1. PA SPREAD Webinar #1

2. Webinar 1 of 3 Introduction Getting Started- Pre-work Empanelment Aim statement Baseline Assessment Webinar #2: Baseline Data Measurement Webinar #3: Introduction to the Models

3. PA Spreading Primary Care Enhanced Delivery Infrastructure Builds on success of PA Chronic Care Initiative Funded by AHRQ to develop infrastructure for supporting/spreading primary care transformation Primary Care Extension Service Apply lessons learned from PA initiative to 2 new collaboratives (SC and NW) Disseminate model, lessons learned in 3 other states (NJ, NY, VT)

4. Model for Primary Care Extension Service Based on the Agricultural Cooperative Extension Model  Most successful innovation spread program in U.S.  1914 – Collaboration of federal, state, county governments, land grant universities  Helped famers adopt best practices

5. LAYING THE FOUNDATION The Medical Home and More

6. The Medical Home

7. The Chronic Care Model Informed and Activated Patient Productive Interactions Prepared and Proactive Practice Team Delivery System Design Decision Support Clinical Info Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Improved Outcomes

8. Transformation/Paradigm Shift Population Management - shift from treating one patient at a time to managing populations of patients Continuum of care - shift from defining a single medical encounter as a complete entity to viewing it as one point on a continuum of care Team-based care - shift from the physician providing care alone to coordinated, physician-led interprofessional team care.

9. NCQA PCMH 2011 Recognition Most commonly used standards for evaluating practice-wide systems of care related to: Access and Continuity Population Management Planning and Managing Care Self Management Support Tracking and Coordinating Care Measuring and Improving Performance

10. How This Work Will Help We will guide you in building these systems of care and discuss relevant NCQA standards and documentation throughout the year. Our focus is on diabetes, but you can apply your systems of care to other chronic and preventive care services. (Note: Both NCQA and Meaningful Use require documentation on at least 3 different preventive care services and 3 different chronic care services.) Lot of crossover between NCQA and Meaningful Use requirements!

11. Meaningful Use Incentives Must attest this year to be eligible for maximum incentive of $44,000 per Eligible Provider under Medicare. CY 2011CY 2012CY 2013CY2014CY 2015 and later CY 2011 $18,000 CY 2012 $12,000$18,000 CY 2013 $8,000$12,000$15,000 CY 2014 $4,000$8,000$12,000 CY 2015 $2,000$4,000$8,000 $0 CY 2016 $2,000$4,000 $0 TOTAL $44,000 $39,000$24,000$0 Medicare penalties for not achieving Meaningful Use begin in 2015!

12. GETTING STARTED Pre-Work

14. Goals are to: 1.Prepare you for the first learning session 2.Give you time to form your improvement team 3.Collect baseline data and information on your practice 4.Allot time for you to meet your practice facilitator

15. Northwest Patricia J. Stubber, MBA Executive Director Northwest PA AHEC 8425 Peach Street Erie, PA 16509-4788 814-217-6029 (phone) 814-594-4740 (cell) 814-864-4077 (fax) pstubber@nwpaahec.org paspread@hmc.psu.edu Please send any questions to Practice Facilitators South Central Sharon M. Adams RN, BA Executive Director Southcentral PA AHEC PO Box 509 Carrolltown, PA 15722 814-344-2222 (phone) 814-344-2221 (fax) sadams@scpa-ahec.org WEBSITE www.paspread.com

16. Role of Practice Facilitators Support practice with QI processes, techniques Serve as sounding board/provide feedback and benchmarking Assist in finding tools and resources Help prioritize change activities Serve as “honey bee” networker Assess practice education, training needs Provide “motivational coaching” (cheerleader) Assist with problem-solving

17. Pre-Work Learning Objectives 1.Understand the concept of empanelment and its importance in assuring continuity of care and develop a plan to organize patients into provider panels if your practice is not already organized that way. 2.Understand the clinical guidelines and related measures for diabetes. 3.Collect baseline data on the number of diabetes patients in your practice and the # meeting evidence-based diabetes measures. 4.Develop an aim statement for what and how much you want to improve over the next year.

