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Virginia Mason’s Hospital Team Reduces Bedsores and Costs

Hospital-acquired pressure ulcers (HAPU), commonly known as bedsores, are increasingly common in hospitalized patients. To address this issue at Virginia Mason, the Zero Hospital-Acquired Pressure Ulcers team was established. The team reviewed guidance materials and brainstormed how to improve the HAPU program already in place at VM. They used the tools of the Virginia Mason Production System. They streamlined the display of the wound/skin assessment forms on the electronic medical record so a patient’s skin status is more apparent. VM recently celebrated 298 days since its last incidence of Stage 3-4 HAPU (the most serious form of bedsore), and their work met the Leapfrog Group’s high standards for reducing preventable medical errors in hospitals.


Virginia Mason’s Hospital Team Reduces Bedsores and Costs

Despite great technological and pharmacological leaps in health care in recent years, hospitals continue to struggle with the problem of hospital-acquired pressure ulcers (HAPU), commonly known as bedsores. These wounds are increasingly common in hospitalized patients, with approximately 600,000 acute care patients dying each year of HAPU complications at an estimated cost of $11 billion.

To address this issue at Virginia Mason, the Zero Hospital-Acquired Pressure Ulcers team was established. The need to reduce the incidence of pressure ulcers at Virginia Mason Hospital was clear. In 2007, the organization reported five Stage 3-4 HAPUs (the most serious type) to the Washington State Department of Health and treated many more Stage 1-2 HAPU with expensive therapies and extra days of hospitalization. The work began in the highest-risk setting for HAPU, the Critical Care Unit. The team implemented a systematic approach to identifying patients at risk of developing HAPU and established standard actions for at-risk patients. As these standards proved successful they were spread to other units. As a result, VM now stands in the top-performing group nationally for averting HAPU injuries.

How it was done.The team began by reviewing guidance materials from national groups and brainstormed how to improve the HAPU program already in place at VM. They used the tools of the Virginia Mason Production System. They streamlined the display of the wound/skin assessment forms on the electronic medical record (Cerner) so that a patient’s skin status is more apparent, which helps staff more easily identify at-risk patients who need more frequent position changes and meticulous skin care.

The team’s key strategy focused on enhancing the inspection process of patients. Inspection can lead to early, preventive action such as implementing a SKIN bundle (Surface, Keep turning, Incontinence, Nutrition) or asking for help from a wound/skin expert. In addition to developing all nurses’ HAPU-prevention competencies, the team also made advanced wound expertise more readily available on units. VM recently celebrated 298 days since its last Stage 3-4 HAPU.

Keywords: Bedsores, care teams, costs of HAPU, Cerner CPOE, Critical Care Unit, electronic medical record, EMR, hospital-acquired pressure ulcers, HAPU, Leapfrog Group, preventable medical error, skin inspection, Stage 3-4 HAPU, value, Virginia Mason Production System

For More Information:

Michelle Peterson
Director, Communications and Public Relations
Virginia Mason Medical Center
100 Ninth Ave, MS GB-ADM
Seattle, WA 98101
(206) 583-6581
michelle.peterson@vmmc.org
http://www.VirginiaMason.org/

Kaiser Permanente’s Healthy Bones Program Results in Reduction in Hip Fractures

According to recent information from the National OsteoporosisFoundationand the Office of the Surgeon General, osteoporosis is a major medical problem. The disease currently affects 8million women and 2 million men in the United States. Kaiser Southern California has a fully integrated Healthy Bones Program in place at all eleven of its medical centers. Using its electronic medical records system is capable of tracking dual X-ray absorptiometry scans, fragility fractures, and the medications used to treat or prevent osteoporosis, Kaiser’s multidisciplinary team prevented 970 hip fractures in calendar year 2007 (2544 hip fractures were predicted and the actual number was 1574), a reduction of 38.1%.

Excerpts from The Journal of Bone and Joint Surgery article:
http://www.ejbjs.org/cgi/content/full/91/Supplement_6/79

“According to recent information from the National OsteoporosisFoundationand the Office of the Surgeon General, osteoporosis is a major medical problem. The disease currently affects 8million women and 2 million men in the United States. An additional 34 million Americans have low bone mass. Each year, an estimated1.5 million individuals in the United States experience a fragility fracture secondary to osteoporosis, resulting in an annual cost of 18 billion dollars. With the rapidly aging U.S. population, the problem of osteoporosis is now reaching epidemic proportions. There are 75 million baby boomers entering the stage in their lives when they are most at risk for osteoporosis. One-half of all women and one-third of all men will sustain a fragility fracture during their lifetime.

