Translational Research at CHCI Informing Practice with Research on the Front Lines of Primary Care Daren Anderson, MD Vice-President/Chief Quality Officer Community Health Center, Inc. 1
Research “Tapas menu” Outline: • CHC overview • How research informs practice: 4 brief case studies: – Completed projects: Telephonic disease management for diabetes, diabetes self management – Current project: Improving pain management – Design phase projects: improving specialty access with eConsults and video conferencing • Questions/Discussion 2
218Locations
Middletown, CT Meriden, CT New Britain, CT New London, CT Norwalk, CT Groton, CT Old Saybrook, CT Clinton, CT Danbury, CT Bristol, CT Stamford, CT Enfield, CT 4
CHC Patient Profile • Patients who consider CHC their health care home : 130,000 • Health care visits : : 350,000 per year CHC Patient tient Demographics aphics 90.80% 100% 64.8% 65% 75% 42% 50% 22% 25% 6% 0% 5
CHC Model of Primary Care • Patient Centered Medical Home (Level 3) • Advanced access scheduling • Clinical dashboard drives improvement • Expanded hours • Clinical integration of all services • Formal research program • Electronic health records • Residency training for nurse practitioners • W.Y.A. (Wherever You Are) Health Care for the homeless • Mobile dentistry services to 150 schools • Outreach and eligibility screening and enrollment 6
Innovations • Fully integrated EMR • Patient portal and HIE • Integrated primary care and behavioral health • Mobile dentistry serving over 150 schools • Automated clinical dashboards • Nation’s first NP residency training program • “In house” IRB • Research partnerships: Yale, VA, Dartmouth, Harvard , UCONN 7
What types of research? • Implementation science • Qualitative • RCT • Financial/health econ • Organizational change • QI 8/19/10 8
Challenges • Busy practices • Poor patient adherence • Language/literacy issues • Financial constraints • Staffing 8/19/10 9
Managing the Space Between Visits: Telephonic Disease Management for Patients with Diabetes in a Community Health Center
Things a diabetic patient should do: • Take meds: QD, QHS, BID, • Floss • Check FS: fasting, 2hr post • See dentist meals, qhs • See ophtho • Check feet/safe shoes • See PCP at least q3mo • Reduce carbs • Attend nutrition/ed • Reduce fat/cholesterol sessions • Increase fiber • Quit smoking • Exercise daily: CV and • Manage hypoglycemia resistance • Home monitor bp • Understand A1C, lipids, • Meal planning complications • Healthy shopping
How would you do with this regimen?
How would you do if you were: • Depressed • Living in a foreign country • Unable to read • Unable to speak the same language as your doctor? • Eating a different diet than “typical”
Not well…
Practice question #1: • How can we provided added support for patients struggling to manage type 2 diabetes? 8/19/10 15
Hypothesis Culturally and linguistically appropriate telephonic disease management, modeled after the DM industry, will lead to improved behavioral and intermediate clinical outcomes in a population of poor, largely non-English speaking medically underserved patients in a community health center Design: RCT
Intervention • Trained staff using DM consultants/ Lorig SM methods • Outbound calls to patients – High risk: weekly – Moderate risk every 2 weeks – Low risk: Monthly • 15 minute duration • Call content: patient driven – Brief assessment – Medication review/adherence – Self management support: diet, exercise, self care goals – Reminders/prompts for needed care
Outcomes: 6 months and one year Diabetes clinical outcomes A1C BP LDL BMI Behavioral Outcomes: Self management goal attainment (attainment score 1- 4) Dietary habits (survey tool) exercise (RAPA survey) Financial outcomes Total healthcare cost Qualitative assessment
Results Summary • Qualitative: – high degree of acceptance and support from patients for this intervention – Significant “navigator” function played by the disease manager – May not be captured by our outcomes assessment • Quantitative – No treatment effect for overall study population for multiple clinical and behavioral outcomes – Trend towards benefit in HbA1C 7-9 group
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Impact of the study on practice • Remote telephonic support did not provide added benefit. • DM call center was shut down • Future efforts focused on more comprehensive, onsite support with multiple team members: PharmD, CDE, nursing 8/19/10 24
