PA SPREAD Webinar #3

1. PA SPREADWebinar #3 Robert Gabbay MD, PhD Penn State College of Medicine

2. Pre-Work Learning Objectives • Understand the concept of empanelment and develop a plan to organize patients into provider panels. • Develop an aim statement for what and how much you want to improve over the next year. • Understand the clinical guidelines and related measures for diabetes. • Collect baseline data on the number of diabetes patients in your practice and the number of patients meeting evidence-based diabetes measures. Webinar #1 Webinar #2

3. List of Pre-Work To-Do’s • Identify a provider champion • Form a multi-disciplinary improvement team • Write an aim statement • Develop a plan to address any issues with provider panels • Complete and submit the PCMH-A assessment • Collect and report baseline diabetes data on the monthly practice status report BEFORE your first learning session • Participate in the 3 pre-work webinars • RSVP attendees for Learning Session #1

4. Any Questions? • Writing your aim statement? • Forming your team? • Identifying a provider champion? • Understanding the measure specifications? • Collecting your baseline data? • Organizing provider panels? • Completing the PCMH-A? • Submitting your baseline report? • Attending the first learning session? • Contact your practice coach or email paspread@hmc.psu.edu.

5. Going Forward- the BIG PICTURE • January 2013 • May 2013 • 4 in-person evening Learning Sessions • May/June • August/September • Facilitator visits in each Action Period • Call or email Patty Stubber (NW) or Sharon Adams (SC) any time! • Monthly webinars • Monthly status reports: data and brief written update • Generally due on the 5th of the month. • Will get feedback from practice facilitators and data benchmarking reports from PA AHEC. • Sharing and networking! • Practice description/photos for www.paspread.com under password protected “Participating Practices” section. • Resources to share on www.paspread.com.

6. PCMH, Chronic Care, PDSAs Implementing the Models to improve patient care

7. Driving Force = 2001 IOM Report Source: http://www.iom.edu/Reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx “Health care harms patients too frequently and routinely fails to deliver its potential benefits. Indeed, between the health care that we now have and the health care that we could have lies not just a gap, but a chasm.” ­­~Institute of Medicine

8. Operationalizing the Medical Home • Chronic Care Model (or more generally “The Care Model”) • NCQA PCMH 2011 Standards

9. Source: http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2

10. Essential Elements of Good Patient Care Source: http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2

11. Informed, Activated Patient Source: http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2 • Patient understands the disease process, and realizes his/her role as the daily self manager. • Family and caregivers are engaged in the patient’s self-management. • The provider is viewed as a partner, guide.

12. Prepared, Proactive Practice Team Source: http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2 • At the time of each visit, the team has the information, decision support, people, equipment, and time required to deliver evidence-based care, filling any gaps in care, and to support patients and their families in ongoing self-care.

13. How would I recognize a “productive interaction?” Source: http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2 • Includes an assessment of self-management skills and confidence as well as clinical status. • Collaborative goal-setting and problem-solving resulting in a shared care plan. • Active, sustained follow-up. • Tailoring of clinical management by stepped protocol.

14. How Do We Get There? Source: http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2 By testing changes in these 6 components of the Chronic Care Model.

15. Clinical Information Systems Source: http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2 • Patient registry functionality in your EMR. • Identify patient subpopulations for proactive outreach (not seen in 6 months, medication recall, uncontrolled). • Capture lab and other info in structured data fields that can be queried for patient care and measurement. • Prepare for visits and provide reminders/status reports for patients and care team. • Use templates to organize patient visits. • Monitor/measure performance.

16. Decision Support Source: http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2 • Use evidence-based guidelines to proactively assess patient risk at each visit. • Provide stepped care based on the needs of patients (closer follow-up, care management). • Activate patients by sharing guidelines (report cards or progress reports) with them. • Consult with specialists and integrate their expertise into primary care.

17. Delivery System Design Source: http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2 • Define roles and delegate tasks across care TEAM using standing orders. • Provide care most effectively and efficiently (e.g., group visits, e-visits, care mgmt, phone). • Track and document referrals and labs. • Schedule visits to assure continuity of care. • Provide patient-centered care (interpreters, visits that accommodate special needs, etc.).

18. Self-Management Support Source: http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2 • Not just education but SUPPORT! • Emphasize patients’ central role in managing their wellness/illness. • Negotiate self-care behavior change goals with patients. • Provide effective behavior change interventions and ongoing support with peers or professionals.

19. Community Resources Source: http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2 • Identify effective wellness and disease management programs and encourage patients to participate in them (e.g., hospital programs, Weight Watchers, walking clubs). • Form partnerships with community organizations to support or develop programs (e.g., housing, transportation, food). • Advocate for policies to improve care.

