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March 2011
Spread Models and Lessons: Learning from the AHRQ Health Care Innovations Exchange
Chair

 Mary P. Nix, MS, AHRQ, Health Care Innovations Exchange Project Officer


Presenters

 Veronica F. Nieva, PhD, Westat, AHRQ Innovations Exchange Editor-in-Chief


 Bruce Leff, MD, Johns Hopkins University School of Medicine


 Tracy Novak, MHS, Johns Hopkins Bloomberg School of Public Health
Panel Slides


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Spread Models and Lessons: Learning from the AHRQ Health Care Innovations Exchange Session 2D

Mary P. Nix, AHRQ
Veronica Nieva, Westat
Bruce Leff, Johns Hopkins School of Medicine
Tracy Novak, Johns Hopkins Bloomberg School of Public Health

4th Annual NIH Conference on the Science of Dissemination and Implementation: Policy and Practice
Bethesda, Maryland
March 21-22, 2011


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The AHRQ Health Care Innovations Exchange promotes the adoption and implementation of health care service delivery innovations and related tools.

GOAL: To accelerate the diffusion and uptake of health care innovations and tools to improve health care quality and reduce health care disparities.

By providing:
  • Usable information on health care innovations and quality improvement tools at www.innovations.ahrq.gov
  • Web events and other learning opportunities
  • A facilitated learning network or community of practice

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This is an image of the Innovations Exchange home page at www.innovations.ahrq.gov.


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Innovations.ahrg.gov

  • Published biweekly
  • Core content
    • Innovation Profiles or Attempts
    • QualityTools
    • Articles and Perspectives
    • Resources
    • Commentaries
    • Stories

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Currently 570+ Innovation Profiles 
  • Focus on patient care process improvement
  • Innovative in a given context
  • Publicly available information
  • Expectation of effectiveness
Currently 1,585+ QualityTools 
  • Practical tools for assessing, measuring, promoting and improving health care quality
  • Checklists, manuals, reports, and others

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Searchable database of service innovations and tools
  • Includes successes and attempts
  • Wide variety of sources including unpublished materials
  • Vetted for effectiveness and applicability to patient care delivery
  • Categorized for ease of use: extensive browse and search functions
  • Innovators’ stories and lessons learned
  • Expert commentaries and perspectives


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Learning & Networking

The Community Care Coordination Learning Network (CCCLN) brings communities together to:
  • Learn and share strategies and techniques needed to implement a community care coordination model, the Pathways Model
  • Share information about individual community efforts and lessons learned
  • Embark on ways to enhance community care coordination

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Learning & Networking (cont'd)

Innovations Exchange Web Events:
  • Disseminate innovations and support exchange among innovators and those who research innovations
  • Often focus on innovations in latest issue of Innovations Exchange
  • Are offered quarterly

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Innovations Exchange Audience

This pie chart shows a breakdown of Innovations Exchange users by role. Nurses comprise the largest user group at 33 percent, followed by other users (such as quality improvement professionals and nurse practitioners) at 18 percent and health administrators at 13 percent. Each of the other groups represents less than 10 percent of users.

Data Source: American Customer Satisfaction Index (ACSI)


Slide 10

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How to Participate

  • Submit service delivery innovations to info@innovations.ahrq.gov
  • Search / Browse the site for improvement ideas
  • Provide feedback through the Comments feature
  • Participate in Web events
  • Sign up for email updates


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Sign Up for Email Updates

  • Quickly find strategies for addressing specific challenges in health care delivery
  • Learn about the process of innovation and the process of adopting innovations
  • Join with like-minded people to solve shared problems

The image shows the Innovations Exchange Contact page, which provides instructions for sending questions or comments and for submitting innovations or quality tools.


Slide 12*

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Innovation Scaling: Models from the AHRQ Health Care Innovations Exchange

Veronica F. Nieva, PhD
Shannon N. Fair, RN, MPH
Russ E. Mardon, PhD
Deborah J. Carpenter, RN, MSN, CPHQ
Elaine K. Swift, PhD

4th Annual NIH Conference on the Science of Dissemination and Implementation: Policy and Practice
March 21-22, 2011


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Innovation Scaling

“Deliberate efforts to increase the impact of health service innovations locally tested in pilot or experimental projects, so as to benefit more people and to foster policy and program development on a lasting basis.”

Source: Simmons R, Fajans P, Ghiron L (2007)


Slide 14

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Dissemination
The targeted distribution of information and intervention materials to specific audiences

Implementation
The use of strategies to adopt and implement interventions within specific settings

Dissemination + implementation leads to scaling. 


