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VITL Summit ‘14 Track 2: Meeting Evolving Requirements
Quality Reporting: Managing Requirements and
Realizing Benefits to Patient Care
Monica Benjamin – MBA, BSN, RN, CLC Rainbow Pediatrics
Middlebury, VT
Jenney Samuelson - Assistant Director Vermont Blueprint for Health, Department of Vermont Health Access
Williston, VT
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VITL Summit ‘14 Track 2: Meeting Evolving Requirements
Quality Reporting: Managing Requirements and
Realizing Benefits to Patient Care
Monica Benjamin – MBA, BSN, RN, CLC
Rainbow Pediatrics
Middlebury, VT
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VITL Summit ‘14 Track 2: Meeting Evolving Requirements
Why Now?
Principles of Patient Centered Medical Home
• Personal physician
• Physician directed medical practice
• Whole person oriented care
• Care is coordinated and/or integrated
• Quality and Safety
• Enhanced Access
• Payment
http://www.aafp.org/dam/AAFP/documents/practice_management/pcmh/initiatives/PCMHJoint.pdf
3
http://www.ihi.org/Engage/Initiatives/TripleAim/pages/default.aspx
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VITL Summit ‘14 Track 2: Meeting Evolving Requirements
Case Study: Rainbow Pediatrics Timeline for PCMH 2011 Standards
• Level 3 recognition in 2009 (2008 standards) • 2011 Standards re-recognition process started in
September 2013 • December 2013: Meetings with Blueprint facilitator began • January 2014: Patient Satisfaction Survey • June 2014: Vulnerable population survey • July 2014: Qualitative feedback from patients obtained • April 2014: “Preview month” • May, June, July 2014: Chart review months • 2011 Standards submitted for review August 2014
– 100% on patient chart review – Binder: NCQA – 92.75/100 points; DVHA – 85.25/100 points
(Level III)
4
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VITL Summit ‘14 Track 2: Meeting Evolving Requirements
Case Study: Rainbow Pediatrics Project Team
• Monica Benjamin – MBA, BSN, RN, CLC – Team Leader & Office Nurse
• Molly Dora – RN – Community Health Team Care Coordinator & Office Nurse
• Lisa Ryan – Practice Manager
• Kate McIntosh – MD, FAAP
• Nancy Abernathy – MSW, LICSW - Blueprint practice facilitator
5
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VITL Summit ‘14 Track 2: Meeting Evolving Requirements
Case Study: Rainbow Pediatrics
Standard 2: Identify and Manage Patient Populations Element D: Use Data for Population Management* • Preventive Care
– 24 month lead level – 24 month hemoglobin level – Completed Gardasil vaccine series @ age 12
• Chronic Care – Asthma Control Test – asthma patients without – ADHD/ADD 3 month follow-up – patients overdue – Depression 3 month follow-up – patients overdue
*Must pass
6
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VITL Summit ‘14 Track 2: Meeting Evolving Requirements
Case Study: Rainbow Pediatrics
Standard 3: Plan and Manage Care
Element A: Implement Evidence-Based Guidelines
• 3 Important Conditions
– 5 year well-child visits
– Bi-annual asthma visits
– ADHD/ADD medication checks*
*Critical factor
7
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VITL Summit ‘14 Track 2: Meeting Evolving Requirements
Case Study: Rainbow Pediatrics
Standard 3: Plan and Manage Care Element C: Care Management • Pre-visit preparation
– 5 year WCC: Bright Futures, PEDS response form, messages regarding immunizations & hgb
– Asthma: Asthma Control Test (ACT) – ADHD/ADD: Vanderbilt, Symptom Checklist
• Care Plan – 5 year WCC: anticipatory guidance – Asthma: Asthma Action Plan – ADHD/ADD: Self care plan
8
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VITL Summit ‘14 Track 2: Meeting Evolving Requirements
Case Study: Rainbow Pediatrics Lessons Learned
9 http://coachingandleading.files.wordpress.com/2012/10/repeat-pdsa-cycle6.png
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VITL Summit ‘14 Track 2: Meeting Evolving Requirements
Case Study: Rainbow Pediatrics Lessons Learned
• Quality improvement
– Manipulation of data
– Assigning “dummy codes” to enable tracking
– Chart review
– Patient & Family feedback
10
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VITL Summit ‘14 Track 2: Meeting Evolving Requirements
Case Study: Rainbow Pediatrics Lessons Learned
11 http://gagandeepsinghanand.wordpress.com/2012/07/
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VITL Summit ‘14 Track 2: Meeting Evolving Requirements
Case Study: Rainbow Pediatrics Lessons Learned
• Practice facilitator is a must
– Interpretation of standards and elements
• Provider present during meetings with facilitator
– Assist with decision making
12
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VITL Summit ‘14 Track 2: Meeting Evolving Requirements
Case Study: Rainbow Pediatrics Lessons Learned
• It takes a team
– Patient is part of this team
– Does patient want to be part of this team?
