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Practice Transformation: A Roadmap for FQHCs

Deena Pourshaban, MPH, PMCH CCEChief Operating Officer

Elevation Health [email protected]

About DeenaDeena’s expertise is in Practice Transformation, Large‐scale Program Design and Management, Business Process Management, Patient Centered Medical Home (PCMH), Social Determinants of Health (SDoH), and Primary Care Workforce Strengthening .

Welcome

Slide 4

Lauren Philp, MSHIProject Manager/Coach

Community Clinic Association of Los Angeles [email protected]

About LaurenLauren is a Six Sigma Black Belt with many years of experience in FQHC quality improvement and risk management. Her expertise is preparing health centers for value‐based payment, work measurement and process improvement, and promoting integrated care.

Welcome

Slide 5

Objectives

By the end of today’s presentation, attendees will:• Increase their understanding of a successful approach to implement practice transformation and PCMH methodologies

• Learn current efforts of 23 Los Angeles FQHC organizations that applied practice transformation to their organization

• Gain access to a practice transformation toolkit in order to implement operational strategies within their own agency.

LA Practice Transformation Network

• Funding to support this work at Los Angeles‐based FQHCs was provided through CMMI’s Transforming Clinical Practice Initiative (TCPi)

• L.A. Care is one of 29 organizations awarded TCPI funding, Los Angeles Practice Transformation Network (LAPTN) helps 3,200 clinicians

• CCALAC provides project management and coaching for the community clinic providers enrolled in LAPTN

• Elevation Health is the lead firm providing an onsite, dedicated masters coaching team to lead the practice transformation effort among 23 FQHCs in Los Angeles County (over 800 providers)

• Four year program through November 2019• Health centers are required to address 27 metrics in order to be ready for Value Based Reimbursement

Practice Transformation Approach

Set aims and enroll practices (align aims

with Federal, State and organizational goals)

Pull baseline data on quality measures

Assign practice coach

Monthly data reporting on

measures. Follow‐up PAT assessment every

6 months

DO THE WORK (implement intervention, empanelment, care teams, QI, ER/hospitalization, pop health, care coordination,

high risk…)

Conduct baseline practice assessment

Assess progress, revise approach if not

meeting target goals

Celebrate success!!!

Implement a sustainability plan to maintain progress

Practice Assessment Tool (PAT)

• A 27 question tool created by CMS to lead progression of practice transformation across 5 phases of maturity ‐ or readiness for value based payment participation

• Based off of Prochaska’s Theory of Change• Engage in PAT every 6 months• Use PAT results to drive improvement • Practice gives a score of 0‐3 on each metric. Each metric has a scoring criteria description

PAT Main Drivers

1. Patient and Family Engagement: Setting self‐management goals, patient feedback into QI clinic system2. Team Relationships: Continuity of care, roles/responsibilities for staff 3. Population Health Management: Empanelment, care management/risk stratification 4. Community Partner: Community referrals 5. Coordinated Care Delivery: Following up on ER visits, care coordination6. Organized and Evidence‐based Care: Address gaps in care, whole person7. Enhanced Care Access: Call patients within 24/78. QI Strategy: PDSA and lean approach, empowering staff9. Transparent Data Monitoring: Produce report and share results 10. Strategic use of Practice Revenue: ROI calculations 11. Joy in work: Workforce and staff satisfaction 12. Analyze and document value: Share financial data, migrate to APM13. Efficient in Operation: Eliminating waste

Practice Transformation

• Our coaching team has assisted the health centers in implementing:

Care teams and huddles

Screening for Social Determinants of

Health

Optimizing EHR use and data reporting

Searching and implementing evidence‐based interventions

Conducting outreach initiatives

Building practice quality

improvement capacity

Team building and communication

Empathy, bias, and motivational skill

building

Risk stratification Empanelment methodologies

Practice Transformation Toolkits

• CQMs: Workflow redesign, coding, addressing data integrity issues, mapping, EMR templates, training and PDSAs • PAT: Created a “Phase Approach” document, that outlines examples for meeting a score of 2 or 3 for each PAT item• Empanelment: Implementing empanelment in an FQHC• PDSA: Database of tailored interventions to improve CQMs (Diabetes, Depression screening and BMI screening)• Business process management: Protocol on using Lean and time and motion studies• SDOH: Workflow implementation for addressing SDOH• Trainings: Motivational interviewing, empathy, SDOH• BH integration into primary care: Assessment tools, policies• Care coordination (diabetes): Job descriptions workflows, manuals • Utilization: Piloting ER/hospitalization program with FQHCs • Data visualization: Templates to trend CQM data (provider level data)• Workforce: Toolkit to implement strategic HR interventions

