1. © Pittsburgh Regional Health Initiative 2014 1 COMPASS Using Data for Improvement Establishing the Current Condition and Identifying Opportunities for Improvement Robert Ferguson Program Manager

2. © Pittsburgh Regional Health Initiative 2014 2 Purpose and Objectives  Purpose  To describe how we collect, display, and use data (not to show you our current outcomes or results)  To elicit your feedback on how we can improve our data displays and your ideas and strategies for collecting, displaying, and responding to data  Learning Objectives  Describe COMPASS-PA’s framework for collecting and responding to data  Discuss five examples of how to collect and display data in COMPASS

3. © Pittsburgh Regional Health Initiative 2014 3 Jewish Healthcare Foundation “A Think, Do, Train and Give Tank” A public charity with two operating arms: Pittsburgh Regional Health Initiative (PRHI) Health Careers Futures (HCF)

4. © Pittsburgh Regional Health Initiative 2014 4 Pittsburgh Regional Health Initiative Pittsburgh Regional Health Initiative (PRHI)  A not-for-profit, regional, multi-stakeholder collaborative formed in 1997 by Karen Feinstein and Paul O’Neill  An initiative of a business group, the Allegheny Conference on Community Development PRHI’ S MESSAGE Dramatic quality improvement (approaching zero deficiencies) is the best cost-containment strategy for health care

5. © Pittsburgh Regional Health Initiative 2014 5 PRHI’s Systems Vision Across Care Settings Essential Services System Requirements Care Mgt Clinical Pharmacy Patient Engagement Health IT QI Training Payment Incentives Collaboration and Integration Medication Reconciliation Data to Treat, Measure, Evaluate Perfect Patient Care Rewards for Collaboration Hospice/Palliative Long Term Care Rehab Hospital Emergency Services Specialty Care Primary Care Screening and Tx Behavioral Health Informed, Activated, Discerning Consumers, particularly at End-of-Life

6. © Pittsburgh Regional Health Initiative 2014 6 Implementation of Evidence-based Behavioral Healthcare in Primary Care 2008 Analyzed Admission Data 2009-2010 ITPC Pilot with local funding 2010-2013 PIC Dissemination in 4 states with AHRQ funding 2012-2015 COMPASS Implementation as a CMMI Sub-Awardee

7. 31 COMPASS-PA PCP Offices from 3 Groups: Saint Vincent Healthcare Partners Excela Health Medical Group Premier Medical Associates

8. © Pittsburgh Regional Health Initiative 2014 8 COMPASS Objectives  By 12/31/13, enroll 375 eligible patients per partner region  By 6/30/14, enroll 675 eligible patients per partner region  By 6/30/15:  Improve depression for 40% of patients  Improve A1c, LDL, BP control rates by 20%  Improve patient/provider satisfaction by 20%  Reduce ER visits by 20%  Reduce hospital admissions by 10%

9. PRHI’s Framework for Collecting and Responding to Data Informed by Motivational Interviewing and PRHI’s Lean-based Perfecting Patient Care SM QI Methodology

10. Process (Eliminate Waste) Philosophy (Long-Term Thinking) The 4 P’S of the Toyota Way People and Partners (Respect, Challenge, and Grow Them) People and Partners (Respect, Challenge, and Grow Them) Problem Solving (Continuous Improvement & Learning) Liker, Jeffrey K. The Toyota Way, New York: McGraw-Hill, 2004. The Lean Perspective

11. The Motivational Interviewing Perspective A way of being with people which is… Collaborative Evocative Respectful of autonomy

12. © Pittsburgh Regional Health Initiative 2014 12 Method  Obtain leadership’s support and direction  Identify the current condition and future state with those who do the work, using multiple data sources to make it meaningful and actionable:  Observations (“go and see”)  Process Mapping  EHR and AIMS CMTS data  HPIER’s Reports  Facilitated by PRHI coaches who are trained in Perfecting Patient Care sm, Motivational Interviewing, and COMPASS processes and skills  Their goal is to develop internal capacity for self-review, learning, improvement, and sustainability

13. © Pittsburgh Regional Health Initiative 2014 13

14. © Pittsburgh Regional Health Initiative 2014 14 TIMELOCATIONACTIVITYOTHER 0:00RegistrationPatient arrives. Patient checks in with registration clerk. Told to wait until called by registration clerk.“you will be paged” 1:35Waiting RoomTakes seat in registration room. 10:42Waiting RoomPatient is paged to the registration booth. 10:52Patient asks another patient for advice on which booth to go to before being directed to correct booth. Patient seems confused as to where to go. 11:41RegistrationPatient completes paperwork, provides insurance information 17:05Patient is asked to take a seat and wait to be escorted to exam room.No seat is available for patient. 27:49MA calls patient name and escorts patient to exam room. Exam Room 3MA collects vitals.*MA is very attentive and seems to listen well to patient 38:03MA is unable to find gown for patient Travels to supply closet to retrieve gown. 41:28Patient is asked to change into gown and wait for physician 1:08:36Exam Room 3Physician enters room and greets patient Physician completes patient assessment and plan. Current Condition Observations

