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Key Performance Report
2012
1
Preface
Frank Vizzare
Key Performance Report
2
Team synergy led to the remarkable results we can proudly share with you today.
Armed with an old management paradigm: “What’s measured improves“, we have
created a measurable, flexible and scalable work environment open for constant
improvement through robust decision support.
We are all thankful for the opportunities that UCLA, the Department of Medicine
and our Division of Digestive Diseases have offered us. We are highly motivated to
enter our second year, which will focus on costs, value-based insurance design, and
facilitating other disease areas to adopt this new exciting form of healthcare delivery.
On behalf of the IBD Team,
Daniel Hommes MD Ph D
Director UCLA Center for Inflammatory Bowel Diseases
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Let’s build a
future, not just
polish the past.
It is amazing how short a time it takes for wonderful things to happen. We started
a year ago in the belief that the safest way to forecast the future was to create it.
Having learned from our past mistakes we knew that spending more effort and
resources on solely increasing efficiency in care would be useless and insufficient
to increase quality and at the same time lower costs. Although we had to think
completely different, there was complete clarity when we began to sketch the
infrastructure of a new solution for disease management. We did not want to merely
solve existing problems, but insisted on starting off with a ‘greenfield’ design.
Merging principles of Value-based healthcare with our expertise in health process
innovation and biobanking, we developed and started to pioneer our new disease
management solution for a prototypic chronic disease: Inflammatory Bowel
Diseases.
2
Table of Content
6.
4
Key Performance Report
7.
8.
9.
Preface ........................................................................................ 3
Table of content. ............................................................................. 5
Executive summary......................................................................... 7
Inflammatory Bowel Diseases........................................................... 9
Situational analysis. ....................................................................... 13
• Introduction.......................................................................... 13
• Why change.......................................................................... 13
• Problem summary + solutions. ................................................. 14
• Patient Value. ........................................................................ 17
Program design. ........................................................................... 21
• Value-based healthcare for IBD: the Value Quotient (vQ)............... 21
• Tight Control Infrastructure. .................................................... 23
• UCLA services beyond borders............................................... 29
• Why is this disease management solution cost-effective?. ........... 31
• From fragmented to coordinated care. ...................................... 32
• The business case.................................................................. 34
Implementation and outcomes. ....................................................... 39
• Organizational Matrix Architecture............................................ 39
•
2012 development at a glance. ............................................... 40
•
First implementations............................................................ 41
•
The first patients. ................................................................. 46
•
The vQ performance. ............................................................ 55
•
A first indication of the strength of the program. ........................ 62
•
IBD Nursing Program. ........................................................... 65
•
The IBD Biobank. ................................................................. 69
•
Social Media........................................................................ 73
Conclusions. ................................................................................ 75
Acknowledgements. ..................................................................... 79
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What is not
measured,
can’t be managed
nor improved.
1.
2.
3.
4.
5.
3
Executive summary
flares every 6 months. I joined the UCLA IBD Program in
February and it has changed my life completely. The IBD team
took the time to analyze my medical history and they created
1.
US healthcare is facing huge challenges – current spending is unsustainable. UCLA
has pioneered a novel disease management solution for a prototypical chronic
disease: Inflammatory Bowel Diseases (Crohn’s disease and ulcerative colitis).
2.
The objective of this disease management solution is to add measurable value to
individual patients at increasingly lower costs. This is captured in a single outcome
measurement: the Value Quotient or vQ.
3.
Individual patient value is defined as disease control, quality of life and daily
productivity during a full cycle of care. The Value Quotient captures individual patient
value (numerator) as well as the number of dollars spent to add value over a full cycle
of care (denominator).
4.
This value-based disease management solution aims to improve the Value Quotient
annually by increasing the level of disease control and/or decreasing the amount of
dollars spent. This is achieved by a cutting-edge macro infrastructure (Educational
and Research programs) and a micro infrastructure of daily care delivery (Tight
Control scenarios).
a specific program to help me get to remission. For the first
time my quality of life and overall wellnesses was taking into
account, and believe me for a chronic patient that means a lot!!!
Thanks UCLA IBD team for giving me my life back!
S.L.
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It is necessary,
therefore it is
possible.
5.
On February 1, 2012 the first implementation phase was launched for Inflammatory
Bowel Diseases in two locations (Westwood and Santa Monica). On December 31,
a total of 373 patients had been enrolled.
6.
In the micro infrastructure, the first 3 elements of the disease management solution
were applied: 1) patient education, 2) process innovation, and 3) objective
outcome assessments. Elements include: standardized, guideline driven care
pathways (Tight Control scenarios), patient participation through home care
solutions, and disease control optimization by specialized nurses and physicians.
7.
In the macro infrastructure, the following elements were launched: 1) a dedicated
tissue repository, or biobank, facilitating state of the art scientific analysis, 2) a study
platform from which all program elements will be tested, validated and improved,
and 3) a Nursing Program to train nurse specialists to work with the new disease
management solution.
G.A.Borghese
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I was diagnosed with Crohns disease 4 years ago, and having
The center for IBD has made a difference in my life since day
one. The staff has it all, from providing full support to their
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Inflammatory Bowel Diseases
amazing knowledge. I can always count on an email from one
of the nurses just to check up on me, and if I ever have any
concerns or questions, I get a quick and helpful response.
Throughout my time at the center I have achieved the confidence
and results I needed to deal with IBD, and know that I have a
whole team behind me rooting for my continuous good health.
IBD
Inflammatory Bowel Diseases (IBD) are chronic inflammatory diseases of the
digestive tract, and include Crohn’s disease and ulcerative colitis.
Crohn’s disease can occur anywhere from mouth to anus, ulcerative colitis typically
occurs in the rectum (proctitis), the left-side of the large bowel, or the entire large
bowel.
A.A.
Large Intestine
Sometimes you
just have to trust
your intuition.
9
Bill Gates
Rectum
Small Intestine
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Stomach
ACTIVE DISEASE
ENVIRONMENT
Phase one
Remission induction
Phase two
Maintenance
genes
start
microbes
immune
system
relapse
figure 1A
Cause
DNA variations in certain genes give rise to genetic susceptibility. As a consequence,
the gut immune system starts an inflammatory response against ‘normal’ intestinal
microbes. The environment plays a role but it’s still unclear how. One example is the
fact that cigarette smoking negatively influences Crohn’s disease.(Figure 1A).
figure 1B
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SURGERY
SCENARIO D
SCENARIO C
SCENARIO B
SCENARIO A
NO MEDICATION
less intense
treatment
(de-escalation)
more intense
treatment
(escalation)
figure 1C
therapy
When the disease is active, medication is used to get the disease under control
(remission induction phase of IBD therapy).
When the disease is quiet, it is essential to avoid relapse with maintenance
medication (maintenance phase of IBD therapy).
For each treatment phase there are a number of treatment scenarios which may
utilize a combination of one or more medications.(Figure 1B).
The intensity of the treatment depends on how difficult it is to control disease
activity over an extended period of time (e.g. a year).
Typically, more intense treatment scenarios combine several IBD medications.
It is seldom that IBD patients are able to control their disease over time with no
medication.
If the disease is quiet for prolonged periods of time, and colonoscopy does not show
inflammation, it is possible to switch to a less intense treatment scenario
(de-escalation). (Figure 1C).
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QUIET DISEASE
10
5
Situational analysis
5.1
Introduction
It is beyond doubt that out of all times, today is the best time to be working in
healthcare. There are critical health system problems, phenomenal technological and
scientific progress are still absent in daily care, and experts have designed models
of reform which are extremely difficult to interpret and operate on a busy Monday
morning with a waiting room full of sick patients. Since the answers are not easy, the
human mind is challenged in an unprecedented way. But healthcare providers have
always been knowledge workers, characterized by high creativity, independence
and strong adaptive abilities. This time, we are challenged to come up with new
innovative ideas and the courage to follow through. What is not tried, won’t work.
5.2
Why change?
1.
2.
3.
4.
5.
US healthcare spending is unsustainable;
Many people lack adequate health coverage;
Despite high spending, US health outcomes are poor;
The system emphasizes treatment instead of prevention;
Health disparities exist among numerous populations;
(Source: American Public Health Association, August 2012)
Seneca
75%
is spent on treatment
3%
is spent on prevention
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It is not because
things are
difficult that we
do not dare; it is
because we do not
dare that things
are difficult.
