From the Frontline of Care Improvement – How to do it Right

Webinar #3 - Diabetes Care Improvement Series

Chris Cammisa, MD. Medical Consultant, California Quality

Collaborative (CQC).

Farhan Fadoo, MD, MS. Chief Medical

Information Officer, San Joaquin General

Hospital (SJGH).

David Eibling, MD. Medical Director, Health Plan of San

Joaquin (HPSJ).

January 18, 2013

Agenda for Today’s Webinar

• Describe a couple of simple improvement models useful to small group practices

• Provide some improvement strategies from our work in a diabetes collaborative in Southern California

• Highlight a local best practice

• How HPSJ supports practices

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The Model for Improvement

• An approach promoted by IHI

• Three basic/key componentso Aim Statement – What are we trying to

accomplish?o Measure – How will we know if we have

accomplished our goal?o Change – What are some interventions we can try

to move toward our goal?

• A really good way to help us focus on the work of improving

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The Care Model

• Developed by the Institute for Healthcare Improvement (IHI)

• Five Key Componentso Clinical Information Systemso Delivery System Designo Organization of Health Careo Self management and adherenceo Maximizing the use of community resources

• The two keys are a Prepared Practice Site and an Engaged Patient

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The Concept of PDSA

• Stands for plan, do, study, act• After setting a goal and a measurement strategy• Try an intervention as a small pilot test• Then evaluate how it went before spreading the change• Implicit in this process is the idea of teamwork• www.ihi.org

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The CQC Collaborative

• Five medical groups/IPAs in the Inland Empire Area

• Ran over a 15 month period from late 2010 to early 2012

• Utilized expert faculty for content

• Cindi Ardans and I were the co-leads

6

Objectives of CCC

• Achieve 20% relative improvement in selected diabetes measures

• Three core measures & four optional to track progress

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Structure

• IHI Breakthrough Series College structure

• Four in-person learning sessions

• Action periods between LS

• Coaching calls with CCC co-leads

• Webinars on related topics

• TA support as needed

• Two site visits

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Action Periods

• Team leader convenes team periodically

• Operationalize work plan

• Conduct PDSA cycles to test changes

• Measurement cycles to assess progress

• Communicated & celebrated progress!

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Outreach Interventions

Activity BFMC DOHC Epic NAMM UFC

Group/sends letters to patients

Group/IPA does outbound calls to patients

Site visits/phone calls to practices

Gap reports to practices

Health ed materials to practices

Health ed materials to patients

Health educator/CDE consults

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Other Interventions

Activity BFMC DOHC Epic NAMM UFC

Registry operational IP

Intensive pharmacist intervention

Financial incentives to practices

Automated lab order entry

Use of CPT Category II codes for BP

Promote diabetes care at health fairs, etc.

Public recognition of high performing physician practices

Process to update patient contact info

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Diabetes Measures

Core (all groups)– A1c test last 12 mos– A1c > 9.0 or no test– LDL-C test last 12 mos

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Optional– A1c <8.0– Nephropathy

monitoring– LDL-C <100– BP <140/90

Results

• Goals calculated as relative improvement 20% of gap between Q4 2010 baseline and benchmark

• Comparing Q4 2011 to Q4 2010, 7 of 8 measures met the goal and 1 measure was unchanged

• Though interventions have not spread to all practices, the ‘grapevine’ promotes adoption

• Interventions working – next steps are spread and sustain improvements

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Lessons Learned

• Functioning registry is fundamental

• Good communication plan is essential

• Small practices may have advantage

• Using proven QI models = improvement

• Persistence, follow-up more critical than brilliant ideas

• Active collaborative participation = motivation

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Changes You Might Want to Consider for Your Practice

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Systems and Process Improvement

• What follows are suggestions to reorganize the practice

• The practice and the patient visit provide opportunities for improving the care

• Promoting a more prepared and proactive team

• Building more informed and engaged patients

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Office Systems

• Identify and train clinical and office staff in their role as members of the diabetes care team

• Implement standing orders for common problems or patient conditions

• Hold a daily huddle prior to the opening of the practice with the office staff

• Trained medical assistants

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Chart Prompts

• Help patients set self-management goals and provide a goals worksheet and daily log

• Develop a follow-up system• Keep a cheat sheet of the diabetes medication copays in

the exam room for health plans common in your practice

• Ask the patient about medication cost issues

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Exam Rooms/Waiting Area

• Post a reminder list of proper procedures for patients with diabetes

• Post a reminder or checklist, visible to the appointment desk staff, providing procedural reminders for visits of patients with diabetes

• Implement regular staff meetings

• Staff conducts “messenger activities”

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Building the Diabetes Care Team

• Attach foot exam results to charts

• Keep flow sheets and/or visit planners in the medical record

• Highlight out of range values for blood pressure, glucose and lipids

• Consider color-coding charts of patients with diabetes

• Review and update the disease registry regularly

• Record the patient’s language and race/ethnicity in the medical record

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Patient Activation/Support

• Place educational posters in patients line of sight oThe information displayed can empower patients to

ask questions and/or remind healthcare professionals of routine care

• Have a brochure rack including diabetes-focused topics

• Information should be provided in multiple languages

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Success in San Joaquin

Next it is my pleasure to introduce Dr. Farhan Fadoo, Chief Medical Information Officer at San Joaquin General Hospital who will talk about what his organization is doing to improve care for their members with chronic conditions.