• Care Coordination
– Referrals and referral tracking
– Patients who need help navigating health care system
13
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VITL Summit ‘14 Track 2: Meeting Evolving Requirements
Case Study: Rainbow Pediatrics Lessons Learned
• Health Information Technology
– Increased utilization of EHR capabilities and registries
– Patient Portal
• Alignment with Meaningful Use Stage 2
– 13/17 Core Objectives
– 2/6 Menu Objectives
– 3/9 recommended Clinical Quality Measures
14
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VITL Summit ‘14 Track 2: Meeting Evolving Requirements
Future of the Patient-Centered Medical Home
• Focus on prevention and disease management
• Increasing patient engagement in their own health care
• Utilize EHRs and patient registries to their full potential
• Team based care and Care Coordination
• Patient-Centered Specialty Practices
15
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VITL Summit ‘14 Track 2: Meeting Evolving Requirements
References • Community Health Association of Mountain Plains States. (2014). Patient Centered Medical Home
Information and Resources. Retrieved from http://www.champsonline.org/ToolsProducts/CrossDiscResources/PCMH.html
• Gogi2468. (2012, July 6.) HR is changing rapidly…are you ready for the shift? [Web log post] Retrieved from http://gagandeepsinghanand.wordpress.com/2012/07/
• Institute for Healthcare Improvement. (2014). IHI Triple Aim Initiative. Retrieved from http://www.ihi.org/Engage/Initiatives/TripleAim/pages/default.aspx
• Intermountain Healthcare. (2013). Fact Sheet for Patients and Families –ADHD Care and Self-Care Plan. Retrieved from http://intermountainhealthcare.org/ext/Dcmnt?ncid=522580754
• National Center for Quality Assurance. (2014). Patient- Centered Medical Home Recognition. Retrieved from http://www.ncqa.org/Portals/0/Public%20Policy/2014%20Comment%20Letters/The_Future_of_PCMH.pdfhttp://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH.aspx
• National Center for Quality Assurance. (2014). The Future of Patient-Centered Medical Homes. Retrieved from http://www.ncqa.org/Portals/0/Public%20Policy/2014%20Comment%20Letters/The_Future_of_PCMH.pdf
• Patient Centered Primary Care Collaborative. (2007). Joint Principles of the Patient-Centered Medical Home. Retrieved from http://www.aafp.org/dam/AAFP/documents/practice_management/pcmh/initiatives/PCMHJoint.pdf
• Sideris, A. & Stosku, J. (n.d.) A Plan-Do-Study-Act-Framework. Retrieved August 28, 2014 from http://coachingandleading.wordpress.com/presentation1/pdsa-and-types-of-change/
16
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VITL Summit ‘14 Track 2: Meeting Evolving Requirements 17
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VITL Summit ‘14 Track 2: Meeting Evolving Requirements
RAINBOWPEDIATRICSADHD/ADDFOLLOW-UPVISITTEAMBASEDCAREFLOW
PRIORTOVISIT DAYOFVISIT CHECK-OUTINBETWEEN
VISITS
PATIENT
Takemedications,workongoals,giveVanderbiltformstoteachers,attendcounselingsessions,etc.