Waste in healthcare expenditure
$ 2,700,000,000,000.00/year (annual increase 5-10%)
20%
$ 190
billion / year
excessive
administrative
costs
$ 130
billion / year
inefficient
delivery
of care
inflated
prices
$ 105
billion / year
fraud
$ 75
billion / year
$ 120
billion / year
unnecessary
services
15%
10%
5%
1970
1980
1990
2000
2007
2010(p) 2018(p)
U.S. Health Care Expenditures as a % of GDP
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World Health Organization. World Health Statistics 2008, Part 2: Global health indicators
prevention
failures
$ 55
billion / year
(Ref: Institute of Medicine, LA Times, Sept 8, 2012)
5.3
Problem summary and Solutions
Any reform therefore needs to address ALL of the following:
In the last decade, various targeted healthcare reforms have led to remarkable
successes; e.g. lowering the price of drugs, introducing new technologies and
improving health plans. However, focusing on these single issue problems
alone did not prevent US Healthcare expenditures from exceeding
$ 2.7 trillion / year.
1.
2.
3.
4.
5.
6.
Huge challenges create huge opportunities. How can recent revolutionary
advances in technology and science lead to low-cost, easily accessible value-based
patient care for chronic diseases?
Adding measurable individual health benefit
Prevention oriented approaches
Cost effective care delivery processes
Quality control and quality assurance
Engagement of all stakeholders
Constant innovation by way of market mechanisms similar to other industries
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1960
5.4
PATIENT VALUE
1. Instead of continuing a short term cost reduction system, the focus needs to
shift to health outcomes achieved per dollar spent.
2. Instead of focusing on individual aspects of the complex structure of healthcare
delivery, the focus should be on individual PATIENT VALUE.
16
It has been suggested that a sustainable solution, present in all other industries,
is the introduction of true competition into healthcare driving constant innovation
to increase quality and lower costs. Healthcare providers who are successful in
improving (measurable) patient value across a full cycle of care will be rewarded,
while those who underperform will go out of business.
Not just healthcare providers, but all stakeholders should become involved
(i.e. patient, healthcare provider, biomedical industry, insurance companies,
government) in order to co-create a durable health system competing to deliver the
best measurable patient value.
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* Value Based healthcare. Porter ME, Olmsted Teisberg E. HBSP 2006; N Eng J Med 2010 (Dec)
Our Main Program Objectives:
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18
The program:
Needs to be developed around patient value
Needs to be prevention oriented instead of symptom oriented
Needs to facilitate patient participation
Needs to harmonize health care delivery by physicians
Needs to allow rigorous task differentiation
Needs to measure objective health outcomes
Needs to be aligned with (inter) national guidelines
Needs to take costs into account
Needs to be flexible and allow for constant technologic and scientific innovation
Needs to be developed generically in order to translate to other disease areas
6
Program design
6.1
I greatly appreciate and value the IBD program at UCLA – the
staff go out of their way to be caring and helpful, and take a
specific interest in getting me the best possible care. I’m given
all the information I could ever need, and it seems like we’re in
near-constant communication. I really like how they’re trying
Patient Value Quotient - vQ
To meet our objectives, we first designed the so-called Value Quotient (vQ) which
captures the value of healthcare services to individual patients over time and
correlates this with its associated costs (both direct and indirect costs).
Being a quotient, the numerator of the vQ represents individual Patient Value.
The vQ denominator represents the costs per unit of value.
new things, like developing their web app and testing it with
the iPad, or paying attention to the “VQ” (Value Quotient) – my
quality of life. Most of all, I never feel like just another patient –
the IBD team makes it so that we work together in order to bring
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20
P.H.
The more original
a discovery,
the more obvious
it seems afterward
Arthur Koestler
For chronic diseases, Patient Value is defined as a combination of:
1. Disease Control
2. Quality of Life
3. (Work) Productivity
The full cycle of care is currently defined per year, which means that at the end
of each year we will have analyzed the vQ over the previous 12 months for each
individual patient together with the associated costs. What is even more important,
we will have a good overview of factors that both positively and negatively influence
individual vQ scores. This will truly drive personalized improvement strategies and
significantly propel our mission to annually improve individual vQ scores. At the end
of each cycle, patients and other direct participants (doctors, nurses, and insurer)
create the strategic plan for the next twelve months, focusing on improvement of
those factors in order to increase the value and decrease associated costs.
The vQ is our UCLA trademarked ‘product’ for chronic diseases. The architecture
is generic, which means this platform can easily be adapted to all forms of chronic
diseases and cancer.
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about the best care possible, and that makes all the difference.
6.2
Self improving Macro infrastructure
I have been fortunate enough to have some incredible doctors
In order to allow monitoring and constant improvement of the Value Quotient,
we have introduced a so-called Tight Control infrastructure. On a macro-level
this involves all the programs and support systems solely designed to constantly
innovate the vQ; on a micro-level this involves the Tight Control care scenarios for
the daily care delivery.
throughout my experience with Crohn’s disease but none have
rivaled the compassion and accessibility that I’ve come to know
from the IBD center. The fast and open communication makes
it so that I can ask any questions I have and receive answers
in an unbelievably timely manner. The IBD Team has managed
to simplify my treatment from long infusions to a simple pill
6.2.1
Macro Infrastructure
keeping me away from the medical center and back to living my
We designed six programs in the areas of Care delivery, Research and Education.
In addition, four support systems have been developed 1) the disease specific data
warehouse 2) eLearning modules for patients, nurses and doctors 3) biobanks and 4)
a platform for systems biology.
life symptom free. I’m very grateful for all of these amazing and
hardworking people!
C.C.
Trial
Center
Care
Programs
H
RC
EA
C
RE
S
E
AR
Research
Programs
Stem Cell
Center
eLearning
Components
Fellowship
Program
Data
Warehouse
O
R
Platform
for Systems
Biology
Nursing
Education
Program
N
PP
T
IO
SU
Biobank
Infrastructure
ED
UC
AT
* Figure represents infrastructure for Inflammatory Bowel Diseases
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TIGHT CONTROL
Decision
flow chart
REMISSION
6.2.2
TIGHT CONTROL
REMISSION
VALUE QUOTIENT
NEW
ABBREVIATIONS
WORK-UP
WORK-UP
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Tight Control Care Program
Together with our patients, we have built so-called Tight Control scenarios for our
care program. Here, our mission was to create simple, easy to understand user
friendly annual care scenarios, in which patients themselves participate. These annual
care plans fully comply with current guidelines, and our quality program keeps them
continuously updated.
Instead of finding out how patients are doing during their clinic visits (static snapshot
model), we continuously capture information on their vQ (i.e. burden of disease,
quality of life and productivity) using our Homecare program (dynamic model) which
generates much more valuable data and decision support for direct intervention when
needed.
After successful training, patients participate by entering the required datasets (clinical
and laboratory outcomes) on dedicated tablet devices. Instant feedback is given and
on-demand eConsulting is offered by nurse specialists. Periodically patients interact
personally with their doctor and their assigned nurse specialist to evaluate or discuss
strategy choices. This type of homecare has already been shown to contribute to
higher patient value.
MY ACADEMY
BIOBANK
MY WORK
MY COACH
WORK-UP
ACTIVITY
ACTIVE
QUALITY Q
New patients are educated about their disease
and the IBD program (My Academy); get
insight into their working ability (My Work);
receive mental support (My Coach) and
are also invited to contribute to high quality
biobanks.
ACTIVE
Micro Infrastructure
LABORATORY
TEST
RADIOLOGY
REMISSION
ANTIB
ANTIBIOTIC FISTULA/POUCH
BIOL
BIOLOGIC
COMB
COMBINED THERAPY
CsA
CYCLOSPORINE
IM
IMMUNOMODULATOR
IMS
IMMUNOMODULATOR SWITCH
STER
CORTICOSTEROIDS
NO MED
• 5ASA
• IM
• BIOL
5ASA
• IM
• BIOL
5ASA
• IM
STER
• 5ASA
• IM
• CsA
IM
• 5ASA
• IMS
• BIOL
BIOL
• 5ASA
• STER
• IM
BIOL
• 5ASA
• IM
ANTIB
• IM
• BIOL
COMB
• 5ASA
TRIAL
STEM CELL
Patients are able to participate in cuttingedge trials. Stem cell treatments for patients
with refractory disease can be offered.
Depending of their disease activity, patients
are placed into remission induction or
maintenance scenarios.
