The Healthy Aging Brain Center (HABC) is a clinical program providing care within WHS to patients and family caregiver with concerns about the emotional and cognitive health of the aging brain. HABC is not supported by research funding to deliver care but it has standardized manual and electronic assessment, management, and performance data that facilitate access to research projects.
Wishard Health Service (WHS)
WHS is a safety net health care system that serves the residents of Marion County in Indiana, including Indianapolis. It is comprised of Wishard Memorial Hospital, 11 community primary care health centers, a center for senior care, and mental health services. The hospital is a 450 bed, university affiliated urban public hospital that serves a population of approximately 750,000 in greater Indianapolis. The community health centers are located within 5 miles of the hospital in a distribution specifically designed to serve distinct communities. Nine of these health centers serve typical urban populations with predominantly African American patients with a low socioeconomic status and two health centers serve a typical non-minority population with a high socioeconomic status. All general internists providing care in these facilities are either faculty in the Division of General Medicine and Geriatrics or house-staff within the department of medicine at Indiana University School of Medicine. In 2007, WHS served approximately 11 thousand patients aged 65 and older via more than 87 thousand visits to any WHS site. Nearly all of these patients have at least one visit to their primary care physician in a given year with an average of about 4 visits per year. It is estimated that 69% of this older cohort are women, 54% are African-American, and 44% have less than 8 years of education. Through the local electronic Regenstrief Medical Record System (RMRS), we have access to data about process of care and comorbid conditions. We have used these data in multiple previous studies. Chronic medical illnesses are common including hypertension (63%), arthritis (30%), diabetes mellitus (25%), chronic obstructive lung disease (18%), coronary artery disease (15%), severe obesity (14%), cancer (10%), congestive heart failure (8%), mild cognitive impairment (MCI) (13%), dementia (6%), and depression (7%).
Implementing the Collaborative Care Model for Dementia within WHS
Traditional conceptual models portray the health care delivery system as a machine-like system with replaceable parts and predictable behaviors that can be changed and reproduced based on financial incentives, regulatory policies, national guidelines, and best practice initiatives. (Boustani et al, 2010
; Institute of Medicine & Committee on Quality of Health Care in America, 2001
) However, the assembly line conceptual model does not fit health care systems. Health care delivery organizations are more accurately conceptualized as a complex adaptive system with local critical nonlinear relationships that produce unpredictable behavioral patterns or dynamics. (Anderson et al, 2005
; Boustani et al, 2007
; Crabtree et al, 2001
; Hagedorn et al, 2006
; Institute of Medicine & Committee on Quality of Health Care in America, 2001
; McDaniel et al, 2003
) Using the lens of the complex adaptive system and the five principles of the reflective adaptive process (Stroebel et al, 2005
), we implemented the Healthy Aging Brain Center as the local collaborative dementia care model within WHS (see ).
Using the reflective adaptive process to develop the Healthy Aging Brain Center.
As a first step in the implementation process, we established an implementation team of representatives from the various disciplines involved in delivering dementia care at WHS. This team included a primary care physician; three memory care physicians; a nurse provider; a social worker; a clinic administrator; two neuropsychologists; a social psychologist; and a local representative of the Alzheimer’s Association. Over a four-month period and in the presence of internal facilitator, the team met every two weeks for two hours to transform the protocols of the collaborative dementia care model into locally sensitive minimum care delivery specifications for HABC. A smaller operational team initiated monthly meetings to monitor the progress of the HABC in order to make small but timely modifications based on incoming data. The core components of the HABC care model are shown in and a detailed manual of HABC standard operation is available online, including the HABC initial diagnostic assessment, the biospychosocial need monitor, and non-pharmacological management protocols for dementia symptoms (www.indydiscoverynetwork.com
The Standardized Minimum Care Delivery Components of the HABC.
Evaluation Platform for HABC Performance
Using the conceptual model of Complex Adaptive Systems and the electronic Regenstrief medical record system (RMRS), we developed an evaluation matrix that provides timely periodic data relevant to the HABC performance for the leadership of WHS.
The RMRS is the primary instrument for processing data and monitoring patient and physician activity for WHS. It is a modular system, composed of Registration and Scheduling, Laboratory, Pharmacy, and Database modules. The Laboratory module handles all inpatient and outpatient data, all lab reports and data used for billing. In addition, this module stores coded results and full text interpretations of all imaging studies and special procedures. The Pharmacy module contains information on dispensing and charges of all medications by the inpatient and outpatient pharmacy. The Database module stores all the above data by date in a fully coded form. Data for large numbers of patients are retrievable using a locally developed English-like language called CARE. Patients can be identified either by a certain restriction list or by clinical criteria. The RMRS maintains a number of other databases including diagnoses, vital signs, results of laboratory tests and diagnostic tests, full-text discharge summaries, preventive health maneuvers, and detailed information on all inpatient and outpatient charges. It also contains death certificate information from the Indiana State Board of Health for all registered patients who die in, or outside of, Indiana. Thus, the RMRS collects and monitors a broad array of physician and patient activity, practice patterns, utilization, diagnostic test finding, and outcomes.
Since 1984, the Medical Gopher system, a network of microcomputer workstations, has allowed physician order entry and other direct interactions between computer and physician. The Medical Gopher is linked to the RMRS and is used by physicians to write all orders at WHS. Physicians in WHS enter all inpatient and outpatient orders directly into physician workstations. They have access to more than 70 personal computer (PC) workstations distributed around the hospital, the emergency rooms, and the community centers. The workstations are linked via a network to a central file server and a cluster of Digital Equipment Corporation's VAX computers. Less than 5% of orders are entered by nursing staff as verbal orders from physicians and these must be entered into the computer within 24 hours.
The WHS leadership agreed upon an evaluation platform to monitor HABC performance that includes ambulatory care utilization, acute care utilization, and a set of quality indicators. The HABC directors use the RMRS system to collect the necessary data for HABC evaluation platform. Based on our previous geriatric health services research activities within WHS and as benchmarking for HABC performance, the WHS leadership requested a side-by-side reporting of similar performance matrix for older adults with a comparable medical and psychiatric comorbidity profile of HABC patients but receiving care within the primary care health centers at WHS. This request contrasts the HABC performance with the performance of primary care clinics (PCC) that delivered care for patients with dementia or depression within the same time period. This PCC cohort was identified using the International Clinical Diagnosis codes (ICD-9) for dementia, MCI, or depression or receiving antidementia or antidepressant medications. Only 21 patients from the PCC cohort had one visit to HABC in 2008 (See ). The WHS leadership is currently monitor HABC performance on an ongoing quarterly base but in this paper we report the performance within the first year of HABC (January 1 to December 31 of 2008). The leadership is not interested in evaluating the statistical significance of the difference between HABC and PCC performances. The leadership uses these data as a decision support for their resource reallocation, future planning, and evaluation of the utility and impact of HABC as a clinical program on the entire system.
The performance and impact of the Healthy Aging Brain Center (HABC) and the Primary Care Center (PCC) in Wishard Health Services (WHS) between January 7 and December 31, 2008*