Approaches to Organizing and Delivering Care to Reduce Disparities

Marshall H. Chin, MD, MPH Associate Professor of Medicine

Co-Director, Hartford Center

of Excellence in Geriatrics

University of Chicago

Director, RWJF Finding Answers:

Disparities Research for Change

Goals• Present conceptual model for reducing disparities• Systematically review evidence for reducing health

care disparities• Raise ongoing research questions from review• Provide example of Health Disparities

Collaboratives (HDC) – clinical, financial, organizational change

• Brainstorm applications to aging

Non

-Min

orit

y

Min

orit

y

Difference

Clinical Appropriateness and Need

Patient Preferences

The Operation of Healthcare Systems and the Legal and Regulatory Climate

Discrimination: Biases andPrejudice, Stereotyping, andUncertainty

Disparity

Qua

li ty

o f H

e al th

Car

eFigure 1: Differences, Disparities, and Discrimination: Populations with Equal Access to Health Care

Populations with Equal Access to Health Care

Institute of Medicine:6 Domains of Quality

• Safety

• Timeliness

• Effectiveness

• Efficiency

• Equity

• Patient-centeredness

Equity as the Poor Stepchild of Quality: Example of SQUIRE Guidelines

Our Philosophy

• “QI should be an integral part of the plan to reduce disparities in care.”

• “danger is that they create the impression that reducing racial disparities is a marginalized activity distinct from the mainstream QI efforts of an organization.”

Chin MH, Chien AT. Qual Saf Health Care 2006; 15:78-79.

Recommendations to SQUIRE

• What is the effect of the QI intervention on racial and ethnic disparities?

• What is the plan for addressing racial and ethnic disparities in health care with the QI intervention?

• Are there important unintended positive or negative consequences from the QI intervention that affect disparities?

Finding Answers: Disparities Research for Change

A national program supported by RWJF with direction and technical assistance provided by the University of Chicago.

www.SolvingDisparities.org

Goals of Finding Answers

• Grant funds to evaluate practical solutions to reduce racial and ethnic health care disparities.

• Conduct systematic reviews of racial and ethnic health care disparities interventions.

• Disseminate results to encourage health care systems to address racial and ethnic gaps in care.

Conceptual Model

Provider

Patient

Financing / Regulation / Accreditation

Health CareOrganization

Person

Community

Process

Outcomes

Access

RWJF Finding Answers:Systematic Review of Interventions to Reduce Racial and Ethnic Disparities

• Medical Care Research and Review 10/07 supplem

• Intro, Cardiovascular, Depression, Diabetes, Breast cancer, Culture, Pay-for-Performance

• www.SolvingDisparities.orgArticles and Searchable database of 200 interv.

RWJF Finding Answers:Disparities Research for Change

Lessons from Systematic Reviews

• Multifactorial interventions that target multiple levers of change

• Culturally tailored quality improvement

• Nurse-led interventions in context of wider systems change

Factors Determining Depression Disparities

• System– Lack of access to mental health providers

• Community– Preference to seek treatment within ethnic community

• Provider– Diagnostic uncertainty / Cultural barriers

• Person– Cultural bias against mental health treatments

Key Findings: Chronic Care Model• Not Effective

– Interventions addressing barriers at only one level• Access to mental health services alone does not reduce disparities

• Single component interventions targeting providers did not reduce disparities

• Effective

– Multi-component primary care interventions using the Chronic Care Model • Addressed factors at system, community, provider and person level

• Improved ethnic minority care processes and outcomes

Case Study: IMPACT Study• Elderly in primary care with depressive disorder• Chronic care model

– Screening in primary care– Consultation liaison psychiatry available for decision support– Case-management assist patients

• Navigate fragmented healthcare system• Enhance trust and knowledge• Reduce stigma and negative attitudes

• Disparities eliminated

Arean PA et al. Med Care. 2005;43:381-390

Key Findings: Socio-culturally Tailored Behavioral Interventions

• Socio-culturally tailored interventions may reduce disparities compared to standard approaches– Focus on unique problems of ethnic minorities– Build on successful coping strategies within patient’s

culture– Incorporate cultural frameworks of target population

Case Study: Mamás y Bebés

• Socio-culturally adapted depression prevention intervention targeting post-partum depression– Focused on problems encountered by low-income new mother in

Hispanic community

– Built on cultural strengths (family solidarity)

– Incorporated Hispanic family culture/structure

• Pilot study– Reduced risk of major depression

Munoz RF et al. Prevention of Postpartum Depression in Low Income Women: Development of the Mamas y Bebes/Mothers and Babies Course. Cognitive and Behavioral Practice. in press.