* Figure represents infrastructure for Inflammatory Bowel Diseases
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ENDOSCOPY
ENDOSCOPY
LABORATORY
TEST
RADIOLOGY
TIGHT CONTROL
TIGHT CONTROL
Highly
personalized dashboards
REMISSION
ENDOSCOPY
VALUE QUOTIENT
Patient participation is determined
REMISSION
ACTIVEby
successful eLearning and patient adherence
to the care program. Participation >80%
will lead to health insurance benefit.
TIGHTdaily
CONTROL
Our
clinical practice
QUALITY QUOTIENT
REMISSION
The vQ is the quantifiable sum of
parameters for 1) disease control 2) quality
of life and 3) work productivity. Individual
vQs are constantly
monitored
and available.
WORK-UP
WORK-UP
LABORATORY
TEST
RADIOLOGY
TIGHT CONTROL
REMISSION
VALUE QUOTIENT
QUALITY Q
ACTIVE
Each patient is educated annually by
completing accredited eLearning modules
in “My Academy”.
During the full cycle of the Tight Control
scenario, optional care procedures are
allowed. WORK-UP
WORK-UP
Should patients experience new symptoms,
immediate visits can be scheduled.
NEW
ABBREVIATIONS
PATIENT:
ANTIB
ANTIBIOTIC FISTULA/POUCH
BIOL
BIOLOGIC
COMB
COMBINED THERAPY
CsA
CYCLOSPORINE
IM
IMMUNOMODULATOR
IMS
IMMUNOMODULATOR SWITCH
STER
PATIENT
PARTICIPATION
95%
DISEASE
CONTROL
QUALITY
OF LIFE
PRODUCTIVITY
87%
74%
83%
92
PATIENT:
Tight Control Scenario
Immunomodulator
OPTIONAL:
MY ACADEMY
MY WORK
MY COACH
CORTICOSTEROIDS
BIOBANK
Months
1
3
4
5
6
7
8
9
10
11
12
5ASA
• IM
STER
• 5ASA
• IM
• CsA
BIOL
• 5ASA
• STER
• IM
ANTIB
• IM
• BIOL
TRIAL
27
NO MED
• 5ASA
• IM
• BIOL
5ASA
• IM
• BIOL
• 5ASA
• IMS
• BIOL
IM
BIOL
• 5ASA
• IM
COMB
• 5ASA
STEM CELL
Each Tight Control care scenario is a standardized treatment pathway for a defined period
during which all participants contribute. Data on disease activity, disease complications, quality
of life, work productivity, process performance and associated costs is repeatedly captured
and processed into decision support for participants by the data warehouse.
* Figure represents infrastructure for Inflammatory Bowel Diseases
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2
ACTIVITY
Biomaterial is collected and stored
anonymously in dedicated biobanks.
Analyses are done on the Platform for
Systems Biology. Results are translated
back to the TC scenarios and contribute
to vQ improvement & cost reduction.
Tight Control assessment is done
periodically using Homecare systems &
devices. Patients participate by entering the
required datasets. Instant feedback (incl
vQ) is given and on-demand eConsulting
is offered by nurse specialists. Periodically
patients interact with their doctor to evaluate
or discuss strategy choices.
* Figure represents infrastructure for Inflammatory Bowel Diseases
TRIAL
PROGRAMS
HOMEPAGE
FELLOWSHIP
ORGANIZATION
I became a patient of the UCLA Center for Inflammatory Bowel
CARE
PROGRAMS
STEM CELL
TRIAL
CENTER
IBD
RESEARCH
FELLOWSHIP
IBD NURSE
HOMEPAGE
PROGRAM
HOME CARE
ABOUT US
LOGIN
STEM CELL
CENTER
CLINIC
RESEARCH
IBD
NURSE
HOMECARE
PROGRAM
DECISION
HOME CARE
MOMENT
LOGIN
LOG OFF
PATHOLOGY
Diseases almost a year ago. For many years I had to suffer and
6.3
UCLA Services beyond borders
endure the frequent flare-ups that will force me to be home
or office bound. Then by pure coincidence I learned about the
In addition to our UCLA patient services, we designed two external services:
new IBD program. On the day of my first meeting I was quite
TRIAL OFF
15 minutes later I had my first meeting with the doctor and his
nurse. They were delightful. They asked me all kinds of questions
HUMAN
to better understand how to choose the best course of action for
my treatment. By the time they were finished I felt they knew me
that my disease can finally be controlled. Things only got better.
The homecare program has empowered me and made me feel
that I am not alone out here in the world. It has helped me better
Key Performance Report
understand my symptoms, recognize when my condition is
HUMAN
NEW
NEW
TRIAL OFF
ACTIVITY
BIRTHDAYS
STE
ACTIVITY
STEM CELL OFF
MONITORING
B)
‘eMonitoring Services’ are eHealth services offered to assist physicians to
SERVICES
ON
tightly monitor and control the diseaseTRIAL
activity
of their patients. Our IT
applications
STEM
CELL ON
will capture, analyze and report back on individual patient outcomes, and offer
decision
support as well as on demand
PATIENT
PEDIATRICS eConsulting.
DOCTOR
SECOND
OPINION
feeling that I finally found a team that cares. I started believing
28
NEW
NEW
better than my best friend did. I still remember the overwhelming
STE
SECOND
DECISION
LOG OFF by our team
A)
‘Expert Opinion Services’MONITORING
are second opinion services offered
HOMECARE
OPINION
SERVICES
MOMENT
TRIAL and
ON the
of experts to establish the correct diagnosis, the present state of illness
optimal long term therapeutic strategy. Patients and their relatives are invited to
spend a day with us at our UCLA Clinic for full work-up, analyses, evaluation and
reporting.
CLINIC
ACTIVITY
ACTIVITY
29
NURSE
ACTIVITY
getting more serious that I need to call in for help, and to realize
that help can be just an email away. I liked so much that it made
me contact my other doctors and complain that they did not
MY ACADEMY
MY ACADEMY
PEDIATRICS
PATIENT
MY COACH
MY COACH
NURSE
DOCTOR
MY ACADEMY
have a similar homecare programs. I am now a more confident
MY COACH
person; traveling a lot more both for my job and my pleasure. I
Key Performance Report
impressed with how cordial and effective the front office was.
feel extremely empowered because of the simple knowledge that
there is an able team ready to help me navigate the muddy waters
that I, sometimes, have to deal with.
MY WORK
MY ACADEMY
MY WORK
MY ACADEMY
MY ACADEMY
MY COACH
MY COACH
MY DONATION
MY COMMUT
MY MESSAGES
DONATION
MY CALENDAR
COMMUTE
MY E-CONSUL
PLATFORM FOR
MY CALENDAR
SYSTEMS
BIOLOGY
BIOBANK
MY
E-CONSULT
MY WORK
MY COACH
M.B.
MY WORK
MY WORK
MY MANAGER
MY WORK
TECHNOLOGY
BIOBANK
MY MANAGER
DATA
MY MESSAGES
WAREHOUSE
BIOBANK
From fragmented care to coordinated care
Weeks are
filled with
doctor visits
6.4
Why is this disease management solution cost-effective?
1. Patient education: well-informed, educated and trained patients have been
3.
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4.
Organized
and coordinated
care pathway
start
1
5.
6.
2
3
4
7.
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2.
shown to feel less anxious, more in control, and interestingly, require less tests
and procedures. This type of engagement significantly drives empowerment
and treatment compliance.
Immediate Intervention (prevention): the decision support systems
dynamically guide healthcare providers and necessary care is delivered
immediately, avoiding unnecessary care and costs.
Eliminating ineffective care: quite uniquely, care delivery is harmonized
among all participating providers using the Tight Control scenarios. Optional
procedures are allowed by individual physicians, but if not effective (i.e.
increase in vQ) those will not be allowed in the following cycle of care (selfimproving system). Expensive drugs will go through central indication and
approval process before administration.
Introducing task differentiation: more than 80% of this type of preventative
care consists of monitoring individual patients. This is performed by nurse
specialists instead of physicians. In IBD, each nurse is the ‘health manager’ of
approximately 150 patients. In turn, one physician supervises approximately
3 nurses and therefore has the medical responsibility for 450 patients.
Reducing administration: patients will participate in data-entry; redundancy
of data collection is eliminated; data traffic is fully digitized; data analysis and
reporting is automated.