Knowledge That What the Orthopaedic Surgeon Does Improves Bone Health

The literature has shown that orthopaedic surgeons have not done enough to aggressively diagnose and treat osteoporosis. It is important for orthopaedic surgeons to know that an aggressive osteoporosis disease-management program can decrease the rate of osteoporosis-related hip fractures by 25% to 50%. One such program is described below.

Background of the Kaiser Southern California Healthy Bones Program

Kaiser Southern California (Kaiser SCAL) is a health-maintenance organization in Southern California that is made up of eleven medical centers with 3.2 million members. Kaiser SCAL has an electronic medical records system that is capable of tracking dual X-ray absorptiometry scans, fragility fractures, and the medications used to treat or prevent osteoporosis. Kaiser SCAL has a fully integrated Healthy Bones Program in place at all eleven of its medical centers. The Healthy Bones Program was established by having orthopaedic surgeons serve as champions in a large multidisciplinary team comprised of healthcare providers from the following disciplines: endocrinology, family practice, internal medicine, rheumatology.

Results

Since the SCAL Healthy Bones Program was adopted, we have seen our annual dual X-ray absorptiometry scan utilization rate rise from 21,557 per year in 2002 to 78,262 per year in 2007, a 263% increase. The annual dual X-ray absorptiometry scan utilization rate in men was 1549 in 2002, and it increased to 15,700 per year by 2007, a 914% increase. The annual number of patients receiving anti-osteoporosis medications rose from 33,208 per year in 2002 to 84,155 per year in 2007, a 153% increase. The annual number of men who received anti-osteoporosismedications in 2002 was 2663, and that number increased to 9310 a year by 2007, a 250% increase. There was a large variation in the reduction in hip fracture rates at the eleven SCAL medical centers during the study period. The reduction in hip fracture rate varied from 31.0% to 54.3%. The overall hip fracture rate reduction was 38.1%. That translated into preventing 970 hip fractures in calendar year 2007 (2544 hip fractures were predicted and the actual number was 1574).

Keywords: Osteoporosis, Kaiser Permanente Southern California, Healthy Bones, electronic medical records, orthopaedic, bone loss, hip fractures, bone loss, multidisciplinary team

FOR MORE INFORMATION:

Jean Sud
Senior Manager, Public Policy & Communications
Kaiser Permanente, The Permanente Federation
1 Kaiser Plaza
Oakland, CA 94612
tel. 510.271.6317
Jean.L.Sud@kp.org
www.kaiserpermanente.org

Information Technology Supported Care Teams Significantly Improve Care for Patients with Heart Disease

Kaiser Permanente Colorado has significantly reduced the mortality rate for patients with heart disease, which is the nation’s number one killer for both women and men. Using team-based medical best practices and computer-supported care registries, doctors and clinical care teams reduced overall mortality by 76 percent and cardiac mortality by 73 percent. Coronary Artery Disease is the dangerous buildup of plaque inside the coronary arteries. Cardiac mortality refers to all deaths related to heart events.


Excerpt from Kaiser Permanente case study:
http://xnet.kp.org/future/ahrstudy/032709cardiac.html

“Kaiser Permanente Colorado has significantly reduced the mortality rate for patients with heart disease, which is the nation’s number one killer for both women and men. Using team-based medical best practices and computer-supported care registries, doctors and clinical care teams reduced overall mortality by 76 percent and cardiac mortality by 73 percent. Coronary Artery Disease is the dangerous buildup of plaque inside the coronary arteries. Cardiac mortality refers to all deaths related to heart events.

The ability of clinical care teams to coordinate their efforts in cardiac care is greatly enhanced by the availability of electronic health information—which provides instant access to patient information—and evidence-based clinical care guidelines and protocols.”