Arrive15minutespriortoappointmenttofill
outpaperwork
Gotofrontdesktomakefollow-up
appointmentperproviderinstructions.
CallforrefillsofmedicationsPRN.
FRONTDESKCallpt/caregiverto
remindaboutappointmentday,time
Checkpatientin,givepatientpaperworkto
fillout.
Schedulefollow-upvisit.Writefollow-upvisitday,timeonCare
Plan,scanCarePlanintopatient’s
ADHD/ADDfolderinEHR,andgivebackto
patient.
Transferrefillrequeststorefillline.Coordinate
referrals.
NURSE
Lookinpatient’scharttoseeiftheyareduetobi-annualCarePlanreview.
Gatherpaperworkfornextday–Parent
VanderbiltFollow-up,CarePlan,ADHD
SymptomChecklist
Roompatient,obtainvitals,completeADHD
ReasonforVisittemplate,reviewSelf-
CarePlanwithpt/caregiver–assess
barriers;ensureallpaperworkis
completedandreadyforprovidertoreview
Sendrefillrequesttoprovideras
appropriate.Callpt/caregiverif
follow-upvisitisneeded.
SendoutTeacherVanderbilts(Care
Coordinator).
PROVIDER
Reviewpatient’schartandanyteacher
Vanderbiltsthathavearrived.Reviewnotes
frompertinentconsults.
FollowAAPalgorithmforADHD/ADDfollow-
upappointments.TransferCarePlaninfo
intoEHR.Referasappropriate.Let
patient/caregiverknowwhentofollow-up.
EnsurePCMHrequired
documentationiscompleted.See‘PCMH
requireddocumentation’
Refillprescriptions.Completereferrals.
18
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VITL Summit ‘14 Track 2: Meeting Evolving Requirements AdaptedfromIntermountainHealthcareADHDCareandSelfCarePlan.Source:http://intermountainhealthcare.org/ext/Dcmnt?ncid=522580754
FACTSHEETFORPATIENTSANDFAMILIESADHD/ADDCareandSelf-CarePlan
PatientName:_____________________________Date:__________________________Atyourappointmenttodaywewilldiscussyourchild’sADHD/ADDandmakeaplanforwhattodonext.Please
fillinallofthefollowingtothebestofyourability.GoalsWewantknowhowyourchildisdoinginschoolandat
home.Whatisgoingwell?Whatisnotgoingwell?Pleasechoosefromthelistbeloworwriteinyourown
goal(s).o Remembertotakemedicationseveryday.o Don’ttalkoutofturninclass.
o Finishhomeworkeachnight.o Finishataskwithouthavingtobeaskedmultiple
times.o Don’targuewithothers.o Stayontaskatschooland/orhome.
o Attendcounselingsessions.o _________________________________________
Self-care· Selfcaregoalsandmonitoringmethodoptions:
SeeADHD/ADDGoalshandout.Alsoavailableon
RainbowPediatricswebsite–www.rainbowvt.com
· Selfmanagement.Wewilldiscusschangesyouand
yourchildcanmakethatwillyoureachyourgoals.1=low,10=high
Howimportantarethesechangestoyou?(1-10):____
Howconfidentareyouthatyoucanmakethesechanges?(1-10):_______
· Self-managementtools:Seehandout.AlsoavailableonRainbowPediatricswebsite–www.rainbowvt.com
· HealthyBehaviors.Thegoal(s)thatyouandyour
childmostwanttoworkonnow.o Eatmorefruitsandvegetables.
o Getmoreexerciseo Sleep______hourspernight
o Drinkatleast______glassesofwaterperdayo Avoidalcoholandtobaccoo DecreaseTV,computertime.
o ReadMore.o _________________________________________
Whatwouldhelpyoureachyourgoal(s)?:_____________
________________________________________________
________________________________________________
Whatdoyouthinkwillstopyoufrommeetingyourgoal(s):
________________________________________________
________________________________________________
________________________________________________
OngoingvisitsImprovementrating:Sinceyourlastvisit,hasyourchildgottenbetteratschoolorathome?