20. Health Care Organization Source: http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2 • Practice/System leaders visibly support quality improvement and include measurable goals in the strategic/business plan. • Align incentives (salary increases, performance reviews) to encourage care coordination, team care, quality improvement. • Partner with hospitals, health plans, specialists, pharmacies, nursing homes, etc. to coordinate care, share information.

21. NCQA PCMH 2011 Standards, Elements NCQA’s Operational definition of the medical home

22. NCQA PCMH 2011 • PCMH 1: Enhance Access and Continuity • PCMH 2: Identify and Manage Patient Populations • PCMH 3: Plan and Manage Care • PCMH 4: Provide Self-Care Support and Community Resources • PCMH 5: Track and Coordinate Care • PCMH 6: Measure and Improve Performance

23. Review of NCQA Standards • One “MUST PASS” element in each standard is noted (6 total). • “MUST PASS” elements are considered the basic building blocks of a Medical Home. • Practices must earn a score of 50% or higher on each of the 6 “MUST PASS” elements. • Slides note the key factors in each element that we will address. • Some are noted as “critical factors” that must be met for NCQA scoring. • NCQA aligns well with Meaningful Use.

24. PCMH 1: Access, Continuity • Element A: Access During Office Hours (MUST PASS) • Same day appointments (Critical Factor) • Timely telephone follow-up • Good documentation • Element B: After-Hours Access • Sharing of clinical information • Element C: Electronic Access • Visit summaries to patients • Web portal or secure email system for Rx refill requests and referral/test results

25. PCMH 1: Access, Continuity • Element D: Continuity • Patients choose personal clinician • Documentation of patient choice • Monitor percentage of visits with selected clinician • Element E: Medical Home Responsibilities • Tell patients about obligations of the medical home and responsibilities of patients/families as partners in care • Element F: Culturally and Linguistically Appropriate Services

26. PCMH 1: Access, Continuity • Element G: The Practice Team (team-based care) • Care teams with defined roles and responsibilities for each team member • Regular team meetings, communications (Critical Factor) • Use of standing orders • Training for team members on care coordination, self-management support, population management, communication skills • Team members involved in quality improvement

27. PCMH 2: Population Mgmt. • Element A: Patient Information • Record name, gender, race, ethnicity, language, contact info, dates of visits, legal guardian/proxy, primary caregiver, advance directives, and health insurance information for each patient • Element B: Clinical Data • Up-to-date problem and medication lists • Documentation of allergies • Blood pressure, height, weight, BMI, tobacco use

28. PCMH 2: Population Mgmt. • Element C: Comprehensive Health Assessment • Age-related immunizations, screenings • Family, social, cultural, communications, medical history, behavioral, mental health issues • Depression screening • Element D: Use Data for Population Mgmt. (MUST PASS) • Use of patient information, clinical data, evidence-based guidelines to generate patient lists and proactively remind patients/families and clinicians of needed services.

29. PCMH 3: Plan and Manage Care • Element A: Implement Evidence-Based Guidelines • Point-of-care reminders • At least one condition must be related to unhealthy behaviors (smoking, obesity), substance abuse, or mental health issue (Critical Factor) • Element B: Identify High-Risk Patients • Develop criteria for high-risk patients and process to identify them • Determine percentage of high-risk/complex patients in your practice

30. PCMH 3: Plan and Manage Care • Element C: Care Management (MUST PASS) • Pre-visit planning • Develop individualized care plans in collaboration with patients and review/update them each visit • Give patients written plan of care and clinical summary at each visit • Assess and address barriers when treatment goals are not met • Identify patients needing more support • Follow up with patients who miss visits

31. PCMH 3: Plan and Manage Care • Element D: Medication Management • Review, reconcile meds during care transitions • Provide info on new prescriptions • Assess understanding of meds, response to meds, and barriers to adherence • Document over-the-counter meds, supplements • Element E: Use E-Prescribing

32. PCMH 4: Self-Care Support and Community Resources • Element A: Support Self-Care Processes (MUST PASS) • Education resources to assist in self-management • Develop, document collaboratively set self-management goals • Document self-care abilities • Provide tools for patients to record self-care results • Counsel patients to adopt healthy behaviors

33. PCMH 4: Self-Care Support and Community Resources • Element B: Provide Referrals to Community Resources • Current resource lists • Track referral • Arrange or provide treatment for mental health, substance abuse • Offer health education programs (group classes, peer support)