Removal of Approvals, Claims & Reimbursements: an annual ‘value
payment’ per disease severity class (mild, moderate or severe) will be allocated
including all scenario activities. At the end of each year, revenues are divided
among participants (including patients with premium reduction or rebate for
those with > 80% participation in Homecare and eLearning)
De-escalation of patients into lower and less costly disease severity class:
put simply, patients will be less sick and therefore less costly. Many examples
have shown that the introduction of compensation for patient participation
and homecare on one hand, and strong decision support for providers on the
other hand, will dramatically impact and reduce the need for hospital visits and
medication.
Prevention oriented care decreases urgency
and allows rigorous task differentiation
APPOINTMENT
IMAGING
ROUNDS
ADMIN
CONSULT
DICTATION
SCHEDULE
LAB
APPOIN
SURGERY
TMENT
From fragmented care to coordinated care
CLINIC
APPOINTMENT
•
Who takes care of the IBD patient?
•
Do they talk to each other to coordinate care?
•
Are strategies aligned?
•
Is it clear to the patient who is in charge?
IBD expert
APPROVALS
DICTATION
(E)CONSULTS
CLINIC
32
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General Gastroenterologist
Primary Care Physician
HOME CARE
SCHEDULE
MONITORING
TECHNICAL
EDUCATION
REPORTING
INFORMATION
SUPERVISION
PATIENT
ADMIN
NURSE
DOCTOR
Rheumatologist
Dermatologist
Surgeon
Task Differentiation
Effects:
Enhanced cost-effectiveness
Empowerment of patients, administrators, and specialized nurses
De-burdening of physicians from administrative activities
Make use of advanced technological solutions (e.g. eConsulting, home care)
Quality improvement through strong 24/7 decision support for all stakeholders
•
•
•
•
•
Key Performance Report
6.5
ADMIN
6.6
The business case
1
2
IBD Epidemiology
3
4
5
6
Kappelman MD, 2007
Armitage E, 2001
Fonager K, 1997
Lapidus A, 1997
Makharia GK, 2006
Yao T, 2000
U.S. prevalence1
Crohn’s disease
Ulcerative Colitis
Cost Components
Cost for Crohn’s Inpatient Care11
Average annual
direct costs
201/100.000
238/100.000
$ 35,378
Charges
Sharp increase
IBD incidence2-6
Surgical
6.9 - 14.6/100.000
Medical
Reimbursement
$ 46,353
$ 28,946
$ 20,744
$ 12,666
Diagnosis of fistulizing disease adds $ 6,268 - $ 10,868/yr12
Yu AP, 2008
Gibson TB, 2008
9
Kappelman MD, 2011
10
Park KT, 2011
7
Costs are associated with Disease Severity13
8
34
Severe
Total costs
Annual Direct IBD Costs7,8
Key Performance Report
U.S.
non-U.S.
$ 15,000 - $ 19,000/pt
$ 5,000 - $ 10,000/pt
Annual U.S. Healthcare Utilization for IBD9
Outpatient
Endoscopy
Emergency
Hospitalization
length of stay
Crohn’s Disease
1030/100
41.4/100
36/100
27.3/100
6.7 days
Ulcerative Colitis
921/100
52/100
26.2/100
19.1/100
6.9 days
Inpatient cost burden
$ 26,875
$ 12,154
$ 12,731
$ 13,516
$ 3,235
$ 2,244
Non-Adherence (5ASA) leads to a 2-fold increase of inpatient costs
(11.7% to 22.8%) and increased utilization of outpatient care.
The overall Paid-Employment costs of IBD in the U.S.15,16
$ 3,6 billion ($ 5,228/person)
$ 5,5 billion ($ 7,987/person)
2009
60%
Mild
Cost for Non-Adherence to IBD therapy14
1998/1999
60% of costs:
surgery and
inpatient care
Moderate
Cohen RD, 2000
Cohen RD, 2008
13
Hillson E, 2008
11
14
12
15
16
Kane S, 2008
Park KT, 2011
Longobardi, 2003
35
Key Performance Report
Utilization & Costs
ASSUMPTIONS
The Tight Control scenarios will de-escalate patients
into less severe outcome categories.
Number
of annual
relapses
Number
of optional
procedures«
Number of
hospitalizations
± surgery
Unforeseen
Mild
20%
0-1
0-2
0
5%
Moderate
60%
2-3
3-6
0
10%
Severe
20%
> 3 or chronic
active
>6
>_ 1
20%
e.g. scans, endoscopy, laboratory
THE BUSINESS CASE PER 1000 IBD PATIENTS
36
Key Performance Report
% of pts
Disease Severity
Mild Disease
Tight Control Care Scenarios will monitor and check patients, and this will:
1. Avoid unnecessary clinic visits
2. Reduce the number of visits to other physicians
3. Decrease the amount of tests and procedures
4. Detect ‘smoldering’ disease activity (active disease not causing symptoms yet)
5. Immediately respond to alarming symptoms
6. Increase drug compliance
7. Decrease anxiety and depression
Two additional factors need to be taken into account (see figure):
1. Depending on their disease severity (i.e. mild, moderate or severe) patients
will experience disease relapse and thus can change treatment scenarios.
2. Optional (unforeseen) activities and procedures need to be accounted for
especially in the more severe disease class.
Costs
N
2012
2013
2014
2015
$
20%
200 pts
300 pts
380 pts
440 pts
+ 220%
470 pts
- 22%
100
Moderate Disease
$$«
60%
600 pts
50
Severe Disease
Estimated
total costs
Cost savings
37
$$$
20%
80
550 pts
40
60
510 pts
20
200 pts
150 pts
110 pts
90 pts
- 55%
22 M
20 M
18.4 M
17.4 M
4.6 M
-
9.1%
16.4%
20.9%
$ = 10,000 ; this example uses 1000 IBD patients; «$$ = current minimal costs
Key Performance Report
«
Disease Severity
7
Implementation and Outcomes
7.1
Organizational matrix architecture
I am a young working professional battling this digestive
disease. I am pleased to have worked with the IBD team as
they are extremely responsive to my issues and concerns.
I am frequently travelling out of the country and sometimes
ORGANIZATIONAL MATRIX ARCHITECTURE
I have severe stomach pains or other related issues, I can shoot
eh
8
9
10
de
Care Program
A
A1
A2
A3
A4
A5
A6
A7
A8
A9
A10
Stem Cell Center
B
B1
B2
B3
B4
B5
B6
B7
B8
B9
B10
Trial Center
C
C1
C2
C3
C4
C5
C6
C7
C8
C9
C10
Recearch
D
D1
D2
D3
D4
D5
D6
D7
D8
D9
D10
Fellowship
E
E1
E2
E3
E4
E5
E6
E7
E8
E9
E10
Nurse Program
F
F1
F2
F3
F4
F5
F6
F7
F8
F9
F10
Prior to implementation, we designed our Matrix architecture around all the
programs, which helped tremendously in assigning tasks and responsibilities to team
members as well as providing weekly progress reports.
39
Key Performance Report
t
rs
g
en
y
e
tin
ol
7
em
6
lit
5
ls
Key Performance Report
ak
St
ke
ar
ag
an
M
M
ua
Q
4
nc
al
3
al
eg
/L
IT
na
Fi
c
hi
Et
2
ia
Jack Welch
1
er
An organization’s
ability to learn,
and translate that
learning into action
rapidly, is the
ultimate competitive
advantage.
at
38
M
A.T.
ce
take this New Year and Holiday spirit to thank the team!
a
Sp
service really helped me cope with my disease. I would like to
l
ne
e
on
rs
ur
ct
Pe
ru
e
St
ur
g
ct
tin tru
ee
tS
M
en
m
cu
Do
an email and get a response within an hour or so. This type of
2012
1
4
7
10
2
5
8
11
3
6
9
..
2012 DEVELOPMENT AT A GLANCE
2012 development at a glance
7.3
First implementations
It was a priori decided that in 2012 only 3 elements of the long list of Value-based
care design elements would be implemented. Reasons for this included the
significant amount of change management in the heart of traditional academic
structures and customs.
