The goal of this 18 month Performance Improvement (PI)/Quality Improvement (QI) project was to improve the process of referral and diagnosis of new Rheumatoid Arthritis patients from community partner practices, thereby reducing the time from referral to initial visit with a specialist and subsequent initiation of appropriate DMARD therapy. Continuing Medical Education (CME) was provided by NJH rheumatology specialists to primary care providers (PCP’s) in the partner clinics at select intervals throughout the project. Performance Improvement CME was provided to participating rheumatologists for ongoing practice assessment. Systems-based changes to address time-consuming and inefficient scheduling processes for referrals were implemented to enhance the rheumatologist’s ability to identify, consult, diagnose, and treat new RA patients sooner.
To accomplish the goal of this project, NJH worked to enlist community partner clinics with established relationships with the health system. Four primary care clinics serving diverse patient populations in the Denver area participated in the initiative. Other components of the project included the addition of a dedicated patient navigator (PN) and advance practice nurse serving as a Patient Case Manager for the rheumatology team.
The aims of this project include:
- Close gaps to treatment to reduce time to treatment:
- Create and disseminate unique referral model to partner clinics that will require key data points and laboratory test results for rheumatologists to effectively identify high priority new RA consultations
- Develop and implement scheduling overflow mechanism to decrease wait time for high priority new RA consultations
- Educate referring community primary care physicians (PCPs) on the importance of early identification and guideline-concordant diagnosis to close knowledge gaps
- Engage participating rheumatologists in ongoing practice assessment to improve performance on targeted patient metrics
- Bolster collaborative multidisciplinary patient care
The educational design of this initiative was driven by Malcolm Knowles’ Four Principles of Andragogy2. In particular, an emphasis on involving participants in the planning and evaluation of the activity and offering case-based content that was readily applicable to the patient populations served were incorporated. A thorough needs assessment was conducted prior to the launch of the initiative. Six knowledge/practice gaps were identified, three of which directly tied to educational strategies implemented throughout the initiative. Furthermore, education-focused project aims tied directly to these gaps and resulted in the addressing of stated needs. The competency-based curriculum and associated learning objectives were designed by the principal investigator following baseline assessment of partner clinic knowledge related to the diagnosis and treatment of RA. The educational strategy included three one-hour CME sessions at designated time points across the 18 month initiative. Sessions were built upon prior knowledge and the results of evaluation data completed post-activity. Medical directors at each partner clinic were involved in the planning and coordination of each activity and were instrumental in identifying key staff to engage throughout the initiative. Practice assessment related to rheumatologist performance on the documentation of TB Screening, DMARD therapy and clinical disease indices (CDAI, MDHAQ) were also analyzed for improvement on a quarterly basis from project initiation through completion. Provider performance not meeting projected goals, was addressed by the principal investigator with feedback and reinforcement. Self-assessment was conducted upon initiation of the project, at mid-point, and upon completion of the initiative. Therefore, the educational design of this initiative worked in tandem with process redesign efforts to foster QI in structure, process and patient outcomes.
The target population included PCP’s and staff at four partner clinics in the Denver Metropolitan area. Ongoing practice assessment was also conducted internally by the rheumatology team. Over the course of the initiative, 160 providers in these clinics participated in focused education (83 physicians and 77 advanced practice providers and other team members) and seven rheumatologists actively assessed improvement on pre-selected performance metrics.
This initiative was supported by an independent educational grant from Pfizer, Inc.
In addition to members of the Rheumatology Division and principal investigator, other NJH team members participating in the initiative included the clinic operations supervisor, a patient navigator, a biostatistician and members of the Office of Professional Education. Over the course of the initiative, the rheumatology division saw 1759 referrals, 106 for RA. Despite the overall focus on RA, streamlined referral processes and systems change impacted the larger referral base. As a result of the educational strategies and system re-design efforts that were employed throughout this initiative, the overall goal of the project, to reduce time to treatment for patients with early RA was met. A total of 106 RA referrals were received throughout this initiative, 61% (N=65) with early RA. The mean time from referral to first visit in Stage A was 103 days and decreased to a mean of 27 days in Stage C (N=106). Statistical analysis revealed significant differences (p<0.0001) between data collected in each stage of this quality improvement initiative. Likewise, the initiation of DMARD therapy for early RA patients from first referral was significantly reduced across the three stages (p<0.0001) with 100% of suspected early RA patients (N=65) being initiated a DMARD within the 3 month therapeutic window, 85% of whom were initiated a DMARD within 1 month.
