Presented at the MeHAF Integration Initiative Meeting July 27 , 2012

1. Better Quality, Lower Cost, Better Population Health • Clinical Transformation with • Focus on Performance Improvement • and Care Management Presented at the MeHAF Integration Initiative Meeting July 27, 2012 James A. Raczek, MD, FAAFP Eastern Maine Medical Center Senior Vice President of Operations and Chief Medical Officer

2. Overview • Beacon Community Grant Program • Bangor Beacon Community • Clinical Transformation • Performance Improvement Intervention • Care Management Model Intervention

3. I. Beacon Community Grant ProgramA. Competitive Grant Overview • Demonstration program for communities that were ahead in Health Information Technology (HIT) and with a history of collaboration among non-related organizations • Funder: Office of National Coordinator (ONC) • $220 million awarded nationally. Funding for three (3) years. • 17 communities selected • EMHS/Bangor received $12.75 million! • Grant funding April 2010 through March 2013

4. I. Beacon Community Grant ProgramB. Beacon Community Vision The Beacon Community Grants Program will provide funding to demonstrate the vision of the future where hospitals, clinicians, and patients are meaningful users of health information technology and together the community achieves measurable improvement in health care quality, safety and efficiency.

5. B. Beacon Community Vision

6. C. Bangor Beacon Community Vision Performance Improvement To improve compliance with influenza and pneumococcal immunization To improve the management of chronic conditions through health information technology and care coordination Population Health To reduce preventable healthcare utilization through improved efficiency of health care delivery Cost

7. C. Bangor Beacon Community Vision To reduce preventable healthcare utilization through improved efficiency of health care delivery

8. II. Bangor Beacon CommunityA. Collaborators - Local • Eastern Maine Medical Center • St. Joseph Healthcare • Penobscot Community Health Care • City of Bangor – Health and Community Services • Acadia Hospital • Community Health & Counseling

9. II. Bangor Beacon CommunityA. Collaborators - Local • Eastern Maine HomeCare • Eastern Maine Community College • Maine Network for Health • Northeast Cardiology • Ross Manor • Stillwater Health Care

10. B. Collaborators - Statewide II. Bangor Beacon Community • HealthInfoNet – Information Exchange • Maine Health Management Coalition • Quality Counts • Office of the State HIT Coordinator • Maine Quality Forum • Maine Primary Care Association

11. B. Collaborators - Statewide II. Bangor Beacon Community • Martin’s Point Health Care • Maine Hospital Association • Maine Center for Disease Control • MaineCare • Maine Osteopathic Association • Leadership from MaineHealth and other health systems

12. C. Communities of Practice Enables Enables Enables Measures Sustains Enables Enables Enables

13. D. Patient Demographics/Health Issues • Bangor Hospital Service Area • Population estimated (2009): 164,099 • 43 cities and towns • 2010 Community Health Need Assessment (CHNA Report) for this area: • 14% uninsured • 14% of residents are age 65+ • 7% heart disease • 8% asthma • 35% overweight/obesity

14. E. Provider Information • Participants in the Bangor Beacon Community: • 65% of the Primary Care Physicians • Impacts directly or indirectly 93,000 active patients from these practices

15. III. Clinical Transformation • Performance Improvement (PI) Intervention • Care Coordination Intervention: • Care Managers – Primary Care Setting • Care Managers – Mental Health • Care Management Forum • Homecare Intervention • Immunization Compliance Intervention • TelePsychiatric Services Intervention for Long Term Care Facilities

16. III. Clinical Transformation A. Performance Improvement (PI) Intervention 1. Multi-Institutional Collaboration

17. A. PI Intervention • Organizational Structure • Clinical Leadership PI Group • Chief Medical Officer (CMO), Medical Directors • Practice Managers • Lead Care Managers • Data and Performance Measurement Personnel • Individual Healthcare Organization PI Groups • CMO or Medical Directors • Lead Physicians • Staff Providers • Care Managers • Medical Assistants

18. A. PI Intervention 3. Methods • Use of basic performance improvement techniques • Group consensus on indicators that would be measured • Group consensus on goals for performance on each indicator • Transparency of performance data within the groups • Institution specific performance data • Provider specific performance data • Care Manager specific performance data • Ninety (90) day action plans (modified Plan-Do-Study-Act cycles) to improve performance

19. A. PI Intervention 3. Methods (continued) • Alert systems in the EMR (Electronic Medical Record) associated with all patient encounters • Chronic disease management • Preventable health • Integrate Care Managers into the practice and empower them to enhance the management of the practice’s patients • Include all members of the clinic staff in the management effort (“Team Sport”) • Empower clinic staff other than just the Care Managers to care for the patient up to their scope of practice and/or job description (e.g. medical assistant, front desk receptionist.