18. Pre-Work To-Do’s  Identify a provider champion  Form a multi-disciplinary improvement team  Write an aim statement  Develop a plan to address any issues with provider panels  Complete and submit the PCMH-A assessment  Collect and report baseline diabetes data on the monthly practice status report  Participate in the 3 pre-work webinars  RSVP attendees for Learning Session #1

19. Selecting a Provider Champion Change and improvement are not possible without committed leadership. Each practice should have a provider champion (not just one for a system of practices). Champion must want to do this work. Champion must have standing in the practice to lead practice-wide changes. Champion (and entire improvement team) should be allotted time to meet, plan, and test changes.

20. Forming an Improvement Team Multi-disciplinary: provider, clinical, and administrative champions. Team members should be able to embrace change. Team members should be leaders among their peers. Team members should be comfortable soliciting and providing feedback to peers and providers.

21. Model for Improvement Three fundamental questions Aim statement Measurement plan Selecting changes to test Plan-Do-Study-Act (PDSA) cycle Scientific method used for action-oriented learning Cycles of testing continue until desired outcomes, implementation, and spread

22. Writing an Aim Statement Agree on what you’re trying to accomplish. Be specific. Set timeframes and numerical goals to clarify the aim, create tension for change, and focus initial changes. Aim high: set stretch goals that cannot be met by just tweaking the system.

23. Aim Statement Example #1 By May 2013, we will adopt components of the Patient Centered Medical Home and Chronic Care Models to improve diabetes care as follows: Less than 15% of our patients will have an A1C greater than 9.0. More than 75% of our patients will have an A1C less than 8.0. More than 75% of our patients will have their most recent blood pressure less than 140/90. More than 60% of our patients will have an LDL less than 100.

24. Aim Statement Example #2 Within the next 12 months, we will implement components of the PCMH and Chronic Care Models to ensure that at least 90% of patients with diabetes in our practice at least annually receive: blood tests for A1c and LDL; a urine test for microalbuminin; a diabetic eye exam; a monofilament foot exam; smoking cessation counseling if they smoke.

25. ASSURING CARE CONTINUITY Empanelment

26. Key to PCMH: Continuity PCMH practices: Assign all patients to a provider panel, confirm assignments with providers and patients, and review and update panel assignments on a regular basis. Assess practice supply and demand and balance patient load accordingly. Use panel data and registries to proactively contact and track patients by disease status, risk status, etc. Source: Safety Net Medical Home Initiative http://www.safetynetmedicalhome.org/change- concepts/empanelment

27. PCMH 1: Enhance Access and Continuity Element D: Continuity The practice provides continuity of care for patients/families by: 1.Expecting patients/families to select a personal clinician. 2.Documenting the patient’s/family’s choice of clinician. 3.Monitoring the percentage of patient visits with a selected clinician or team. NCQA PCMH 2011

28. Value of Empanelment Empanelment promotes: Continuity of care with personal PCP Improves quality, patient safety Organized approach to care delivery Continuity increases efficiency by at least 15%. Management of provider demand to panel size Improves patient access to care Provider accountability for population management Facilitates team-based care

29. Patients in Provider Panels PROVIDER 1PROVIDER 2 PROVIDER 3 PROVIDER 5 PROVIDER 4 PROVIDER 6

30. Each Provider Responsible For The care of each patient in his/her panel. Population management for his/her entire panel. Clinical outcomes improvement for his/her panel of patients. The overall effectiveness and efficiency of his/her practice.

31. Creating Provider Panels NCQA Requirements: Document and follow a process to encourage and ask patients to choose a personal provider. During check-in? When patients call for an appointment? Materials/handouts letting patients know value of choosing a personal provider and process to do so? What about patients who are seen infrequently? Send a mailing? Document and track each patient’s choice of a personal provider. Put in EMR and scheduling system, if not integrated. Must be available when booking appointments, checking in patients. Needed for population management reports.