Onsite Practice Coaching

0

500

1000

1500

2000

2500

3000

1.3.1 Assign topanels

Diabetes CQM 3.2.3 CultivateJoy

3.3.4 Documentvalue

2.2.2 Build QIcapability

Total H

ours

Top 5 PAT Tasks: 2018‐August 2019

2018 2019 Grand Total

Practice Coaching

0100200300400500600700800900

1000

Total H

ours

Other PAT Tasks: 2018‐August 2019

2018 2019 Grand Total

Onsite Assistance

0 100 200 300 400 500 600 700 800 900 1000

All for HealthAll‐Inclusive Community Health Center

Asian Pacific Health Care VentureBAART

Bartz‐Altadonna (BACHC)East Valley Community Health Center

Eisner Pediatric & Family Medical CenterFamily Health Care Centers of Greater LA

Harbor Community ClinicHCHC

JWCH InstituteNortheast Valley Health Corp

Pomona Community Health CenterSouth Bay Family Health Care

St. John's Well Child and Family CenterT.H.E. Clinic Inc

Tarzana Treatment Centers, Inc.The Children's Clinic

Valley Community HealthcareVenice Family ClinicWatts Healthcare

Westside Family Health CenterWilmington Community Clinic

Hours

Onsite vs. Offsite‐2018

Offsite Onsite

0 100 200 300 400 500 600 700 800

All for HealthAll‐Inclusive Community Health Center

Asian Pacific Health Care VentureBAART

Bartz‐Altadonna (BACHC)East Valley Community Health Center

Eisner Pediatric & Family Medical CenterFamily Health Care Centers of Greater LA

Harbor Community ClinicHCHC

JWCH InstituteNortheast Valley Health Corp

Pomona Community Health CenterSouth Bay Family Health Care

St. John's Well Child and Family CenterT.H.E. Clinic Inc

Tarzana Treatment Centers, Inc.The Children's Clinic

Valley Community HealthcareVenice Family ClinicWatts Healthcare

Westside Family Health CenterWilmington Community Clinic

Hours

Onsite vs. Offsite: Jan‐Aug 2019

Offsite Onsite

Practice Coaching

• Coaching model: 2+ check‐ins per month solidified engagement and accountability

• Phase approach based on change package

• 6 month practice assessments

Savings to Health Plan

• L.A. Care Health Plan has reported that the LAPTN program has realized more than $150,00,000 in cost savings as of August 2019 toward a goal of $60 million by 2019*

• Saved in hospital related claims for diabetes and depression

*Presented at the California Transformation Summit August 21 2019

CCALAC Network Progress (9/2019)

Phase Current % Achieved Goal Achieve

By

# Completed Phase 3 23 96% 24 5/31/18

# Completed Phase 2 24 100% 24 12/31/17

# Completed Phase 5 21 87% 20 9/30/19

# Completed Phase 1 24 100% 24 12/31/16

# Completed Phase 4 21 87% 24 3/31/19

CQM Improvement: 2015‐2019

20

Measure 2015 Baseline

LAPTN Threshold

August 2019

Hemoglobin A1c Poor

Control >9%38.91% 29% 32.39%

Medical Attention for Nephropathy

71.92% 80% 86.32%

Screening for Clinical

Depression & Follow‐Up

40.57% 58% 71.27%

BMI Screening & Follow‐Up 50.49% 51% 86.72%

A1c CQM Improvement

Nephropathy Screening CQM Improvement

Depression Screening CQM Improvement

BMI Screening CQM Improvement

Practice Transformation Toolkits

Empanelment Toolkit & Approach

Panel Calculation Tool & Four Cut Access Database

Training Content

PCP Change Process

Team‐based care

Policies & Job Descriptions

EMR Coordination

Empanelment Toolkit & Approach

Diabetes: Demonstrating A1c Improvement

Data Integrity

• Ensure report mapping is accurate

• Verify lookback period is independent from reporting period

• Working lab interface OR coding is accurate

Gap Outreach

• Check unmatched lab results in interface holding tank

• Implement standing orders for A1c

• Outreach campaigns

• Point of Care testing

Care Management

• Health education classes or videos

• Group visits• Care management program for new diabetics

• Clinical Pharmacist for titration and adherence


• Pair and Share Activity!• Review A1c checklist for 2 minutes on your own• Notice:

• Where your organization may be skipping a step• Opportunities for further improvement• Steps that seem insurmountable

• Share your thoughts with a partner or two for 3‐4 minutes• Volunteer to share a‐ha moments with group?