The 3 elements are 1) patient education 2) small scale process innovation and
3) objective outcome assessments. Because of the complex nature of cost price
structure, charges and reimbursements across the numerous health plans, we
entered the preparatory phase of value-based insurance design but did not include
costs into our vQ yet.
admin
RN
added:
2 MD, 1 RN
3 MD, 1 RN, 1 admin
MD
1
N = 373 IBD PATIENTS
PREPARATORY STAGE
Patient Education
• Training sessions during clinic visits about disease, medication, and program
process
• eLearning through ‘My Academy’
• Q&A messaging about problems related to medication, stress, coping,
depression, anxiety and pain
• Feed back about participation and outcomes (activity indices, vQ, tests or
procedures)
N = 104 SPECIMENS BANKED
2
Process innovation
• Organized care delivery during full cycles of care (Tight Control scenarios)
• Patient participation through ‘Home care’
• Accelerated approval, scheduling, and prescription services
• 24/7 messaging availability (Q&A, activity indices, vQs)
• Prevention: proactive communication & intervention upon significant Value
Quotient changes
• Decision support for nurses and physicians (dashboard statistics on both
individual patients and summary)
3
Objective outcome assessment
• Objective assessment:
• 1] disease activity, quality of life and productivity (Value Quotient)
• 2] patient satisfaction scores
• 3] healthcare utilization (e.g. ER, clinic visits, hospital stay, surgery, laboratory,
imaging, procedures)
biobanking
DEVELOPMENT eIBD PLATFORM
December
live!
November
October
September
August
testing beta-version
July
June
May
April
March
programming
February
104
PREPARATORY STAGE
Key Performance Report
40
January
373
added:
1 admin
Start Santa Monica MD’s
PREPARATORY STAGE
PREPARATORY STAGE
PERSONNEL
41
Key Performance Report
7.2
STEM CELL
CENTER
RESEARCH
Changing the Clinic Visit process
CLINIC
HOMECARE
(Westwood and Santa Monica)
IBD NURSE
PROGRAM
HOME CARE
LOGIN
DECISION
MOMENT
LOG OFF
TRIAL OFF
SECOND
OPINION
1.
Admin
•
•
My experience with the IBD program at UCLA has been a great
one. From the start, I felt very confident that I would receive great
MONITORING
SERVICES
3. Physician
• Welcome & introduction
Scheduling
Confirmation 1 day in
advance
HUMAN
NEW
care. The things I liked most were the fact that you had a “plan”.
•
Consultation (history,
physical)
•
•
Outside records
Dashboard prep
•
Training session 1: IBD
•
Educational package prep
NEW
•
general
Discuss Tight Control
•
Biobank prep
•
Scenario of choice
Introduction IBD Nurse
You laid out what you thought would work best to treat me and
STE
5. Research Nurse
TRIAL ON
•
Training session 3: trials &
biobanking
•
Q&A
•
•
Informed consent
Include in biobank and /
ACTIVITY
STE
ACTIVITY
or trials
get me feeling well and also an alternate if things didn’t go well.
PATIENT
Just knowing you already knew what I may need and how to treat
PEDIATRICS
DOCTOR
NURSE
my needs was so reassuring. I felt excited and eager to share how
1
I felt each visit, whether it was great or not quite 100% because
4
5
6
43
I knew the information I gave you would fit into your “formula”
and you would know what would help. I also liked the emails and
MY ACADEMY
MY COACH
MY ACADEMY
questionnaires asking about my progress weekly. It made me feel
Key Performance Report
3
MY COACH
MY ACADEMY
like I would never get as sick as I was when I first came to see you
MY COACH
because any difference in questionnaires would be addressed
immediately and taken care of before things got bad. Overall, I’m
VERY, VERY pleased with my care and treatment. It’s comforting
MY WORK
MY WORK
when I visit each location to see the same “team”. I feel you guys
2. Front desk / Nurse stationMY
• Welcome at the front desk
• Administration
• Info and educational
package
• Vital signs
know me and my needs and treat me very well.
Y.B.
•MY MANAGER
Medication lists
MY DONATION
4. IBD
WORK
•
•
•
•
•
Nurse
Training session 2: the IBD
Program
Q&A
Complete medical orders &
prescriptions
Complete reporting
MY MESSAGES
Introduce Research Nurse
MY COMMUTE
6. Front desk
• Processing orders
• Collect questionnaires
• Collect patient satisfaction
scores
• End of clinic visit
MY CALENDAR
MY E-CONSUL
3.+ 4. Physician + IBD Nurse
TECHNOLOGY
DATA
WAREHOUSE
•
•
•
•
•
Summarize consult
Discuss recommendations
Discuss short + long term implications
Q & A FOR
PLATFORM
BIOBANK
SYSTEMS
BIOLOGY+ reporting
Finish consult
BIOBANK
BIOBANK
TREATMENT
Key Performance Report
42
2
HUMAN
NEW
NEW
PATIENT
ACTIVITY
PEDIATRICS
ACTIVITY
DOCTOR
ACTIVITY
NURSE
Introducing patient education
MY ACADEMY
MY COACH
MY ACADEMY
My
Academy
MY COACH
MY ACADEMY
MY COACH
eLearning
MYthe
WORK
About
Center for Inflammatory Bowel Diseases
MY WORK
MY DONATION
Inflammatory
Bowel Diseases: An introduction
MY WORK
Diagnosis of Inflammatory Bowel Diseases
Therapy of Inflammatory Bowel Diseases
Special situations
in Inflammatory Bowel Diseases
MY MESSAGES
MY CALENDAR
MY MANAGER
MY E-CONSULT
45
TECHNOLOGY
Tell me and I forget
Teach me and I will learn
Involve me and I will remember
PLATFORM FOR
SYSTEMS BIOLOGY
DATA
WAREHOUSE
BIOBANK
BIOBANK
Key Performance Report
Key Performance Report
44
MY COMMUTE
BIOBANK
TREATMENT
REMISSION
MEDICINE
SURGERY
ENDOSCOPY
RADIOLOGY
TIGHT CONTROL
TIGHT CONTROL
REMISSION
ACTIVE
LABORATORY
TEST
VALUE QUOTIENT
QUALITY QUOTIENT
7.4
First Patients
TOTAL: 373 PATIENTS
PATIENTS PER PHYSICIAN
200
160
180
140
160
46
140
120
120
100
100
47
80
80
Key Performance Report
40
40
20
20
Dr. Hollander
Dr. Hommes
Dr. Ovsiowitz
Dr. Roth
From February 1 to December 31, 2012 (11 months)
Dr. Getzug
5
Dr. Connolly
8
Dr. Cole
Misdiagnosed
172
Dr. Choi
Indeterminate colitis
188
0
Dr. Cho
Ulcerative colitis
0
Crohn’s disease
Key Performance Report
60
60
New to UCLA
Established
1
0
36
109
0
4
0
6
0
1
9
18
66
72
2
6
21
22
Total
1
145
4
6
1
27
138
8
43
MY MANAGER
SECOND
OPINION
TECHNOLOGY
Origin
Health plan
HEALTH PLAN
NEW
22%
Other
TREATMENT
New to
UCLA
134 36%
10%
Medicare
PATIENT 9%
MEDICINE
Blue Cross / Shield
5%
Healthnet HMO
SURGERY
PEDIATRI
7%
Anthem Blue Cross
6%
Aetna PPO
Age
NEW
28%
Anthem Blue
Cross PPO
3%
Cigna PPO
4%
Anthem Blue Cross
Student health
MONITOR
SERVICES
PLATFORM FOR
SYSTEMS BIOLOGY
DATA
HUMAN
WAREHOUSE
ORIGIN
From 239
UCLA
64%
MY MESSAGES
6%
United Healthcare
48
49
60
MY ACADEMY
50
ENDOSCOPY
RADIOLOGY
MY ACADEMY
Medical specialties during Tight Control scenarios:
40
30
Gastroenterology
Key Performance Report
Key Performance Report
MY ACADEMY
Radiology
20
Surgery
MY WORK
MY WORK
10
Pathology
TIGHT CONTROL
Dermatology
0
10 - 19
20 - 29
30 - 39
40 - 49
CD
UC
Crohn’s disease age: mean 41 year (range 18-82)
Ulcerative colitis age: mean 40 year (range 18-85)
50 - 59
60 - 69
70 - 79
80 - 89
MY WORK
TIGHT
CONTROL
REMISSION
Rheumatology
Psychiatry / psychology
REMISSION
Gynecology ACTIVE
Obstetrics
MY MANAGER
MY MESS
Medical outcomes
Of the 373 patients that entered the program, 126 patients have both demonstrated
to be fully compliant to home care and have spent enough time in the program to
be evaluated. Figure 1 depicts the initial allocation to the different groups of Tight
Control scenarios.
FIGURE 1
13%
Work up
29%
Remission
Induction
51
58%
Maintenance
Figure 1
Work up (13%)
New IBD patients can’t always be immediately assigned to a Tight Control scenario,
because it is not always clear whether the disease is active or not. In total 17 out of
126 patients (13%) in this first cohort required initial diagnostic tests & procedures.