32. Other Things to Consider Historical information on patient visits: Which provider seen most often Which provider did last physical exam Which provider seen last Maximum panel size for each provider based on: # of hours/provider/year # of provider appointments available/hour Type of patient population and related visits/year (risk stratification) Goal is to balance supply and demand and balance provider panels.

33. Maximum Panel Size Formula A part-time provider working 1,000 hours per year (20 hr/wk x 50 wks) and having 4 appointments/hour has 4,000 appointment slots per year. If the patient population requires 10 visits/year, the panel size for the provider could not exceed 400 patients. If the population requires 4 visits/year, the panel size could be 1,000 patients. Example (# of hours worked/year) x (# of appointments/hour) (average # visits/year for panel of patients) = maximum provider panel size

34. Ongoing Support, Monitoring Need scheduling policies to support patient visit continuity with selected provider. Likely need some form of open access scheduling to facilitate sick visit continuity. Same-day appointments (NCQA PCMH Standard 1, Element A: Access During Office Hours—MUST PASS and CRITICAL FACTOR). Evaluate weekly schedules to see which days more open appointment slots are needed to accommodate patient demand. NCQA: Practice should monitor the percentage of visits that occur with the selected clinician and team.

35. NCQA Documentation Documentation Needed for NCQA: Documented process for patient/family selection of a personal clinician. Screen shot from electronic system showing documentation of patient/family choice of clinician. One week of data showing proportion of patient visits that occurred with chosen clinician.

36. Empanelment Resources Safety Net Medical Home Initiative Offers Implementation Guides and Webinars on Empanelment http://www.safetynetmedicalhome.org/change- concepts/empanelment

37. BASELINE ASSESSMENTS PCMH-A and Clinical Measures

38. Assessing Where You Are Now Two types of baselines PCMH Assessment (PCMH-A) Clinical measures baselines: Topic of Webinar #2 Practice Facilitators also will be collecting some baseline assessment information when they visit with you.

39. The PCMH-A Self-assessment tool developed by Qualis and the MacColl Institute for the Safety Net Medical Home Initiative. Assesses current level of “medical homeness.” Identifies areas for improvement. Should be completed at the practice level by the team leader or provider champion in consultation with improvement team.

40. Completing the PCMH-A Available online at: http://www.safetynetmedicalhome.org/sites/default /files/PCMH-A.pdf. http://www.safetynetmedicalhome.org/sites/default /files/PCMH-A.pdf Will also be emailed to key contacts (person who completed your application). When you’re done, save a copy for your files and print a copy to share with us. Please email a copy of your completed PCMH-A by May 11 to paspread@hmc.psu.edu or fax it to 717-531-0182.paspread@hmc.psu.edu

41. UPCOMING DATES Webinar #2, #3; Learning Session #1

42. Dates for Upcoming Sessions Webinar #2: Baseline Data Measurement May 2: 7-8am May 8: 5-6pm Webinar #3: Introduction to the Models May 16: 7:30-8:30am May 21: 4-5pm NW Learning Session #1: May 23, 5-9pm SC Learning Session #1: June 7, 5-9pm Please RSVP the team members who will be attending Learning Session #1 to paspread@hmc.psu.edu by May 11. paspread@hmc.psu.edu

43. Pre-Work To-Do’s  Identify a provider champion  Form a multi-disciplinary improvement team  Write an aim statement  Develop a plan to address any issues with provider panels  Complete and submit the PCMH-A assessment  Collect and report baseline diabetes data on the monthly practice status report  Participate in the 3 pre-work webinars  RSVP attendees for Learning Session #1

44. Practice Facilitators Northwest Patricia J. Stubber, MBA Executive Director Northwest PA AHEC 8425 Peach Street Erie, PA 16509-4788 814-217-6029 (phone) 814-594-4740 (cell) 814-864-4077 (fax) pstubber@nwpaahec.org South Central Sharon M. Adams RN, BA Executive Director Southcentral PA AHEC PO Box 509 Carrolltown, PA 15722 814-344-2222 (phone) 814-344-2221 (fax) sadams@scpa-ahec.org paspread@hmc.psu.edu Any Questions CENTRAL EMAIL WEBSITE www.paspread.com