Slide 15

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Key Concepts

  • Types of Scaling
  • Methods of Scaling
  • Factors Affecting Scaling

 
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Types of Scaling

Top-down

  • Hierarchical
  • Centralized

Bottom-up

  • Led by inspired individuals

Relational

  • Network based
  • Participatory


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Types of Scaling

This graphic illustrates 4 types of scaling:

1. Quantitative or horizontal scaling, which involves geographical spread
2. Functional scaling, which involves increasing the scope of activity
3. Political scaling, which is expansion through efforts to influence the political process and other stakeholder groups
4. Organizational scaling, which includes the expansion of the implementing organization, involvement of other existing institutions, or creation of a new institution


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Methods for Scaling

  • Natural Diffusion--spontaneous, “let it happen”
  • Executive Mandates--orders within hierarchical system
  • Extension Agents--community leaders or mobile workers
  • Collaborative Learning--peer-to-peer exchange
  • Wave sequence--multi-level approach within large systems
  • Campaign--large scale, distributed field operations


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Methods for Scaling

  • Technical Assistance Center--non-profit office to provide support for scale
  • Consulting--for-profit service
  • Licensing/Franchises--adopters act as agents or clones of originating organization
  • Credentialing--certifying professional qualifications
  • Research and Implementation Partnerships--joining with others to scale


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Factors Affecting Scale Up

  • Social and policy environments
  • Dissemination methods
  • Intermediary organization
  • Adopting organization
  • Innovating organization
  • The innovation


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Organizational Players
Scaling requires developing relationships and aligning incentives among institutional players. 

The graphic shows the multiple stakeholders involved in scaling. It demonstrates the interactions among likely sources of innovation (such as universities), potential adopters (such as health care systems and community and outpatient clinics), potential funders (such as foundations and Federal agencies), and other organizations.


Slide 22

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Individual Players

Scaling requires individual change.

  • Providers
  • Patients
  • Researchers
  • Consultants


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Do we need to grow change champions?


Slide 24

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Examples from the AHRQ Innovations Exchange

 
Slide 25

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More Examples from the AHRQ Innovations Exchange


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Thank You

Here are two stories from our innovators.


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References

Cooley L, Kohl R. Scaling Up: From Vision to Large Scale Change--A Management Framework for Practitioners. Management Science International. Washington DC, March 2006.

Going to Scale: Can we bring more benefits to more people more quickly? Workshop Highlights (draft) presented by the CGIAR-NGO Committee and The Global Forum for Agricultural Research (with other organizations), April 2000.

Greenhalgh, T., Robert, G., Macfarlane, F., Bate, P., & Kyriakidou, O. (2004). Diffusion of Innovations in Service Organizations: Systematic Review and Recommendations. Milbank Quarterly, 82(4), 581-629.
 
Hartmann A, Linn JF. Scaling Up: A Framework and Lessons for Development Effectiveness from Literature and Practice. Brookings Institute (Wolfensohn Center for Development) Working Paper 5, Oct 2008.

Massoud MR, Donohue KL, McCannon CJ. Options for Large-scale Spread of Simple, High-impact Interventions. Technical Report, Sept 2010 for USAID.


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References

McCannon CJ, Berwick D, Massoud MR. The Science of Large Scale Change. JAMA. 2007; 298(16):1937-1939.

Norton WE, Mittman BS. Scaling Up Health Promotion/Disease Prevention Programs in Community Settings: Barriers, Facilitators, and Initial Recommendations. Jan 2010, Report submitted to Patrick and Catherine Weldon Donaghue Medical Research Foundation (available on sss.donaghue.org).

Rogers, E. M. (2003). Diffusions of Innovations. New York: Free Press. Fifth Edition
Simmons R, Shiffman, J. Scaling-up health service innovations: A framework for action. In Simmons R, Fajans P, Ghiron L (Eds.), Scaling-up health delivery: From pilot innovations to policies and programmes. Geneva, Switzerland: World Heath Organization, 2007. 
Uvin, P (1995). “Fighting Hunger at the Grassroots: Paths to Scaling Up,” World Development, 23(6): 927-939.

Yuan CT, Nembhard IM, Stern AF, Brush JE, Krumholz HM, Bradley EH. Blueprint for the Dissemination of Evidence-Based Practices in Health Care. The Commonwealth Fund. Issue Brief, May 2010.


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Learnings from the AHRQ Health Care Innovations Exchange: Hospital at Home

Bruce Leff, MD, Professor of Medicine Johns Hopkins University Schools of Medicine & Public Health
4th Annual NIH Conference on the Science of Dissemination and Implementation
March 21, 2011
Rockville, MD


Slide 30

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Let's Think About...