Practice question #2: • Can SM goal setting be effectively deployed and have benefit for underserved patients cared for at CHC? 8/19/10 25
Enhancing Diabetes Care Through Self Management 8/19/10 26
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Impact of the study on practice • All nurses and incoming APRN’s trained in self management goal setting • SM goal setting incorporated into diabetes care and other chronic illnesses • Universal screening for depression • Co-location of behavioral health in primary care 8/19/10 30
Project STEP-ing Out A Collaborative Project between VA Connecticut and CHC Inc. to Improve the Care of Patients with Chronic Pain 8/19/10 31
Practice question #3 • What is the impact of pain on primary care practice • What gaps exist between “best practices” for pain care and our own clinical practice? • How should we design an agency wide pain QI intervention to improve our care of patients with pain? 8/19/10 32
Project Goals – Conduct a formative evaluation of pain and pain management in primary care at a large, statewide Community Health Center. – Adapt the VA Stepped Care Model to meet the needs of CHCI unique settings and patient population. – Study the adoption and implementation of the stepped care model at a non-VA site. – Reduce the impact of pain and suffering on CHC patients – Reduce the community burden of unintended opioid addiction, diversion, and street use 8/19/10 33
Data sources • EHR data • Chart review • Staff surveys 8/19/10 34
Pain Frequency H O W C O M M O N I S PA I N AT C H C A N D W H AT P E R C E N TAG E O F O U R V I S I T S I N VO LV E PAT I E N T S W I T H C H R O N I C PA I N
Adult Pain Scores at CHCI 160000 142089 140000 120000 100000 80000 60000 49834 (35%) 40000 24090 (17%) 20000 10333 (7%) 0 All visits Visits with pain score >=4 Visits with pain score >=8 Visits with NULL pain scores
Average Number of Visits per Patient 16.00 15.03 14.00 12.11 12.00 11.16 10.00 8.00 5.78 6.00 4.00 2.00 0.00 Agency-wide Opioid Cohort Pain >=4 Cohort Chronic Opioid Cohort
Percent Total Visits by Patients in Each Cohort 39% Meriden Medical 18% (n=53460) 5% New Britain Medical 37% 13% (n=43871) 2% Middletown 43% 20% Medical (n=34180) 6% New London 52% 39% Medical (n=24769) Visits in Pain 15% Cohort Clinton Medical 48% 36% (n=11011) 9% Visits in Opioid 25% Danbury Medical 15% Cohort (n=14735) 3% 24% Enfield - Medical 19% (n=14204) Visits in 5% Chronic Opioid 20% Groton Medical Cohort 29% (n=15773) 7% 36% Bristol Medical 20% (n=3792) 4% Stamford Medical 2% 1% (n=3773) 0% Norwalk Medical 2% 17% (n=929) 2% 0% 25% 50% 75% 100%
Knowledge and confidence W E W I L L L O O K AT C H C P R I M A RY C A R E P R OV I D E R’ S S C O R E S O N A PA I N K N OW L E D G E A S S E S S ME N T A N D T H E I R E X P RE S S E D AT T I T U D E S A B O U T PA I N C A R E
Avg CHCI KP50 Baseline Score Comparison (2 Standard Deviations) 250.00 200.00 178 152.49 150 150.00 138 100.00 50.00 0.00 CHCI Providers (n=47) Davis et al. Validation Cohort: Davis et al. Validation Cohort: Davis et al. Validation Cohort: Internists (n=84) Pain Experts (n=22) Academic Physicians (n=27) Max possible score=250
Average CHCI Clinician Attitudes Baseline Survey Score (n=47) 0.00 1.00 2.00 3.00 4.00 5.00 S KILLED CHRONIC PAIN MANAGEMENT IS A HIGH PRIORITY FOR ME . 3.74 M Y MANAGEMENT OF CHRONIC PAIN IS INFLUENCED BY EXPERIENCE WITH ADDICTED 1.15 PATIENTS . M Y MANAGEMENT OF CHRONIC PAIN IS INFLUENCED BY FEAR OF CONTRIBUTING TO 1.36 DEPENDENCE . I HAVE ADEQUATE TIME TO MANAGE MOST PATIENTS WITH CHRONIC PAIN . 1.81 F EAR OF NARCOTIC REGULATORY AGENCIES / ADMINISTRATION INFLUENCES MY 2.04 DECISIONS REGARDING CHRONIC PAIN MANAGEMENT . A NALGESIC SIDE EFFECTS HINDER MY EFFORTS TO TREAT PATIENTS WITH CHRONIC PAIN . 2.17 P ATIENTS I TREAT BECOME ADDICTED TO OPIOIDS . 2.55 I USE AN OPIOID AGREEMENT WITH MY PATIENTS . 4.45 I USE A PAIN ASSESSMENT OR MONITORING TOOL . 3.77 I AM CONFIDENT IN MY ABILITY TO MANAGE CHRONIC PAIN . 2.77 I AM SATISFIED WITH THE QUALITY OF RESOURCES AVAILABLE TO HELP ME MANAGE 1.53 PATIENTS WITH CHRONIC PAIN .
Referrals/specialty support H E R E W E L O O K AT T H E P E R C E N TAG E O F PAT I E N T S W I T H C H R O N I C PA I N R E F E R R E D T O O U T S I D E PA I N - R E L AT E D S P E C I A L I S T S
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