Several years ago, CareSouth Carolina (Hartsville, South Carolina, USA) chief executive officer Ann Lewis says she fantasized about chucking it all and raising horses for a living. "Everything in health care seemed so dismal," she recalls. "You would ask yourself daily, ‘Why am I doing this?’"
Today, in her 25th year as CEO of this rural community health center, all that has changed. "I feel like a missionary," she says. "I want to tell everyone that it can be so much better. You just have to do it. The improvement work we’ve done has put the fun back in health care."
As a member of IHI’s IMPACT network, CareSouth, which serves 20,000 patients in six locations, is a heavy hitter when it comes to improvement work, determined to make significant improvements in its office practices in all six categories, or aims, identified by the Institute of Medicine (IOM), plus an additional one of equal importance to them.
"Let’s Just Do It"
"This work is really a marriage between what we have learned about chronic care management, and advanced practice concepts like advanced access," says Lewis. As one of the first participants in the Health Disparities Collaborative, run jointly by IHI and the US Bureau of Primary Health Care, which provides significant funding for CareSouth and other similar clinics throughout the nation, CareSouth focused on improving access to quality care for patients with diabetes, asthma, and depression. The results inspired Lewis to lead her organization into further improvement efforts.
"When we started the diabetes collaborative, the average HbA1c of the patients we were tracking was over 13," Lewis recalls. "I didn’t even know what that meant. But I learned that every percentage drop in HbA1c represents a 13% drop in mortality, and that got my attention. And I would go to group visits where patients with diabetes were practically in tears with gratitude about how much our new approach to care was helping them."
"And that’s when I thought, this is really it," says Lewis. "It’s not about the business or economics of health care, it’s about the outcomes."
The ambitious nature of CareSouth’s goals in IMPACT is testimony to Lewis’ success as a missionary in her own land. For example, the clinic aims for a 7.0 average HbA1c for patients with diabetes; that 80% of patients’ self-management goals will be met; that 80 percent of each patient’s total visit time will be spent face-to-face with a provider of care; and that the third next available appointment (a standard measure of access) will be in 0 days.
"To be truly patient-centered," says Lewis, "it’s not enough to help patients set goals. It’s meeting the goals that puts the rubber to the road. We want the healthiest patients in America," she says. "Why not? Between the Health Disparities Collaborative and IMPACT, the knowledge is there. We know how to make people healthy and how to make care accessible. Let’s just do it."
CareSouth’s work in each of their seven areas of focus reflects creativity, doggedness, and steadfast attention to the voice of the customer, their patients. "We ask the patients all the time what they want, what they think," says Lewis. "They always tell us. But you have to ask."
CareSouth is working diligently to improve in each of the six IOM aim categories. Staff chose to add one more category, Vitality, a measure of staff morale. While their progress so far toward achieving their ambitious goals is varied, their determination is unflagging.
Goal: 100 percent of all medication lists will be updated at every visit.
Actions: "Patients have a hard time remembering what medications they are taking, especially when they take several," says Lewis. "It’s best if they bring their medications to each appointment. Patients told us that it would help if they had something to bring them in. So we had very nice cloth medication bags made for everyone on three meds or more. They have our logo on them, and a reminder to bring their medications to each visit. It’s a low-tech solution, but it has made a huge difference. We’ve had some early success in the work, as well as some recent set-backs, but I’m sure we’re on the right track."
Results to Date:
Goals: Asthma patients will have an average of 10 or greater symptom-free days out of 14. Diabetes patients will have an average HbA1c of 7.0 or less.
"The experience that CareSouth staff had already gained in chronic care management through the Health Disparities Collaborative gave them the tools they needed to improve effectiveness of care," says Lewis. This has been further supported by their participation in IMPACT. "One of the most important things IMPACT does is to give us a well-defined process, a road map, that we can follow. Once you know the model — self-management support, decision support, delivery system design, organization of health care, clinical information system, community support — you can transfer it from one condition to another pretty smoothly." Lewis is referring to the Chronic Care Model
developed by Ed Wagner, MD, MPH, FACP, which is widely regarded as today's standard for chronic care management. Wagner, a general internist and epidemiologist, is the director of Improving Chronic Illness Care (ICIC) and the Seattle-based MacColl Institute for Healthcare Innovation at the Center for Health Studies, Group Health Cooperative.
