Primary Care Practice Redesign - Successful Strategies

描述(由申请人提供)：摘要本项目的目的是通过重新设计犹他大学社区诊所的护理服务，展示护理质量的重大改进。社区诊所(CC)是一个按服务收费的10个地点的初级和二级保健系统，约有50名初级保健医生，每年有350,000人次就诊，120,000名活跃患者。自2003年以来，CC一直在领导初级保健提供改革，当时我们开始开发和实施一种新的护理模式，称为按设计护理(CBD)。CBD的三个组织原则是：适当访问(AA)、护理团队(CT)和计划护理(PC)。我们将在现有的系统设计范围内进行更多的重新设计。在这个项目中，我们将针对患有多种慢性病的患者实施全面的护理管理计划。我们的交付重新设计将包括有效管理护理过渡以及积极筛查和治疗抑郁症的策略，这对许多慢性病患者来说是一种复杂的共同发病率。我们的干预措施建立在CBD的基础上并加强，以实现护理质量的重大改善。我们将比较CCS目前的临床结果与引入CBD系统设计之前的结果，以及与我们重新设计组件所取得的结果。此外，准实验性队列设计将记录临床质量的改善以及患者和护理团队的参与，因为诊所在三年项目中顺序地提高了CBD。中期结果将包括提供者和工作人员使用EMR最佳实践提醒的比率，以及患者和护理团队遵守CER通知的指南。患者参与度将通过患者对我们网络门户的使用、护理经理的支持以及对个性化护理计划的遵守情况进行评估。我们将使用我们的EMR和CBD实施工具来评估员工、提供者和患者的行为，并对患者的积极性、护理体验和生活质量以及提供者对患者自我管理的态度进行调查，以评估质量。我们项目的一个重要目标是评估我们的干预措施和策略对临床ROI的影响。随着我们更有效地管理高危患者的护理需求，我们预计辅助测试、服务和药房的数量和相关收入将发生变化。我们将评估在我们的服务环境收费中实施目前未补偿的护理组件的业务案例。此外，通过使用两个独特的全州范围的数据库，我们将通过衡量急诊科就诊、住院、再入院和相关的护理成本，评估重新设计对护理总成本和成本效益的影响，展示在更广泛的社区中降低护理成本的潜力。这些数据是为增强型CER知情护理的可持续性创建商业模式的关键。我们强大的跨学科研究团队确保了这一项目的成功完成。该团队包括CBD的开发者、老年病学和药房实践方面的临床医生专家、具有质量改进、生物统计学、定性研究、行为科学和经济学专业知识的成员，以及一个包括实践重新设计和多方法评估方面的领先专家的国家咨询委员会。该项目的结果将为其他寻求在初级保健实践中实施CER知情保健的人提供实践指导。 公共卫生相关性：该项目具体涉及赠款计划的目的，以证明在提供系统中实施循证护理改进战略和干预措施的可行性和价值，以及2010年健康人的若干目标，包括改善获得全面、高质量卫生保健服务的机会。该项目为患有多种慢性病的患者实施全面的护理管理计划，并评估在服务于广泛患者群体的大学网络中向初级保健实践的PCMH提供模式转变的影响。该项目解决了2010年健康人的一个广泛目标，即通过在我们的电子病历中实施最佳做法提醒、访问前规划和基于登记的外展来“实现所有美国人获得预防服务的机会”。

DESCRIPTION (provided by applicant): Summary The purpose of this project is to demonstrate major improvements in care quality through redesign of care delivery in the University of Utah Community Clinics. The Community Clinics (CC) are a fee-for-service 10-site primary- and secondary-care system with about 50 primary care physicians, 350,000 annual visits, and 120,000 active patients. The CC have led primary care delivery reform since 2003 when we began the development and implementation of a new model of care called Care By Design (CBD). The three organizing principles of CBD are: Appropriate Access (AA), Care teams (CT), and Planned care (PC). It is within this existing system design that we will implement additional redesigns. In this project we will implement a comprehensive care management program targeted to patients with multiple chronic conditions. Our delivery redesign will include strategies for effectively managing care transitions and for aggressively screening for and treating depression, a complicating co-morbidity for many patients with chronic conditions. Our intervention builds upon and strengthens CBD in order to achieve major improvements in care quality. We will compare the CCs' current clinical outcomes with outcomes prior to introduction of CBD's system designs and with those achieved with our redesign components. In addition, a quasi- experimental cohort design will document improvements in clinical quality and engagement of patients and care teams as clinics enhance CBD sequentially over the three year project. Intermediate outcomes will include provider and staff use rates of EMR best practice reminders and patient and care team adherence to CER-informed guidelines. Patient engagement will be assessed by patient use of our web portal, care manager supports, and adherence to personalized care plans. We will use our EMR and CBD implementation instrument to assess staff, provider, and patient behavior, and surveys of patient activation, experience with care, and quality of life, and of provider attitudes toward patient self-management to assess quality. An important goal of our project is evaluation of the impact of our interventions and strategies on clinic ROI. We anticipate changes in volume and related revenue for ancillary tests, services, and pharmacy as we manage the care needs of our high risk patients more effectively. We will evaluate the business case for implementing currently uncompensated components of care in our fee for service environment. Additionally, by using two unique state-wide databases, we will evaluate the impact of our redesign on total cost and cost effectiveness of care by measuring emergency department visits, hospital admissions, readmissions, and associated costs of care, demonstrating the potential for decreased costs of care in the broader community. These data are key to creating a business model for sustainability of enhanced CER-informed care. Our strong interdisciplinary research team ensures successful completion of this project. The team includes developers of CBD, clinician specialists in geriatrics and pharmacy practice, members with expertise in quality improvement, biostatistics, qualitative research, behavioral sciences, and economics, and a national advisory committee that includes leading experts in practice redesign and multi-methods evaluation. Results of this project will provide practical guidance for others seeking to implement CER-informed care in primary care practices. PUBLIC HEALTH RELEVANCE: This project specifically addresses the purposes of the grant program to demonstrate the feasibility and value of implementing evidence-based care improvement strategies and interventions in delivery systems as well as a number of objectives of Healthy People 2010 including improving access to comprehensive, high-quality health care services. This project implements a comprehensive program of care management for patients with multiple chronic conditions and evaluates the impact of transformation to a PCMH delivery model of primary care practices in a University network serving a broad patient population. The project addresses a broad goal for Healthy People 2010, to "Achieve access to preventive services for all Americans" by implementing best practices reminders in our EMR, pre-visit planning, and registry-based outreach.