The presenters have nothing to disclose.
M7: Improving Clinical Flow ECHO Kristin Batts June Gillespie Elizabeth Clewett Roger Chaufournier Kathy Reims
4.20.17
Overview of the Session • Journey of an organization to improve efficiencies of care • Change package and measures to improve clinical flow • Project ECHO clinic simulation • Alien abduction exercise
Table Introductions • Name • Organization • One thing you hope to learn • Report out themes of desired learning
The presenters have nothing to disclose.
Improving Clinical Flow ECHO: Cherry Health Kristin Batts, LMSW, HOTC Adult Site Manager June Gillespie, RN BSN, Echo Project Manager
4.20.17
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“Before”- Why Project ECHO? • Agency committed to Triple Aim Improved Population Health Improved Patient Experience Reduced Health Systems Cost
• Chris Shea, CEO, saw Project ECHO as opportunity to answer question: How can we make systems more efficient so we can see more patients in cost effective way?
• Video Vignette
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3 Cherry Health Sites chosen • Westside- largest Family Practice site • 4.5 Provider FTE Family Practice (excluding PEDS), • ~5800 Patient panel
• Cherry Street- 2nd largest Family practice site • 4.3 Provider FTE Family Practice (including PEDS) • ~5700 Patient panel
• HOTC Adult- Internal Medicine, Strong interest in Quality Improvement. • 3.6 Provider FTE • ~2900 Patient panel
Improving Clinical Flow Driver diagram Change Package Roger Chaufournier Kathy Reims
Improving Flow: an IHI Quality Improvement and Project ECHO Collaborative Primary Drivers
Engaged Leadership
Change Concepts Devel op culture for transformation
Lead collective understanding of business case
Assure s ustainable change
Quality Improvement Strategy
Aim: Create clinic work environment that supports:
Objectives: 1.meeting patient care needs 2.joy in work* 3. optimization of resources
Use a formal model
Establish/monitor metrics Assign patients to provider panel
Empanelment
Assess suppl y and demand
Optimize the Care Team
By: 7/31/2016
Use panel s and registries proactively
Provide organizational support
Manage patient expectations of care
Function at top of skills
Ensure patients s ee their as signed prov ider
Enable independent work
Create standard work
Manage pan el Organized RelationshipBased Care
Identi fy and remove waste Improve work flow
Listen to customers Patients as Partners
Outcome M easures
Process Measures
1. % state, ”I get what I want and need when I want and need it.”
1. % state, “Does not waste my time.”
2. % seen by PC P
2. % empaneled
3. % No Shows * as ses sment in pre-work/end
3. average cycle ti me minutes
Provide care in context of “what matters” to pt
Balance Measures
Leadership M easures
1. % colorectal cancer screening
1. % visits per Provider FTE
2.% DM in contro l (A1c >9)
2. cost per patient visit
3. % pers istent asthma o n controller 4. # of days to 3rd next available
3. net margin
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Engaged Leadership
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Quality Improvement Strategy
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Empanelment
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Optimize the Care Team
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Organized, Relationship-based Care
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Building Blocks Exercise • Instructions • End Goal: Construct a visual structure for health center change. • Each block must be labeled with a word from the Driver Diagram handout • Use the dry erase marker to label blocks • Be prepared to explain the rationale for your design
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An Overview of Project ECHO® (Extension for Community Health Outcomes)
Presented at the 18th Annual Summit on Improving Patient Care in the Office Practice and the Community: IHI Summit Elizabeth Clewett, PhD, MBA
Path for this Conversation
• What is the ECHO model • How was it used for this project? • How to connect to an ECHO project near you
At ECHO, our mission is to democratize medical knowledge and get best practice care to underserved people all over the world. Our goal is to touch the lives of 1 billion people by 2025. Supported by New Mexico Department of Health, Agency for Health Research and Quality, New Mexico Legislature, the Robert Wood Johnson Foundation, the GE Foundation and Helmsley Charitable Trust
Problem (2003): 8 month wait in clinic to be treated for Hepatitis C Estimated 28,000 in NM with Hep C
In 2004 less than 5% had been treated No primary care physicians in the state would treat due to complex treatment with serious potential side effects Few specialists available to see Hep C patients Photo: Dr. Sanjeev Arora, Director and Founder of Project ECHO and the GI clinic at the University of New Mexico
Goal: A system that would • Develop capacity to safely and effectively treat HCV in all areas of New Mexico and to monitor outcomes.
