Development of a modified TRANSLATE assessment tool for the TRANSLATE-CKD Study

Vanessa Nguyen, MPH Kris Neuhaus, MD, MPH North American Primary Care Research Group, PBRN Conference 2015 Monday, June 29, 2015

Original TRANSLATE rubric § Derived by Dr. Kevin Peterson for a study to improve diabetes care in multiple primary practices

§ Purpose: provide a framework for evaluating practice transformation using the chronic care model

Interven'on    Components  Target high risk patients

Registry

Administration

Notify and remind

Site coordinator

Local physician champion

Audit and feedback

Track performance

Education

Target  high  risk  pa-ents  Registry  Administra-on  No-fy  and  remind  Site  coordinator  Local  physician  champion  Audit  and  feedback  Track  performance  Educa-on  

Scoring     1  point     2  points     3  points     4  points    

Target  measures   No  targets  set    Vague  or  non-­‐measurable  targets    

Clear,  measurable,  but  not  feasible  targets    

Clear,  measurable  and  feasible  targets    

Reminders     No  Reminders  available    

Reminders  available  but  never  used    

Reminders  available  but  used  infrequently    

Reminders  rou-nely  used    

Administra-ve  buy-­‐in     Leadership    resistant    

Leadership  agreeable,  but  unwilling  to  commit  resources    

Leadership  willing,  but  limited  resources    

Leadership  commits  all    necessary  resources    

Network  Informa-on  Systems    (registry)  

Unable  to  create  registries    

Able  to  create  registries,  but  none  created    

Registries  used  for  fewer  than  3  condi-ons    

Registries  used  for  3  or  more  condi-ons    

Site  Coordinator     No  site  coordinator  iden-fied    

Site  coordinator  has  no  -me  for  QI  ac-vi-es    

Site  coordinator  has  limited  -me  to  do  QI    

Site  coordinator  with  clear  mission,  resources  and  personnel    

Local  Physician  Champion    

Not  iden-fied     Iden-fied  but  uninvolved     Lukewarm  support     Enthusias-c  support    

Audit  and  Feedback     Never  done    Reports  available  but  not  disseminated    

Reports  disseminated  less  than  twice  per  year    

Reports  disseminated  more  than  twice  per  year    

Team  approach     No  teams  formed    Limited  teams,  using  a  top-­‐down  approach    

Limited  teams,  with  input  from  only  a  few    

Non-­‐hierarchical,  broadly-­‐based  teams    

Educa-on     No  opportuni-es  for  educa-on    

Rare  educa-onal  opportuni-es    

Occasional  educa-onal  opportuni-es    

Frequent  educa-onal  opportuni-es    

Standardized Care for CKD •  Select protocol for managing patient care (CKD flow sheet)•  Modify protocol for office environment (Vitamin D standard, no annual hormone w/o indications, etc.) •  Set up standing orders•  Determine workflow for supporting protocol including standing orders and reflexive lab testing •  Use protocol at every patient visit •  Monitor use of protocol, standing orders, & reflexive lab testing

Outcomes Change ConceptsKey Drivers

PROCESS OUTCOMES

Documentation of CKD in problem listCalculated eGFR in lab reportsAddition of appropriate meds:

* ACE/ARB* Aspirin (consider)* Vitamin D (consider)

Avoidance of unsafe meds: If GFR 30-60 avoid regular use of * NSAIDS and COX-2 inhibitors If GFR <30 discontinue use of * NSAIDS/COX-2 inhibitors

* Bisphosphonates* Metformin* Allopurinol

Caution with IV contrast, especially gadolinium

Lab tests:GFR < 60 (do every 6 months):* A1c* Lipid PanelGFR < 60 (do annually):* Urinalysis* Urine microalbumin or UACR* Calcium and Phosphorus* PTH (intact molecule)* 25-Hydroxy Vitamin D* CBC* Iron/TIBC (if Hgb < 12.0)

Prevention:* Annual flu vaccine* Pneumococcal vaccine: once before and

once after age 65* Smoking cessation counseling* Patient education* Vein preservation

CLINICAL OUTCOMES BP < 140/90 A1c < 7.0 LDL < 100 Stable GFR Completed nephrology referral if GFR < 30 Improved flu shot compliance Improved pneumovax compliance Improved vein preservation