It is believed that the education employed in this initiative was a key factor in the projects’ overall success. A total of 9 educational sessions were held with four partner clinics over the course of the 18 month project. Each session was designed to build upon evaluation feedback from prior sessions and included segments about improved communication between the primary care clinic and the specialty clinic. Overall participants in the educational sessions demonstrated a 51% relative gain in knowledge and competence related to the diagnosis and treatment of RA. One participant stated that the session “was really awesome and one of the best lectures we’ve had this year”.
Dr. Isabelle Amigues, rheumatologist from National Jewish Health and principal investigator, educates primary care providers at Stout Street Clinic in Denver, Colorado.
Other positive impacts of the initiative included:
Enhanced clinic team performance with clearly delineated roles
Adoption of a streamlined referral process with prioritization of high need patients
Re-designed rheumatology clinic workflow with dedicated appointments for RA patients
Nurse case manager and patient navigator roles improved communication with partner clinics
Internal provider performance data revealed improvements on all metrics from baseline through project completion
One hundred percent of the NJH Rheumatology providers indicated that process changes implemented in the initiative were sustainable. Hard-wired workflows and data fields in the EMR also support the ongoing collection of disease activity metrics and patient reported outcomes to enhance overall disease management. In addition, the Rheumatology Division is in the process of seeking support to make the Patient Navigator a permanent position. The clinical care delivery model designed as a result of this pilot initiative is replicable, scalable, and can be expanded to additional therapeutic areas.
The educational design was critical to the success of the complex 18 month initiative. This multi-faceted initiative drastically reduced time to treatment for the targeted patient population while also improving access to care within a narrow therapeutic window. Enhanced partner communication and care coordination efforts including the addition of a patient navigator and dedicated nurse practitioner facilitated bi-directional communication resulting in a more efficient referral process. In addition, ongoing educational efforts with partner clinics removed barriers and nurtured relationships between primary care clinics and the rheumatology division. Consequently, one of the partner clinics requested that NJH participate in the formulation of a care compact to enhance care transitions between primary and specialty care to support their involvement in a value-based reimbursement model to enhance population health. Another partner, revealed that primary care practices feared losing their patients to specialty centers upon referral. Thus, the educational endeavors conducted in this initiative broke down barriers and removed walls that catalyzed change and fostered trust to improve transitions of care between and among primary care and specialty care.
The impact of the education resulted in some unintended consequences. One of those was the creation of an algorithm based about the American College of Rheumatology’s Guideline for the Treatment of Rheumatoid Arthritis1 adapted for a Primary Care audience. This was a direct result of feedback received in early sessions of the education. Requests for this algorithm led the project team to develop more formalized practice aid that was distributed in the final educational sessions.
In addition, it was mentioned that the unique relationships formed throughout the educational sessions and through referral consultations resulted in a request to formulate a care compact with one of the partner clinics participating in the Colorado Patient Centered Medical Home Initiative3. Both of these “unintended consequences” hightlight the power of education to foster collaboration, communication and coordination of care.
- Jasvinder, S. et al. 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis. Arthritis Care and Research. 2015; DOI:10.1002/acr.22783.
- Knowles, M.S. Andragogy in Action. 1984. San Francisco: Jossey-Bass.
- Colorado Systems of Care/Patient Centered Medical Home Initiative. Primary Care-Specialist Collaborative Guidelines: 2010. Colorado Department of Health Care Policy & Financing Solicitation #: 2017000265.