Results to Date:
Goal: 80 percent of self-management goals set by patients will be met.
Actions: "One of the biggest challenges the health care system faces is to help patients meet their own goals," says Lewis. "We ask our patients in three ways how they want us to help them with self-management: through surveys, in one-on-one patient interviews, and in small focus groups." Through these means CareSouth staff are learning how to help patients tailor achievable goals. "Don’t tell me to lose 40 pounds," Lewis says, explaining what patients often say. "Tell me how to do it in small steps."
CareSouth has also learned that listening to their patients is their best source of guidance regarding what system changes to make. Some of the feedback they get is surprising, says Lewis. "Some of our elderly patients say they like it better when they can spend more time here, not less," she says. "And we’ve learned that centralized appointment scheduling and medical records is not what our patients want. They want to talk with the same person each time they call, someone in their own doctor’s practice." Little changes also mean a lot to patients, she says. "They told us to stop weighing them in the hallway where everyone can watch."
Results to Date:
Goal: The average amount of time spent with the clinician in an office visit will be 12 minutes or greater.
Actions: Working to increase patient time with clinicians and decrease non-value-added time has been challenging for the CareSouth staff, but they are making headway. Again, the patients told them what they wanted. "They told us they didn’t care about the cycle time, they wanted a rich visit, more comprehensive, where they could get more done," says Lewis. Patients like group visits, time with the nurse as well as the doctor, opportunities for health education, and the CareSouth staff is working to organize the delivery system accordingly. The average time patients spend with their doctors is also moving upwards.
Results to Date:
Goal: The third next available appointment shall be in 0 days.
Actions: Staff began by combing the schedule for opportunities for more efficient care management of patients, especially looking for ways to reduce unnecessary follow-up visits by substituting telephone follow-up when appropriate. "Implementing care management and deleting all those short-term return visits from the schedule gave us a big drop in appointment waiting time," says Lewis. Decentralizing appointment tracking is another means of improving timeliness because each micro-team is more aware of patients’ needs and able to structure providers’ schedules in ways that reduce backlog.
Results to Date:
Goal: There shall be zero disparity by race for each key Effectiveness measure.
Actions: With a patient population that is 69 percent non-Caucasian, CareSouth is all about equity. "This is our strong suit," says Lewis. "It is woven into our very culture." To counter the "clinic mentality" with which community health centers are often wrongly saddled, CareSouth is not just conscientious about providing top-quality care to its patients, but also about maintaining the perception of quality. "We look good," she says. "We remodeled, refurnished, repainted, and we say we offer first-class care for first-class people. Disparity is not just about outcomes, it’s also about how you treat your patients. That’s been part of our culture since the very beginning."
Disparity is defined by subtracting the score for the African American population from the score for the Caucasian population. For diabetes, for example, the percent of patients who had an HbA1c score of less than or equal to 7.0 for each patient population were compared. When calculating percentages that are compared for disparities, the denominators are patients per race per disease.
Results to Date:
Goal: 0 percent of the office team shall report a somewhat or very stressful work environment.
Actions: Organizations such as CareSouth that take on improvement work in multiple categories find that there is considerable overlap among those areas. Lewis says that all the improvements they are making in efficiency and effectiveness are improving staff morale and "firing everyone up" about the potential for even greater changes. "We have fun here," she claims, "and we work hard. The one thing providers have told us consistently through the years is that they don’t like being stuck in the office later and later each day because patients and paperwork have backed up. They want the workday to go smoothly. And all the changes we are making are addressing that. I’m sure that the stress in our workplace will decrease as these changes take hold."
Results to Date:
Lewis is confident that all of these measures will continue to show improvement as the improvement programs become fully engaged. She has seen a lot of changes in health care, and in her own health center, in her years as CEO. But this recent period of growth and change has been unprecedented, she says. "You go home at night dead tired," she admits, "but knowing you are doing incredible things, and providing the best possible care for people who would not have access to it otherwise."