Rick Dell MD

congress.cpb.de

Rick Dell MD

TRANSFORMING MEDICARE CARE DELIVERY

2012 FFN Berlin Meeting , Sept 6-9

Healthy Bones – 10 Steps to Osteoporosis and

Geriatric Fracture Prevention

Rick Dell MD


KP SCAL Healthy Bones

Model of Care

2


AHRQ Innovation Website

AHRQ – Agency HealthCare Research and Quality

http://innovations.ahrq.gov/content.aspx?id=2826


Healthy Bones Model Used The SIMPLE Approach

S – Simple in design

I – Inexpensive to start and maintain

M– Measurable outcomes

P – Pays for itself to make it last

L – Lasts (the program must survive)

E – Evolves with time to survive


Systems Approach – 10 Steps

1. Build a team lead by a champion

2. Set a goal

3. Identify the population

4. Risk stratifies the population – Build work list

5. Work is done by right person at the right time

6. Measure what you did

7. Look for variation and improve by stealing ideas

8. Incentives versus punishments

9. Evolve until goals are met

10. Set higher goals once goals are met


Build a Team Lead by a Champion(s)

Champion(s)

• Tough as nails

• Goal focused

• Works well with a team

• Works well with administration

• Fosters communication

• Get things done


Build a Team Lead by a Champion(s)

The Team

• Goal focused

• They must feel they are part of a team

• Must be competitive

• Must be cooperative

• Know the are part of something much bigger


Set an Achievable Goal

A 20% reduction in the hip fracture rate

In line with the “20/20 Vision” of the

National Bone Health Alliance

We have achieved a >40% reduction in

our expected hip fracture rate in KP

SCAL


Identify Patients at Risk for a Hip Fracture

EMRs – Patients with prior fractures

Clinic visits

In-patient admissions

Emergency room patients

Operating room schedule

Consults

Automate the steps to find fx patients


Old Way - Monthly List


New Way - Daily List

Automatic Data Warehouse Reports

Updates Healthy Bones Web Page


The Work List is updated

daily and is interactive


Work - Done by right person at the right time

Care Managers (RNPs, PAs, RNs)

Work under protocols

“Just in Time” Clinic Visits

Try to off-load work of PCP

Any PCP’s in the audience?

A quick message from our team…

YOUR WELCOME! 21


Systems Approach – 10 Steps

1. Build a team lead by a champion

2. Set a goal

3. Identify the population

4. Risk stratifies the population – Build work list

5. Work is done by right person at the right time

6.Measure what you did


Patient Stratification by Region

Risk Group

by 8/31/10

Region ANT BF BP FON KRN LA OC PC RV SB SD WH WLA

Hip Fx Pts Need

Rx

3,259 114 155 142 361 128 218 330 261 308 155 654 292 141

Osteoporosis Pts

need Rx1 Fx Pts Needs

20,903 586 1,269 1,069 2,701 669 1,650 1,799 1,291 1,383 1,307 3,440 2,762 977

Current DXA

and/or Rx2 17,563 208 1,293 724 1,980 472 1,618 2,044 871 1,659 1,008 3,625 1,124 937

Total 41,745 908 2,717 1,935 5,042 1,269 3,486 4,173 2,423 3,350 2,470 7,719 4,128 2,055

NON-COMPLIANCE Pts by 6/30/103 With Fx

(pre/post Rx)

18,863 417 1,403 1,349 2,180 517 1,507 2,008 1,032 1,296 1,159 2,950 1,890 1,155

Without Fx

(pre/post Rx)

42,337 852 3,716 3,513 4,002 1,145 4,174 4,856 2,406 3,076 2,869 5,376 3,392 2,660

Total 61,222 1,269 5,119 4,862 6,182 1,660 5,681 6,864 3,438 4,372 4,028 8,326 5,582 3,815

NEED DXA SCREENING Pts by 6/30/10

Female 65+ 21,222 373 1,403 903 2,309 426 2,356 2,228 959 1,818 1,480 3,728 1,348 1,891

Male 70+ 20,325 299 1,501 915 1,983 395 2,599 2,062 1,022 1,817 1,220 3,329 1,586 1,597

Total 42,433 672 2,904 1,818 4,292 821 4,955 4,290 1,981 3,635 2,700 7,057 2,934 3,488

1 This category includes patients with a bad DXA score or a diagnosis code of osteoporosis, but no Osteo RX

2 This category includes patients with a fracture, no Osteo Rx and no DXA (2-years prior OR after their fracture date)

3 This category includes patients who have no record of an RX dispensed in the last 180 days; and no current KP code

for RX from outside of KP (7351A)