Key Findings—Heart Failure

• Care Management—can ↓ hospitalization rates in advanced heart failure

• Useful elements— specialty nurse case management, education, frequent telephone follow-up with medication adjustment, oversight by a specialist

Key Findings—Diabetes

• No single optimal target

• Culturally-tailored interventions may be > standard QI programs

• Human capital interventions > technological interventions

• Better utilization of non-physician staff can improvements in diabetes care

REACH 2010:Charleston and Georgetown Diabetes Coalition

• South Carolina – 28 coalition partner organizations

• Health system change

– Chart audits, feedback to organization, diabetes registry

– Patient empowerment – Gold Card, ABCs of diabetes

• Community development, empowerment, and education

– Interdisciplinary team– Five community health workers

• Eliminated disparities in processes and outcomes

Finding Answers Intervention Research

FAIR Database• 206 Articles• Designed to provide a customized list of interventions that

match a user’s interest– health topic

– racial/ethnic population

– organizational setting

– intervention strategy

• http://www.SolvingDisparities.org/fair_database

Priority Research Questions from Review

• What parts of a multi-component intervention provide the most value?

• How can interventions developed in the research setting be successfully implemented in other organizations and patient populations?

Research Questions 2

• Given heterogeneity within each type of intervention, what conclusions can be made about the effectiveness of classes of interventions?

• What interventions reduce disparities in understudied populations such as American Indians and Asian American subgroups, and pediatric and geriatric ethnic subgroups?

Research Questions 3

• How can we comprehensively integrate the strengths of the community and health care system?

• What effect do policies linking quality to payment and other performance incentives have on disparities?

RWJF Aligning Forces for Quality / Regional Quality Strategy

• Improve quality of care and reduce disparities in 14-20 regions of country

• Principles– QI– Public reporting of performance data– Consumer engagement

• Nursing, community involvement

RWJF Commission to Build a Healthier America

• Mark McClellan, Alice Rivlin – Co-Chairs

• 2 year effort – recommend short and longterm strategies

• Look beyond health care system

• Education, environment, income, housing, personal health choices

Observations for ABIM:Cultural Competency Useful

But Not Enough

• CC improves knowledge, attitudes, skills

• Lacks comprehensive skill set– Social, political, economic

• Fail to demonstrate improved health outcomes

Observations for ABIM:3 Levels of Systems

• Health care organizations – QI

• Health care organization – community linkage– E.g. – community health workers, patient navigators

• Macro health policy systems

Health Disparities Collaboratives:A Quality Improvement Collaborative• National effort in about 1000 health centers

beginning in 1998

3 Components

• CQI: Rapid Plan-Do-Study-Act cycles

• Chronic Care Model

• Learning sessions

Plan-Do-Study-Act Cycles (PDSA)

Associates in Learning / Institute for Healthcare Improvement

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

Functional and Clinical Outcomes

DeliverySystemDesign

Decision Support

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community

Health Care Organization

MacColl Institute Chronic Care Model

Breakthrough Series

• Commitment of CEO

• HDC QI team in each of health center

• 4 regional learning sessions

• Cluster coordinator support

• Monthly telephone conference calls

• Monthly written progress reports

• Computer listserver

Organizational Schema of Intervention

Collaborative

Team

Center

15-20 HCs / Trainers

HDC QI Team

Providers & Patients at HC

Methods

• Systematic review of literature

• Focus on key studies in this presentation

Results: Participants’ Perceptions of Outcomes

• HDC is a success and worth effort > 80%

• Improved patient outcomes 88%

• Improved processes of care 83%

• Improved patient satisfaction 71%

• Qualitative interviews Similar

Chin et al.; Chin et al. Diabetes Care 2004; 27:2-8.

Short-Term Clinical (1-2 years):Diabetes

• Random chart review

• Pre-post improvement in 7 diabetes processes of care

• No improvement in intermediary outcomes

Chin et al. Diabetes Care. 2004.

Short-term Clinical:Asthma, Diabetes, Hypertension

• Pre-post controlled (1 yr pre and 1 yr post)• Improvements in processes of care for asthma and

diabetes– Asthma – Rx anti-inflam med 14%– Diabetes – HbA1c measurement 16%

• No improvement in intermediary outcomes

Landon et al. NEJM 2007; 356:921-934.

Long-term Clinical (2-4 years):Processes of Care (%)

Process of Care 1998 2000 2002

At least 1 A1c 71 88 92

Lipid assessment 52 65 70

Aspirin 22 37 41

ACE inhibitor 33 42 50

Chin et al. Medical Care 2007.

Long-term Clinical:Outcomes

Outcome 1998 2000 2002

HbA1c (%) 8.6 8.5 7.9

LDL (mg/dl) 127 116 108

Systolic BP (mm Hg) 133 135 133

Diastolic BP (mm Hg) 79 80 78

Chin et al. Medical Care 2007.

Societal Cost-Effectiveness Analysis: Diabetes

• Incorporate clinical results into a NIH simulation model of diabetes complications

• Simulation model needed to translate changes in processes and risk factor levels into complications

Huang et al. HSR 2007.