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Rethinking Primary CareLeveraging Population Management Tools to Enhance

Data Visibility and Impact Care Quality

Farhan Fadoo, M.D., M.S.Chief Medical Information OfficerSan Joaquin General HospitalJanuary 18, 2013

• 27 Clinics (4 Primary Care, 2 Peds, 2 OB/GYN, 19 Specialty)

• 3 Residency Programs (IM, FM, GS)• 200k OP encounters/year; ~100 providers (incl. residents)• Operational staff = 5 FTE• Vulnerable patient population – payer mix tilted towards

self-pay and medically indigent, followed by Medi-Cal• Challenges with Patient Access and PCP Continuity and

Patient Satisfaction• Tension between educational mission and patient care in

residency clinics• Striking appropriate balance with SJGH inpatient priorities• Uncertain climate around payment reform

SJGH Ambulatory Care Services

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Operational• Delivery System Reform Incentive Program (DSRIP)• Patient-Centered Medical Home (PCMH)• Changes in rules governing residency programs

(ACGME/RRC)• Transition to FQHC-LAL (primary care)• Future??? An eye towards ACOs…

Technological• Meaningful Use (MU) and ARRA/HITECH• Community HIE• ICD-10 Conversion

Change is Upon Us…

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PCMH: The Triple Aim1

• Improved Patient Experien

ce

• Lower per capita

Healthcare Cost

• Improved

Population

Health

1 Source: Berwick, D.M., Nolan, T.W., and Whittington, J. (2008)

At SJGH:Doing Better,

For More,With Less

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Improved Population Health

• Decrease Overall Disease Burdeno Preventiono Wellnesso Screeningo Immunization

• Decrease Hospitalizations• Decrease Acute Illness• Improve Mental Health• Expanded Access to Health Care Services

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Improved Patient Experience

• Self Management Support2

• Enhanced Communication• Decreased Waits/Delays

• Improved Patient Satisfaction Scores

• Coordination of Care

2 Source: Patient-Centered Primary Care Collaborative (2010).28

Lower Per Capita Healthcare Cost

• Decreased ED Utilization• Decreased Hospital Admissions• Shorter LOS• Case Management

Proactive

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Population Management Tools• Unique Vantage Pointo Not just about individuals but populations

• Leverage Multiple Sources of Data• Reporting and Dashboardso Daily, Monthly, Quarterlyo Provider-specifico Disease-specific

• Goals/Targets

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Population Management Tools

Computerized Chronic Disease Registry

• Powerful• Visible• Interfaced

• Actionable Reporting

= Paradigm Shift

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Interface Spaghetti

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• i2iTracks

• DEMOGRAPHICS

• VISITS

• CPT

• ICD-9

• APPOINTMENTS

• POINT

• OF

• CARE

• LAB

Disease Registry Interfaces

EHR Clinicals

Vitals

PharmacyImaging

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Sep-

11

Nov-1

1

Jan-

12

Mar-

12

May

-12

Jul-1

2

Sep-

12

Nov-1

2

Jan-

130%

20%40%60%80%

100%

A1c <8 (Outcome) -Initial Population of

Focus

Sep-

11

Nov-1

1

Jan-

12

Mar-

12

May

-12

Jul-1

2

Sep-

12

Nov-1

2

Jan-

130%

40%

80%

BP <140/90 (Outcome) -Initial Population of

Focus

Sep-

11

Nov-1

1

Jan-

12

Mar-

12

May

-12

Jul-1

2

Sep-

12

Nov-1

2

Jan-

130%

20%

40%

60%

80%

100%

BP (Process) -Initial Population of Focus

Sep-

11

Nov-1

1

Jan-

12

Mar-

12

May

-12

Jul-1

2

Sep-

12

Nov-1

2

Jan-

130%

40%

80%

Depression Screening (Process) -

Initial Population of Focus

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Diabetes and Obesity

6/1/2012 7/1/2012 8/1/2012 9/1/2012 10/1/20120%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Process: BMI >=27 with intervention

Percent of Patients with BMI >=27 who received interventionTarget >60%

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Diabetes and Tobacco

Jun-12 Jul-12 Aug-12 Sep-12 Oct-120%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Process: Tobacco Screening

