Rick Dell MD

TRANSFORMING MEDICARE CARE DELIVERY
2012 FFN Berlin Meeting , Sept 6-9
Healthy Bones – 10 Steps to Osteoporosis and
Geriatric Fracture Prevention
Rick Dell MD

KP SCAL Healthy Bones
Model of Care
2

AHRQ Innovation Website
AHRQ – Agency HealthCare Research and Quality
http://innovations.ahrq.gov/content.aspx?id=2826

Healthy Bones Model Used The SIMPLE Approach
S – Simple in design
I – Inexpensive to start and maintain
M– Measurable outcomes
P – Pays for itself to make it last
L – Lasts (the program must survive)
E – Evolves with time to survive

Systems Approach – 10 Steps
1. Build a team lead by a champion
2. Set a goal
3. Identify the population
4. Risk stratifies the population – Build work list
5. Work is done by right person at the right time
6. Measure what you did
7. Look for variation and improve by stealing ideas
8. Incentives versus punishments
9. Evolve until goals are met
10. Set higher goals once goals are met

Build a Team Lead by a Champion(s)
Champion(s)
• Tough as nails
• Goal focused
• Works well with a team
• Works well with administration
• Fosters communication
• Get things done

Build a Team Lead by a Champion(s)
The Team
• Goal focused
• They must feel they are part of a team
• Must be competitive
• Must be cooperative
• Know the are part of something much bigger

Set an Achievable Goal
A 20% reduction in the hip fracture rate
In line with the “20/20 Vision” of the
National Bone Health Alliance
We have achieved a >40% reduction in
our expected hip fracture rate in KP
SCAL

Identify Patients at Risk for a Hip Fracture
EMRs – Patients with prior fractures
Clinic visits
In-patient admissions
Emergency room patients
Operating room schedule
Consults
Automate the steps to find fx patients

Old Way - Monthly List

New Way - Daily List
Automatic Data Warehouse Reports
Updates Healthy Bones Web Page

The Work List is updated
daily and is interactive

Work - Done by right person at the right time
Care Managers (RNPs, PAs, RNs)
Work under protocols
“Just in Time” Clinic Visits
Try to off-load work of PCP
Any PCP’s in the audience?
A quick message from our team…
YOUR WELCOME! 21

Systems Approach – 10 Steps
1. Build a team lead by a champion
2. Set a goal
3. Identify the population
4. Risk stratifies the population – Build work list
5. Work is done by right person at the right time
6.Measure what you did

Patient Stratification by Region
Risk Group
by 8/31/10
Region ANT BF BP FON KRN LA OC PC RV SB SD WH WLA
Hip Fx Pts Need
Rx
3,259 114 155 142 361 128 218 330 261 308 155 654 292 141
Osteoporosis Pts
need Rx1 Fx Pts Needs
20,903 586 1,269 1,069 2,701 669 1,650 1,799 1,291 1,383 1,307 3,440 2,762 977
Current DXA
and/or Rx2 17,563 208 1,293 724 1,980 472 1,618 2,044 871 1,659 1,008 3,625 1,124 937
Total 41,745 908 2,717 1,935 5,042 1,269 3,486 4,173 2,423 3,350 2,470 7,719 4,128 2,055
NON-COMPLIANCE Pts by 6/30/103 With Fx
(pre/post Rx)
18,863 417 1,403 1,349 2,180 517 1,507 2,008 1,032 1,296 1,159 2,950 1,890 1,155
Without Fx
(pre/post Rx)
42,337 852 3,716 3,513 4,002 1,145 4,174 4,856 2,406 3,076 2,869 5,376 3,392 2,660
Total 61,222 1,269 5,119 4,862 6,182 1,660 5,681 6,864 3,438 4,372 4,028 8,326 5,582 3,815
NEED DXA SCREENING Pts by 6/30/10
Female 65+ 21,222 373 1,403 903 2,309 426 2,356 2,228 959 1,818 1,480 3,728 1,348 1,891
Male 70+ 20,325 299 1,501 915 1,983 395 2,599 2,062 1,022 1,817 1,220 3,329 1,586 1,597
Total 42,433 672 2,904 1,818 4,292 821 4,955 4,290 1,981 3,635 2,700 7,057 2,934 3,488
1 This category includes patients with a bad DXA score or a diagnosis code of osteoporosis, but no Osteo RX
2 This category includes patients with a fracture, no Osteo Rx and no DXA (2-years prior OR after their fracture date)
3 This category includes patients who have no record of an RX dispensed in the last 180 days; and no current KP code
for RX from outside of KP (7351A)

