DOH: ROI Five Year Chronic Care Initiative

Community Health Administration

Request for Information

Five-Year Chronic Care initiative for Washington, DC
October 10, 2008

Overview:.

The Bureau of Cancer and Chronic Disease (the Bureau) in the Department of Health’s Community Health Administration is soliciting input from community groups, business interests, clinical providers, and DC residents on the opportunities and challenges of improving service delivery for persons living with hypertension, diabetes, chronic kidney disease, cardiovascular disease, stroke, and chronic obstructive lung disease. Washington, DC, has already done a great deal to meet the health care needs of our population, but serious shortcomings remain – mostly arising from the way that service delivery is organized rather from lack of expertise or dedication among our health care workers.

The Bureau is especially interested to hear from parties that want to implement major improvements, and especially when those changes cover a large proportion of the settings and time course of the conditions for a shared patient population (e.g., including community-based screening, health and self-care educators, outpatient and inpatient medical care providers, home care and hospice providers, and those concerned with family and caregiver issues). The Bureau expects this Initiative to use continuous quality improvement methods, including by creating a learning environment for the city.

How to Give Input:

The input can take two forms: orally at meetings and written comments. In both cases, the deadline for submissions will be November 4, 2008. The Bureau will not necessarily summarize or respond to comments. The Bureau may summarize or respond to comments in the eventual RFA. The RFA for the Initiative will be issued within a few weeks after the close of this information period.

Meetings:

There are two scheduled meetings at this time, as follows:

1st Meeting 2nd Meeting

Monday, October 20, 2008

9 am - 10:30 am

825 North Capitol Street, NE
Room 2125

Washington, DC 20002
Thursday, October 23, 2008
4:30 pm - 6 pm
825 North Capitol Street, NE
Room 2125
Washington, DC 20002

The time for each person’s comments will be limited in order to allow many to participate. If the volume of people prepared to comment is substantial, attendees will have the opportunity to submit their comments in writing.

In addition, the Bureau staff is willing to try to participate in meetings interested groups. Please send your meeting response e-mails to geraldine.pierce@dc.gov and suggest the times, likely attendees, and subject matter. We will try to participate in a broad array of such meetings to hear suggestions and priorities.

The Bureau welcomes written comments from groups and individuals. Please e-mail comments to ChronicCareInitiative@dc.gov - or mail comments to Geraldine Pierce, c/o Dr. Joanne Lynn, Bureau Chief, Cancer and Chronic Disease, District of Columbia Department of Health’s Community Health Administration, 825 N. Capitol St., NE, 3rd Floor, Washington, DC 20003. Please include contact information in case the Bureau needs to follow-up on your comments.

Topics:

The Bureau is seeking comment on any aspect of the overall Initiative, as outlined below. We have included certain questions (numbered as Q1, Q2, etc.,) that might benefit from community input, but these should not be taken to indicate that other issues are of any lesser importance. Feel free to comment on any aspect of the Initiative.

Target Population:

Persons at risk for or living with any stage or severity of this group of overlapping illnesses: cardiovascular disease (e.g., heart failure, heart attack, angina, peripheral vascular disease), hypertension, stroke, chronic kidney disease, diabetes, and chronic obstructive lung disease (emphysema and chronic bronchitis).

Q 1	How would the Initiative best sub-divide the population: by severity, by dominant condition, by disability, by demographic characteristics, or in some other way?
Q 2	Are there conditions that should not be included, or others that should be added, and why?

General Aims:

To have a longer and healthier life at each stage of these illnesses – from detection of early conditions, through living with mild to moderate disease, to living with and dying from advanced illness;
To deliver highly reliable, evidence-based services at the right time and with the lowest possible cost, for all residents of DC.

Measurement:

The overall Initiative requires methods for monitoring and evaluating progress throughout. Some of the measurements that offer opportunities include utilization of hospitals and emergency rooms, rate of end-organ damage such as progression of renal failure or amputations, and measures of disease management such as hemoglobin A1c or blood pressure. The Initiative will also require assistance to specific intervention implementation projects to measure their progress.

Q1	What databases might be useful?
Q2	Is there a coordinated strategy that would be efficient?
Q3	Could that strategy require cooperation among multiple parties, possibly including the Department of Health or other city agencies, and the Medicaid/Alliance Managed Care Organizations (MCO’s)?
Q4	How could measurement support for specific intervention strategies be done efficiently and in a way that supports Continuous Quality Improvement (CQI) for those projects?
Q5	The major measurement strategy is likely to be annotated time series, but are there more rigorous measurement and evaluation opportunities that should be considered?
Q6	What parameters should be measured and how?