% Patients with Tobacco Screening

% Patients receiving Tobacco Cessation In-tervention

Target for Intervention >80%

n=62

n=70

n=66n=55

n=33

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Registry Reports

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• Aggressive empanelment activity• Building culture around datao Diabetes and Depression as Use Caseso Office of Panel Management and Specialty Referrals

• Strong Collaborative Partnership with HPSJ• Lean Healthcare Principleso Workflow Standardization / Minimizing Wasteo Risk Management / Root Cause Analysiso Care Team Models / Operational Efficiency

• NCQA Recognition – Diabetes (Aug. 2012)

SJGH PCMH Progress

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NCQA DRP

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The Physician Cup Runneth Over

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• Deploy Integrated Ambulatory Practice Management System (PMS) and Electronic Health Record (EHR)o Scheduling, Revenue Cycle, Messaging, CPOE/CDS, E-Rx

• Expand Use of i2iTracks Disease Registry for Population Mgmt.o Asthma/COPD; Women’s Health; Immunizations; Pain Management

• Continue to Foster an Organizational Culture around Datao Deliver Value through Analytics and Business Intelligenceo Operational, Financial, and Clinical Dashboardso Participate in Community-Wide HIE

• Achieve NCQA Recognition for Level 3 PCMHo Advanced Access, Enhanced Continuity, Sophisticated Care Coordination,

Population Management

SJGH Ambulatory Care Services – Future Strategy

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Takeaways• Healthcare reform will drive adoption of

“PCMH-like” models of care delivery that heavily leverage care teams• Progressive alignment of financial incentives• Data visibility is key to managing population

health• San Joaquin County’s population is poised to

receive innovative service deliveryfrom SJGH and its communitypartners

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References• Berwick, D.M., Nolan, T.W., and Whittington, J. (2008). The Triple Aim: Care Health, and

Cost. Health Affairs. 27(3), 759-69. Retrieved on 11/11/12 from http://content.healthaffairs.org/content/27/3/759.full.pdf+html

• California HealthCare Foundation, (2004). Chronic Disease Registries: A Product Review. Retrieved on 11/11/12 from http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/C/PDF%20ChronicDiseaseRegistryReview.pdf

• Institute of Medicine (2012). Primary Care and Public Health: Exploring Integration to Improve Population Health. Retrieved on 11/12/12 from http://www.iom.edu/~/media/Files/Report%20Files/2012/Primary-Care-and-Public-Health/Primary%20Care%20and%20Public%20Health_Revised%20RB_FINAL.pdf

• National Committee for Quality Assurance (2011). Standards for Patient-Centered Medical Home (PCMH). Retrieved on 10/20/12 from http://www.iafp.com/pcmh/ncqa2011.pdf

• Patient-Centered Primary Care Collaborative (2010). Transforming Patient Engagement: Health IT in the Patient Centered Medical Home. Retrieved on 11/12/12 from http://www.pcpcc.net/files/pep-report.pdf

• Robert Graham Center (2007). The Patient Centered Medical Home: History, Seven Core Features, Evidence and Transformational Change. Retrieved on 11/10/12 from http://www.aafp.org/online/etc/medialib/aafp_org/documents/about/pcmh.Par.0001.File.dat/PCMH.pdf

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HPSJMeeting Significant Healthcare Needs

With Limited Resources

HPSJ Goals

Easy AccessHigh Quality of CareCoordinated Care to Achieve

1. Individual Health Improvement

2. Population Health Improvement

3. Cost Savings

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Integrated Patient Centered Medical Home

• Patients• Hospitalists• PCPs• Residentialists• Nurse Case Managers• Social Service Case Managers• MH/BH Counselors• MA Health Navigators• Peer Educators/DM• Wellness Educators• 24/7 Advice Nurse• IHSS Workers

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Transitional Care

• Visiting Home Family Nurse Practitioner

• Physician Home Visits (“Residentialists”)• Home Behavioral Health/Mental Health

Counselors

• Home Monitoring Technology– Glucometers – Blood Pressure Monitors– Scales for congestive heart failure– Oximeters for chronic obstructive pulmonary

disease–Medication Dispensing

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50

Fora Care Conversion from TrueTrack

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Technology to Achieve Goals

Home Biometrics Devices Telemedicine Consults Advice Nurse Coordination Ambulance CM/ER Integration Pocket Device with 360 Care Plans Social/Electronic Media DM & ED Programs

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Presentation Slides

• Can be found here: http://www.thecmafoundation.org/projects/aped/

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Next Presentation

Promoting Patient Self-Management and Medication Adherence

Wednesday, January 23rd 12:15 - 1:15 pm

Learn how to help your patients take charge of their health, with a guest speaker from the California Diabetes Program sharing lessons learned from 25 years of on-the-ground improvement work.

Dial-in Info: 1-800-615-2820, Passcode 415-615-6376; Webinar link: pbgh.adobeconnect.com/webinar4/

Please RSVP at: www.caldiabetes.org/events_display.cfm?eventsID=896

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