  • The innovation--Hospital at Home; why we need it, what it is, and the evidence for it
  • Our experience in disseminating Hospital at Home--successes, challenges
  • Moving forward


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Why We Need It: Why We Need Hospital at Home

  • Walter, 82, lives with his cat
  • Multiple chronic conditions, meds, and admissions
  • Walter’s Gripes
    • “I can’t get nebs on time so I end up on the tube”
    • “Food stinks”
    • “Wake up in middle of night and can’t get to bathroom”
    • “No one talks to me”
    • “I get confused –get tied down”
    • “I always come home with a completely new set of medicines”
    • “I won’t go to the hospital”

The image shows an elderly man with a cat in his lap. The caption across the photo reads, "Frail but not fearful."


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How It Helps: The Hospital at Home Model

Homeward bound: snapshot of the Hospital at Home process

Assessment
Patient presents to ED. Clinicians determine patient has acute illness that could be treated at home. Patient chooses home-care option.

Transport
Patient transported home accompanied by nurse or physican with appropriate medications and equipment, including oxygen, if necessary

Home Care
Nurse remains with patient.

Discharge
Nurse provides instruction about medications, follow-up care, sends letter to primary care physician.

Source: Watch interview, 5/8/06; Naik, Wall Street Journal, 4/19/06; Leff et al., Annals of Internal Medicine, December 2005. 


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How It Helps: Brief History of Hospital at Home

1995: Determined who and what to treat

1997: Developed eligibility criteria (JAGS 45:1066, 1997)

1998: Evaluated patient acceptability of program (JAGS 46:605, 1998) (Early experience with CMS)

1999: Pilot Studies: clinical/econ feasibility (JAGS 47:697, 1999)

2000: RFP to managed care organizations

2001-04: National Demonstration & Evaluation Study (Annals 143:798-808, 2005)

2005: Dissemination efforts


The image shows the exterior of a hopsital campus.


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How It Helps

Annals of Internal Medicine: Improving Patient Care

Hospital at Home: Feasibility and Outcomes of a Program to Provide Hospital-Level Care at Home for Acutely Ill Older Patients

Bruce Leff, MD; Lynda Burton ScD; Scott L. Mader, MD; Bruce Naughton, MD; Jeffrey Burl; MD; Sharon K. Inouye, MD, MPH; William B. Greenough, III, MD; Susan Guido, RN; Christopher Langston, PhD; Kevin D. Frick, PhD; Donald Steinwachs, PhD; and John R. Burton, MD

  • 61% chose HAH care
  • HaH is feasible and efficacious
  • High-quality care
  • Fewer complications
  • Higher satisfaction
  • Lower costs of care
  • Less CG stress
  • Better function
  • High provider satisfaction

Ann Intern Med. 143:798-808, 2005. J Am Geriatr Soc. 54:1355-1363, 2006. J Am Geriatr Soc. 2008;56(1):117-23. Am J Manag Care. 15:49-56, 2009. J Am Geriatr Soc. 2009;57(2):273-8. Medical Care, 47(9):979-85, 2009.


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Spreading Success: Moving From Research to Practice

This is an image of the exterior of a medical campus.


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Spreading Success: Dissemination of Hospital at Home

1. Broaden awareness and create interest in HaH

2. Define dissemination paths in Medicare managed care, VA, fee-for-service, & home care

3. Shrinkwrap the HaH model to enable adoption

4. Provide technical assistance to dissemination sites


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Spreading Success: Endorsements By Thought Leaders

  • AHRQ Health Innovation Exchange
  • The Advisory Board
  • Robert Wood Johnson Foundation

The images represent initiatives and resources developed by thought leaders including the AHRQ Healthcare Innovations Exchange and the Robert Wood Johnson Foundation.


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Spreading Success: Important Media Coverage

The image shows a partial Page One from the Wall Street Journal Online from April 19. 2006. The page shows a sketch of Paul Willer with the accompanying headline:

House Calls
Portland Hospital Gives Accutely Ill a Homecare Option
To Free Up Valuable Beds, Care is Brought to Patient; An Alternative for Elderly


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Spreading Success: Packaging HaH and Providing Technical Assistance to Adopters

  • Technical assistance manuals
  • Interactive financial models
  • Protocols for additional conditions
  • Ongoing technical assistance to adopters


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Spreading Success: Dissemination Paths

  • VA
  • Managed care
  • FFS--CMS
  • ACOs
  • Home Care
  • International
  • Business approaches/VC

The images represent the various dissemination paths, including the U.S. Department of Veterans Affairs, Medicare brochures, and clinical staff.


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The Future: Academic-based Dissemination of Complex Clinical Service Delivery Models is Difficult

Venture capital


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Spreading Success: Some Lessons Learned

The Evidence:
scientific evidence of effectiveness does not prove effectiveness of implementation of models of care. Most adopters really don’t care about p values and many think our best scientific evidence is misguided. (Berwick)

The Model: complex interventions are a special challenge

The Field: geriatrics is viewed as a negative

The Adopters: suspicious of academia, no two are alike

The Business Issues are absolutely key: chasing reimbursement, difficult to value savings in a revenue driven world, financial incentives lacking, silo-based money, start up costs, scalability


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The Future: Keep in Mind…

The image on the left shows a patient in a hospital bed in approximately the mid-twentieth century. The patient is being attended to by two nureses.