Clinical Information Support:

Clinical Information Support: Persons living with these conditions in Washington, DC, often use various sources of services, and mostly these services are not connected by a coherent plan of care or a medical record. The Initiative will probably have much better opportunity to succeed if at least the more seriously ill residents have a useful clinical record available at all times.

Q1	What strategies could work?
Q2	What existing projects could anchor such work?
Q3	How can security for private information be assured?

Support for Continuous Quality Improvement:

Washington, DC, has the opportunity to achieve a highly reliable, highly efficient, care delivery system for a substantial population facing these illnesses. No other sizeable population in the U.S. has yet succeeded in engineering such a health care system. Washington, DC, starts with a health care delivery system that is generally using more resources per patient than other parts of the country, without showing better quality, so the opportunity for improvements in both quality and efficiency are evident. However, achieving that aim will require trying out various strategies, measuring the effects, continuing and expanding those that offer advantages to patients and discontinuing those that do not work well, and generally learning a great deal about how to engineer quality and efficiency into our service delivery system. One major method for this will be continuous quality improvement (CQI), and many of the participants in this Initiative would benefit in having available, not only the measurement skills mentioned above, but also the coaching and guidance of persons with substantial experience in CQI.

Q1	Some of the improvement work has to do with transitions across settings of care or clinical providers. What changes would work well in Washington, DC, and why?
Q2	There may be opportunity for CQI collaboratives with participants from multiple care settings (e.g., multiple hospitals and nursing homes and home care, each set of which serves a shared population). How would these be implemented, and who has that expertise?
Q3	What sort of evidence should be taken to show that a proposal is likely to be effective in this setting?

Public Information:

This Initiative will be of great interest to the public, and ensuring that reliable information is published in useful ways will be essential to broad understanding and support.

Q1	Should the public information be intrinsic to other parts of the work, or should it be a separate funded activity?
Q2	To whom should the public information function be accountable, and what should it entail?
Q3	What communication strategies should be included?

Initiative Leadership and Participant Meetings:

This Initiative will require ongoing learning and strategic setting of priorities. The Bureau envisions having three rounds of competition for the interventions, over the first fifteen months. The work must evidence investment in high-yield strategies, and knowledge about what works will change as participants learn what is working well or poorly. There will need to be meetings that bring together affected residents, clinicians, business interests, community organizations, and government. Generating leadership and vision, as well as concrete details, will move along better with support for meetings, drafts, survey of findings elsewhere, and other tasks needed for success in meetings of such groups.

Q1	Should the Initiative generally expect groups that are geographically-based, linked to hospital areas, linked to diseases or severity, linked to demographic characteristics of the population, or organized in some other way?
Q2	What sort of support will groups need in order to learn from early experience and efficiently engender shared priorities?

Interventions:

This Initiative seeks to utilize evidence-based interventions where those are available. The interventions can start with reasonably well-tested interventions, though most of them have never been “brought to scale” in serving a whole population. Such interventions as medication reconciliation, self-care education, team-based care, transition coaching, advance care planning, feedback to clinicians on quality and cost, and shared care pathways across settings are examples. The general field of care coordination underlies much of this work, but adding another person to the delivery system to coordinate autonomous fragments may not be the most efficient or sustainable strategy to reform service delivery.

Q1	Proposed interventions must be reasonably likely to succeed, have substantial effects in improving care, be monitored to assess effects and to watch for any adverse effects, and be measured in order to gain insight about effectiveness. Should that review rest with the Bureau and the DOH, or should other parties be involved? How?
Q2	Virtually every strategy for improvement works well on a small population for a limited time, and the professional literature is rife with reports of one or another strategy that works in that setting. Most of these have not performed well when applied to a large population, and probably for a number of reasons. What is the “minimum size” that justifies investing public funds to test it?
Q3	What existing initiatives should anchor this work, or might be synergistic?
Q4	What are the highest value changes that could be implemented in the next two years?

Special Considerations in Making Awards:

Some awards will be for a full three years, and others will be for shorter periods. However, all awards can be expected to have frequent reporting requirements and built-in contingencies for adjustment on the basis of evidence. The Initiative concerns the city of Washington, DC, and the answers must be home-grown; non-residents and businesses located elsewhere will have some disadvantage in participating. Very little funding, if any, will go to support direct clinical services (except perhaps in a small pilot). The funding generally will have much more leverage in making it easy to monitor and implement changes than in providing direct services for a limited time. Most proposals should include more than one entity and a plan for making gains permanent.

Q1	Are these reasonable, and are there other general considerations that should be articulated?

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