Keywords: CAD, care coordination, care teams, cardiac care program, chronic care, collaborative care, colorado, communication, coronary artery disease, electronic medical record, evidence-based medicine, health information technology, integrated care, Kaiser Permanente, KP Healthconnect, patient support, population health, preventive care, safety, treatment, value

FOR MORE INFORMATION:

Jean Sud
Senior Manager, Public Policy & Communications
Kaiser Permanente, The Permanente Federation
1 Kaiser Plaza
Oakland, CA 94612
tel. 510.271.6317
Jean.L.Sud@kp.org
www.kaiserpermanente.org

Depression Care Curbs Rate of Suicides at Henry Ford

A quality improvement initiative for the Health Alliance Plan members who receive care at Henry Ford Medical Group resulted in dramatically bringing down the rate of suicide in its 200,000 patient population. Over 9 consecutive quarters, there were no suicides among the patients of the Perfect Depression Care Program of the Behavioral Health Services division of Henry Ford, in stark contrast to the 230 suicides expected in an average population of 100,000. The goal of the initiative was to completely redesign care delivery around the six aims outlined in the Institute of Medicine’s Crossing the Quality Chasm report–safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity—in order to reduce the number of suicides to zero. The belief held by the program is that perfect depression care would result in no suicides—not just a reduced risk of suicide.


Excerpted from:
Depression Care Effort Brings Dramatic Drop in Large HMO Population’s Suicide Rate
Tracy Hampton, PhD
JAMA. 2010;303(19):1903-1905.
http://jama.ama-assn.org/content/303/19/1903.extract

“While physicians and other health care workers may not be ableto predict which of their patients will attempt suicide, theycan implement preventive strategies that markedly lower therisk of such tragedies. Now, one pioneering program has demonstratedthe importance of pursuing 2 key approaches at once: carefullyassessing patients for risk of suicide and adopting measuresto reduce the likelihood that a patient will attempt suicide.

The example comes from a quality-improvement initiative that succeeded in substantially bringing down the rate of suicide in a population of about 200 000 members of a large health maintenance organization (HMO). Through the second quarter of last year, the Perfect Depression Care program of the Behavioral Health Services (BHS) division of the Henry Ford Health System resulted in 9 consecutive quarters without any suicides, a dramatic contrast to the annual rate of 89 suicides per 100,000 members at baseline and approximately 230 suicides per 100,000 individuals expected in a patient population . . .”

Keywords: care team; depression; Henry Ford Health System; Michigan; Perfect Depression Care Program; prevention; quality improvement; rate of suicide;

FOR MORE INFORMATION:

Dwight Angell
Director of Public Affairs
Henry Ford Health System
One Ford Place
Detroit, Michigan
tel.313-876-8709
Dangell1@hfhs.org
www.henryfordhealth.org

Diabetic Care Management at Intermountain Healthcare

Diabetes is the sixth leading cause of death by disease in the US. But caring for diabetic patients is remarkably simple. Most health care providers understand what needs to be done to keep diabetics well, but it is difficult and time-intensive to get the patient to participate in the process — and it’s easy for things to fall through the cracks. To care effectively for diabetic patients, a care management model must be put in place and followed consistently in order to keep diabetic patients healthy. Intermountain Healthcare’s system makes it easier for the health provider and the patient to do the right thing.


Diabetic Care Management at Intermountain Healthcare Diabetes is the sixth leading cause of death by disease in the US. But caring for diabetic patients is remarkably simple. Most health providers understand what needs to be done to keep diabetics well, but it is difficult and time-intensive to get the patient to participate in the process — and it’s easy for things to fall through the cracks. To care effectively for diabetic patients, a care management model must be put in place and followed consistently in order to keep diabetic patients healthy. Here’s how Intermountain Healthcare does it:

  1. When a diabetic patient is identified (in one of its 140 clinics, 21 hospitals, or among its 400,000 health plan members), this is noted in Intermountain’s advanced computerized electronic patient record.
  2. This electronic record then follows the patient wherever they go in the Intermountain system and identifies them to caregivers as diabetic.
  3. Patient education is provided in the physician office as well as in regular, consistent mailings. Care managers (typically nurses) are assigned to help individual diabetic patients and make outreach phone calls.
  4. Most of Intermountain’s hospitals and large clinics offer diabetic education classes as well as diabetic educators who visit the patients in their hospital room. There are multiple Diabetes Education Centers that have more than 20,000 patient visits each year.
  5. Patients are strongly encouraged and frequently reminded to get tests and screenings related to their diabetes. This helps them keep their blood sugar in control and avoid other complications.
  6. Intermountain’s health plan sends quarterly diabetes reports to physician offices listing the names, screening statuses, and lab results of diabetic patients. If patients have not been filling their diabetic medication prescriptions, the physician is notified so he can follow up with the patient. This report also allows physicians to see how his/her diabetes patient management compares to other physicians.
  7. Clinical teams of physicians, nurses, pharmacists, diabetes educators, and computer specialists meet monthly to measure and refine the process.