Figure 2 shows the choice of Tight Control scenario after completing the Work up
scenario (2 patients have not been completed).
REMISSION INDUCTION
WORK UP, N=17
67%
START
FINISH
ALLOCATION
33%
REMISSION INDUCTION
Figure 2
Key Performance Report
Key Performance Report
50
Remission Induction (29%)
A total of 36 patients entering the program were immediately assigned to the
Remission Induction Tight Control scenario. Figure 3 demonstrates the different
therapeutic types of remission induction scenarios.
FIGURE 3
17%
SASA
Remission Induction, N=36
44%
Steroids
Weeks
39%
Biologics
52
53
Follow up after remission induction scenarios:
When assigned to a remission induction scenario, it means that the disease is active
and the patient needs anti-inflammatory medication. It is our mission to achieve
disease control <6 weeks. A total of 30 out of 36 patients (83%) completed their
remission induction scenario successfully and were rolled over to their maintenance
scenario. Figure 4 shows the type of maintenance scenario that was chosen.
FIGURE 4
ACTIVE DISEASE
Phase one
Remission induction
start
Phase two
Maintenance
0%
No Med
17%
5ASA
20%
M IM
24%
M Biol
32%
M Combo
Figure 4
QUIET DISEASE
Key Performance Report
Key Performance Report
Figure 3
Maintenance (58%)
A total of 73 patients entering the program were immediately assigned to
the Maintenance Tight Control scenario. Figure 5 demonstrates the different
therapeutic types of maintenance scenarios.
7.5
Health outcomes are expressed as vQ. The vQ consists currently of entities
correlating with health value: 1) disease control (inversed disease activity
scores*) = 60% 2) quality of life score (IBDQ*) =20% and 3) Work productivity
(WPAI*) =20%. The vQ ranges from 0 to 100.
*Harvey-Bradshaw Index (Lancet 1980;8:514); Partial Mayo Score (IBD 2008);
IBDQ (Am J Gastroenterol 1996); WPAI (Clin Ther. 2008)
Maintenance, N=73
2
3
4
5
6
7
8
9
10
11
12
Months
We will now evaluate the first trends of the vQ in the various Tight Control scenarios.
Please remember that these are only the initial observations and trends in our limited
first number of 126 patients. Also, the vQ in this phase of the program is defined as
a composition of disease control (60%), quality of life (20%) and productivity (20%).
The cost component will be introduced in 2013 to further complete Value Quotient.
Figure 6 gives an overview of our Tight Control scenarios in which the vQs were
assessed.
Key Performance Report
54
ACTIVE DISEASE
FIGURE 5
Phase one
Remission induction
7%
No Med
1.
2.
3.
4.
5.
19%
IM
26%
Biologics
21%
Combo
Figure 5
Phase two
Maintenance
start
27%
5ASA
1. 5ASA
2. Steroids
3. Biologics
QUIET DISEASE
55
Key Performance Report
1
vQ performance
No medication
5ASA
Immune suppressives
Biological therapy
Combination therapy
Figure 6
SURGERY
SCOPY
LABORATORY
TEST
RADIOLOGY
VALUE QUOTIENT
QUALITY QUOTIENT
I.TIGHT
vQ CONTROL
performance in active patients
entering the 5ASA scenario
REMISSION
The first group of patients that we will evaluate are patients who entered into a
Remission Induction scenario with 5ASA. Figure 7A shows the average vQs during
the Remission Induction phase, and also the vQs of their subsequent MaintenanceREMISSION
phase. Figure 7B shows the individual patient changes.
T CONTROL
ACTIVE
WORK-UP
Key Performance Report
56
MEDICINE
SURGERY
ENDOSCOPY
RADIOLOGY
LABORATORY
TEST
TIGHT
VALUE QUOTIENT
QUALITY
QUOTIENT
II.
vQCONTROL
performance in active patients
entering the Steroids
scenario
REMISSION
Next is the group of patients who entered into a Remission Induction scenario with
steroids. Figure 8A shows the average vQs during the Remission Induction phase,
and also the vQs of their subsequent Maintenance phase. Figure 8B shows the
individual patient changes.
TIGHT CONTROL
ACTIVE
WORK-UP
WORK-UP
WORK-UP
100
100
100
100
90
90
90
90
80
80
80
80
70
70
70
70
60
60
60
60
50
50
50
50
40
40
40
40
30
30
30
30
20
20
20
20
10
10
10
0
63.7%
90.2%
Average vQ
in RI
Average vQ
in M
0
0
1
2
3
4
5
6
57
Key Performance Report
CINE
10
61.1%
85.5%
Average vQ
in RI
Average vQ
in M
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Single bars represent patients who have not yet completed their
remission induction scenario.
Figure 7A
Figure 7B
Figure 8A
Figure 8B
CINE
SURGERY
SCOPY
LABORATORY
TEST
RADIOLOGY
ACTIVE
WORK-UP
SURGERY
ENDOSCOPY
RADIOLOGY
LABORATORY
TEST
TIGHT CONTROL
TIGHT CONTROL
QUOTIENT
IV.
vQ performance in remissive
patients in MaintenanceVALUE
scenarios
REMISSION
After a robust clinical remission has been achieved, patients exit their remission
induction phase and enter a maintenance phase. Figure 10 shows the average vQs
REMISSION during their respective
ACTIVE
maintenance therapy. Below it is also demonstrated the
number of relapses during the observation period (range 2-9 months).
TIGHT
QUOTIENT
QUALITY
QUOTIENT
III.
vQCONTROL
performance in active VALUE
patients
entering the Biologics
scenario
REMISSION
The last group of patients with active disease are those that entered into a
Remission Induction scenario with biologics. Figure 9A shows the average vQs
during the Remission Induction phase, and also the vQs of their subsequent
Maintenance phase. Figure 9B shows the individual patient changes.
T CONTROL
MEDICINE
WORK-UP
WORK-UP
100
100
90
90
80
80
QUALITY QUO
WORK-UP
100
90
80
70
70
60
60
50
50
40
40
30
30
20
20
10
10
58
83.8
79.5
82.2
79.4
77.8
59
70
60
Key Performance Report
Key Performance Report
50
40
30
20
0
68.5%
10
87.5%
0
0
Average vQ
in RI
Average vQ
in M
1
2
3
4
5
6
7
8
9
10
11
12
13
14
M No Med
M 5ASA
M IM
M Biol
M Combo
no relapse
1x
1x
2x
1x
Number of relapses during observation period.
Figure 9A
Figure 9B
Figure 10
INITIAL RESULTS
Months in the
program
Number
Clinic visits
Number
of Home care
visits
Work up
6.5
2.5
3.0
7.0
RI 5ASA
5.0
1.8
1.8
10.3
RI Steroids
5.4
2.5
Key Performance Report
of a very well trained and intelligent staff and I love the tight knit
12.4
RI Biologic
5.1
2.1
2.4
11.3
RI Antib
n.a.
n.a.
n.a.
n.a.
M No Med
4.6
1.1
1.1
5.4
M 5ASA
7.1
1.4
1.4
6.2
M IM
5.9
1.5
M Biologic
7.1
1.7
1.7
11.4
M Combo
7.3
1.7
1.7
7.1
61
assuring me that I am in the best care I can possibly be in, it
really gives me peace of mind knowing that I’m under the care
2.4
1.5
1.5
2.1
5.5
7.1
care that I’m receiving. Everyone seems to be very interested
and caring with my case and I can’t be more happy with the
treatment I’ve received. The follow up questionnaires are great,
again it’s nice knowing I have a support team that is constantly
following up and making sure I am doing well, I honestly can’t
say enough good things about your program and I look forward
to everything you guys have in store for 2013! Thanks so much
Initial conclusions
to all of you!
1. Upon training & education, a significant proportion of patients are compliant in
D.S.