Baseline Data•  Assess practice level data

Use of Registry to Manage Patient Population

•  Identify  each  affected  patient   every visit •  Identify  needed  services  •  Recall  patients  for  follow-up

Use Data to Guide & Monitor Change

1) Create system for monthly audit and feedback 2) Create workflow for audit and feedback 3) Maintain audit and feedback 4) Use audit and feedback to guide change

Standardized Care •  Practice-wide guidelines implemented for CKD

Self-Management Support •  Realized  patient-care team partnership

Referrals for CKD •  Effective  referrals  and   consultation with Nephrologist

Point of Care Decision Support •  Data Refreshes nightly into data repository•  Front office prints Point of Care reports•  Nurse/MA reviews with patient and completes any standing orders•  Provider utilizes report to facilitate patient encounter•  Upon exit: report given to patient for home use OR report placed in confidential recycle bin

Create CKD Monitoring System •  Designate  the  “CKD  champion”  at  practice  who  will  be   responsible for monitoring quality •  Create monthly CKD monitoring report template •  Create workflow for report generation and use •  Use report to guide practice change

Use Registry to Manage CKD Patient Population •  Determine staff workflow to manage registry •  Populate registry •  Maintain registry •  Use registry to manage patient care and support population management

Self-Management Support (SMS) for CKD •  Obtain patient education materials •  Determine staff workflow to support SMS •  Provide training to staff in SMS •  Collaboratively set patient goals (e.g. healthy diet, increased exercise, medication compliance) •  Document and monitor progress towards goals •  Refer to community resources

Community Linkages – Referrals for CKD •  Identify referral options •  Create workflow for making and monitoring referrals

Planned Care •  Care  team  aware  of  patient  needs   and works together to ensure all indicated services are provided

Our purposes for the revision “360o tool” §  Research evaluation – compare with performance §  Practice facilitation – more operationalized goals §  Practice site self-management – tracking status

Guiding models: §  Normalization Process Theory (NPT) §  Re-AIM framework §  [Precaution Adoption Process (PAPM)]

Normalization Process Theory (NPT)*

*http://www.slideshare.net/CarlRMay/new-introduction-to-npt2

Beyond our scope to cross-walk the full NPT model into TRANSLATE § Targets  § Registry  reminders  

§ Administra-ve  buy-­‐in  

§ Network  informa-on  systems  

§ Site  Coordinator  § Local  physician  champion  

§ Audit  &  feedback  § Team  approach  

§ Educa-on  

§ People/roles  §  Admin  buy-­‐in  §  Lead  clinician  §  Site  coordinator  

§ Objects  §  Targets  §  Registry  §  Network  informa-on  systems  §  Audit  &  feedback  

§ Context  §  Team  approach  §  Educa-on  

PAPM stages of readiness

http://www.psandman.com/articles/PAPM.pdf “The Precaution Adoption Process Model” by Neil D. Weinstein, Peter M. Sandman, and Susan J.

Blalock, in Karen Glanz, Barbara K. Rimer, and K. Viswanath (eds.), Health Behavior and Health Education, 4th. ed. (San Francisco: Jossey-Bass, 2008), pp. 123–147.

Re-AIM influence on rubric scoring

TRANSLATE-CKD survey tool

§  Excel worksheet

§  9 domains

§  5 conditions for each domain: §  specific items deemed most important to effective facilitation

§  balanced number for easy analysis (no need to weight)

Conclusion and next steps §  Further refine (based on feedback from

practices, facilitators, mentors/researchers)

§  Standardized administration of the rubric and scoring

§  Validate the tool? •  specific to study, so “less generalizable” by

design

Pros and cons of “score”

§  Focus on “score” may detract from the component tasks – consider using stage acronyms, then convert to number once the tool is familiar

§  Naturally competitive “So, how much did my score go up?”

“Joining Mensa means you are a genius…

That's the kind of person they're after.... I

worried about the arbitrary 132 cutoff

point, until I met someone with an I.Q. of

131 and, honestly, he was a bit slow on the

uptake.”

- Steve Martin New Yorker Magazine

THANK YOU! Q & A

Department of Family Medicine