Health System Intervention: Back of the Envelope to Statewide Transformation of Occupational Health Care Delivery

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(1)

Thomas Wickizer, PHD, MPH College of Public Health

Ohio State University

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Health System Intervention: Back of the

Envelope to Statewide Transformation

of Occupational Health Care Delivery

7

th

Annual Conference on the Science of

Dissemination and Implementation

Bethesda, Maryland

December 9, 2014

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Evaluation and Implementation Team

WA State Dep’t of Labor and Industries (DLI):

– Gary Franklin, MD, MPH, Medical Director, DLI and Research Professor University of Washington

– Robert Mootz, DC, Associate Medical Director, DLI

– Roy Plaeger-Brockway, MPP, Project Manager, DLI

University of Washington:

– Tom Wickizer, Ph.D., Professor

– Deborah Fulton-Kehoe, Ph.D, Research Scientist

– Terri Smith-Weller, RN, COHN, Research Coordinator

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Presentation Topics

• Topics:

– Project context of workers’ compensation (WC):

• Highly adversarial environment: business vs. labor

• Poor quality and outcomes

• Poor satisfaction

– Pilot design and implementation strategy – Pilot evaluation methods and findings – State law and institutionalization of pilot

– Lessons learned regarding implementation of intervention • Take Home Point:

– Successful dissemination and implementation will be fostered by:

• Strong executive leadership

• Meaningful organizational learning

• Ongoing strong stakeholder involvement and support

• Identification of principles to guide the implementation effort

• Good science for implementation and evaluation

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Washington State Workers’ Compensation

WA State WC is organized as a “state fund” system

administered by Dep’t of Labor & Industries (DLI)

All employers who don’t self-insure must, by law,

purchase WC insurance through DLI

Thus DLI is the single payer for WC health care

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WC Disability Prevention:

Good News—Bad News

Workers who remain on disability for longer

than 2-3 months have greatly reduced chance

of returning to work

Effective occupational health care can reduce

the likelihood of long-term disability

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Bad News

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Changes in Disability Status among

Injured Workers in WA State

12 11 10 9 8 7 6 5 4 3 2 1 0 0 20 40 60 80 100 % Workers Receiving Disability Payments

Time Loss Duration (months)

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$0 $150 $300 $450 $600 $750 $900

Medical Cost Disability Costs

$587 $342 $748 $625 Managed Care FFS Key Finding 7

Cost per claim

DLI Managed Care Pilot Cost Findings

(n=2,217)

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Beginning Organizational

Learning and Policy Study

DLI executive management embraced findings of

managed care pilot evaluation

Working closely with stakeholder business-labor

group, Wickizer and team conduct 18-month policy

study to assess feasibility of designing a quality

improvement (QI) initiative

Policy report adopted and sets forth key principles

for QI initiative:

– Increased provider accountability

– Improved worker and employer satisfaction

– Improved outcomes, with key outcome defined as reduced work disability

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Occupational Health Services (OHS)

Quality Improvement Intervention

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OHS Project

WA State OHS Project initiated in 1998:

To improve quality and outcomes of occupational

health care

To enhance patient and employer satisfaction

OHS is not “managed care”

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System Redesign through OHS

Four quality indicators, representing an occupational best

practice, linked to physician payment incentives

– Each time a physician performed a best practice he/she received added payment

Community-based pilot centers for occupational health and

education (COHEs)

Quality improvement (QI) activities:

• Care coordination

• Mentoring and CME for community MDs

• Disseminate treatment guidelines and best practices information

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OHS-COHE Organization

Pilot Community

COHE

Advisory GroupBusiness/Labor

Community Physicians Dep’t of Labor & Industries UW Research Team

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Location of COHE Pilot Sites

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Spokane Renton

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Intervention Components

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Quality Improvement Component Quality Improvement Objective

Structural Change Components

 Physician Continuing Medical Education (CME)

 Enhance physician knowledge and training in treating occupational injuries

 Health Services Coordinators

 Improve care coordination

 Improve communication with employers to promote return to work

 Reduce provider administrative burden

 Information technology  Improve patient tracking Financial Incentive Component

 Enhanced provider payment

 Promote best practices

- Submission of accident report - Use of activity prescription form - Communication with employer - RTW impediments assessment

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OHS Evaluation

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Intervention & Comparison Groups

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Renton

Intervention Group

10,725

Comparison Group

45,772

Intervention Group

26,367

Spokane

Intervention Group

24,222

Comparison Group

9,245

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Outcome and Covariate Measures

Outcomes assessed:

Off work on disability at one year post injury

Total disability days

Disability and medical costs

Covariates

Age

Gender

Type of injury

Provider specialty

Industry

Provider claim volume

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Statistical Results

Measure

Statistical (Marginal) Estimates

All

Cases

Back

Sprain

Cases

High Adopter vs.

Lower Adopter

Cases

On disability at 1 year (OR) .79 * .63 * .63 * Disability days - 3.3 days * - 8.1 days * - 6.9 days * Disability costs - $267 * - $542 * - $384 * Medical costs - $145 - $191 - $372

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Passage of State Law Expanding COHE

on a Permanent Statewide Basis

In March 2011, WA State Governor signed a

law expanding COHE on a permanent

statewide basis

Key factors underlying passage of the law:

Good science underlying evaluation results

Strong bipartisan support from business and labor

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Summary and Concluding Points

Passage of legislation institutionalizing the DLI QI

initiative on a permanent statewide basis represents a

highly successful dissemination-implementation effort

Keys to success were:

– Strong ongoing stakeholder support from business and labor

– DLI organizational learning that occurred over time in support of pilot work and innovation

– Presence of an “idea champion” in the form of the DLI Medical Director

– Good evaluation science that produced credible results the legislature could act on

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Summary and Concluding Points (2)

Currently COHEs are delivering care in 38 of 39 WA

counties

By July 2015, 3,500 physicians will be treating 50,000

COHE patients annually

Further analysis will document the effects of this

expansion

Thank You !

Thomas Wickizer, PhD

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