15. © Pittsburgh Regional Health Initiative 2014 15 Process Mapping Visualizing the Current and Future Condition Improvement Opportunity Well-functioning aspect of work

16. © Pittsburgh Regional Health Initiative 2014 16 A3 Improvement Plan

17. © Pittsburgh Regional Health Initiative 2014 17 Incremental Improvements Towards the Ideal PDSA/A3 Each improvement moves the process closer to the ideal Current Condition Target Condition

18. Motivational Interviewing Observation Form to Elicit Feedback on Skill Development

19. Example 1: EHR Data at One Medical Group

20. © Pittsburgh Regional Health Initiative 2014 20 Population Health Current Condition January 2013

21. © Pittsburgh Regional Health Initiative 2014 21 PHQ-9 Screening Current Condition, by Office 44% PHQ-9 Completion 19% PHQ-9 > 9 67% Enrollment October 2013

22. Example 2: Displaying HPIER’s Reports, by Medical Group

23. © Pittsburgh Regional Health Initiative 2014 23 COMPASS Patient Enrollment By Regional Partner June 13, 2014

24. © Pittsburgh Regional Health Initiative 2014 24 Initial Data Completeness By Medical Group June 13, 2014

25. © Pittsburgh Regional Health Initiative 2014 25 PHQ-9 Documentation June 13, 2014

26. © Pittsburgh Regional Health Initiative 2014 26 Depression Improvement: Baseline vs. Most Recent Score June 13, 2014

27. © Pittsburgh Regional Health Initiative 2014 27 Depression Remission: Among Those in COMPASS for > 119 Days June 13, 2014

28. © Pittsburgh Regional Health Initiative 2014 28 A1c Documentation June 13, 2014

29. © Pittsburgh Regional Health Initiative 2014 29 A1c Control Rate: Baseline vs. Most Recent Value June 13, 2014

30. © Pittsburgh Regional Health Initiative 2014 30 BP Documentation June 13, 2014

31. © Pittsburgh Regional Health Initiative 2014 31 BP Control Rate: Baseline vs. Most Recent Value June 13, 2014

32. © Pittsburgh Regional Health Initiative 2014 32 Hospital Admissions (Self-Reported) June 13, 2014

33. Example 3: CMTS Data at One Medical Group

34. Entered in CMTS Initial Contact PH-9>9 Last Follow-up PH-9<10 No Follow-up PH-9 Initial Contact PH- 9<10 Last Follow-up PH-9>9 Last Follow-up PH-9<10 99% 1% 28% 32% 41% 100% COMPASS PHQ-9 May 2014 CMTS Data Median Contacts Per Patient with Initial PHQ-9>93 Median Treatment Weeks Per Patient with Initial PHQ-9>938

35. Entered in CMTS Initial Contact A1c > 7.9 Last Follow-up A1c<8.0 No Follow-up A1c Initial Contact A1c<8.0 Last Follow-up A1c>7.9 Last Follow-up A1c<8.0 No Follow-up A1c Last Follow-up A1c>7.9 49% 30% 12% 47% 41% 43% 10% 48% COMPASS A1c May 2014 CMTS Data Median Contacts Per Patient with Initial A1c > 7.93 Median Treatment Weeks Per Patient with Initial A1c > 7.929

36. Entered in CMTS Initial Contact SBP>139 Last Follow-up SBP<140 No Follow-up SBP Initial Contact SBP<140 Last Follow-up SBP>139 Last Follow-up SBP<140 No Follow-up SBP Last Follow-up SBP>139 COMPASS SBP May 2014 CMTS Data 60% 37% 23% 15% 62% 48% 17% 36% Median Contacts Per Patient with Initial SBP>1393 Median Treatment Weeks Per Patient with Initial SBP>13942.5

37. Example 4: CMTS Data at Another Medical Group

38. March 2014

39. Example 5: CMTS Data of Follow-up Contacts

40. © Pittsburgh Regional Health Initiative 2014 40 Follow-up Contacts and Active Caseload by Month and Care Manager Care Manager’s Current % Time on COMPASS # Follow-up Contacts # Pts. Active End of…. NovDecJanFebMarAprMayFebMarAprMay 100%1142433549545783888289 100%2437222852364176687477 100%588859586449 738182 20%NA 0 0 90%NA 11615NA 1618 5%31200309999 2%11011011222 5%105543457778 5%01340125444 01113124544 359978108898 2%00000114555 5%64810007899 100%13112113510510312211186NA99101

41. © Pittsburgh Regional Health Initiative 2014 41 COMPASS-PA’s Next Steps  Analyze internal EHR data (PHQ-9, A1c, BP)  Continue to base the Steering Groups’ discussions around the data  Use AIMS’ CMTS Caseload Statistics and Caseload Summary for real-time data and monitoring  Continue to dig into the CMTS data  Continue to utilize Lean-based quality improvement methods at the front-line  Move meaningful, actionable data to where the work is occurring

42. © Pittsburgh Regional Health Initiative 2014 42 Care of Mental, Physical, and Substance use Syndromes The project described was supported by Grant Number 1C1CMS331048 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.