Work Measurement Toolkit

Value47%

Necessary15%

Defects2%

Over‐production12%

Not utilizing Talent14%

Extra‐Processing10%

• Gemba = the real place• Going from guessing what the problem is to knowing what the problem is

• Set a goal and observe the current state

• Empower front‐line staff to participate in improvement

• Apply DOWNTIME to evaluate activities

• Choose intervention, work it, and remeasure!


Type of Waste Examples

Defects Incorrect entry of ICD/CPT code, incorrect EMR mapping with external software, computers freezing, mediation of interpersonal issues

Overproduction Send info automatically when not required, printing and filing unnecessary documents, long set‐up times

Waiting Patient waiting to be seen by provider, patient waiting to get vitals complete

Non‐utilized or underutilized talent

Having Care Managers work the front desk

Transportation Moving files from one location to another, scanning documents

Inventory Running out of flu vaccines, unused or rarely used equipment

Motion People searching for materials, tools or equipment, looking for support staff, too many clicks in the EMR to complete a task

Excess Processing Too many approvals to get a task completed, double documenting


Clinic Testimony:This time and motion study has been exceedingly helpful in identifying inefficient workflows with our clinics. As a result, we have a comprehensive list of changes that we can implement to improve efficient, high value work at our clinics. Our hope is this will make patients more satisfied and thus more compliant with clinical goals and staff happier with their employment experience. One center director told me this study was “ the most important information he’s ever gotten in running this clinic.”

Poll!

• Poll Everywhere• Text ELEVATIONHEA964 in body of text to 22333 to sign up for access

Workforce Pilot and Tools

Measure and EvaluateImplement HR ApproachData Report-Out

Phas

es Trend and Analyze Data

Tim

ing

Key

Act

iviti

es

Schedule working session to collect turnover data

Complete workforce assessment data collection tool

Data will be collected by staff and by department

Collect turnover data as far back as possible

Workforce project team to trend and analyze data using Tableau

Analysis will stratify turnover rates by position, determine turnover rates by clinic site

Needs assessment with clinic stakeholders

Schedule meeting with clinic executive team to share data summary and findings

Workforce project team will prepare a list of HR recommendations to implement

Selection of HR strategic approach to implement

Implementation of strategic HR approach

• Manager Trainings• Exit Interviews• Data Collection &

Analysis• Onboarding• Performance

Evaluation• Staff Engagement• Stay Interviews

Jan 2018-Feb-2019 March-June 2019 July-Present 2019Oct-Dec 2018

Remeasure turnover data

Present findings

Conduct post-intervention surveys & intervention

Focus-group interviews

Draft scale up and spread plan (if HR strategic approach worked)

Nov-Dec 2019

Baseline Data Collection

Workforce Tools

FQHC Workforce Maturity Model• Talent Acquisition• Employee Recognition• Performance Management

• Leadership Development

Turnover Data Collection• Exit Interview Policy• Exit Interview Questionnaire

• Data collection template (Excel)

• Turnover rate calculator

Manager Training• Coaching Model of Management

• Trust and Grow the Model

• Feedback and Time Management

Policies and Procedures (Gaps)• Staff Onboarding• Data Collection• Performance Evaluation• Staff Engagement

Workforce Interventions•3‐ series training on how to effectively manage your staff, use of empathy, how to coach and support staff, implementation of the GROW Model, and time prioritization

• 4 clinics implemented

Manager Trainings

• Levering HRIS system to accurately capture and report data to develop retention strategies


Data Collection and Analysis

•Employee pulsing; stay interviews, 360‐degree feedback; exit interviews•2 clinics implementedEmployee Engagement