How does diabetic care at Intermountain compare to the U.S.? Two examples:

  • Intermountain ranks above the national average in getting patients to do annual extensive HbA1c (blood sugar) testing, with 90 percent participating appropriately.
  • Only 22 percent of Intermountain patients have poor HbA1c control compared to the national average of 29 percent. Poor control can contribute to a variety of other health problems.

It’s important to note that it’s unlikely any health care organization will achieve perfection. Much of this process depends on personal involvement by the patient, and some patients are more motivated than others.

Keywords:care teams, care management, care coordination, communication, diabetes, electronic medical record, EMR, evidence-based medicine, health information technology, Intermountain Healthcare, Salt Lake City, Utah, safety, treatment, value

FOR MORE INFORMATION:

Dave Green
Communications Manager
Intermountain Healthcare
36 South State Street
Salt Lake City, UT 8411
tel. 801.442.2844
dave.green@ihc.com
www.ihc.com

Enhancing Primary Care for Mental Health Patients – at a Lower Cost

Intermountain Healthcare, a non-profit integrated healthcare system with 22 hospitals in Utah and Idaho, has had a long-established clinical integration structure, which enables physicians, nurses, and medical assistants to collaboratively treat most patients with chronic illnesses. However, doctors in primary care often struggle with the burden of demand. In particular, these physicians felt ill-equipped to meet the needs of patients with co-occurring mental health conditions.

To address this issue, over the past decade, Intermountain has introduced a new model of mental health integration (MHI), radically changing the way in which primary care is delivered by improving coordination of services between the various parties involved. As of early 2010, the program has been implemented in over half (69) of Intermountain’s 130 primary care clinics. A leadership team has been established at each regional site to design, implement, and evaluate the program across all clinic sites.


Enhancing Primary Care for Mental Health Patients – at a Lower Cost The introduction of an integrated model of care has brought considerable benefits to patients, their families, healthcare providers and community partners in the US states of Utah and Idaho. By focusing on routine primary care for patients with mental health conditions, Intermountain Healthcare has achieved demonstrable improvements in quality with financial savings.

Patients treated in mental health integration (MHI) clinics have a lower rate of growth in charges for all services, with savings of 30% to 80%. In addition, the number of emergency visits for depressed patients fell by over half. The program places mental health at the heart of primary health care and is being replicated by local community health clinics in several other states.

The challenge

Intermountain Healthcare is a non-profit integrated healthcare system with 22 hospitals in Utah and Idaho. It has more than 2900 affiliated physicians, 700 of whom are employed with the medical group. Intermountain also has over 130 ambulatory care practices and its own health plan.

The group’s long-established clinical integration structure enables physicians, nurses and medical assistants to collaboratively treat most patients with chronic illnesses. However by the late 1990s it became clear that doctors in primary care were struggling with the burden of demand. In particular these physicians felt ill-equipped to meet the needs of patients with co-occurring mental health conditions. Dealing with such patients is inevitably more complex and often involves their wider families.

The approach

Over the past decade, Intermountain has introduced a new model of mental health integration (MHI), radically changing the way in which primary care is delivered by improving coordination of services between the various parties involved. As of early 2010 the program has been implemented in over half (69) of Intermountain’s 130 primary care clinics. A leadership team has been established at each regional site to design, implement, and evaluate the program across all clinic sites.

How the program works

When a patient arrives at the primary care clinic he or she automatically receives both a physical and mental health assessment via a questionnaire. This helps the primary care physician, the patient, and their family to identify and determine the nature and extent of any mental health problem, classified as:

  • Mild: requiring routine care with care management or peer advocacy
  • Moderate: requiring care management with additional mental health support from a mental health specialist or peer advocates within the team
  • Severe: requiring direct consultation with a mental health specialist and support from all team members.

The assessment also notes how much support is available to a patient and family to help them manage their chronic condition. Keeping everyone informed is vital, so information is exchanged routinely between all members of the team including patient, families, and specialized mental health providers. The team has a number of common tools available and results are reported centrally, which encourages consistency of practice based upon evidence. As Brenda Reiss-Brennan, the Director of MHI observes: “Standardized assessment tools and meaningful data really drive the clinical decision making that is matched to the appropriate level of team resource.”

