. Improvements in patient safety and patient outcomes will be achieved through planned care, communication, documentation of care, and the partnership between health staff and patient.

 

Goals

 

The Health Disparities Collaborative includes measurable goals of progress toward the project Aims. The goals are to reduce cardiovascular risk and improve outcomes in the cardiovascular population.

 

These outcomes will be achieved by improving processes of care for assessment, intervention and follow-up for those patients with cardiovascular disease by increasing adherence to guidelines for cardiovascular screening, medication management, patient education, and self-management.

 

Specific goals for cardiovascular patients seeking care from participating providers include:

 

REQUIRED MEASURES
Measure	Definition		Data Gathering Plan	Goal
1. Hypertensive Patients with appropriate BP control	The number of CVD patients with a 1. diagnosis of hypertension (but not DM) whose last BP (taken with the last 12 months) was less than 140/90 OR 2. diagnosis of hypertension AND DM whose last BP was less than 130/80 DIVIDED by the total of CVD patients with hypertension in the clinical information system. Multiply by 100 to get a percentage.		On the last workday of each month, search the clinical information system for all CVD patients with a 1. diagnosis of hypertension (but not DM) whose last BP (taken with the last 12 months) was less than 140/90 OR 2. diagnosis of hypertension AND DM whose last BP was less than 130/80 Also, count the number of CVD patients with hypertension in the clinical information system.	>50%
2. Hypertensive Patients with 2 BP’s in Last Year	The number of hypertensive patients in the clinical information system who have had two BP’s in the last 12 months, divided by the total number of hypertensive patients in the clinical information system. Multiply by 100 to get a percentage		On the last workday of each month, search the clinical information system for all patients with CVD who have had two BP’s within the last 12 months. At the same time, count the number of CVD patients.	>90%
3. Documentation of Self-management Goal Setting	The number of CVD patients in the clinical information system with documented self-management goals in the last 12 months divided by the total number of CVD patients in the clinical information system. Multiply by 100 to get a percentage.		On the last workday of each month, search the clinical information system for all patients with a diagnosis of CVD who have documented self-management goals set with a clinician in the past 12 months. At the same count the number of CVD patients.	>70%
4. Patients with appropriate fasting lipid profile documented	The number of CVD patients in the clinical information system with a documented fasting lipid profile within the condition appropriate time frame (1 year for patients with CAD or CAD risk equivalent by ATP III guidelines; 1 year for patients with dyslipidemia and 5 years for patients with hypertension only who are not in high risk category) divided by the total number of CVD patients in the clinical information system. Multiply by 100 to get a percentage.		On the last workday of each month, search the clinical information system for all CVD patients with a documented fasting lipid profile within the condition appropriate time frame (1 year for patients with CAD or CAD risk equivalent by ATP III guidelines; 1 year for patients with dyslipidemia and 5 years for patients with hypertension only who are not in high risk category). At the same time count the total number of patients with a diagnosis of CVD.	>80%
5. Patients with LDL Cholesterol level treated to goal	The number of CVD patients with fasting LDL documented in the appropriate time range and whose last fasting LDL is in appropriate range: 1. LDL < 100 if CAD or CAD risk equivalent – high risk 2. LDL < 130 if 2 or more risk factors without CAD or CAD risk equivalent – moderate risk 3. LDL < 160 if 0-1 risk factor without CAD or CAD risk equivalent – low risk Divided by the number of CVD patients in the clinical information system with fasting LDL documented in the appropriate time range (measure 3). Multiply by 100 to get a percentage		On the last workday of each month, search the clinical information system for all CVD patients with fasting LDL documented in the appropriate time range whose last fasting LDL is in appropriate range. At the same time count the number of CVD patients with fasting LDL documented in the appropriate time range (measure 3).	>60%
6. Aspirin or Other Antithrombotic Agent Use	The number of CVD patients with CAD (no age limit) in the clinical information system who have a current prescription for aspirin or other antithrombotic agent divided by the number of CVD patients with CAD in the clinical information system. Multiply by 100 to get a percentage.		On the last workday of each month, search the clinical information system for all patients with CAD who have a current prescription for aspirin or other antithrombotic agent. At the same time count the number of patients with a diagnosis of CAD.	>90%
ADDITIONAL RECOMMENDED MEASURES: Team must choose at least one of these onal measures in addition to the Required Measures.
Measure		Definition	Data Gathering Plan	Goal
7. ACE Inhibitor /ARB Use		The number of CVD patients, age > 55, with CAD or DM in the clinical information system who have been prescribed ACE inhibitors or ARBS, divided by the total number of CVD patients, age > 55, with CAD or DM in the clinical information system. Multiply by 100 to get a percentage.	On the last workday of each month, search the clinical information system for all CVD patients, age > 55, with CAD or DM in the clinical information system who have been prescribed ACE inhibitors or ARBs.. At the same time count the total number of CVD patients, age > 55, with CAD or DM.	>70%
8. Beta Blocker Use		The number of patients with CAD in the clinical information system who have a prescription for a beta blocker, divided by the number of patients with CAD. Multiply by 100 to get a percentage.	On the last workday of each month, search the clinical information system for all patients with CAD in the clinical information system that have a prescription for a beta blocker. At the same time, count the number of patients with a diagnosis of CAD.	>70%
9. Depression Screening (12 months)		The number of CVD patients in the clinical information system who have been screened for depression in the past 12 months, divided by the total number of CVD patients in the clinical information system. Multiply by 100 to get a percentage.	On the last workday of each month, search the clinical information system for all CVD patients in the clinical information system that have been screened for depression in the past 12 months. At the same time count the total number of CVD patients.	>50%
10. Patients with 2 HbA1c’s in Last Year (at Least 3 Months Apart)		The number of patients with CVD and DM in the clinical information system who have had two HbA1c’s (at least 91 days apart) in the last 12 months, divided by the total number of patients with CVD and DM in the clinical information system. Multiply by 100 to get a percentage	On the last workday of each month, search the clinical information system for all patients with a diagnosis of CVD and DM who have had two HbA1c’s within the last 12 months (at least 91 days apart). At the same time, count the number of patients with both CVD and DM.	>90%
11. Weight Reduction		The number of CVD patients with a BMI >25 at any time in the last 12 months who have lost 10 pounds (by comparing their maximum recorded weight in the 12 months period to their latest recorded weight), divided by the total number of CVD patients who have or had a BMI > 25 at any time in the last 12 months. Multiply by 100 to get a percentage.	On the last workday of each month, search the clinical information system for all CVD patients with a BMI >25 at any time in the last 12 months who have lost 10 pounds (by comparing their maximum recorded weight in the 12 months period to their latest recorded weight). At the same time count the total number of CVD patients who have or had a BMI > 25 at any time in the last 12 months.	>30%
12. Exercise		The number of CVD patients whose last documented exercise rate (within the last 12 months) was 3Xweek @ least 20 minutes, divided by the total number of CVD patients. Multiply by 100 to get a percentage.	On the last workday of each month, search the clinical information system for all CVD patients whose last documented exercise rate (within the last 12 months) was 3Xweek @ least 20 minutes. At the same time count the total number of CVD patients.	>60%
13. Patients who are current smokers		The number of patients in the registry who are current smokers (documented within the last 12 months), divided by the total number of CVD patients in the registry with smoking status documented within the last 12 months. Multiply by 100 to get percentage.	On the last workday of each month, search the registry for all patients with CVD who are current smokers (documented within the last 12 months). At the same time count the total number of patients with CVD in the registry with smoking status documented within the last 12 months.	<12%