• Protocol to onboard and train employees, cost of onboarding template• 1 clinic implementedOnboarding

•Protocol for conducting performance evaluations. Provider‐specific and MA‐specific performance


Performance Management

Workforce Tools

Workforce Maturity Model

Social Determinants of Health

• Support Health Centers to understand the screening tools available, tailor services and solutions to the resources of the organization, develop optimal workflow, collect patient level data, better understand the resources in their community, and build the necessary partnerships to address the Social Determinants of Health (SDoH) affecting their patients

• Toolkits and workflows were created to address food insecurity, housing and transportation referrals

• Our “Training Through Empathy: SDoH Screening in Primary Care” incorporates the latest evidence base in team care, medical home, social linkages, and empathy to empower care teams to address SDoH in the primary care setting

Hunger Vital Sign• Implemented 2 question food insecurity

screening questionnaire • Within the past 12 months you worried

whether your food would run out before you got money to buy more?

• Within the past 12 months the food you bought just didn’t last and you didn’t have money to get more.

• Would you like a referral to services that can help you?

Practice In ActionJWCH Food Insecurity Approach Agency Overview • 15 main clinic sites (31 health center sites)

• Services 36,472 patients • Secured $75,000 in funding to address food insecurity from LA Care Health Plan

Food Insecurity Intervention

• Implement Hunger Vital Sign Questionnaire for all patients. • Patients screened at every visit• Patients who screen positive have 3 opportunities for follow‐up: Rx Food Guide, direct referral to nutritionist and referral to CalFresh Application Assistor

• Ensured all Diabetes Care Coordinators and enrollment specialists were certified as application assistors

• Developed internal referral• Provided incentives to staff to meet target enrollment goals• Timeline for implementation 6 months • Conducted site specific trainings • Public Charge Talking points

Outcomes • Timeline: Jan‐August 2019• Need total number of certified application assistors: 26 • Total number of submitted CalFresh applications : 339• Total CalFresh approved: 151• Total CalFresh pending: 22• Total CalFresh denied: 166

Competencies and Tools for SDoH

Validated Tools and Technology

Empathy, Bias and Humility

Training

Data Collection and Reporting

Motivational Skill Building

Community Partnerships

Training slide decks*

Food Rx Guide*

Workflow Models*

Scripts and talking points*

Sample Reports*

Evidence Based Screening Tools*

Food Rx Guide

Food Insecurity Reports Application Assistor Approved Pending Grand Total

Timeline: Jan‐August 2019Fernando 2 0 2Aileen 11 3 14Andrea 26 9 35Carlos 27 4 31Denise 21 2 23Felicia 6 2 8Iridian 15 4 19Maria 11 1 12Maribel 18 2 20Grand Total 137 27 164

1 1 1 13 2 2

1

25 1

24

6

5

41 2 51

6

63

3 1

34

6

104

4

33

32

2 5

5

2

21

2

1

21

12

0

5

10

15

20

25

30

? Aileen Andrea Carlos Denise Felicia Iridian Maria MaribelTotal n

umbe

r of C

alFresh Ap

ps

Approved CalFresh Applications: Jan‐August 2019

1‐Jan 1‐Feb 1‐Mar 1‐Apr 1‐May 1‐Jun 1‐Jul 1‐Aug

Talking Points: MA and Provider

MA Talking Points

• We have a food resource guide that you and your family can use to access resources to keep you healthy

• If you need food immediately. There are places in the community that offer free groceries. Here is list (Give patient list)

• I will let the provider know, so you and him/her can discuss the best options for you and your family

Provider Talking Points

• Food is important to our health. I want to make sure you have access to enough food and the right types of food. This guide has a lot of great resources for you. I am also referring you to Cal Fresh (Insert info about Cal Fresh).

• If you need more community resources please speak with the Diabetes Care Coordinator and she/he will make sure you get the resources you need.

Provider Talking Points

• Many of the other patients use food assistance programs and it is really helpful.

• This guide has many resources that are available to you. I am also referring you to nutrition services.

• A nutritionist will contact you to help answer any of your nutrition questions and connect you to additional resources.

Questions

Thank You!

Deena Pourshaban, MPH, PCMH CCEElevation Health Partners, [email protected]‐313‐3321

Lauren Philp, MSHI Community Clinic Association of Los Angeles County, [email protected]‐201‐6520

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