Such a team-based approach considers the needs and satisfaction of all parties involved: patient, family, physician and staff, ensuring:

  • True integration: mental health becomes a fundamental feature of primary health care and is accessible to all patients, regardless of complexity of condition or financing. A mutually agreed treatment plan reflects the assessments and any observed problems
  • Real support to physicians: although patients and their families are the focus, the program also recognizes the challenges facing doctors, both in terms of work load and complexity
  • All contributions are acknowledged: reflecting the involvement of all members of the team in improving the quality of care, including the patients, carers and community members

The importance of training
A vital feature of Mental Health Integration is a standardized ongoing training program. This is offered to all team members, with dedicated implementation specialists and analysts working alongside to achieve continuous quality improvement. There are five key components of mental health integration:

  • Leadership and cultural integration: to identify and integrate leadership ‘champions’ — people with mental health and medical backgrounds — to provide institutional commitment and accountability for the integration goals
  • Workflow integration: training all staff from different provider backgrounds to work together as a team in the primary care setting, utilizing standardized clinical tools and creating complementary team roles. This also helps change the culture, reducing the stigma associated with mental health conditions and helping people identify the physical symptoms linked to such conditions
  • Information systems integration: a secure, centralized data repository for data enables all team members to access and update clinical and financial records and communicate with each other. This creates coordination between clinic administrators, physicians, nurses, and medical assistants, bringing greater continuity in patient and family care. Patients also have the facility to email their primary physician.
  • Economic and financing integration: linking clinical and financial outcomes brings together payers and providers, giving a comprehensive overview of all financial costs in the context of improved quality
  • Integration with the community: one of the most challenging and critical aspects of integration, this training encourages members of the community to become active partners with the MHI team and leaders and offer enhanced community support to patients and families beyond the clinic.

Continuous improvement is a key objective, according to Dr. Charles Sorenson, CEO of Intermountain Healthcare: “… our organization sets goals around six dimensions of care — clinical care and service, physician and employee engagement, operational excellence and community stewardship. What is so promising about the Mental Health Integration initiative is the opportunity it gives us to demonstrate benefit and add value in virtually every one of these dimensions.

The model developed by Intermountain Healthcare is now being taken up by local community health clinics across the US in Mississippi, Maine, New Hampshire, Oregon and Utah.

The results

Intermountain Healthcare is now internationally recognized as a high performing system, with US President Barack Obama, speaking at a recent 2010 joint session of congress on healthcare, citing the organization as offering “high-quality care at costs below average”. Evidence of this can be found in improved physician, staff and patient satisfaction, lower costs and better quality outcomes.

A more robust evaluation carried out in 2009 aimed to understand the impact of the MHI on quality (as measured by reduced in-patient admissions and emergency room visits) and cost (measured by allowable charges to the health plan). These findings are published in a 2010 edition of the Journal of Healthcare Management:

  • Lower average growth in patient charges:
    Patients treated in an MHI clinic have a lower rate of growth in charges for all services (with the exception of outpatient psychiatry charges, and prescriptions for anti-depressants, indicating more timely treatment and referral) – In the 12-month period following diagnosis average patient charges increased by 73% for MHI patients compared with 100% for usual care clinics patients – Patients with one other diagnosis in addition to depression had only an 8% increase in average charges in the 12-month period following initial diagnosis, while similar patients treated in a traditional care clinic have a 90% increase – For all levels of complexity (mild, moderate and severe) and overall, patients with depression treated in a MHI clinic cost less in the year following their diagnosis than those treated in usual care clinics. The rate of growth of expenses was $405 US less than for patients in the traditional care group — a 10% reduction – In the 12 months following diagnosis of depression, the 429 patients in the traditional care group in the study would have saved almost US$300,000 in charges, had they been treated in an MHI clinic
  • Lower utilization of emergency room services:
    Depressed patients treated in MHI clinics are 54% less likely to have emergency room visits than depressed patients treated in non-MHI clinics

As Dr Linda Leckman, CEO, Intermountain Healthcare Medical Group, explains: “Physicians not only have a higher level of sensitivity to mental health issues, they are more confident in their own ability to provide care because they have these resources at hand. So it not only results in better care for the patient, but higher physician satisfaction as well.”