• Develop a model to treat complex diseases in rural locations and developing countries cost-effective way
Copyright 2015 Project ECHO®
Solution: ECHO Model – four pillars Use Technology to leverage scarce resources
Sharing “best practices” to reduce disparities Case based learning to master complexity Web-based database to monitor outcomes Copyright 2015 Project ECHO
ECHO Applies Adult Learning Theory Adults will learn only what they need to learn Their learning is primarily problem-based rather than subject-based They have a rich reservoir of experience to apply to their learning They learn best in informal settings
They want guidance rather than instruction
Disease Selection Common diseases Management is complex Evolving treatments and medicines High societal impact (health and economic) Serious outcomes of untreated disease
Improved outcomes with disease management Copyright 2015 Project ECHO®
Successful Expansion into Multiple Diseases Mon
Tue
Wed
Thurs
Fri
Hepatitis C
Namibia HIV
IHS Navajo HIV
Hepatitis C in Prisons
Nurse Practitioners
• Arora • Thornton Rheumatology
• Struminger
• Iandiorio
Endocrinology & Diabetes
• Bankhurst
Partners in Good Health and Wellness
• Thornton Chronic Pain and Headache • Shelley
HIV
• Struminger Bone Health
• Bouchonville
• Van Roper Integrated Addictions and Psychiatry
• Iandiorio
• Liewicki
Improving Clinical Flow • IHI
Complex Care
Prison Peer Educator Training
Crisis Intervention for Community Policing Agencies • Duhigg Epilepsy
• Komaromy Tuberculosis
• Komaromy
• Thornton
• Immerman Copyright 2016 Project ECHO®
Cardiology
• Struminger
ECHO Replication Sites Worldwide:
Part 2: IHI-PROJECT ECHO COLLABORATIVE Goal: To test whether the ECHO model can be used to support training for quality improvement and complex systems redesign.
Clinical Flow in Primary Care Clinics Focus
Effective and efficient Use of Provider Time Optimizing Care Teams Patient and Staff Satisfaction Empanelment and Managing Case Loads
Removing waste Using Data to Drive Changes Spreading and Integrating Changes Over Time
Developing a Business Case for Changes
Overview of Project Pre-work-organize improvement team + baseline assessment Face to Face Learning Session 2 Virtual Learning Session Monthly Data reporting Monthly Leadership Calls Weekly 2 hour teleECHO Clinics (10/22/15)
Video-conferencing Platform Case based learning
Participants: 15 community clinics 1 year, 10 continued for additional 6 months
Represent 7 CHCs 15 FQHCs, Serving 134,061 Patients
systems with a total of 68 FQHCs
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Learning Session 1: Face to Face
Provider Cup full
Exercise: distribution of tasks in the clinic
RN, MA, front desk cups often low
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Anatomy of our weekly TeleECHO Clinic Sessions Introductions Case Presentation #1 by clinic team (30-40 minutes) Clarifying questions (clinics, faculty) Recommendations (round robin of teams) Presenting team tells group what suggestions they are most likely to implement Didactic (20-30 minutes) Interactive
Case Presentation #2 (30-40 minutes) Clarifying questions (clinics, faculty) Recommendations (round robin of teams if time) Summary of discussion 5 minutes to fill out weekly survey Post Clinic: recommendations sent to each presenting team
Data Transparency: key indicators shown regularly during case presentations and displayed in clinics
Measures—tracked at least monthly
Outcome
Process
Balance
1. Continuity
1.Empanelment
1.Colorectal screening
2. No shows
2. Cycle time
2.% DM in control (A1c >9)
3.Patient experience
3. % patients who say does not waste my time
3. % persistent asthma on controller 4. # of days to 3rd next available
Red indicates areas of overall improvement for participating sites
Increase in Colorectal Screening: Possible Reasons Why (Average from 31% to 41% over 18 months)
Greater awareness of data—shown each week in case templates. 1. Focus over 18 months on empanelment, care team coordination creating better relationship with patients
3. QI skills of PDSA testing, process mapping, and using data to refine systems of patient outreach and follow up 4. Copycat Effect: As saw teams focused on colorectal screening, focused didactics to use colo-rectal screening as an example for variety of topics, including engaging patients, developing a business case etc..
