The Alliance to Reduce Disparities in Diabetes
http://ardd.sph.umich.edu/
The Alliance is working to improve communication between patients and health care providers. Effective communication among providers, patients and their family members is a critical component of efforts to promote optimal care outcomes, enhance prevention and management of diabetes and reduce disparities in care.
The Merck Company Foundation launched the Alliance to Reduce Disparities in Diabetes in 2009 to address the growing problem of health care disparities in Type 2 diabetes in the United States among low-income and underserved adult populations. Through this Alliance, the foundation supports comprehensive, multifaceted, community-based programs to improve health outcomes for people living with diabetes in five grantee communities: Camden, New Jersey; Chicago, Illinois; Dallas, Texas; Wind River Reservation, Wyoming; and Memphis, Tennessee. These sites are working to change the systems and policies related to diabetes management and prevention in their communities.
This presentation has three objectives: To develop a common understanding of what is meant by “policy and systems change” Provide some examples of policy and systems change efforts currently underway around the country ; and Facilitate discussion and peer-to-peer learning.
For the purposes of the Alliance work, what do we mean by policy and policy change?
First, we make the distinction between two kinds of policy: public and organizational.
Public policy is: A set of agreements about how government will address society’s needs and spend public funds that are articulated by leaders in all three branches of the government and embedded in many different policy instruments (for example, laws and regulations)
Organizational policy is: A set of written rules and policies that govern behavior and practice within an organization, business or agency.
Routine practices, cultural norms, customs, and unwritten agreements about behavior are not policy, but can influence and be influenced by policy Example: It may be a custom or normative practice in a clinic that a receptionist greets and welcomes a patient and refers to him/her by name. “Hello Mr. Jones. Good to see you.” This practice is common but its not written down anywhere. For the purpose of this webinar, we will focus on formal policy change (rather than customs and practices) and look specifically at organizational policy examples rather than public policy examples.
What is organizational policy change? It’s the creation of new written policies or rules or a change in the current policies or rules of an organization. The change is generally agreed upon by a decision-making body or by an individual in a leadership position.
Now, for the purposes of the Alliance work, what do we mean by systems and systems change?
A system is a group of independent but interrelated and interacting elements–individuals, institutions and infrastructure–that form a unified whole. For instance, the health care delivery system is a large and complex system with many interacting components that affect our health and well-being. There are doctor’s offices, clinics, hospitals, health departments, pharmaceutical companies, insurers etc. that combined comprise the health system. Other systems also affect our health, such as the food system.
Systems are not static entities. They are constantly changing and evolving. So what does it mean to talk about systems change? Systems change occurs when one or several elements in a system, change, altering both their relationship to one another and the overall structure of the system itself. In addition, change in one system can effect change in other systems.
There are a number of ways in which systems can change. Changes in new or existing policies, organizational practices, social and cultural norms and changes to infrastructure all have an impact on systems.
What is the relationship between policy and systems change? Policy change is an important driver of systems change and will help to ensure the sustainability of the changes over the long-term. By setting anew policy the practices and relationships within and between organizations change.
Now I’d like to talk about some examples of organizational changes going on around the country related to diabetes management, education and prevention. Health care organizations around the country are experimenting with new and innovative approaches to diabetes management.
One such example is in the rural Pee Dee region of South Carolina. CareSouth Carolina is a community health center that has grown from a small, one-physician office to a regional health provider serving more than 35,000 patients at nine different medical centers. Despite this growth, CareSouth has remained committed to it’s community-based approach to health care and has been recognized by the Institute for Healthcare Improvement for its innovative approach to diabetes care. While CareSouth has adopted many changes to their health care delivery system over the last several years, the change that we are going to discuss is their implementation of a “health care team approach”.
The team approach consists of a care manager, behavioral health counselor, nurse and a physician. While the physician remains a strong partner in the team, CareSouth added care managers to the team and enhanced the roles of nurses and behavioral health counselors in caring for diabetes patients.
CareSouth added a new member to their traditional doctor/nurse team – a care manager. A written job description was drafted and the health center’s Board of Directors had to approve the new position. One challenge was that the new position required additional funding, so the Board had to allocate funding for the new position. In order to persuade the Board to make this change, the CEO of CareSouth used a business model plan to show that adding care managers would mean that the Center could increase the number of patients seen and this would offset the additional cost. It worked and the funding was allocated. This change meant that the health care team is now able to spend more time with patients. Care managers meet with patients individually to provide prevention and self-management education and help with individual goal setting. Care managers also hold group classes for diabetes patients and are able to get to know patients.
In this new team approach, nurses have an expanded role that allows them to order lab tests, refill medications and adjust insulin doses. According to the CEO of CareSouth, this has made patient office visits much more efficient. CareSouth implemented this change by creating a series of standard written “standing orders” from physicians for things such as drawing blood, ordering lab tests or EKGs, and refilling medications. Creation of the standing orders had to be approved by the chief medical officer at CareSouth, which was not difficult, according to the CEO because the Chief Medical Officer realized that the change would save physicians time and make the process much more efficient. All procedures and guidelines for creating and implementing these new standing orders were documented in the Center’s Clinical Manual of written policies and procedures.