Sources

  1. Interview with Brenda Reiss-Brennan, Mental Health Integration Director, Intermountain Healthcare Medical Group, February 2010
  2. Conis, E [2009] A model for mental health integration. Health Policy Monitor, October.
  3. Reiss-Brennan B et al [forthcoming] Cost and quality of Intermountain’s Mental Health Integration Program Journal of Healthcare Management
  4. Health Policy Monitor [2009] USA/Utah: Mental health — from isolation to routine healthcare www.HealthPolicyMonitor.org

Keywords: behavioral health, care coordination, care teams, clinical integration, cost, EMR, electronic medical records, evidence-based medicine, health information technology, Intermountain Healthcare, mental health integration, prevention, Salt Lake City, Utah, safety, treatment, value

FOR MORE INFORMATION:

Dave Green
Communications Manager
Intermountain Healthcare
36 South State Street
Salt Lake City, UT 84111
tel. 801.442.2844
dave.green@ihc.com
www.ihc.com

Reclaim Your Health: Cleveland Clinic’s Lifestyle 180 Program

Lifestyle choices that include poor nutrition and a lack of physical activity are key contributors to the development of chronic illnesses, such as heart disease, diabetes and cancer. Furthermore, these two lifestyle choices – in addition to tobacco use – account for 40 percent of all health care expenses in the United States.

Cleveland Clinic’s innovative Lifestyle 180 program was designed to halt or reverse the effects of several common chronic diseases by teaching lifestyle changes through stress management, yoga, nutrition, exercise and hands-on cooking instruction. The program accepts patients with metabolic disorders (hypertension, hyperlipidemia, obesity, and diabetes), active surveillance breast and prostate cancer, multiple sclerosis, Crohn’s disease, ulcerative colitis and fatty liver disease (NASH).

Lifestyle 180 is a year-long program consisting of 18 sessions conducted at the Cleveland Clinic Wellness Institute in Lyndhurst, Ohio. The program begins with a six-week immersion phase consisting of twice-weekly four-hour group sessions. The remaining six sessions occur at periodic intervals throughout the year.

The Lifestyle 180 pilot class was launched in October 2008. Since then, more than 300 participants have successfully completed the program. Preliminary outcomes show that patients experience a decrease in LDL and insulin levels, and waist circumference. In addition, many patients have experienced a significant reduction in medications, an increase in mobility and energy, improved stress management skills, and an overall adoption of healthier habits including increased exercise and physical activity, healthy cooking, relaxation and healthy food choices.

Another unexpected but significant outcome of Lifestyle 180 is the “multiplier effect.” Participants in the program are taking the skills learned back to their spouses, children, family, and friends which is improving the health of others as well.

Keywords: care team, chronic care, chronic disease, coordinated care, Cleveland Clinic, Lifestyle 180, prevention, lifestyle, Ohio, wellness

For more information, go to:
http://my.clevelandclinic.org/wellness/reclaim_your_health.aspx

FOR MORE INFORMATION:

Megan Pruce
Senior Manager, Communications & Public Affairs
Cleveland Clinic
tel. 216- 445-7452
prucem@ccf.org
www.clevelandclinic.org @ccf.org

Best Practices at Scott & White Healthcare Reduces Incidence of Common ICU Infection

Ventilator associated pneumonia (VAP) is the most common serious infection reported in intensive care units (ICU). For patients on mechanical ventilation, VAP is associated with increased patient mortality and a longer length of stay. It also burdens the healthcare system with additional costs — up to $40,000 per patient. To reduce VAP rates at Scott & White Healthcare, a task force was convened in 2007. As a result o ftheir work, the rate of VAP cases at Scott & White decreased from 4.87 per 1,000 patients in 2008 to 1.24 in 2009. Success also included decreases in patients’ length of stay and ICU days on mechanical ventilation.

A task force was convened in 2007; its goal was to reduce VAP rates at Scott & White Healthcare. The task force included Chairman, Department of Internal Medicine Alejandro Arroliga, MD; Chief Medical Officer Robert Pryor, MD; and representatives from nursing, respiratory therapy and patient safety. The group’s work led to almost a 75% reduction in the identification of VAP cases. The task force established criteria for diagnosing patients with VAP and subsequent prevention measures. Diagnosis included visual inspection of patients to determine VAP onset.

Closely monitoring patients served as the foundation for identified prevention measures, including:

  • Favorable patient to nurse ratios (no more than two patients per ICU nurse)
  • Ongoing collaboration between respiratory therapists and nurses to ensure patients’ heads are elevated in their beds
  • Oral care with chlorhexidine for patients
  • Introduction of silver-coated endotracheal tubes for appropriate patients to prevent bacteria colonization
  • Ongoing education of clinical staff, including video and in-person presentations

The rate of VAP cases at Scott & White decreased from 4.87 per 1,000 patients in 2008 to 1.24 in 2009. Success also included decreases in patients’ length of stay and ICU days on mechanical ventilation.