Healthy Bone Model of Care Performance
Jan-June 2009
Measure 1: 60+ with Fracture, received DXA within 180 days
Measure 2: Bad DXA (-2.5 or less) on Osteo Medication within 180 days
(%)
100
90
80
60
40
20
0
Target 90% for BOTH measures
AV BF BP FON KRN LA OC PC RV SB SD WH WLA Region
60+ FX w/DXA 75.13 72.75 79.18 80.05 82.91 77.65 81.06 85.75 79.12 85.63 73.94 85.53 79.78 79.54
DXA -2.5 or less
w/RX 62.73 72.82 79.21 64.48 75.54 75.68 77.68 75.41 72.11 66.34 78.88 64.54 82.94 73.28

CSG HEDIS- Post FX TX/Women 67+
2008-2010
(%)
100
80
60
40
20
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14
2008 YE 56.9 73.7 77.2 66.7 45.6 69.7 70.4 73.7 67.1 56.4 56.9 74.5 62.7 65.2
2009 Per 1 63.5 75.2 73.9 69.6 49.2 72.3 74.0 76.1 67.1 57.6 65.1 77.2 67.9 67.5
2009 Per 2 65.0 80.4 76.3 70.4 50.0 71.0 73.0 75.1 67.5 58.2 69.3 82.4 70.2 68.7
2009 Per 3 64.4 76.7 76.8 68.9 51.9 70.5 72.2 76.0 67.2 60.0 69.9 82.3 75.6 69.5
2009 Per 4 60.9 81.4 76.4 68.7 59.3 70.0 73.1 73.4 69.8 59.4 74.1 80.3 81.0 70.3
2009 Per 5 54.5 80.8 73.4 72.0 58.2 68.1 74.1 72.0 70.1 55.7 73.1 84.7 79.9 70.6
YE 2009 50.7 78.5 72.6 73.0 61.9 66.5 76.1 71.5 71.4 56.8 76.1 85.8 79.9 70.6
2010 Per 1 44.0 70.9 70.0 67.6 68.0 66.3 76.0 72.0 76.0 54.2 78.5 81.9 76.6 68.9

100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
DXAs and/or Treatment In Fragility Fracture Patients
65-69 70-74 75-79 80-84 85+ Average
Age Groups
Males
Females

Keep what works/share best ideas
Use ideas that are out there such as:
Other Kaiser Med Centers
Other Kaiser Regions
Geisinger, NOF, NBHA, Surgeon General
IOF, FLS, NHS, and Blue Book
Don’t re-invent the wheel

Outcome and Process Measures
Increase in:
Number of patients receiving DXA scans
Appropriate pharmacologic therapy
Post-fracture patient education
Work ups for secondary osteoporosis
Reduction in:
Incidence of subsequent fractures
Costs due to fractures
Hospital readmissions within 30 days and 1 year
Expected morbidity and mortality

Incentives versus punishments
Maintaining a 5 Star ranking
Staying #1 on HEDIS
New Joint Commission Rules
KP Bonuses

Systems Approach – 10 Steps
1. Build a team lead by a champion
2. Set a goal
3. Identify the population
4. Risk stratifies the population – Build work list
5. Work is done by right person at the right time
6. Measure what you did
7. Look for variation and improve by stealing ideas
8. Incentives versus punishments
9. Evolve until goals are met
10. Set higher goals once goals are met

Sets a Measurable Goal
Sets a Time Frame (2020)
Sets Priority – Reduce Hip Fractures
Make sure the goal is achievable
Others have already achieved this goal
Kaiser has reduced the expected hip
fracture rate by over 40%

Critical Pathways
Identify patients at high risk for hip fractures
using IT Systems
Risk stratify those patients
Start screening those at highest risk
Treat those that need treatment
Track for compliance of the patient
Track for performance of the program

Reset Your Goal To A Higher Level
A journey of constant improvement for
you and your Healthy Bones Team

People
Processes
Technology
Success

AHRQ Innovation Website
AHRQ – Agency HealthCare Research and Quality
http://innovations.ahrq.gov/content.aspx?id=2826

Q&A
Richard.M.Dell@kp.org
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