Promote Institutional Change for Sustainability
CHA built its Planned Care Program "not by creating new jobs, but by showing the staff we had already, how to do their jobs better," according to Gray. To institutionalize the program, CHA redesigned its work flows and developed the resources and systems, such as the electronic registry and medical records system, to make it easier for staff to deliver the quality care the program was designed to achieve. CHA expanded the patient care team to include the IT staff, empowering them to take a more active role in care delivery. By integrating the IT function, CHA created the organizational design that made delivering the Planned Care model feasible and sustainable. CHA also increased its effectiveness by expanding the care team to include the patients themselves. CHA insists that patients have AAPs that get updated regularly. This approach creates efficiencies and savings because it promotes better patient self management.
The patients are the ones who sustain their level of care and CHA has seen those changes reflected in population level data. Gray says, "we have been able to sustain our results because this program is so integrated into the operations of CHA and is not an add-on. Looking at monthly data for last month compared to a year ago, you see that it is flat. In other words, we have been able to hold our results constant. That's because we built the infrastructure to support and sustain our improved outcomes."
CHA recognized that childhood asthma was a major problem in its community and looked for a proven model to help reduce the burden. With grant support from the Robert Wood Johnson Foundation (RWJF) and help from the Institute for Healthcare Improvement, CHA built the infrastructure, including an electronic asthma registry, to implement the Planned Care for Childhood Asthma Model.
INTEGRATED HEALTH CARE SERVICES--FACILITATE COMMUNICATION ACROSS THE CARE TEAM
CHA's asthma registry is a highly effective communication tool that links schools, clinics, hospitals, outreach workers and other members of the care team in real-time conversations about children with asthma in their program.
Ensure Mission-Program Alignment
CHA is a mission-driven organization that puts performance improvement at the center of its work. When building the asthma program, CHA focused on the Institute of Medicine's (IOM) aim of delivering safe, timely, effective, efficient, equitable and patient-centered care. CHA staff embodies the organization's mission and commitment to the IOM's standards, so Planned Care for Childhood Asthma was a natural fit for the staff. The Planned Care model is designed to achieve high-quality health outcomes: the same common goal of all CHA programs.
Collaborate to Build a System that Will Last
CHA clinical staff collaborated with a wide variety of players, including politicians, local government officials, health plans, school nurses and other hospitals on the Planned Care work. This collaboration ensured program sustainability. For example, school nurses are part of the asthma care team and are connected to the asthma registry, so they can see patient asthma history, report on care delivered at school and provide a link for providers to one of the environments in which pediatric asthma patients spend their time. The public health department, also connected through the registry, supports Healthy Homes visits for patients referred by CHA and reports findings in the registry to share information with the providers.
CHA operates a pay-for-performance model for its providers. Financial incentives for physicians and clinical staff encourage attention to all of the asthma registry elements, including severity classification, appropriate medications, environmental home visit referrals and completion of individualized asthma action plans (AAPs). The registry produces monthly reports, which are sorted by provider and clinical care site and highlight gaps in compliance with evidence-based guidelines. Every provider team in the system receives an individualized report with the names of patients who are "not in compliance with guidelines" showing up in red ink at the top of the page. Financial performance incentives help ensure that providers pay attention to the red ink and proactively manage their patients who are not "under control."
CHA's care team can refer children living in Cambridge or Somerville to the Cambridge Public Health Department's Healthy Homes Program for home visits. A full-time nurse and one staff person manage the Healthy Homes Program to ensure that referred families receive prompt and comprehensive home visits.
COMMITTED LEADERS & CHAMPIONS--USE OUTCOMES DATA TO PROMOTE CHANGE
The team of Dr. Link and Laureen Gray, RN, insist on a "relentless commitment to evaluating outcomes" to drive quality improvement. They talk about the importance of outcome measures to successful program planning and implementation whenever they get the chance.
Evaluate Program Implementation
Dr. David Link, the Chief of Pediatrics and Laureen Gray, Program Director of Cambridge Health Alliance's Planned Care Program, spearheaded the RWJF-funded effort to develop an electronic patient registry. During 2005-2006, the CHA Information Technology (IT) Department deployed an electronic medical record (EMR) that could download critical information into the registry, thus avoiding the need for double data-entry. This integration of the EMR and the registry developed by the IT Department has been key to sustaining the work and achieving the dramatically improved outcomes. With the click of a button, the registry allows everyone involved with CHA's Asthma Program to see outcomes on inpatient stays and ED visits for children with asthma. Program partners, including school nurses, pediatricians, allergists and Healthy Homes staff, can view asthma information online and immediately see trends in health outcomes and quality of life indicators. CHA uses the registry data to drive program improvement and demonstrate to staff the health outcomes related to their efforts. The system also allows clinical teams to compare their results with other teams and identify areas in which they can improve. The data-driven process delivered remarkable results: a 45% decrease in inpatient admissions and a 50% drop in annual asthma-related ED visits for patients enrolled in the program for two years.
The IT infrastructure at CHA enables the program leaders to monitor their outcomes continuously so that even the slightest slippage in ED visits, for example, can immediately be identified and corrected. The data-driven culture at CHA not only allows the Planned Care Program to drive consistent care delivery across its provider network, but it also allows CHA to sustain its remarkable health outcomes over time: CHA has held hospitalizations for children with asthma to 2-3% per year and annual ED visits for asthma to 6-8% for 4 years in a row.