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Document Sample
The 20-Minute Medicare Visit
David B. Reuben, MD
Archstone Foundation Chair and
Professor
David Geffen School of Medicine
at UCLA
Overview of Talk
• What’s the problem here?
• Fixing the problem
– Changes you can make on Monday
– Longer term practice redesign changes
• An example of practice redesign
• Does practice redesign work?
• Learning more
The Problem
Physicians are unable to provide high
quality of care for conditions affecting
older persons within the context of busy
primary care practices.
Health care quality for vulnerable
elderly
• Assessing Care of the Vulnerable Elderly
(ACOVE) project
– identified elders at increased risk for
death or functional decline,
– created quality indicators based on
literature review and expert panel for 22
conditions
ACOVE results
• Overall, 55% of Quality Indicators passed
• Compliance for geriatric conditions was
worse than for general medical conditions
(31% versus 52%)
• Care for specific conditions varies greatly
– Stroke 82%; end-of-life care 9%
Wenger NS et al. Ann Int Med 2003
Barriers to good health care
• Insufficient cognitive capacity
• Not enough time
• The health care system isn’t a system
• Rewards are wrong
Insufficient cognitive capacity
• Too much to know
– During 2001, the US National Library
of Medicine added more than 12,000
new articles per week to its on-line
archives
– To maintain current knowledge, a
general internist would need to read
• 20 articles per day
• 365 days per year
» Shaneyfelt TM. JAMA 2001; 286:2000-2601
Insufficient cognitive capacity
• Too much to know
• Too much to remember
– Heart failure management
• 10 ACEIs
• 7 ARBs
• 3 Beta-blockers
• 2 aldosterone antagonists
– All with different starting and target doses
Not Enough Time
• Assuming
– practice size 2500 patients
– age and chronic disease distribution of US
population
– following guidelines for 10 chronic diseases
• Would take 10.6 hours per day!
• Plus time for management of other
problems.
» Ostbye, Ann Fam Med 2005; 3:209-214.
The Health Care System isn’t
a System
• Duplication
– Reordering tests rather than looking for
results
• 34% sometimes or often
• Unavailability of needed clinical info
• 72% sometimes or often
Source: The Commonwealth Fund National Survey of Physicians and
Quality of Care. 2005
The Health Care System isn’t a
System
• Behind the times
– In 2006, only 12.4% of offices had EMRs that had:
• Computerized orders for prescriptions and tests
• Test results and clinical notes
• Source: NAMCS 2007
– In 2007-2008, only 4% of offices had above plus
electronic decision support systems.
• Source: DesRoches N Engl J Med. 2008 Jul 3;359(1):50-60
– But 73% use IT for electronic billing
• Source: The Commonwealth Fund National Survey of Physicians and Quality of Care. 2005
The Wrong Reward System
• Productivity is most important factor in
determining income
• Having more time to spend with patients is
best method for improving quality
• Over half believe that providing higher
quality of care often/sometimes means
less income
Source: The Commonwealth Fund National Survey of Physicians and
Quality of Care. 2005
Fixing the Problem
• Ground rules
• Run a more efficient practice
– Things you can do on Monday
– Longer term changes: practice
redesign
Ground rules (assumptions)
• Follow-up visit cannot take more than
20 minutes
• General medical care cannot be
compromised
• No electronic medical record
• Office staff can provide some help
Run a More Efficient Practice
1) Delegate data collection
Out-of-Office
Preparation
Office Visit
Physician-Patient
Encounter
$$$$
$$
$
1. Reduce time but 2. Always push to
increase outermost possible
effectiveness/efficiency circle whenever
of the inner circle possible
Delegation to Patients
• Pre-visit questionnaires
– Initial
– Follow-up
Pre-visit Questionnaire
1. Past medical history
- Current medications
- Drug allergies
- Surgical & medical hospitalization
- Social history (habits, sociodemographics)
- Preventive services, including lifestyle
2. Home safety checklist
3. Advance Directives
Pre-Visit Questionnaire
• Specific questions on:
– Vision
– Hearing
– Dentition
– Falls
– Urinary incontinence
– Nutrition
– Depressive symptoms
– Functional status
Follow-up Questionnaires
• General
– 2 most important issues
– Mini-ROS
– Other doctors they have seen
– Medications
• Condition-specific
– Keeps issues on the table
– Monitors adherence and response to treatment
– Prompts asking questions about next steps
Delegation to Patients
• Pre-visit questionnaire
– Initial
– Follow-up
• Lists
• Diaries
Delegation to Office Staff
• Screening/Case identification
• History gathering
– Following up on triggers
• Medications/allergies
• Enhanced vital signs/physical exam
– Orthostatic blood pressure readings
– Visual acuity testing
• Patient education
Run a More Efficient Practice
) Delegate data collection
) Minimize data recording time
Dictation
Templates
Computerized medical records
Strategies for Savings Time in
Clinical Practice
3) Keep information needed for decision-
making readily available
• Pocket guides
• PDA programs
• Useful books
• Computer retrieval system
4) Delegate plan execution
• Network of health professionals
• Health educators
Longer Term Practice
Redesign Changes
• To improve care, change must focus on
three key levels
– patient
– provider
– practice
• Must fundamentally change the office visit
• Does not need to be expensive
Practice Redesign (ACOVE-2)
• Case finding (identification)
• Delegation of data collection
• Structured visit notes that lead
physicians through appropriate care
processes
• Physician and patient education
• Linkage to community resources
Case Finding
• Several options
– Telephone call prior to visit
– Medical staff prior to placing patient in room
– Pre-visit questionnaires in waiting room
• Brief questions to identify bothersome
incontinence, memory loss, and falls or
fear of falling
• Responses are given to provider at clinic
appointment along
Structured Visit Note
• History items and simple procedures
(completed by office staff)
• More detailed H & P, ordering tests
(completed by physician)
• Impression and plan (completed by
physician)
VISIT FORM: FALLS/MOBILITY PROBLEMS
Reason for Visit: Fall since last visit (or in last year, if new patient) Fear of falling, balance/trouble walking
History of Present Illness:
1. If patient fell, date of last fall: __________________ 5. Uses device for mobility: YES NO
2. Circumstances of fall: YES NO Cane………………………………………..
Loss of consciousness…………………. Walker……………………………………....
Tripped/stumbled over something…….. Wheelchair…………………………………
Lightheadedness/palpitations…………. Other, specify: ____________________
Unable to get up within 5 minutes……..
Needed assistance to get up………….. 6. Other conditions (e.g., Parkinson’s, CVA,
cardiac, neuropathy, severe OA), specify:
3. Psychotropic medications (specify): ________________________________
Neuroleptics: ____________________
Benzodiazepines: ________________ 7. Vision:
Antidepressants: _________________ Noticed recent vision change…………….
Eye exam in past year…………………….
4. 2 or more drinks alcohol each day……..
Examination:
1. Lying: BP: _____/_____ Pulse: _____ 2. If NO eye exam in past year, Visual Acuity: OS: 20/_____
Standing: BP: _____/_____ Pulse: _____ OD: 20/_____
OU: 20/_____
3. Cognition: 3-Item recall: PASS FAIL If FAIL Cognitive status:
4. Gait: NORMAL ABNORMAL
Abnormal if: -Hesitant start -Heels do not clear toes of other foot
-Broad-based gait -Heels do not clear floor
-Extended arms -Path deviates
5. Balance: YES NO If indicated: YES NO
Side-by-side, stable 10 sec…. Can pick up penny off floor ………..
Semi-tandem, stable 10 sec .. Resistance to nudge……………….
Full tandem, stable 10 sec…..
6. Neuromuscular: YES NO YES NO
Quad strength: Can rise from chair w/o using arms……… Rigidity (e.g., cogwheeling).
Bradykinesia……………..
If indicated, hip ROM and knee exam: Tremor……………………
Diagnosis/Treatment Plan:
Lab/Tests: EKG Impression: Strength problem Severe hip/knee OA
Holter monitoring Balance problem Other: ______________
Other: _________________ Parkinsonism
Treatment:
Patient education handout: Referral for PT
“Falls” Assistive device: __________________________________
“Home safety checklist” Referral for home safety inspection/modifications
Strength/balance exercises: Change in medication(s): ___________________________
Upper body Lower body Referral for eye exam
Community resources Cardiology consult
Community exercise program Neurology consult
Other: _________________________________________
Provider’s Signature_________________________________________ Date of Visit______________
Patient Name: ____________________________
Med. Rec. # ______________________________
(Medical Group logo here)
Date of Birth: _____________________________
PCP: ____________________________________
Patient educational materials
• Assembled for each condition
• Readily available to the clinician to
facilitate treatment
• Community resources
• Follow-up visit sheet
Decision Support-Physician
Education
• Small group educational sessions aimed
at practical approaches
• Written briefs that describe management
of the condition
Flexibility
• Must address all conditions using all
components of the intervention
• Flexibility in administration and content
– Decide how much of the intervention is
performed by staff rather than physicians
– Can modify content and supporting
materials
ACOVE-2 Medical Groups
Site 1 Site 2
Structure Primary care Multispecialty
# patients 22,000 140,000
# physicians 30 100
# office visits/yr 44,000 500,000
% managed care 67% 50%
Patient Characteristics
Intervention Control
N 357 287
Surrogate response 20% 16%
Age, years, mean 81 81
Female 63% 70%
White 97% 94%
Married 46% 52%
Education
High school or less 38% 36%
Income
<35K 59% 55%
VE score 4.8 4.4
General health (1=poor 5=exlnt, 2.9 2.9
mean)
*p<0.05
Quality Scores after Intervention
for Dementia, Falls & UI
Intervention Group Control Group
Dementia 44% 43%
Falls 44% 23%
Incontinence 37% 22%
Overall 41% 25%
Better Care as a Result of the
Intervention
• Falls
– Perform fall exam (45% versus 12%)
– Treat strength/gait problem (89% versus 58%)
• Incontinence
– Take history (36% versus 12%)
– Use behavioral treatment first (33% versus 4%)
• Dementia
– Check blood tests (46% versus 25%)
Summary of main findings
• A practice-based, low tech intervention can
improve care for falls and incontinence.