2. The home care is not perceived as too burdensome for most patients
3. The vQ (without the cost component) seems to correlate well with disease
their home care visits
activity
4. Home care messaging decreases as soon as the disease comes into a clinical
remission
5. Patient satisfaction is high: (N = 51: satisfaction rate = 98%)
6. The current Tight Control scenarios seem to adequately categorize patients into
guideline-based care
Key Performance Report
You and your whole staff have been amazing since day 1
15.5
3.1
2.1
60
Number
of Home care
messaging
7.6
A first indication of the strength of the program
N=20 patients
Crohn’s disease = 11
Single practice IBD specialist
Compliant patients (both pre and post)
All well characterized and representative IBD patients
Complete analysis for 6 month pre- and 6 months post program
Ulcerative colitis = 9
POST-PROGRAM 2012
01/02/2012
PRE-PROGRAM 2011
6 MONTHS
100
90
80
Clinic visits
70
60
50
40
30
20
6 MONTHS
10
10
20
73
30
40
50
60
70
80
90
Clinic visits
24
100
RESULTS
-67%
Key Performance Report
62
63
Home care
0
Messaging
0
1
Hospitalization
4
Surgeries
3
Radiologic procedures
14
11
Home care
67
8
Steroid use
Endoscopic procedures
52
2
0
Messaging
Steroid use
-87%
Hospitalization
-50%
Surgeries
9
Endoscopic procedures
-36%
8
Radiologic procedures
-17%
Key Performance Report
•
•
•
•
ORGANIZATION
CARE
PROGRAMS
IBD
FELLOWSHIP
TRIAL
7.7
STEM CELL
I was diagnosed with Crohn’s disease in 2006. Since my
CENTER
ABOUT US
IBD Nursing Program
“It is our Mission to develop inspiring educational programs, both hands-on and
IBD NURSE
HOME CARE
PROGRAMfor nurses working in the
LOGIN
online,
field of Inflammatory BowelPATHOLOGY
Diseases (IBD), to
create a national network of highly motivated IBD nurses for exchange of best
practices and IBD nursing guideline development, and to advance knowledge and
offer practical steps on how to integrate IBD nursing into our daily practice to offer
the best value for our IBD patients.” RESEARCH
diagnoses it has impacted my daily life tremendously. I have
spent countless days in the hospital, seen numerous doctors,
been on what seems like every medication made, and lived with
severe pain, fatigue, and stress caused by my illness. I’ve never
felt so alone and was giving up on all hope until I joined
the
CLINIC
HOMEPAGE
DECISION
LOG OFF
MOMENT
The
UCLA Center for Inflammatory Bowel Diseases
HOMECARE
UCLA IBD program in May 2012. Since I’ve been under the care
BIRTHDAYS
of the IBD team my symptoms and well-being has improved
64
value the most is how compassionate, helpful, and prompt the
entire team is whenever I have any questions or concerns.
SECOND The
MONITORING
SERVICES
OPINION
communication is phenomenal and it’s comforting to have a
Key Performance Report
Doctor and team that reassure me that they have a medical plan
HUMAN in my IBD
for my future. I have so much faith and confidence
team that I travel four hours from my residence in Clovis, CA
NEW
just to be in their care. I’m very blessed to be a part of the IBD
NEW
ACTIVITY
program and look forward to helping them grow and research
my disease in any way that I possibly can.
PATIENT
PEDIATRICS
A.H.
Developed IBD Nursing Curriculum:
Class I
Epidemiology, pathophysiology and clinical presentation of IBD
STEM CELLassessment
OFF
Class IITRIAL OFF Diagnosis of IBD: physician
and nursing assessment
Class III
Medical management of adult IBD
TRIAL ON
STEM CELL ON
Class IV
Medical management
of pediatric IBD
Class V
Surgical management of IBD
Class VI
Dietary considerations in IBD
Class VII
Fertility and Pregnancy in IBD
ACTIVITY
ACTIVITY
Class VIII
Psychosocial
aspects of IBD
Class IX
The IBD Patient: views and values.
Class X
The organization of IBD care delivery
Star Class*
Value-based healthcare delivery
DOCTOR
Star
Class*
Stem Cell careNURSE
in IBD
Star Class*
IBD Healthcare ethics
Star Class*
Leadership skills
MY ACADEMY
MY ACADEMY
MY COACH
MY COACH
MY ACADEMY
MY COACH
MY WORK
MY WORK
MY DONATION
MY WORK
MY COMMUTE
65
Key Performance Report
dramatically and I finally have control of my disease. What I
EMY
IBD
FELLOWSHIP
TRIAL
HOMEPAGE
ABOUT US
STUDENT EVALUATIONS (N=122)
32%
MECN
2%
PhD
IBD NURSE
2%
PROGRAMUnknown
RESEARCH
HOME CARE
LOGIN
PATHOLOGY
First Student Course: August 17 2012
11%
Not returned
Nurse Education for Inflammatory Bowel Diseases
53%
BSN
Morning Program
HOMECARE
DECISION
MOMENT
80
LOG OFF
60
40
66
Key Performance Report
20
MONITORING
SERVICES
TRIAL OFF
0
0
Q1
Q2
Q3
Q4
Q5
Strongly disagree
Neither
Disagree
Agree
TRIAL ON
Q6
Q7
STEM CELL OFF
Q8
STEM CELL ON
Q9
Strongly agree
7:30
Coffee & Registration
8:00 – 8:10
Welcome
Cathryn Gabster
8:10 – 8:40
BIRTHDAYS
The World of Inflammatory Bowel Diseases
Daniel Hommes
8:40 – 9:00
How do I diagnose IBD?
Jennifer Choi
9:00 – 9:20
What is a colonoscopy?
Lizzie Inserra
9:20 – 9:40
Measuring IBD disease activity
Laurin Eimers
9:40 – 10:00
Take Home Messages: Etiology and Diagnosis
Daniel Hommes
10:00 – 10:20
BREAK
10:20 – 10:40
The principles of IBD therapy
Jennifer Choi
10:40 – 11:00
Commonly used IBD medication Lizzie Inserra
11:00 – 11:20
The IBD Care Pathway
Daniel Hommes
11:20 – 12:00
Introducing Tight Control scenarios
Laurin Eimers
12:00 – 12:20
Take Home Messages: Therapeutic management
Jennifer Choi
12:20 – 13:00
LUNCH
Afternoon Program
13:00 – 13:10
IBD Cases: Introduction of break-out sessions
Daniel Hommes
4 Groups of 30 students
PEDIATRICS
Q1 The course objectives were clear
Q2 The content ofACTIVITY
this course was appropriate
Q3 My knowledge on the subject matter increased
Q4 The difficulty level of this course was appropriate
Q5 The pace of this course was appropriate
Q6 I accomplished the objectives of this course
Q7 The course met my expectations
Q8 The course instructors were
helpful and courteous
DOCTOR
Q9 I would recommend this course to others
ACTIVITY
NURSE
MY COACH
ACTIVITY
13:10 – 13:20
Case Presentation & QuestionsGroup Leader
13:20 – 13:50
Discussion
13:50 – 14:00
Preparing Case Presentation
14:00 – 15:00
4x Case Presentations
15:00 – 15:20
BREAK
15:20 – 15:40
Coping with IBD
Laurin Eimers
15:40 – 16:00
Value-based Health Care for IBD
Jennifer Choi
16:00 – 16:20
A career in IBD Nursing
Lizzie Inserra
16:20 – 16:40
IBD Nursing Programs
Adriana Centeno
16:40 – 17:00
Closing
Daniel Hommes
17:00
Certificates and Reception
67
Key Performance Report
100
MY WORK
NEW
NEW
ACTIVITY
ACTIVITY
ACTIVITY
MY WORK
MY DONATION
MY COMMUTE
MY CALENDAR
MY E-CONSULT
MY WORK
PATIENT
PEDIATRICS
DOCTOR
MY ACADEMY
NURSE
MY COACH
MY ACADEMY
MY COACH
MY MANAGER
MY MESSAGES
MY COACH
MY ACADEMY
7.8
IBD Biobank
MY WORK
TECHNOLOGY
MY WORK
MY DONATION
MY COMMUTE
45
Biobanked CD
MY WORK
BIOBANK
PLATFORM FOR
SYSTEMS BIOLOGY
DATA
WAREHOUSE
MY MANAGER
TECHNOLOGY
MY MESSAGES
MY CALENDAR
47
BIOBANKBiobanked UC
BIOBANK
MY E-CONSULT
281
Remaining
TREATMENT
68
69
BIOBANK
Key Performance Report
BIOBANK
92 patients where already biobanked successfully from August 1 to
December 31, 2012 (5 months) (24% of total).