 

 

 

 

 

 

Methods

 

TPCA will utilize the Learning Model, adopted by the Institute for Healthcare Improvement (IHI) Breakthrough Series to conduct pre-work, learning sessions, and action periods designed to effect organizational change. (See figure 1)

 

(3-6 Month Cycles)

Figure 1

 

The TPCA will sponsor the initial learning sessions in 2008 for those FQHC teams that meet participation criteria and are ready to engage in this collaborative process. Expert faculty guidance, sharing among participants and application of the learning in individual settings will provide a rich supportive environment for participants.  Following the initial learning phase, participants will continue to sustain and spread the improvement methods with an aim of total system transformation as part of the national HDC community.

 

Participating teams will consist of 3-4 team members from each health center. The project faculty and TPCA staff will assist these participating clinical teams in improving care through the provision of training, tools and support. Health centers will be asked to set specific goals for the improvement of care. Health centers will receive continuous feedback and coaching designed to help teams spread the improvements throughout their health center.

 

Each health center is expected to identify a specific population of patients with cardiovascular disease that can be monitored in the health collaborative program. This is called a population of focus and is defined by a specific group of clinics, practitioners or locations. A patient database must be used to track patient results and interventions. Participating health centers must plan to change practices and systems in order to improve clinical management and office efficiency.

As the Health Centers embed their work into their organizational frameworks and continue improvements, they are supported by continued coaching and feedback.

The Care Model

 

Knowing what you should do and actually being able to consistently do it has proven to be a challenge in today’s busy practices. So part of every collaborative is a “change package” (as shown on next page), which is designed by the experts to help teams eliminate the gap. These ideas guide participants to focus on key areas that have been demonstrated to create positive change.

Tennessee will use the structure of the Care Model (see Figure 2), adapted from HRSA Health Disparities Collaboratives. This model identifies 6 major categories that must be addressed to achieve substantial change:

1. The health care organization
2. Community resources and policies
3. Self-management support
4. Decision support
5. Delivery system design
6. Clinical information systems

 

Figure 2

 

Acknowledgements:
Improving Chronic Illness Care, a national program of the Robert Wood Johnson Foundation, MacColl Institute, Seattle , WA

More about Care Model Change Concepts can be found at http://www.improvingchroniccare.org/change/model/components.html

 

 

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TPCA Medical/Clinical Directors of Organizational Member Clinics