An Extension Program for Primary Care James W. Mold, MD, MPH Department of Family and Preventive Medicine University of Oklahoma Health Sciences Center.

An Extension Program for Primary Care

James W. Mold, MD, MPHDepartment of Family and Preventive

MedicineUniversity of Oklahoma Health Sciences

Center

Disclosures and Disclaimers

As the vision I’m going to present becomes reality, I plan to obtain funding from a variety sources to participate in its development.

However, at present I have no financial conflicts of interest to report.

The Patient Protection and Affordable Care Act of 2010

2074 pages; 9023 Sections

Section 5405: Primary Care Extension Program

Section 3502: Establishing community health teams to support the patient-centered medical home

Section 4201: Community transformation grants Section 5403: Interdisciplinary, community-based

linkages

Health Care Reform: Explore

Regarding Babies and Bathwater

Talking Dog for Sale

www.okprn.org

The Oklahoma Physicians Resource/Research Network (OKPRN)

The Oklahoma Physicians Resource/Research Network (OKPRN)

Founded in 1994 as joint project of the OAFP and the OU Department of Family Medicine

220 primary care clinicians in 140 separate practices throughout Oklahoma

501c3, not-for-profit charitable organization Contracts with the OU Department of Family

and Preventive Medicine for administrative and methodological support

So far, > $5 in external funding to support network projects

OKPRN MissionOKPRN Mission

To improve the primary health services To improve the primary health services available to Oklahomans available to Oklahomans by developing and by developing and sharing resourcessharing resources and conducting relevant and conducting relevant practice-based research.practice-based research.

OKPRN Clinical StudiesOKPRN Clinical Studies

Use of e-mail and the internet by primary care patients in Oklahoma

Epidemiology, prognosis, and management brown recluse spider bites

Prevalence, causes, and consequences of night sweats Prevalence and consequences of peripheral neuropathy

in older primary care patients Reasons older Oklahomans change primary care

physicians Reasons primary care clinicians don’t always follow ADA

guidelines for BP control in diabetic patients Natural history and management of poison ivy

Okarche, OK circa 1999

The QIO keeps sending me performance reports showing how bad I am doing. That really doesn’t help me. If they would just tell me who is doing it well, maybe I could call them and find out how they do it. Mark Gregory, M.D.

Best practices Research

Almost every primary care clinician has discovered something that other clinicians would like to know about. (We are all researchers.)

Identification, description, and combination of the most effective and efficient principles, techniques, and scripts being used effectively/efficiently in practice

Best Practices Projects

Pneumonia vaccinations Management of lab test results Management of patients with diabetes mellitus Management of prescription refills Reduction and management of no-shows Delivery of adult preventive services Maximizing rate and quality of well child care Helping patient lose weight and keep it off

Bottom up or Top Down?

Push - Pull

Push - Pull

Push – Pull

Delivery of Preventive Services

Recall and reminder system (PSRS) Standing orders Wellness visits Prevention nurse Case management - outreach Wellness portal (personal health record) Health risk appraisal tool

Performance Feedback

Academic Detailing

Facilitation

IT Support

Local Learning Collaboratives

Practice Enhancement Assistant

Research Results and Local Best Practices

Implementation of Innovations in Primary Care

Challenges

Little infrastructure other than in OKPRN and other networks or large health systems

Expensive Time Travel

Disconnected Availability of assistance may not correspond with readiness to

participate Too little long term follow-up and reinforcement

Non-strategic Involved practices may not be “opinion leaders” so innovations

may not diffuse optimally

“Innovations” Awaiting Broader Dissemination and Implementation

Collaborative care models involving primary care and mental health care

Care management embedded within primary care Open access scheduling Cluster and group visits E-visits, e-consultations, HIE, and telemedicine Home sleep testing Automated and internet-based support for healthy

behaviors and chronic disease management Health risk appraisal – directed preventive services

Clinical Knowledge and Skills that Need Broader Dissemination

Diagnosis and management of chronic hepatitis B and C Recognition, diagnosis, and management of obstructive

sleep apnea Cognitive screening and diagnosis of cognitive problems Office pulmonary function testing Aggressive management of congestive heart failure Diagnosis and management of urinary incontinence Management of chronic pain patients Management of morbid obesity

Rural Oklahoma

Piedmont Family Care (The Cormans)

Cooperative Extension

Cooperative Extension 1796: George Washington proposed an office to

promote evidence-based farming 1810: First agricultural journals

Few farmers read them 1862: Land-Grant College Act

Enrollment slow Farmers thought their children could learn better by doing than

by studying, and they were needed on the farms Little to teach because little relevant science; mostly taught farm

operations 1882: Hatch Act established funding for “experimental

farms” Local in order to conduct experiments under local conditions Exposed students to research and researchers to local farmers

Cooperative Extension 1889: Dept of Agriculture began issuing Farmers’

