The system is brokenWould you hire a package delivery company that:
You probably wouldn't stay in business long if this was acceptable to you. But that is the reality of health care in America, said Jonathan Ater, keynote speaker at the third annual CareOregon CSSI Conference, October 11, in Portland. Ater is senior partner and chairman at Ater Wynne, LLC; and vice chair of the Oregon Health Fund Board.
Ater listed five problems that need to be addressed simultaneously to fix health care: 1. Allow everyone to get the health care services they need when they need it. Share the risk of costly medical care over the entire population. Most Americans who have insurance now still could not handle major problems. In 2004 and 2005, half of the personal bankruptcies in the U.S. stemmed from medical costs of people who had insurance. 2. Change the way health care services are delivered from the current practice that focuses on short encounters with medical people when we are sick. “Many of the players in the current system are making substantial profits from the built-in inefficiencies of the current system,” he said. 3. Integrate financing and care systems for mental and physical illnesses. “Most health care dollars are spent providing care to chronically ill individuals, many of whom have both physical and mental health issues,” he said. Even those with insurance for mental illness have no coverage for social work and case management support that can keep them healthy. 4. Use modern information and diagnostic technology to take better care of people and help them take better care of themselves. “In our current financial model, providers don't get paid for the better outcomes resulting from the judicious use of technology,” Ater said. “They get paid for each use of the equipment, whether productive or not.” 5. Commit to making our lives healthier. “No system, doctor or government agency can mandate that we change our individual or collective lifestyles. But, there are things we can do in a shared way to reduce tobacco usage, change our eating and shopping habits, and improve dental health,” he said. It is more likely that substantive change will come from the states rather than the federal government, Ater said. That’s one reason the innovation represented by the CSSI programs are so important. “The people in this room are really the people who are driving health care reform at the grass roots level in Oregon,” Ater said.
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Fixing health care: Patients are the winners at CSSI Conference
In October, participants shared the results of their 2007 efforts at the Oregon Convention Center at the third annual CareOregon (CSSI) Conference. Teamwork was a common mechanism to help reach the CSSI goal: “to foster a culture of evidence-based practice and continuous improvement in CareOregon provider organizations.” In three years, CSSI has had an impact on 48 organizations and on CareOregon itself. “This program has really changed the company, the way we think about change and improvement, and the way we think about business,” said Patrick Curran, CareOregon Medicare Director. Primary Care Renewal process and progressIn 2007, CareOregon and five partner organizations made an effort to connect the fragmented parts of primary care through Primary Care Renewal (PCR). PCR is a way to integrate preventive, chronic and behavioral health care with acute care in a holistic way, said David Labby, MD, PhD, CareOregon medical director. It is a method to change the common care pattern, where everything flows through the physician, to a division of labor among the care team. Representatives from the six inaugural PCR clinics discussed some of the lessons they learned during implementation of Primary Care Renewal. Several themes were common: Without leadership, change will not happen, said Maryna Thompson, who spoke for Legacy Clinic Emanuel. Support from leaders is critical because significant change requires such a major commitment by the team. Primary care renewal takes time, said Susan Kirchoff, RN, of Multnomah County Health Department. Two Multnomah County clinics—the HIV Health Services Center and Mid County Health Center—adopted the PCR program just last summer and are now in the early stages of change. “You can’t just drop system change on top of everything else,” she said. “It’s like living in a house while you are remodeling it.” Communication with the entire organization is crucial, said Ted Amann, Director of Health and Improvement at Central City Concern’s Old Town Clinic. Buy-in from all levels of the organization is critical, and priorities can change when input is welcomed. “I have a lot of ideas about improvement,” he said, “but it turns out there were other things that were much more important to the people on the ground.” Use data to drive change, Amann added. Old Town Clinic has learned to measure many things, use what they can, and stop gathering what they can’t use. At one point, the clinic tracked weather patterns to see if they affected the no-show rate. They found no correlation, so stopped gathering weather reports. However, the clinic was able to free time for its PCR provider using the data she collected on the quantity and quality of interruptions.
Teamwork is more effective than going it alone, said Lynn Jacobs, MD, of Virginia Garcia Memorial Health Center’s Cornelius Clinic. As a doctor in a small clinic, much of the load under the old system fell on her shoulders, she said. Now her load has been lightened by the PCR team, and they have the time to look proactively at preventive care for whole populations, such as all patients with hypertension, or all adolescents. Teamwork helps build patients’ trust in providers, said Ann O’Connell of Oregon Health & Science University’s Richmond Clinic. The Richmond Clinic’s PCR team practices a “warm handoff” when a patient meets with both the primary care provider and a behavioral health consultant. “Contact with the provider is much better than coming in cold to engender trust,” she said. The power of teamworkNoontime presentations by three different types of health care providers focused on the role of teamwork in quality improvements. Comprehensive Options for Drug Abusers (CODA), Inc., added a case manager at its Portland outpatient medication-assisted treatment program. The goal was to link clients with primary health care as they enter the program. The case manager also works to improve clients’ participation in treatment by addressing their needs for transportation, employment and housing. Since Case Manager Kevin Brown joined the team, fewer clients have no primary care providers, and the percentage of clients who successfully participate in four treatment sessions within 30 days of enrollment has more than doubled. Community Health Center in Jackson County added exceptional needs care management to its care management teams. The program started with 20 patients with diabetes at one clinic, said Ginger Scott, RN, BSN. It has expanded to 159 patients and plans to expand to two of the health center’s three clinics. While it’s too early for statistically significant data, she said, early progress toward clinical benchmarks show a positive trend.
Tuality Healthcare wanted to reduce mortality for patients hospitalized for congestive heart failure (CHF) and acute myocardial infarction. An effort to reduce “door to balloon time— the interval from patient arrival to inflation of the balloon catheter within the patient's blocked artery—involved a large team, including the emergency department, nursing staff, cardiology, pharmacy, and the cath lab, said Vincent Reyes, MD. Before the CSSI project, Tuality had a mean door-to-balloon time of 110 minutes. The CSSI project included analysis and improvement of 17 separate steps in the process. Now the mean door-to-balloon time is 81 minutes. That's well within the 90-minute quality-of-care benchmark set by the American College of Cardiology and the American Heart Association. The importance of culturally competent careTwenty-one organizations presented reports in break-out sessions, including several that touched on the importance of providing care appropriately for an increasingly diverse population. Yakima Valley Farm Workers Clinic, which has primary care facilities in Portland, Salem and Hermiston and at Salud Medical Center in Woodburn, reported that adoption of the “Tomando Control de su Diabetes” course has increased participation in diabetes self-management by Spanish-speaking patients. Tomando is developed specifically for people from Spanish-speaking cultures, rather than utilizing material translated literally from English. The classes are led by lay leaders from the community. As a result, the community has been more accepting and participation is greater than with prior efforts. “In teaching the Tomando classes, you really see them make changes,” said Sue Plaster, the project director. “And that’s really cool to me.” |
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Since 2004, CareOregon has worked through its Care Support and System Innovation (CSSI) program to partner with provider organizations and explore new ways to improve the health care delivery system.