No
Change
Slightly
Better
Alot
Better
Much
Better
Home
School
Self-managementprogress:Whathaveyouandyourchildbeenabletodosinceyourlastvisit?
o Rememberedtotakemedicationso Counseling
o Eathealthiero Getmoreexerciseo Hobbiesandfunactivities
o Getsupportfromfamily/friendstoworkonbehavior
o Finishhomeworko Stayontaskatschooland/orhome
o Other:________________________________________________________________________Management–tobefilledoutbynurse,provider,frontdeskstaff.· Assessment
ADHD/ADDSymptomChecklistmostrecentlycompleted:______________________
TeacherVanderbilt(s)mostrecentlycompleted:_______________________________ParentVanderbiltmostrecentlycompleted:
_______________________________
· Medicationgoalsetwithprovider:
o Beginamedication.Seeproviderin_________
weeks/months-Date/Time:_____________________
o Continueamedication.Seeproviderin________
weeks/months-Date/Time:____________________
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VITL Summit ‘14 Track 2: Meeting Evolving Requirements
Contact Information
Monica Benjamin
Email: [email protected]
Phone: 802-989-9695
20
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VITL Summit ‘14 Track 2: Meeting Evolving Requirements
Quality Reporting: Managing Requirements and
Realizing Benefits to Patient Care
Jenney Samuelson - Assistant Director
Vermont Blueprint for Health, Department of Vermont Health Access
Williston, VT
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VITL Summit ‘14 Track 2: Meeting Evolving Requirements 22
Department of Vermont
Health Access
Building A Foundation For The Future
• Patient Centered Medical Homes (PCMH)
• Community Health Teams
• Community Based Self-management Programs
• Multi-insurer payment reforms
• Health Information Infrastructure
• Evaluation & Reporting Systems
• Learning Health System Activities
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VITL Summit ‘14 Track 2: Meeting Evolving Requirements
Patient Centered Medical Homes and Community Health Team Staffing in Vermont
# o
f C
HT
FT
Es a
nd
Pra
cti
ces
# o
f P
ati
en
ts
Department of Vermont
Health Access
133.0
123
205,015
271,282
526,242
293,862
0
100,000
200,000
300,000
400,000
500,000
600,000
0
100
200
300
400
500
600
Att
rib
ute
d P
atie
nts
CH
T FT
E an
d #
Re
cogn
ize
d P
ract
ice
s
# CHT FTEs
# Recognized PCMHs
Commercial & Medicaid Payer AttributedPatients
Commercial, Medicaid, & Medicare PayerAttributed Patients
Onpoint Attributed (3 Commercial + Medicaid)
Practice Reported Patients for PCMH PlusFrontloading (Incl. Duplicates Across Practices)
Onpoint Attributed (All Insurers)
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VITL Summit ‘14 Track 2: Meeting Evolving Requirements 24
• Multi-disciplinary quality improvement team
(NCQA PCMH recognition)
• Seamless coordination of care
(CHT development)
• Information technology
(DocSite/VITL interface)
Blueprint Patient Centered Medical Homes
Department of Vermont
Health Access
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VITL Summit ‘14 Track 2: Meeting Evolving Requirements
• Set of national standards
• Aligned with the ACO standards
• The intent of the standards give a general framework for how
to implement the principles of the patient centered medical
homes
• Strives to achieve the triple aim improved population health;
enhanced patient experience; and appropriate per capita
health care costs.