Outcomes were presented at the American College of Chest Physicians Annual Meeting in San Diego, CA, in November 2009.

Dr. Arroliga credits the integrated team’s expertise for the dramatic reduction in the ICU VAP rate. “This is a real high performance team, a group whose collaboration helped make the VAP rate decrease substantially,” he says. “We’re very proud of the team’s work, especially because of the tremendous benefits to patients.” Dr. Arroliga adds that the team’s work is just beginning, and further progress is anticipated. Keywords: Alejandro Arroliga, MD, care team, NICU, mechanical ventilation, patient support, Robert Pryor, MD, Scott & White, Texas, treatment, VAP, value, ventilator associated pneumonia

FOR MORE INFORMATION:

Katherine Voss
Media Relations Manager
Scott & White
2401 S. 31st St.
Temple, TX 76508
tel. 254-724-4097
kvoss@swmail.sw.org
www.sw.org

HomeCare Program Delivers Coordinated Care to High Risk Patients at Home

HealthCare Partners believed that high risk patients could have better medical outcomes if cared for in a home setting using an interdisciplinary team approach that focuses on both the patient and his/her family and caregivers. To better care for its highest risk patients, HealthCare Partners Medical Group implemented a HomeCare Program in 2008. The program uses an interdisciplinary team approach to provide coordinated care to patients, with a focus on including the patient’s family and caregivers. The goal of the program is to improve the quality of life and clinical outcomes for homebound and other high risk patients.

Patients are referred into the HomeCare Program by our primary care physicians, hospitalists, and specialists. To identify the initial group of patients to be seen as part of the HomeCare Program, HealthCare Partners also used a health plan stratification tool. The target population may not always be physically homebound, but may have complex psycho-social needs that require in-home management.

Services and goals of the HomeCare Program may include acute medical management after a hospitalization or skilled nursing facility stay, management of chronic medical conditions, assistance with complex social situations, advanced care planning, and a change in living arrangements for some patients.

The program’s current staffing model includes two physicians, two nurse practitioners, one social worker, and two medical assistants to manage a panel of approximately 360-400 patients. A clinician initially sees each patient for a 90-minute consultation, and then the patient is seen monthly on a routine basis, and urgently as needed. Patients, families, and referring physicians are given 24/7 direct telephone access to the HomeCare team.

Clinicians are able to complete medical record documentation in the patient’s home using a laptop with a wireless connection to our Electronic Medical Record system. The HomeCare team holds weekly meetings to review patient status, treatment, and progress, and to determine follow-up needs. Pharmacists, geriatricians, and behavioral health providers participate in the team meetings as needed.

To maximize the effectiveness of the HomeCare Program, the HomeCare team continues to work closely with the patients’ primary care physicians, specialists, and hospitalist teams. The HomeCare team has access to a rich database of claims, pharmacy, and electronic medical record data, which provides point-of-care evidence-based reminders for preventive and chronic care needs to enhance the clinical outcome for these high risk patients.

The program’s success is measured on such dimensions as patient satisfaction, chronic disease measures (e.g., LDL, HbA1C, blood pressure, acute hospital admits, acute hospital days, ER visits, Urgent Care visits, and PCP visits), and overall cost of care compared to a control population.

Keywords: HealthCare Partners Medical Group, HCP, coordinated care, homecare, home care, homebound, high risk patient, care team, electronic medical record, electronic health record, EMR, EHR, evidence-based medicine, health information technology, hospital readmission, integrated care, medical management, treatment

FOR MORE INFORMATION:

Robert Klein
HealthCare Partners Medical Group
19191 S. Vermont Avenue
Torrance, CA 90502
tel. 310.630.4126
rjklein@healthcarepartners.com
www.healthcarepartners.com

Integrating Depression Screening and Treatment in Primary Care Clinics

Depression often remains undetected despite its high prevalence. From 2005-2008 Henry Ford developed, tested, and refined a model for integrating depression screening and treatment into primary care clinics. Pilot study outcomes resulted in a 23% detection rate for depression (220/974 patients). Clinical action to positive screenings (treatment or referral) was 90%, and patient refusal for screening was only 1%. The practice model utilized a nurse practitioner experienced in Behavioral Health to serve as coach to the primary care clinic team for implementing depression screening processes and tools. Medical assistants determined patients’ screening eligibility and administered screening tests, and physicians used test results to drive discussion with patients for diagnosis and treatment plans. The Behavioral Health nurse served to reinforce clinical screening and treatment guidelines and also provide psychiatric treatment. Henry Ford integrated two depression screening tools, as well as evidence-based treatment guidelines, into the electronic medical record system for availability to all Henry Ford clinicians.