CareSouth also integrated behavioral health counselors into the regular care of patients. While counselors were available to patients before on a pre-scheduled basis, CareSouth integrated same day, same location behavioral health counseling services for all patients. Having a counselor available to patients when they come in for other appointments and on an as needed basis, has made all the difference according to CareSouth. They did this by adopting a 45/15 appointment scheduling rule that requires all on-site health counselors to keep the first 15 minutes of every hour open and available for patients with immediate counseling needs. The health counselors are licensed, maters-level social workers with experience working with patients on issues related to depression and problem solving. This change took the form of a written appointment rule change and was documented in the Center’s Clinical Manual. Also, the job description for the behavioral health counselors was revised to include the 45/15 model. The CEO of CareSouth approved this change. Since it was not considered a new formal policy per se, but rather a change in practice and procedure, the Center’s Board of Directors did not need to approve.
CareSouth clinicians have reported that implementing the “team approach” has improved health outcomes and helped to reduce disparities among patients. Before the “team approach” was implemented only 15% of patients had A1c Hemoglobin levels under control with a measurement of 7 or less. Today 54% of diabetes patients at CareSouth have levels of 7 or less. In addition, the “team approach” has helped them move toward their goal of 0% disparities in hemoglobin A1c levels. Currently, their disparity level measures 6%, indicating that A1c levels are about 6% higher in non-white populations than white populations. Although CareSouth has not yet reached their target, their level of 6% is vastly better than surrounding rural communities which experience disparities at a level of approximately 100%.
The next example we will discuss includes recent changes implemented at St. Peter Family Medicine Clinic in Olympia, Washington. St. Peter is one of 14 family medicine programs affiliated with the University of Washington and is one of the Robert Wood Johnson Foundation’s Diabetes Initiative grantees. With funding from the Foundation’s Diabetes Initiative, St. Peter was able to redesign their diabetes care.
St. Peter now offers three different types of non-traditional medical office visits along with the more traditional 1-on-1 patient/doctor visit. These include: planned visits, mini-group medical visits and open office group visits.
“ Planned visits” between a medical assistant and patient serve to prepare both the patient and physician for their scheduled visit in the following 1-2 weeks. Medical assistants initiate lab testing, routine measurements, and goal setting at the “planned visit” in order for the results to be ready for the traditional physician-patient visit. This change required that explicit standing orders be created for the medical assistants to follow during these visits in a sort of “cookbook “ fashion. The creation of “planned visits” redefined the role of medical assistants and added new protocols and curriculum to their training. Despite apprehension, the staff at St. Peter’s reports that after a period of adjustment, the medical assistants became comfortable with the new responsibilities and many report higher job satisfaction now.
St. Peter also implemented “mini- group” medical visits as an option to replace the traditional office visit with a physician. “Mini-group” visits involve 2 or 3 patients meeting at one time with a doctor and a medical assistant for a longer visit, allowing more opportunities for patients to question their health care provider and to share experiences with one another. “ Mini-group” visits include discussion of medications, hemoglobin levels, blood pressure and other health measures. The cohort of patients are offered the opportunity to schedule follow-up “mini-group” sessions, and many times patients develop ongoing supportive relationships. Patients participating in the “mini-group “ visits were required to sign HIPAA- compliant patient confidentiality forms agreeing not to share the health information of other patients. According to clinic providers it was very important to make sure it was all HIPAA compliant. And, of course, the clinic manual had to be changed to reflect these new policies and procedures.
An additional option for patients is an “open office group” visit which includes 7 to 12 patients at one time in a 2-hour session that is coordinated usually by 1 or 2 physicians, medical assistants, and nurses. This structure provides patients with the opportunity to ask questions and talk openly with each other. An extensive training curriculum was developed by St. Peter’s to prepare their physicians for the counseling role of “open office group” visits. Not all physicians at St. Peter are willing to lead these group visits, but they are all willing to refer patients into the group visits . The changes required approval by the Chief Medical Officer.
At St. Peter the policy changes came AFTER they were able to show positive outcomes from a small pilot project undertaken by one physician and one medical assistant. Their aim was to show small, rapid, cycle improvements . These improvements provided convincing evidence for a clinic-wide change to the office visit structure. Given the scope of the project, the clinic-wide change took close to 5 years to fully adopt and implement.
After they were able to show these initial positive outcomes they had to get buy-in from the clinic’s medical director to move forward with larger scale clinic-wide changes. After they had this, they began discussing these changes with their Organizational Operations Committee or OOC committee. This is a leadership committee made up of doctors and nurses that meet weekly and set the policy for the clinic. While there was not a formal process of voting on the policy changes related to office visits, they had to go slowly and could only move forward when they had consensus from this group.
St. Peter found that changing their office visit structure did make a difference. Survey data showed that patients felt well-cared for, better supported and more successful and confident. Medical assistants reported gaining knowledge and confidence and increased job satisfaction. Physicians reported becoming more comfortable with providing self management support.
The changes also yielded some positive health outcomes. They found that patients participating in group visits were more likely to have lower A1c levels than other clinic patients and they were more likely to have greater A1c reductions. They also found significant reductions in LDL cholesterol levels for patients participating in planned visits.
Belinda
Belinda
The changes also yielded some positive health outcomes. They found that patients participating in group visits were more likely to have lower A1c levels than other clinic patients and they were more likely to have greater A1c reductions. They also found significant reductions in LDL cholesterol levels for patients participating in planned visits.