34. PCMH 5: Track, Coordinate Care • Element A: Test Tracking and Follow-up • Track lab/imaging orders until receive results, flag and follow up on overdue results (Critical Factor) • Flag abnormal results and make clinician aware • Notify patients of normal and abnormal results • Electronically order and receive results • Record results electronically structured data

35. PCMH 5: Track, Coordinate Care • Element B: Referral Tracking and Follow-up (MUST PASS) • Give consultant/specialist clinical reason for referral and pertinent information (electronically) • Track referrals and follow up to obtain results • Establish, document co-management agreements

36. PCMH 5: Track, Coordinate Care • Element C: Coordinate with Facilities and Manage Care Transitions • Identify patients with hospital admission, ED visit • Share clinical info with hospitals, EDs (electronically) • Obtain discharge summaries • Follow up with patients after discharge

37. PCMH 6: Measure and Improve Performance • Element A: Measure Performance • Document the measurement period, number of patients represented by the data (at least 75% of eligible population), and patient selection process. • Element B: Measure Patient Experience • Survey experience related to access, communication, coordination, whole-person care/ self-management support • PCMH version of the CAHPS Clinician Group survey • Experience of vulnerable groups • Qualitative feedback

38. PCMH 6: Measure and Improve Performance • Element C: Implement Continuous Quality Improvement (MUST PASS) • Set goals and act to improve performance • One measure related to disparity in care or for vulnerable populations • Involve patients in QI team or advisory council. • Element D: Demonstrate Continuous Quality Improvement • Track results over time • Assess the effect of your actions • Improve performance on 1-2 measures

39. PCMH 6: Measure and Improve Performance • Element E: Report Performance • Within the practice by individual clinician and across the practice • Outside the practice to patients or publicly • Element F: Report Data Externally • To CMS or state • To other external entities

40. OK… So what do we do now? Rapid cycle testing of changes

41. Improvement Model • Write your aim statement • What you want to improve, by how much, by when, and generally how you will do it. • Use the diabetes measures to know when a change is an improvement. • Think of things you can try to change (the tests you will Plan, Do, Study, and Act on).

42. Deciding Which Tests to Try • Components of the Chronic Care Model. • NCQA PCMH Standards/Elements • Areas for improvement in your data. • Foundational elements we’d like you to work on. (At the bottom of Page 1 of the Monthly Status Report template.)

43. Critical Changes to Make • Population alert • Use of flow sheet/template embedded with clinical guidelines • Standing orders • Planned care at every visit • Patient report card/progress report • Patients setting self-management goals • Risk assessment at every visit • Follow-up care for high-risk patients Initial Focus

44. Critical Changes to Make • Population alert • Flag/color/icon to readily see diabetes patients in medical records when they call or visit office (without having to look in problem list). • Goal = take advantage of every opportunity you have to provide evidence-based care. • Improves patient safety when making medication decisions.

45. Critical Changes to Make • Use of flow sheet/template with embedded clinical guidelines • Prompts (flags/colors) to identify when services are due/overdue. • Prompts (flags/colors) to identify when labs, vitals are out of evidence-based range. • Tracking of information in structured data fields that can be queried.

46. Critical Changes to Make • Standing orders • Grant permission for staff to order, provide, document needed services. • Delegate tasks across team. • For blood tests, urine test, foot exam, eye exam referral/tracking, blood pressure measurement, height/weight/BMI, tobacco query and counsel, self-management support, etc. • Improve efficiency, save provider time.

47. Critical Changes to Make • Planned care at every visit • Proactive approach to care. • Fill any gaps in care, keep current with guidelines at every visit—even sick visits when feasible. • Schedule follow-up care for any services still needed or for closer monitoring. • Pre-visit planning to ensure all needed info (lab results, referral reports) is available at the visit. • Pre-visit lab work, so medication decisions can be made at visits.

48. Other Changes to Test • Your biggest frustrations—processes that don’t work well in your office (e.g., test/referral tracking, Rx refills, processing patient forms, scheduling, phone calls, billing). • Things that patients have complained about.

49. There’s Value in Knowing How to Make Changes • One SE PA practice identified adoption of the PDSA process as its most important lesson learned in Year 1 of its collaborative. • Was impetus/focus for weekly meetings. • Allowed smooth transitions to new protocols. • Gave them “permission” to take chances and try new things. • Strengthened their concept of team.

50. How to Test: Plan • Step 1: Plan the test • State the objective of the test: • What are you trying to change? • Predict what will happen and why. • Develop a plan to test the change (who will do it, what they will do, when they will do it, where they will do it, how they will do it). • Identify other data that will be useful (patient feedback, how much time the change added or saved, how it worked for staff). • Think ahead what subsequent tests might be.