• The intervention’s effectiveness was only
moderately effective.
Why wasn’t ACOVE-2 more
effective?
• Failure to delegate data collection?
• Not enough recognition of inadequate
practices with subsequent modification?
• Not enough patient empowerment?
Recently Completed Practice
Redesign Projects
• Make intervention more powerful
– Add quality improvement component
• ACOVEprime (Atlantic Philanthropies-ACP)
– Partner with community based organizations
• ACOVE AD (Alzheimer’s Association)
– Increase delegation to office staff
• Nurse practitioner co-management of chronic
conditions- (Hartford Foundation)
ACOVEprime
• 5 Practice sites (intervention and control)
• 2 conditions (Falls and UI)
• Modified ACOVE-2 intervention
• Variation in implementation
– High versus low delegation to staff
– EHR versus handwritten notes
– Planned F/U visits to address conditions
versus integrating into current visit
ACOVEprime Implementation
• 6140 older persons aged > 75 y screened
• 2884 (47%) screened positive
• Staff were able to accommodate changes
• Physician response was variable
– Not enthusiastic about QI component
– Liked falls more than incontinence
• Logistic obstacles to planned F/U visits
ACOVEprime Results
• Knowledge scores
– Increased by 14.8% intervention versus
3.2%, in control group, p=0.007
• Confidence in managing falls and UI
– mean change 0.64 on 5-point scale versus
0.10, respectively, p<0.05
ACOVEprime Quality Results
• Results based on 1229 medical record
abstractions
• Falls: 11 quality indicators
• Urinary Incontinence: 10 quality indicators
ACOVEprime Final Results
Intervention Control
(N=595) (N=634)
Overall quality 58% 36%
Falls quality 62% 40%
UI quality 48% 28%
ACOVEprime Final Results
Intervention Control
Site A (N=287) 57% 35%
Site B (N=307) 68% 46%
Site C (N=157) 58% 24%
Site D (N=302) 51% 31%
Site E (N=176) 57% 33%
ACOVEprime Falls Results
Intervention Control
Orthostatic BPs 36% 0%
Visual testing 62% 28%
Gait/balance/strength exam 50% 27%
Discontinue benzodiazepines 31% 9%
Home hazard evaluation 31% 17%
Exercise/PT program 89% 68%
ACOVEprime UI Results
Intervention Control
Incontinence history 57% 19%
Discuss treatment options 50% 25%
Assess response to treatment 33% 23%
Behavioral/lifestyle treatments 66% 18%
ACOVEprime No Differences
Intervention Control
Cognitive exam for fall 86% 82%
Assistive device review for fall 83% 84%
UI exam 63% 63%
ACOVEprime
• The enhanced ACOVE-2 practice redesign
can dramatically improve the quality of
care that practicing internists provide
• Some QIs still had low performance
ACOVE Alzheimer’s Disease
• 2 Sites-intervention only for Dementia
• 1179 older persons screened
• 121 (10%) positive
• Numbers and positive rates variable by MD
– Range 0-41; uncommon in primary care
• Linkage to local Alzheimer’s Assoc chapters
for counseling, support, referral
• Referral to Alz Assoc: pre: 0% vs post:17%
ACOVE-Alzheimer’s Disease
Pre Post
Summary Quality score* 38 46
Site A 46 46
Site B* 33 46
Yes No
If referred to Alz’s Association* 65 41
NP Co-management of
Chronic Conditions
• UCLA Geriatrics practice; ½ geriatricians
• Option to refer for co-management
– Falls
– Urinary Incontinence
– Dementia
– Depression
– Heart Failure
NP Co-management Program
• 158 referred; 345 would have been referred
• Anecdotal experience extremely positive
• Shares some elements with Guided Care
• Ripe for Patient-centered Medical Home
NP Co-management Program
Summary Quality Scores*
Condition Intervention Usual Care
Dementia 49 34
Depression 51 28
Falls 45 17
Heart failure 82 71
UI 63 26
The Bottom Line
• Practice redesign can improve the
quality of care of older persons
• Takes a product champion and
commitment to change
• Not rocket science but hard work
• It’s your patients and you who stand to
benefit from change or bear the
inadequacy of business as usual