Bulletins and the Yearbook of Agriculture; experimental farms issued research and “popular” bulletins Publications reached small proportion of farmers, many of whom

distrusted “book farming” 1880 -1911: Establishment of “farmers institutes” and

“mobile institutes” to reach more farmers 1906: S. A. Knapp (Terrell, TX) hired the first county

extension agent to demonstrate evidence-based methods and spread them throughout the county through personal relationships and direct assistance

Rasmussen WD. Taking the University to the People, Iowa State University Press, 1989

Gawande A. Testing, Testing. In The New Yorker, Dec 14, 2009

Farmers Market

The Importance of Local Control Health and health care improvement

initiatives are more likely to be successful if they are managed locally. Local challenges Local resources Local relationships Local personalities and politics

Centralized QI efforts are inefficient and largely ineffective. Performance reports, admonitions, and printed

guidelines that go in the circular file

Primary Care Extension

PBRNCBPR

Parks &Recreation

HospitalPublic Health

Schools

Primary Care

MentalHealth

Extension Center

University/AMC

1. Quality Improvement/Practice Transformation

2. Patient-Centered Medical Home

3. Accountable Care organizations

4. Health Improvement Coalitions

5. Research and Development Engines

CareCoordination

Payers

Sub-specialists

Productive [push-pull] Interactions

Informed Activated

Community

Prepared Proactive

Research Team

Improved Population Health

Dissemination/Implementation Infrastructure

External Research Resources and

Policies

Community Cohesiveness and Priorities

Advisory Board Needs Assessment Education/Training Rewards/Incentives Fiscal Entity (e.g. 501c3)

Population Health

Mission

Rules of Engagement

Coordinating Center Prioritization Education/Training Rewards/Incentives

Longitudinal Respectful

Evidence-Based Knowledge

Relationships

Community Test Sites

Try it. You’ll like it!

Funding

Stable infrastructure funding Federal government (?also state, local govt.?) Insurance companies Miscellaneous (contributions, local industries, etc.)

Project-specific funding Public health (CDC, OSDH, etc.) Dept. of Defense (preparedness, surveillance, obesity,

etc.) Foundations (demonstration projects) Research (NIH, AHRQ) Manpower development (HRSA, etc.)

Plenty of Project-Specific Funding

Few Receptor Sites

Care Management

When Medicare decided to fund 15 care management experiments across the country, they chose not to collaborate with primary care practices.

Instead, they funded private care management companies (e.g. Life Masters).

Largely because of the lack of integration with primary care, 13 of the 15 the experiments failed to improve quality or reduce cost

Preparing for Pandemic Influenza

In 2006 and 2007, the CDC distributed around $200 million to state departments of health to prepare for pandemic influenza.

Guidelines and toolkits were prepared to help primary care practices.

However, practically none of the money and no assistance made it into primary care offices where most of the action will take place in an epidemic.

Dissemination/Implementation of Asthma Guidelines

We recently received a $1.7 million grant from the National Heart, Lung, and Blood Institute to study ways to implement their most recent asthma guidelines in 48 practices in Oklahoma and western New York.

We have received more than $8 million in grants and contracts for similar projects (limited mainly by manpower to write grant applications and run projects).

Evidence for “Traction” Payer and Academic Health Center Initiatives

Community Care of NC (Medicaid and Medicare) Oklahoma Health Access Networks (Medicaid) Vermont’s Community Health Boards (all payers) The Health Extension Program in New Mexico NIH Clinical and Translational Science Awards

Health Information Technology Extension Oklahoma Foundation for Medical Quality

U.S. Senate health care reform legislation $120 million proposed funding for “Primary Care

Extension” 10 states initially plus planning grants

HIT Extension and HIE

American Recovery & Reinvestment Act of 2009 Health Information Technology Extension

(HITECH) Oklahoma Foundation for Medical Quality

State Level Health Information Exchange OK Health Information Exchange Trust

HIE

HIE HIE HIE

HIE HIE HIE

HIE

501c3

501c3501c3501c3

501c3 501c3 501c3

501c3

Statewide HIE Backbone

HIT Decision Support Applications

Health Information Exchange

Let’s go for it!

References Grumbach K and Mold JW. A health care cooperative

extension service: Transforming primary care and community health. JAMA 2009; 301(24): 2589-2591

Scutchfield FD. The cooperative medical extension program: Translation of medical best practices to practicing primary care providers. Am J Prev Med 2009; 37(4): 374-376

Kaufman A, Powell W, et al. Health extension in New Mexico: An academic health center and the social determinants of disease. Ann Fam Med 2010; 8(1): 73-81

Weil A and Scheppach R. New roles for states in health reform implementation. Health Affairs 2010; 29(6): 1178-1182

Abrams M, Schor EL, and Schoenbaum S. How physician practices could share personnel and resources to support medical homes. Health Affairs 2010; 29(6): 1194-1199

Steiner BD, Denham AC, Ashkin E, Wroth T, and Dobson LA. Community care of NC: Improving care through community health networks. Ann Fam Med 2008; 6(4): 361-366

Are there any questions?