Healthy Bone Model of Care Performance

Jan-June 2009

Measure 1: 60+ with Fracture, received DXA within 180 days

Measure 2: Bad DXA (-2.5 or less) on Osteo Medication within 180 days

(%)

100

90

80

60

40

20

0

Target 90% for BOTH measures

AV BF BP FON KRN LA OC PC RV SB SD WH WLA Region

60+ FX w/DXA 75.13 72.75 79.18 80.05 82.91 77.65 81.06 85.75 79.12 85.63 73.94 85.53 79.78 79.54

DXA -2.5 or less

w/RX 62.73 72.82 79.21 64.48 75.54 75.68 77.68 75.41 72.11 66.34 78.88 64.54 82.94 73.28


CSG HEDIS- Post FX TX/Women 67+

2008-2010

(%)

100

80

60

40

20

0

1 2 3 4 5 6 7 8 9 10 11 12 13 14

2008 YE 56.9 73.7 77.2 66.7 45.6 69.7 70.4 73.7 67.1 56.4 56.9 74.5 62.7 65.2

2009 Per 1 63.5 75.2 73.9 69.6 49.2 72.3 74.0 76.1 67.1 57.6 65.1 77.2 67.9 67.5

2009 Per 2 65.0 80.4 76.3 70.4 50.0 71.0 73.0 75.1 67.5 58.2 69.3 82.4 70.2 68.7

2009 Per 3 64.4 76.7 76.8 68.9 51.9 70.5 72.2 76.0 67.2 60.0 69.9 82.3 75.6 69.5

2009 Per 4 60.9 81.4 76.4 68.7 59.3 70.0 73.1 73.4 69.8 59.4 74.1 80.3 81.0 70.3

2009 Per 5 54.5 80.8 73.4 72.0 58.2 68.1 74.1 72.0 70.1 55.7 73.1 84.7 79.9 70.6

YE 2009 50.7 78.5 72.6 73.0 61.9 66.5 76.1 71.5 71.4 56.8 76.1 85.8 79.9 70.6

2010 Per 1 44.0 70.9 70.0 67.6 68.0 66.3 76.0 72.0 76.0 54.2 78.5 81.9 76.6 68.9


100.0%

90.0%

80.0%

70.0%

60.0%

50.0%

40.0%

30.0%

20.0%

10.0%

0.0%

DXAs and/or Treatment In Fragility Fracture Patients

65-69 70-74 75-79 80-84 85+ Average

Age Groups

Males

Females


Keep what works/share best ideas

Use ideas that are out there such as:

Other Kaiser Med Centers

Other Kaiser Regions

Geisinger, NOF, NBHA, Surgeon General

IOF, FLS, NHS, and Blue Book

Don’t re-invent the wheel


Outcome and Process Measures

Increase in:

Number of patients receiving DXA scans

Appropriate pharmacologic therapy

Post-fracture patient education

Work ups for secondary osteoporosis

Reduction in:

Incidence of subsequent fractures

Costs due to fractures

Hospital readmissions within 30 days and 1 year

Expected morbidity and mortality


Incentives versus punishments

Maintaining a 5 Star ranking

Staying #1 on HEDIS

New Joint Commission Rules

KP Bonuses


Systems Approach – 10 Steps

1. Build a team lead by a champion

2. Set a goal

3. Identify the population

4. Risk stratifies the population – Build work list

5. Work is done by right person at the right time

6. Measure what you did

7. Look for variation and improve by stealing ideas

8. Incentives versus punishments

9. Evolve until goals are met

10. Set higher goals once goals are met


Sets a Measurable Goal

Sets a Time Frame (2020)

Sets Priority – Reduce Hip Fractures

Make sure the goal is achievable

Others have already achieved this goal

Kaiser has reduced the expected hip

fracture rate by over 40%


Critical Pathways

Identify patients at high risk for hip fractures

using IT Systems

Risk stratify those patients

Start screening those at highest risk

Treat those that need treatment

Track for compliance of the patient

Track for performance of the program


Reset Your Goal To A Higher Level

A journey of constant improvement for

you and your Healthy Bones Team


People

Processes

Technology

Success


AHRQ Innovation Website

AHRQ – Agency HealthCare Research and Quality

http://innovations.ahrq.gov/content.aspx?id=2826


Q&A

Richard.M.Dell@kp.org

41

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