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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




Monica Benjamin – MBA, BSN, RN, CLC

Rainbow Pediatrics

Middlebury, VT


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


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


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


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

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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



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


Case Study: Rainbow Pediatrics Lessons Learned

9 http://coachingandleading.files.wordpress.com/2012/10/repeat-pdsa-cycle6.png



• Quality improvement

– Manipulation of data

– Assigning “dummy codes” to enable tracking

– Chart review

– Patient & Family feedback

10



11 http://gagandeepsinghanand.wordpress.com/2012/07/



• Practice facilitator is a must

– Interpretation of standards and elements

• Provider present during meetings with facilitator

– Assist with decision making

12



• 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

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• 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

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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


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/

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http://www.champsonline.org/ToolsProducts/CrossDiscResources/PCMH.html

http://www.champsonline.org/ToolsProducts/CrossDiscResources/PCMH.html

http://gagandeepsinghanand.wordpress.com/2012/07/






http://intermountainhealthcare.org/ext/Dcmnt?ncid=522580754







http://www.ncqa.org/Portals/0/Public Policy/2014 Comment Letters/The_Future_of_PCMH.pdf






http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH.aspx











http://coachingandleading.wordpress.com/presentation1/pdsa-and-types-of-change/









VITL Summit ‘14 Track 2: Meeting Evolving Requirements 17


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

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:____________________

19


Contact Information

Monica Benjamin

Email: [email protected]

Phone: 802-989-9695

20




Jenney Samuelson - Assistant Director

Vermont Blueprint for Health, Department of Vermont Health Access

Williston, VT


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


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


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)


• Multi-disciplinary quality improvement team

(NCQA PCMH recognition)

• Seamless coordination of care

(CHT development)

• Information technology

(DocSite/VITL interface)

Blueprint Patient Centered Medical Homes


Health Access


• 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


Health Access


• “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


Health Access


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


Health Access


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


Health Access


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


Health Access


• 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


Health Access

Practice Facilitation in 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


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


• 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


• Counseling

• Population Management

Samuelson


Contact Information

Jenney Samuelson

Email: [email protected]

33

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