Care by Design™ at University of Utah: Developing and Implementing Care Management, Engaging Patients, and Assessing Cost of Care

Slide Presentation from the AHRQ 2011 Annual Conference

On September 20, 2011, Michael Magill made this presentation at the 2011 Annual Conference. Select to access the PowerPoint® presentation (3.4 MB). Plugin Software Help.

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Care by Design™ at University of Utah: Developing and Implementing Care Management, Engaging Patients, and Assessing Cost of Care

Michael K Magill, MD

Professor and Chairman
Department of Family and Preventive Medicine.

University of Utah
School of Medicine and Community Clinics.

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Primary Care Practice Redesign—Successful Strategies

AHRQ Grant #1R18HS020106

Michael K. Magill, MD, Principal Investigator.

Images: Photographs of two road signs, one reading "Work In Progress," the other, "Caution: Work In Progress."

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Implementation and Research Team

  • Tatiana Allen.
  • Julie Day, MD.
  • Timothy Farrell, MD.
  • Karen Gunning, PharmD.
  • Teresa Hall, PT.
  • JaeWhan Kim, PhD.
  • Michael Magill, MD.
  • Annie Mervis, MSW.
  • Ruth Murdock.
  • Debra Scammon, PhD.
  • Andrada Tomoaia-Cotisel, MPH, MHA.
  • Norman Waitzman, PhD.

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11 Community Clinics

Visits (FY11): 317,000

Active patients: 157,000

Images: A map of Salt Lake City and photos of community clinics are shown.

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Image: A book titled Care by Design is shown.

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Care by Design™—Early days

  • Appropriate Access—2003:
    • Balance visit supply and demand.
    • Standardized schedules.
  • Care Team—2004:
    • Expanded MA role.
    • Providers and MAs working in teams electronic medical record (EMR) tools (BPAs, Xfiles).
  • Planned Care—2006:
    • Protocols, order sets.
    • Pre-visit planning, labs.
    • Registries.

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Care by Design™—Moving Forward

  • Care Management Program for patients with chronic diseases:
    • Embed care managers in clinics.
    • Facilitate clinical care.
    • Coordinate care.
    • Promote patient self-efficacy and self-management.
  • Transitions management.

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Care Managers

Image: A graph displays the following in a series of concentric circles:

  • Environment:
    • Compensation System.
    • Institutional Priorities.
    • EMR.
  • Macro Team:
    • Appointment/Message Call-Center.
  • Expanded Team:
    • Clinical Pharm.
  • Care Team:
    • Visit.
    • NonVisit.

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Care Managers

  • Multidisciplinary backgrounds:
    • Social Work, Nursing, Healthcare Administration, Health Education, Hospice, Chaplain.
  • Formal training in care management techniques and motivational interviewing.

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Selection of Patients for Care Management

  • Data driven:
    • Patients with diabetes, heart failure, coronary artery disease.
    • Age of patient.
    • Last appointment.
    • Next scheduled appointment.
    • Last 3 Hgb A1c.
    • Last 3 LDL.
    • Last 3 Blood Pressures.
  • Provider referral.

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Care Management Program

  • Assessment Tools:
    • Patient Activation (PAM).
    • Quality of Life (RAND36).
    • Depression Screening (PHQ9).
  • Motivational interviewing.
  • Individualized patient self-management goals in EMR.
  • Self-monitoring tools via EMR patient portal ("MyChart").
    • Blood glucose, blood pressure, exercise, weight.

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Patients Participating in Care Management

Number of Patients by Number of Visits
Mar-Aug 2011

Image: Bar chart presents the following data:

  • 1 visit, 149.
  • 2 visits, 54.
  • 3 visits, 15.
  • 4 visits, 9.
  • 5 visits, 4.
  • 6 visits, 3.

n=234

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Transitions Management

  • Objective: prevent unnecessary readmissions.
  • Focus: Inpatient → outpatient.
  • Population: Community Clinics patients recently discharged from University of Utah Hospital.
  • Mechanism:
    • Daily electronic registry generated from EMR.
    • Care managers call recently discharged patients listed on this registry.

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Key Transitions Questions

  • How feeling since discharged?
  • Questions you have that�were not answered?
  • Changes to medications (while in ED/hospital)?
  • Who is primary care provider?
  • Follow-up appointment with this provider?
  • Do you know danger signs to indicate you need to return to hospital/call doctor?

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Patients Participating in Transitions Management

Image: Bar chart presents the following data:

  • Total Discharges, 641.
  • Calls to Eligible Patients, 230.
  • Contacts, 196.

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Care Management: Notes From the Field

  • "Mr. RR was able to finally admit that he has difficulty with Drs and being able to understand teaching that is provided. He says that Drs use 'all those big words' that he does not understand. He expressed an appreciation for me explaining cholesterol, diabetes complications and HgbA1C lab results."

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Care Management: Notes From the Field

  • "Ms ZZ seems to deal with her anxiety and stress about her husband's condition by monitoring all his intake. This causes stress between them. Ms ZZ had a misunderstanding about some things the patient should or should not eat. They were both receptive about going to the Diabetic Nutrition Class."

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Care Management: Notes From the Field

  • "Mrs. CCC seems motivated and is ready to go. She reports that she has already made changes in her diet. After setting a goal and making a return appointment, she said 'I'm excited.'"

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Plan: Measures of Success

  • Patient activation score:
    • Patient Activation Measure (PAM).
  • Patient outcomes:
    • Patient functional status (RAND36), clinical quality, address depression (PHQ9).
  • Patient experience:
    • PCMH CAHPS® pilot survey.
  • Cost
    • ED visits, hospitalizations and readmissions.

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Care Management: Plan to Assess Impact on Utilization and Cost

  • Data—patient level linkage to...
    • Medicare and All-Payer data from 2007-2012.
  • Outcomes—Utilization and Cost:
    • Inpatient Care.
    • Outpatient, home health, nursing home.
    • Prescription Drug.

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Delivery Systems Research: Challenges

  • Clinical Operations vs. Research:
    • Relationship-building: care manager role, patient consent.
    • Data needs are different.
    • Business decisions and environmental events affect implementation.
  • Institutional Review Board (IRB), Health Insurance Portability and Accountability Act (HIPAA):
    • Access to PHI.
    • Linking PHI to external data.
Page last reviewed March 2012
Internet Citation: Care by Design™ at University of Utah: Developing and Implementing Care Management, Engaging Patients, and Assessing Cost of Care. March 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/conference/2011/magill/index.html