Integrating Depression Screening and Treatment in Primary Care Clinics
http://www.henryford.com/body.cfm?id=52274

Aim
To improve the detection and appropriate treatment of clinical depression in Primary Care using an integrated, collaborative depression care model.

Measures
In the first month we tracked weekly the number of eligible patients screened (chart audit of all filled appointments).

  • Number of patients screening positive for depression (DST > 10).
  • Disposition of those screening positive (#/% receiving antidepressant treatment versus referred to Behavioral Health Services versus patient refusal, etc.)
  • Clinical outcomes of antidepressant treatment (mean DST change score, % with 50% reduction in DST score, % with DST < 5).
  • Impact on comorbid chronic disease clinical parameters (e.g., pre-post change in LDL and HgA1C).

Changes
Embedded a nurse practitioner experienced in Behavioral Health in the Primary Care clinic to serve as a depression coach/mentor in a team approach.

Trained the team how to use a standardized screening tool for depression (e.g., DST adapted from the PHQ-9) and evidenced-based treatment guidelines. Convened a team that included representation from all clinic roles (e.g., clinic service representative, medical assistant, RN, MD) to help develop a clinic process for depression care that would be sustainable.

Developed screening criteria for high-risk patients.
Moved from a paper process to the DST embedded within the electronic medical record (EMR) system.

Moved to a two-step screening process, using the PHQ-2 followed by the full DST when the PHQ-2 was positive.
Collaborated with Information Technology to build two new note types in the EMR to document the PHQ-2 screening, and worked to build electronic reports to track monthly depression screening rates.

Results
Pilot results indicated that approximately 50% of eligible patients were screened although initial screening criteria were too broad, resulting in over 300 patients being screened in the first month with a 21% detection rate. This led to the process being amended in two ways: 1) screening criteria were streamlined to patients with either CAD, HF, DM, or complaints of depression; and 2) the PHQ-2 was added, with only those positive on the two-question survey going on to complete the full DST. After adding the PHQ-2, detection with the DST rose dramatically to approximately 60% while significantly reducing the time burden on clinical staff. The integrated model led to Primary Care physicians addressing detected depression > 90% of the time, with initiation of an antidepressant in about 70% of the cases.

Clinical outcomes were impressive, with a group mean change in DST score from 15 at baseline to 7 at 24-week follow-up (50% reduction indicates treatment response and a DST score of < 5 indicates remission).

Further subanalysis of patients with comorbid DM showed that for patients whose depression was successfully treated (DST reduction by at least 50%), 65% showed improvement in HgA1C with a group mean pre-post drop in HgA1c of 1.01 (a 1 point drop in HgA1c has been shown in the literature to significantly reduce diabetes complications).

Next Steps/Lessons Learned

  • Produce electronic monthly reports to track PHQ-2 frequency by site and provider; can assess usage trends over time; email these reports to administrators at the pilot sites monthly.
  • Booster (training) sessions at the initial pilot sites at set time intervals to re-review the process.
  • Periodic case conference at sites that have implemented this process to promote continuous learning and collaboration with Behavioral Health Services.
  • Use of the DICE tool with the design team at the beginning was critical to assess the perceived importance of the initiative and likelihood of project success.
  • Involving the clinical staff (end users) was critical to help build the process.
  • Use of multiple PDCA cycles to test the processes developed, and to revise what was not working well, helped the team to make changes quickly as needed.
  • Giving clinical staff frequent data reports helped each to know how they were performing and what positive impact the new process (and their actions) had on patients.
  • Plan to roll out the program across the Henry Ford Medical Group over time.

Contact Information: Terri Robertson, PhD, Project Manager, Center for Clinical Care Design, Henry Ford Health System, 313-874-2495.

Keywords: access, behavioral health, care team, chronic care, Detroit, depression, evidence-based medicine, Henry Ford Medical Center, health information technology, health screening, Michigan, MyHealth web portal, patient support, patient web portal, safety, treatment, value

FOR MORE INFORMATION:

Dwight Angell
Director of Public Affairs
Henry Ford Health System
One Ford Place
Detroit, Michigan
tel.313.876.8709
Dangell1@hfhs.org
www.henryfordhealth.org