Janice Bacon, MD - MSQII-2 Leadership Advisory Team

Central MS Health Services

Alicia Barnes, MBA, – MSQII-2 Consultant & Facilitator

BC3 Technologies, LLC

Community Health Center Association of Mississippi

Annual Conference | Biloxi, MS

August 1, 2019

History of MSQII-2

- Established in 2013, by the Mississippi State Department of Health (MSDH) Office of Preventive Health, Chronic Disease Bureau (CDB)

- Funded by Centers for Disease Control and Prevention (CDC) to prevent and control Diabetes, Heart Disease, Obesity, and associated risk factors in Mississippi.

- Leadership Advisory Team established to assist in the development of Mississippi Quality Improvement Initiative (MSQII-2) curriculum and Funding Opportunity Announcement in June 2014

- Awards given to:- 5 organizations in 2014

- 6 organizations in 2015

- 4 organizations in 2016

About MSQII-2

• A systematic approach to healthcare quality improvement in which

organizations and providers test and measure practice innovations via

PDSAs, then share their experiences in an effort to accelerate learning

and widespread implementation of successful change concepts and

ideas in a group setting.

• The Learning Collaborative uses the following Concepts and Models:

• Expanded Chronic Care Model

• Patient Centered Medical Home Concepts

• Model for Improvement

• Improve health outcomes by learning from each other’s successes and

challenges

• Changing from a provider-oriented system to a patient/family community-

oriented system of care utilizing a team-based approach

MSQII-2 Goals

• Increase implementation of quality improvement processes in

health systems

• Increase use of team-based care in health systems (nurses,

pharmacists, nutritionist, physical therapists, patient navigators,

and community health workers)

• Increase use of lifestyle intervention programs such as Diabetes

and Chronic Disease Self-Management programs

• Increase the use of health care extenders in the community in

support of self-management of high blood pressure and diabetes

Featured Components

• MSQII-2 E –Collaborative (www.msqii2.net)

• Public Website

• Learning Community Virtual Office

• Web-based reporting site and dashboard

• Pre-Learning Sessions and Learning Sessions

• Storyboards

• Pre/Post –Test Evaluation

• Quarterly Webinars /One-on-One Support

Participating Organizations

(2013 -2018)

• 2013 – 2018, 15 participating organizations:

• 3 Rural Health Centers

• 10 FQHCs

• 2 Private practices

• Aaron E. Henry Health Services Center, Inc. – Cohort 1

• Family Health Center, Inc. – Cohort 1

• Coastal Family Health Center, Inc. – Cohort 1

• North Hills Family Medical Clinic – Cohort 1

• Phillips Medical Clinic – Cohort 1

• Access Family Health Services – Cohort 2

Participating Organizations

(2013 -2018)

• Acute Care Health Services – Cohort 2

• Greater Meridian Health Clinic – Cohort

• Pioneer Health Services – Cohort 2

• Nina Jurney

• Community Health Aberdeen

• Southeast MS Rural Health Initiative, Inc. – 2

• Central MS Health Services – Cohort 3

• G.A. Carmichael Family Health Center – Cohort 3

• Mallory Community Health Center – Cohort 3

• Glover Primary Care Clinic – Cohort 3

Accomplishments –MSQII-2

Hypertension/Diabetes

• Reached over 100,000 patients with Diabetes, Coronary Artery

Disease, and Hypertension to improve health outcomes

• Over 100 healthcare professionals received SME training on

improvement efforts in Diabetes, Coronary Artery Disease, and

Hypertension

• Over $200,000 received by healthcare organizations and or

providers through Meaningful Use Incentive payments

Accomplishments –MSQII-2

Hypertension/Diabetes

• Incorporated MSQII-2 in organization QI Committee

• In-house nutrition referral for all Hypertensive and Diabetic

patients

• Implemented Standing Orders

• Implemented Morisky’s Medication Adherence Scale for

medication compliance

• Implemented Community Health Worker

• Transitioned to new Electronic Medical Records

• Meaningful Use Incentive payment receipt

• Team-based approach

• Implemented Protocols for Hypertension Management based on

Target BP, Million Hearts, and American Heart Association

• Received PCMH Recognition while participating

• Awarded supplemental grant with American Heart Association

• Clinical support guidelines embedded in EMR

• Staff training on updated guidelines

• Blood Pressure training

• Workflow Redesign to include best practices

• Self-management support classes for patients

Accomplishments –MSQII-2

Hypertension/ Diabetes

• Integrated Medication Therapy Management (MTM)

• Developed Care Plan for uncontrolled hypertension patients

• Integrated Behavioral health services

• Recalls for patient compliance with BP and A1c checks

• Established process to give BP monitors for high risk patients for

home monitoring

• Partnered with Managed Care Organizations (United Health Care and

Magnolia) Case Managers to assist in Self-management

• Created and customized hypertension and diabetes templates in EMR

• Established and implemented protocol for high bp 2nd check prior to

leaving clinic

Accomplishments –MSQII-2

Hypertension/ Diabetes

Accomplishments –MSQII-2

Hypertension/ Diabetes

• Educate patient and staff on setting self-management goals

• PDSAs incorporated in Performance Improvement Plan

• Created alerts/reminders in EMR to inform clinical staff of labs

due or overdue

• Educated patients on “Know Your Numbers” – BP

• Provider education –CME/CEU on evidence based guidelines

• Implemented Teach Back Method with patients

• Started Data Validation for QI reports

• Implemented Team Huddle

Integration of MSQII-2 Asthma(2017- present)