20. B. PI Metrics – Diabetes • Successes

21. B. PI Metrics – Diabetes • Successes

22. B. PI Metrics – Diabetes • Successes

23. B. PI Metrics – Diabetes • Successes

24. B. PI Metrics – Diabetes • Successes • New definition for BP changed the bundle • Current value: 12% • Target: > 20%

25. B. PI Metrics – Cardiovascular Disease • Successes

26. B. PI Metrics – Cardiovascular Disease • Successes

27. B. PI Metrics – Cardiovascular Disease • Successes • Blood pressure tracking • New definition was incorporated during Q1 2012 • Current value: 78% • Target: > 80% • CVD Bundle tracking • New definition for BP changed the bundle • Current value: 23% • Target: >30%

28. B. PI Metrics – Chronic Obstructive Pulmonary Disease (COPD) • Successes

29. B. PI Metrics – Chronic Obstructive Pulmonary Disease (COPD) • Successes

30. B. PI Metrics – Asthma • Successes

31. B. PI Metrics – Asthma • Successes

32. C. Care Management Intervention 1. Primary Care Models • Role of Care Managers: • Management of HR/HC patients using disease specific protocols • Care Transitions/ Care Coordination • Patient Education • Patient Self-Management PCHC 3 RN Care Managers 3 MA Health Coaches 3 LCSW St. Joseph 1 RN Care Manager EMMC 5 RN Care Managers • Focused on DM, COPD, CHF, and Asthma • All models have 1 RN Coordinator who manages ED/WIC use and hospital discharges

33. C. Care Management Intervention • Evaluation of the PCP Care Management Model on High Risk/ High Cost Chronic Condition Patients Healthcare Goals Quality: Better Care Cost: Affordable Care Experience: Improved Experience of Care Outcomes Clinical and Preventive Measures Healthcare Utilization Patient Reported Measures Providers perception of care management

34. Care Management Intervention 3. Results - High Risk/High Cost Chronic Condition Patients Enrollment Update

35. Care Management Intervention 3. Results - High Risk/High Cost Chronic Condition Patients Successes • Clinical Measures Within the first 6 months of receiving care management • The percentage patients with HbA1C >9 were reduced from 40% to 16% • The percentage of patients with HbA1C <8 increased from 32% to 61%

36. Care Management Intervention 3. Results - High Risk/High Cost Chronic Condition Patients Successes • Healthcare Utilization • Hospital admissions were reduced by 43.7% • ED visits were reduced by 38.4% • Walk-in-care visits were reduced by 48.7%

37. Care Management Intervention 3. Results - High Risk/High Cost Chronic Condition Patients Successes - Patient Reported Measures

38. Care Management Intervention 3. Results - High Risk/High Cost Chronic Condition Patients Provider Perception about the Care Management Model • Benefits of the Care Management (CM) model: • Helped to reach those patients who had not effectively managed their health before without a care manager because we did not have the time. • Increased communication about patients reduces my workload and clearing things off of my desktop. • Patients feel like there is a group of people taking care of them instead of only one person. • They are able to reach patients on a more personal level and help them.

39. Care Management Intervention 3. Results - High Risk/High Cost Chronic Condition Patients Provider Perception about the Care Management Model Limitations of the Care Management (CM) model: Financial sustainability of having additional team members to help care for patients. Being interrupted in order to go meet with a patient who is being CM in order to complete the visit and to be reimbursed. Initially explaining to patients the benefits of a care management model Lacking clinical protocols to identify what the different responsibilities are by role (PCP, CM, health coach, etc.)

40. C. Care Management Intervention4. Care Management Forum Total number of CM: 26 Total number of patients who had received CM services: 1,217 Care Coordination Interventions: Medication reconciliation Discharge summary flow Care Manager performance dashboard Disease-specific education opportunities Patient text messaging reminders Patient assistance program

41. Dale Hamilton, Executive Director for Community Health and Counseling ServicesCare Management within Mental Health Centers and the Important Contributions Beacon has Made to Develop a System the Supports Improved Health for Individuals with Mental Illness

42. Panel Discussion