25
NCQA PCMH Recognition
Department of Vermont
Health Access
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VITL Summit ‘14 Track 2: Meeting Evolving Requirements
• “Additional emphasis on team-based care”
• “Care management focused on high-risk patients”
(identifying patients based on criteria including social determinants of health, behavioral health, high cost/utilization and/or poorly controlled or complex conditions who may benefit from care management and self-care support and using evidence-based decision support to treat them)
• “More focused, sustained QI on patient experience, utilization, and clinical quality”
• “Align with Meaningful Use State 2”
• “Further integration of behavioral health”
(show capability to treat, refer, and co-manage unhealthy behaviors, mental health and/or substance abuse)
26
Key Changes with NCQA PCMH 2014
Department of Vermont
Health Access
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VITL Summit ‘14 Track 2: Meeting Evolving Requirements
NCQA PCMH 2014 QI: It is a Process
NCQA is emphasizing PCMH is a ‘process and not an event’:
• Demonstration that the practice is following standards over time
• Present 2 years of data collection and quality improvement (QI)
• Define how the teams are involved and trained on QI
27
Department of Vermont
Health Access
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VITL Summit ‘14 Track 2: Meeting Evolving Requirements
For each of the focus areas the practice must demonstrate 3 phases, set goals, analyze data, and act to improve on the measures.
• Immunizations
• Preventive services
• Chronic conditions
• Care coordination and utilization
• Disparitities in health services for vulnerable populations
• Set goals and analyze resource use (coordination, utilization)…then act to improve on the measure
28
NCQA PCMH 2014 QI: Three Phases
Department of Vermont
Health Access
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VITL Summit ‘14 Track 2: Meeting Evolving Requirements
Practice Facilitation in Vermont
• Ongoing long-term support for practices
• Focused on continuous QI and NCQA PCMH recognition
• 9 FTE (13 people)
• 1:10 ratio of facilitator to practice
• Typically meet at least twice a month with each practice
• Special skills and experience (clinical with QI, critical thinking, data savvy)
• Identify guidelines-based care, design processes, measure outcomes
Department of Vermont
Health Access
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VITL Summit ‘14 Track 2: Meeting Evolving Requirements
• Assists practices with forming a multi-disciplinary improvement team
• Ensures leadership involvement and communication
• Encourages/fosters practice ownership and support for Continuous Quality Improvement to improve patient-centered care (culture)
• Supports teams to implement improvement cycles, including guidelines-based care, self-management support, panel management, or mental health and substance abuse treatment into clinical practice (work plan)
• Ensures that practices develop an action plan for NCQA PCMH recognition
• Supports the incorporation of the CHTs into practice workflow
• Deploys innovative strategies for communication and learning between practices, such as learning collaboratives or online learning environments
30
Department of Vermont
Health Access
Practice Facilitation in Vermont
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VITL Summit ‘14 Track 2: Meeting Evolving Requirements 31
Department of Vermont
Health Access
Community Health Teams
• Multi-disciplinary support for PCMHs & their patients
• Work locally in communities and directly with practices
• Functionally integrated into the practice setting
• Team is scaled based on the # patients in the PCMHs they
support
• Core resource that is readily available to patients based on
need
• The ‘glue’ in a community system of health for the general
population Samuelson
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VITL Summit ‘14 Track 2: Meeting Evolving Requirements 32
Higher
Acuity &
Complexity
Lower
Acuity &
Complexity
Locus of Service & Support
Lev
el o
f Need
• Health Maintenance
• Prevention
• Access
• Communication
• Self Management Support
• Guideline Based Care
• Coordinate Referrals
• Coordinate Assessments
• Panel Management
• Specialty Care
• Advanced Assessments
• Advanced Treatments
• Advanced Case Management
• Social Services
• Economic Services
• Community Programs
• Self Management Support
• Public Health Programs
Advanced Primary
Care Practice
Community Health
Teams
Specialized & Targeted
Services
Continuum of Health Services - General
• Support Patients & Families
• Support Practices
• Coordinate Care
• Coordinate Services
• Referrals & Transitions
• Case Management o Medicaid Care Coordinators
o Senior Services Coordinators
• Self Management Support
• Counseling
• Population Management
Samuelson
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VITL Summit ‘14 Track 2: Meeting Evolving Requirements
Contact Information
Jenney Samuelson
Email: [email protected]
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