Thomas Wickizer, PHD, MPH College of Public Health
Ohio State University
1
Health System Intervention: Back of the
Envelope to Statewide Transformation
of Occupational Health Care Delivery
7
thAnnual Conference on the Science of
Dissemination and Implementation
Bethesda, Maryland
December 9, 2014
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
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
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
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
5
Bad News
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)
$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)
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
Occupational Health Services (OHS)
Quality Improvement Intervention
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”
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
11
OHS-COHE Organization
Pilot Community
COHE
Advisory GroupBusiness/LaborCommunity Physicians Dep’t of Labor & Industries UW Research Team
Location of COHE Pilot Sites
13
Spokane Renton
Intervention Components
14
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
OHS Evaluation
Intervention & Comparison Groups
16Renton
Intervention Group
10,725
Comparison Group
45,772
Intervention Group
26,367
Spokane
Intervention Group
24,222
Comparison Group
9,245
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
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 - $37219
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
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