Base Case ResultsProgram 1:

Without HDC Program 2:

With HDC

Blindness,% 17 15

ESRD,% 18 15

Amputation,% 20 20

CHD,% 28 24

Quality-adjusted life years, mean

10.58 10.93

Lifetime costs, mean

$90,085 $101,770

ICER = $33,386/QALY

Business Case: Case Study of 5 Health Centers with Diabetes

Huang ES, et al. The cost consequences of improving diabetes care: the community health center experience. Joint Commission Journal on Quality and Patient Safety 2008; 34:138-146.

Brown SES, et al. Estimating the costs of quality improvement for outpatient health care organizations: a practical methodology. Quality and Safety in Health Care. 2007; 16 (4): 248-251.

Local Economy

External Environment

Payor Mix

Insurance reimbursement and incentives

Internal Environ-ment

Admini-strative

Revenues Grants Donations -

Costs Daily QI activities Personnel Equipment

= Administrative Balance

ClinicalPatient care revenues

Patient care costs =- Clinical Care Balance

Overall Overall center revenues

Overall Center Costs =- Direct Overall Balance

+ + +

===

Indirect Benefits Improved clinical care Morale

-Costs Focus of leadership on other priorities =

Indirect Balance

Patient Demographics and numbers

Accreditation Bodies

Conceptual Model of the Short-Term Financial Impact of Quality Improvement for Outpatient Facilities

Direct

Business Case Study Results

• Additional admin cost = $6-$22 per patient (Year 1)

• No regular source of revenue for these costs

• Balance of diabetes clinical costs/revenues did not clearly improve

• Diabetes Collaborative 2-8% of health center budget

• QI programs represent a new cost

Organizational Change and Implementation

• Common barriers

– Lack of resources

– Lack of time

– Staff burnout

Chin et al.

Wish List fromBureau of Primary Health Care

Percentage Ranked #1

Direct patient care services 44

Data entry activities 34

Staff time spent on quality improvement 26

Training in quality improvement techniques 20

Information system technical support 18

Additional Support

• Help patients with self-management 73%

• Information systems 77%

• Get providers to follow guidelines 64%

Predictors of Staff Morale and Burnout

• Low cost– Personal recognition– Career promotion– Skills development– Fair distribution of work

• More expensive – Funding, personnel

Graber et al. HSR 2008.

Unintended Consequences

• Quality of care of chronic conditions not emphasized by HDC increased 45%

• HDC has drawn time, energy, resources away from other health center activities 61%

Chien et al.

Summary Conclusions

• HDC improve clinical processes of care over short-term 1-2 year time periods and improve both processes of care and outcomes over longer 2-4 year periods.

Conclusions 2

• Diabetes Collaborative is societally cost-effective, but there are no consistent financial streams for individual centers, raising concerns about the whether there is a business case for CEOs to adopt and sustain the HDC over the longterm.

Conclusions 3

• Some methods to enhance implementation of the HDC are low-cost and reasonably feasible.

• Some methods to enhance implementation of the HDC will require more resources and work.

Key Research Questions

• How to tailor implementation of the HDC to different HCs that may be at different stages of organizational readiness to change and that may have different strengths, weaknesses, organizational contexts, and patient populations?

Research Questions 2

• How to create a viable long-term business case for the HDC to complement the analysis demonstrating that the Diabetes Collaborative is societally cost-effective?

Research Questions 3

• How to successfully spread the HDC across multiple diseases, conditions, and processes?

• How to sustain the HDC over time?

• How to integrate the general QI process of the HDC with menus of specific model programs?

Applications for Aging

• Fundamental tenets are natural to aging– Multifactorial– Cultural tailoring– Nurses, interdisciplinary teams

• 3 levels of systems– QI – organization– Organization-community linkage– Health care system – health policy

Describing and Evaluating Model Programs in Aging

• What’s the intervention? – Black box

• What’s the implementation process?

• What’s the business case?

• Where’s the toolkit?

Financial Models – Medicare and Others

• Patient-Centered Medical Home– Access, continuity, care coordination

• Pay for Reporting (PQRI – Physician Quality Reporting Initiative)– Race/ethnicity, SES (education), language

Financial Models 2

• Pay for Performance– What measures?

• Global

• Disease-specific

• Syndrome-specific

– Scheme design and unintended consequences• “Rich get richer”

• Absolute vs. relative improvement

Framing the Disparities Issue

• Moral imperative

• Quality issue

• [Economics]

• Regulation and incentives are coming– Be positioned to address disparities well

Disparity Questions for You

• What is the disparity challenge for your organization?

• What are your barriers and facilitators?

• What are your interventions and solutions?

• What is the business case?

• What is the policy fix?

Funding

• AHRQ R01 HS 10479 • AHRQ/HRSA U01 HS13635 • NIA 1K23 AG021963• NIH/NIDDK P60 DK20595 Diabetes Research & Training

Center • NIDDK K24 DK071933 • RWJF Generalist Physician Faculty Scholar • RWJF Finding Answers: Disparities Research for Change