Some lessons learned Weekly rhythm of teleECHO sessions helped drive quality improvement work into the daily and weekly workflow. Making data visible: Embedding data (run charts) in weekly case templates helped create a culture of data transparency QI skills (PDSA rapid cycle testing, process mapping etc..) seem to have become more embedded in work of staff. Peer Learning: Importance of learning from other teams, hearing their struggles and what had tried
Overall 1. We believe ECHO is useful for QI learning and creating communities of QI learners (still in testing phase) Next wave of testers: HealthInsight, QIOs, and NY State Dept of Health
2. We hypothesize that the ECHO model will provide a dramatically more efficient, cost-effective, and engaging way to teach QI methods to teams spread across large distances, compared to traditional collaborative and webinar models of learning 3. Joy of work: Well run ECHO projects create communities of practice where participants want to come because they feel connected, engaged, and part of the community (not unusual to hear ‘this is the best hour of my week) 4. Promote a culture of continual learning: ECHO projects create learning loops where participants who like on-going learning thrive.
How to Join an ECHO project near you Go to http://echo.unm.edu/ Join an ECHO
Moving Knowledge Instead of Patients
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ECHO Clinic
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HOTC Adult Presentation • Order Follow-up • Update since presentation: • Process map done for Referral tracking • Identified Gap in obtaining Scheduled date of referral/ diagnostic test (Still working on filling that gap) • Have begun reporting % Completed for Diagnostic Tests and Referrals by Site and PCP monthly • Working with Specialists- new relationships and opportunities for uninsured patients
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‘After’ Project ECHO • Video Vignette • Continuing to use principles learned to test new Operational processes and new ideas • Have a “ECHO Planning” Team that approves ‘new’ change ideas for testing. (Changes that may benefit multiple sites/programs, tie to Operational Plan, have baseline data and reasonable expectation of success
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Dashboard HOTC Adult (Kristin) ECHO Dashboard for Cherry_Heart as of January 21, 2017 100
Percent
60 40 20 0
5 0
40
20 0
1000
100
600 400
# of Visits
120
800
80 60 40 20
200 0
0
Percent
8. DM Not In Control (>9) 1400 1200 1000 800 600 400 200 0
# of Patients
Percent
7. Colorectal Cancer Screening 90 80 70 60 50 40 30 20 10 0
25
600
20
500 300
10
200
5
100
0
0
Days
10. Third Next Available Appointment 140 120 100 80 60 40 20 0
# of Patients
Percent
400
15
9. Persistent Asthma on Controller 102 100 98 96 94 92 90 88 86 84
16000 14000 12000 10000 8000 6000 4000 2000 0
6. Percentage Empaneled 1200
Percent
Minutes
5. Cycle Time 70 60 50 40 30 20 10 0
# of Surveys
10
60
70 60 50 40 30 20 10 0
90 80 70 60 50 40 30 20 10 0
# of Patients
15
80
Percent
20
100
# of Appointments
25
Percent
4. Does Not Waste My Time 1400 1200 1000 800 600 400 200 0
# of Patients
3. No Show Percentage 30
1400 1200 1000 800 600 400 200 0
80
# of Visits
2. Continuity to PCP or Care Team 70 60 50 40 30 20 10 0
# of Surveys
Percent
1. Patient/Family Experience 90 80 70 60 50 40 30 20 10 0
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Alien Abduction Table Exercise
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