• Began December 2017 by Mississippi State Department of Health Asthma Program

• Funded by Centers of Disease Control and Prevention (CDC)

• FOA was disseminated

• Three (3) FQHCs – 2017

• Three (3) FQHCs – 2018

• Learning and implementing the Chronic Care Model and Improvement Model (PDSA) to help improve health outcomes on pediatric and adult Asthma patients

Participating Organizations - Asthma

(2017 – present)

• Central MS Health Services – Cohort 1

• Family Health Center – Cohort 1

• Mallory Community Health Center – Cohort 1

• Aaron E. Henry – Cohort 2

• G.A. Carmichael – Cohort 2

• Jefferson Comprehensive – Cohort 2

• Implementation of Team Based Care

• Integration of Pharmacist and Community Health Worker on

team

• Integration of Behavioral Health

• Creation of Asthma templates in EMR

• Reassessment of Asthma diagnosis according to severity

assessment per ICD 10 codes

• Workflow redesign to capture Asthma patients ED/hospital

visits

• Trained staff on Managed Care Care Gaps

• Implementation of new EMRs

Accomplishments –MSQII-2 Asthma

• Environmental /Food Allergy Testing integration in-house

• Establishment of Asthma policies

• Received mattress covers, and pillows for high need patients

• Created protocol on dissemination of mattress covers and pillows

• Staff training on Asthma guidelines and protocols

• Sharing Best Practices Working with IT/EMR vendor

• Staff training on workflow process to capture Asthma measures

• Dedicated staff time to review Asthma measures

• Education to staff on Evidence Based Guidelines for Asthma

• New partnerships

• Thermo Fischer

• American Lung Association

• Asthma Coalition

Accomplishments –MSQII-2 Asthma

MSQII-2 ASTHMA

MEASURES PROGRESSJUNE 2019

MSQII-2 Asthma POF /POS

• Cohort 1

• Patients ages 5 -17 =388

• Patients 18 and older =185

• Total Patients = 573

• Cohort 2

• Patients ages 5 -17 = 147

• Patients 18 and older = 213

• Total Patients = 358

• MSQII-2 Asthma Total Patients

• Patients ages 5 -17 = 535

• Patients 18 and older = 396

• Total Patients = 931

Source: MSQII-2 Asthma Dashboard Report June 2019

67.87

87.33

53.87

97.03 96.2

74.77

0

20

40

60

80

100

120

PA on Anti-inflammatory Meds

Severity Assessment Asthma Action Plan

Baseline

Current

Improvements:

The number of patients

on Anti-inflammatory

Meds increased by

42.98%.

Goal =95

The number of patients

with a severity

assessment increased by

10.15%.

Goal = 90

The number of patients

receiving an Asthma

Action Plan increased by

38.80%.

Goal = 70

MSQII-2 Asthma Cohort 1

Population of Focus (POF)

29.6

21.119.7

45.2

39.3

3.6

0

5

10

15

20

25

30

35

40

45

50

ETS assessmentexposure

ETS assessmentintervention

ED/Urgent Care visits

Baseline

Current

Improvements:

The number of patients

receiving ETS assessment

exposure increased by

52.70%.

Goal =20

The number of patients

exposed to ETS receiving

an intervention assessment

increased by 86.26%.

Goal = 20

The number of patients

going to the ED/Urgent

care visits decreased by

81.73%.

Goal <5

MSQII-2 Asthma Cohort 1

Population of Focus (POF)

MSQII-2 Asthma Cohort 2

- Cohort 2 had a late start beginning data collection in January

2019. We are currently validating and processing their data

outcomes.

MSQII-2 Challenges

• EMR Reporting

• Competing organizational priorities

• Patient Transportation

• Staff retention

• $$$ - more funding to assist with solutions for social determinants of health (SDOH)

• Data capture of measures – templates vs. scan

• Workflow redesign

• Staff wearing multiple hats

• Seeing MSQII-2 as a Program/Project

• Time to put process in place

• Resources

Lessons Learned

• Quality Improvement is Continuous

• Change takes time

• Be patient

• PDSA, PDSA, PDSA

• Leadership Buy-in is a MUST

• Work together as a TEAM

• Review and discuss QI reports and create a plan (3 month, 6

month, 9 month, 12 month)

• Document process as they change

• Train staff on EMR as upgrades are performed

• Make sure a Clinical /Data Expert is on the team

MSQII-2 Highlight Video

MSQII-2 Highlight Video

• https://www.youtube.com/watch?v=H1Qw0z-yMyk

Contact

Janice Bacon, MD

Central MS Health ServicesEmail:jbaconwest@outlook.com

Alicia Barnes, MBA

BC3 Technologies, LLC

Email: abarnes@bc3technologies.com

Website: www.bc3technologies.com

Phone: (601) 852.3894

Visit www.msqii2.net for more information!