The image on the right shows a patient and a surgical team during a modern high-tech medical procedure.


Slide 44***

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The Guided Care Model

The 4th Annual NIH Conference on the Science of Dissemination and Implementation: Policy and Practice
Tracy Novak
March 21, 2011


Slide 45

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In 2010, Mrs. Jones had

  • 22 prescriptions, 8 meds
  • 19 outpatient visits
  • 3 hospital admits
  • 6 weeks sub acute care
  • 2 nursing homes
  • 5 months home care
  • 2 home care agencies
  • 6 community referrals

Administered by: 8 Physicians, 6 Social Workers, 5 Physical Therapists, 4 Occupational Therapists, 37 Nurses

The image depicts the face of an elderly woman.


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Today's chronic care is:

  • Fragmented
  • Hard to access
  • Inefficient
  • Unsafe
  • Expensive

The pie chart shows that one quarter of all seniors have 4+ chronic conditions and account for 80 precent of health care spending.


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Guided Care: A Path to Transform into Patient-Centered Medical Homes or Accountable Care Organizations

Comprehensive, team-based primary care for people with multiple chronic conditions

  • Evidence-based and proven to improve care
  • May reduce cost in well-managed systems
  • Can help shift culture to a collaborative model
  • Easy to implement and ready for adoption

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About the Guided Care Model

  • Specially-trained RNs are based in physicians’ offices
  • The nurse collaborates with 3-4 physicians in caring for 50-60 high-risk older patients with chronic conditions and complex health needs
  • The nurse partners with the patient for the rest of their life; it is NOT a “one episode” solution

The images depict a nurse reviewing information with a patient and caregiver and a nurse meeting with a doctor.


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Guided Care Nurses

  • Assess patient needs & preferences
  • Create an evidence-based Care Guide and Action Plan
  • Monitor patient proactively
  • Support patient self-management
  • Smooth transitions between sites of care
  • Coordinate with all providers:
    • Hospitals, EDs, specialty clinics, rehab facilities, home care agencies, hospice programs, and social service agencies
  • Educate and support family caregivers
  • Facilitate access to community services

Source: Boyd et al. Gerontologist 2007


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Who Is Eligible?

The graphic illustrates that if you consider all patients age 65+ and review previous year’s claims data with PM software, you find that 25 percent are high-risk and eligible while 75 percent are low-risk and ineligible.


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Evidence-Based and Proven to Improve Care

A three-year randomized trial: 904 high-risk older patients of 49 community-based primary care physicians practicing in 14 teams

  • Early results show improved utilization, higher physician and nurse satisfaction, and improved care quality
  • Physician/patient teams randomly assigned to receive Guided Care or “usual” care
  • Outcomes measured at eight, 20 and 32 months

Source: Boult et al. J Gerontol 2008


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Preliminary results from RCT suggest that Guided Care

  • Improves patients’ and family caregivers’ perception of quality of care [Boyd CM et al. 2010; Wolff JL et al. 2009]
  • Improves physicians’ satisfaction with chronic care [Marsteller J et al. 2010]
  • Improves nurses’ job satisfaction
  • May reduce the use and cost of expensive services, especially in well-managed systems [Boult C et al. 2011]

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Easy to implement, ready for adoption, free support

  • Practices planning to use Guided Care to become a PCMH or ACO can get free technical assistance.
  • FREE Implementation Manual
  • FREE book for patients and families
  • Online course for RNs (SCHOLARSHIPS AVAILABLE)
  • Online course for physicians and practice leaders

For details, go to www.GuidedCare.org/adoption.asp  

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Other Diffusion Activities

  • Messaging for Stakeholder Audiences
  • Website
  • Videos
  • Press Campaign
  • eAdvocate List
  • Profiles
  • Presentations and site visits
  • National and International Awards
  • Active Learning Community

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Spread of Guided Care

  • Use of Tools
    • 1,400 implementation manuals
    • 190 nurses took GCN course
    • 468 practice leaders took PLMH course
  • 5 Organizations signed License Agreement
  • Reimbursement is the biggest limitation
  • Much international interest


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Lessons Learned About Changing Policy

  • Important to engage stakeholders
  • Have solid data
  • Charismatic champions with compelling anecdotes often exert more influence on forming health policy than rigorous scientific studies do.
  • Private insurers can set example
  • Grassroots initiative

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The image depicts a nurse talking with a patient.

The caption reads: "It's like having a nurse in the family."

www.GuidedCare.org


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Guided Care Study Supported By

  • AHRQ
  • National Institute on Aging
  • The John and Valerie Langeloth Foundation
  • The John A. Hartford Foundation