BIOBANK
MEDICINE
SURGERY
TREATMENT
MEDICINE
SURGERY
ENDOSCOPY
ENDOSCOPY
RADIOLOGY
TIGHT CONTROL
TIGHT CONTROL
REMISSION
TIGHT CONTROL
REMISSION
ACTIVE
LABORATORY
TEST
RADIOLOGY
LABORATORY
TEST
VALUE QUOTIENT
Key Performance Report
PLATFORM FOR
SYSTEMS BIOLOGY
DATA
WAREHOUSE
QUALITY QUOTIENT
TIGHT CONTROL
REMISSION
VALUE QUOTIENT
QUALITY QUOTIENT
MY WORK
MY WORK
MY DONATION
MY COMMUTE
MY WORK
HUMAN
NEW
NEW
MY MANAGER
ACTIVITY
ACTIVITY
MY MESSAGES
MY CALENDAR
MY E-CONSULT
PATIENT
PEDIATRICS
DOCTOR
ACTIVITY
NURSE
TECHNOLOGY
BIOBANK
PLATFORM FOR
SYSTEMS BIOLOGY
MY ACADEMY
DATA
WAREHOUSE
MY ACADEMY
BIOBANK
MY COACH
MY COACH
BIOMATERIALS
COLLECTED
BIOBANK
MY ACADEMY
MY COACH
50
I am a 54 year old retired police officer. I was diagnosed with
Crohn’s disease
TREATMENT
ulcerative colitis 4 years ago. During this time, we tried many
ulcerative colitis
40
different diets and medications to control my disease with
little or no change in my symptoms. Ulcerative colitisMEDICINE
began to
SURGERY
MY WORK
MY WORK
30
MY DONATION
control my life. I began to feel helpless, because it felt as if no
MY WORK
MY COMMUTE
20
one knew what I was going through. When I called UCLA to set
up my initial appointment, I knew instantly that I was dealing
10
with an organization that would make a difference. The person
0
ENDOSCOPY
that answered the phone and set up my first appointment
was
70
LABORATORY
DNA
TEST
MY MESSAGES
RADIOLOGY
MY MANAGER
very professional and was able to make the appointment with
Blood,
active
Blood,
inactive
MY
CALENDAR
Biopsies,
active
Biopsies,
Surgical
inactive MY E-CONSULT
specimens
71
my schedule and disease in mind. The questions asked on my
initial questionnaire were relevant to my disease and were easy
TECHNOLOGY
disease was controlling my quality of life. They explained
the
TIGHT CONTROL
TIGHT CONTROL
REMISSION
DATA
WAREHOUSE
mission of the UCLA IBD unit and how along with the proper
VALUE QUOTIENT
PLATFORM FOR
SYSTEMS BIOLOGY
to understand. I believe, together we can find a way to “quiet”
ACTIVE
TREATMENT
Scientific technology has reached a level of maturity that allows the integration of
daily clinical data with data derived from complex molecular profiles offering unique
insights into disease mechanisms.
this disease. Each time I leave my appointment I feel like they
are doing everything medically possible to help me get well. My
BIOBANK
Platform for Systems Biomedicine
“The discovery of new disease markers and new BIOBANK
drugs”
medications we would be able to control my disease. I received
REMISSION
a handout which explained the disease in a
way that I was able
QUALITY QUOTIENT
BIOBANK
MEDICINE
SURGERY
WORK-UP
WORK-UP
daughter once told me, “without HOPE what else is there?” I tell
her, there is the UCLA IBD unit that gives me HOPE.
R.S.
ENDOSCOPY
RADIOLOGY
TIGHT CONTROL
TIGHT CONTROL
REMISSION
LABORATORY
TEST
VALUE QUOTIENT
QUALITY QUOTIENT
Key Performance Report
Key Performance Report
to understand. I felt as if someone was listening to how this
Did You know?
7.9
Social Media
45%
of consumers say social media affects their
decision to get a second opinion.
41% says social media affects their choice of a specific
doctor, hospital or medical facility.
72% of consumers would like help in scheduling
appointments through social media
>80% between the ages of 18-24 say they would share
their health information on social media.
72
90% between the ages of 18-24 say they trust the
73
Key Performance Report
Key Performance Report
information found on social media.
Twitter followers 2012
Watch the movies about our
Value Based healthcare programs.
Facebook fans 2012
8
Conclusions
What great
things would you
attempt if you
knew you could
not fail?
Undoubtedly there are many solutions for fixing our healthcare system and building
sustainable infrastructures for future generations.
We have designed and developed a disease management solution that so far shows
promising results:
• It looks at patient value and its associated costs as outcome measures
• It captures this in one single parameter: the Value Quotient (vQ)
• In our first analyses, the vQ correlates well with disease control
• Patient engagement through home care resulted in high satisfaction scores
• It suggests a remarkable reduction in health system utilization
• It harmonizes care between providers and allows robust quality control
Robert Schuller
The IBD Team.
75
Key Performance Report
Key Performance Report
74
It will be our great pleasure to continue on this road in 2013, and to keep adding
value to our IBD patients. Their willingness to help us has been phenomenal and
we thank them from the bottom of our hearts. Validating our data-model for value,
introducing new technologies and adding the cost-component will continue to
mature this new and exciting solution for the management of chronic diseases.
I had a flare-up of my condition that wasn’t responding to
medication. I had gotten extremely ill and had been ill for about
a year. I was down to 92 pounds and had been told by my then
gastroenterologist that I would never recover. An emotional low
in my life which lead me on the search for another doctor who
could help me. I found the UCLA Center for Inflammatory Bowel
Diseases through a recommendation by another doctor. When
I met the team I was finally on my way to recovery, had gained
weight, but still had a ways to go.... determined to recover
my health, and doing everything I could to personally aid in
that (did a lot of online research). What was seriously lacking
was quality medical care for my disease. I was scared I would
slip backwards and felt alone and isolated. I can’t say enough
positive things about the IBD Center and the beyond excellence
76
in care I now receive. I know that it was having the IBD Center
team that sped up my recovery time. What an amazing,
77
positive feeling to know that any time I needed assistance or
was amazingly fast. For the very first time in my life, I didn’t
feel alone and isolated with my condition. My positive feeling
knowing that I have a team dedicated to manage my condition
and keep me in optimum health is truly priceless. I feel like I
have found an amazing “home”. This year I am almost 100%
recovered from my serious bout of this illness and looking
forward to many healthy years to come thanks to you and your
team. I’m so thankful to have found you!
Your very grateful patient, J.G.
Key Performance Report
Key Performance Report
had a question, I could email the Center. The response time
Our aspirations
are our
possibilities.
Robert Browning
9
Acknowledgements
Center for Inflammatory Bowel Diseases
Daniel W. Hommes, MD, PhD Director
Jennifer Choi, MD Associate Director
Elizabeth Inserra, RN, BSN IBD Nurse
Laurin Eimers, RN, BSN IBD Nurse
Ellen Kane, RN, BS Research Nurse Coordinator
Leticia Gutierrez Assistant Manager
Antonio Lopez Administration
Angelos Oikonomopoulos, PhD Research / Biobank
Welmoed Van Deen, MD Research / Biobank
Division of Digestive Diseases
Gary Gitnick, MD Division Chief
Eric Esrailian, MD, MPH Division Vice-Chief
Adriana Centeno Assistant Director
Trisha James Assistant Director, Business Development
78
Physicians (Westwood) Physicians (Santa Monica)
Bennett Roth, MD Daniel Cho, MD
Daniel Hollander, MD Daniel Cole, MD
Terri Getzug, MD Lynn Connolly, MD
Wendy Ho, MD Mark Ovsiowitz, MD
79
Epidemiology & Social Media
Martijn van Oijen, PhD Co-Director, Center for Outcomes Research & Education
Lam Nguyen
Medical Students
Varun Shai
Marc Berns
Clinical Nurses & Front Desk Staff: Westwood, Santa Monica
UCLA
Computing Technologies Research Lab (CTRL)
Robert Dennis, PhD
Khy Huang
Gene Lacson
Division of Digestive Diseases
Department of Medicine
Department of Surgery (J. Sack, J. Yoo)
Broad Stem Cell Research Center
UCLA School of Nursing
UCLA Center for Health Policy Research
Division of Nanomedicine
Department of Psychiatry
Department of Pathology
Department of Radiology (B. Kadell)
Michele van der Kemp, MSc Strategy, Marketing & Communications
© 2013 The Regents of the University of California. UCLA Health Center for Inflammatory Bowel Diseases™.
All Rights Reserved. Do not copy, distribute or otherwise use this Work without written permission.
Key Performance Report
Key Performance Report
Laboratory
Harry Pothoulakis, MD Director, IBD Basic Science Center & Research Integration
Dimitrios Iliopoulos, PhD Director, Center for Systems Biomedicine
Value Redefined