Right Care Initiative Blue Shield of California Participation UBP November 2017 Scott Flinn, MD Regional Medical Director Blue Shield of California

Care Worthy of our Family and Friends that is Sustainably Affordable

Bottom Line Up Front – Right Care Initiative (RCI) Blue Shield of California (BSC) has historically been in the middle of the pack w.r.t. RCI scores. In October 2015, Blue Shield was required by DMHC to develop a plan with a goal of achieving the 90th percentile in RCI metrics by end MY 2018. Blue Shield of California has developed that plan and has begun the process of implementation; this presentation is a review of progress to date. Ultimately, the goal is the elimination of preventable strokes and heart attacks for all Californians.

Based on RY 2017 NCQA Quality Compass for HMO

RCI at BSC Improving Quality is a BSC priority; incentives aligned Internal incentives External incentives – e.g. ACO quality contract, Medicare Advantage RCI efforts synergize with other Quality Improvement efforts ACO Medicare OPA Hypertension (HTN) and Diabetes Mellitus (DM) care are focus across all Lines of Business (LOB)

What we are doing Attending the 2 RCI UBPs in LA and Sacramento and attending Be There in San Diego Dr Flinn on Be There San Diego Executive Steering Committee Dr Flinn participates in LA UBP planning Utilizing information gathered at these venues to further the effort.

What we are doing – Engaging our Partners Engaging partner Provider Organizations that have enough membership to allow us to reach 90th percentile by end of MY 2018. Currently 23 organizations agreeing to participate - 200,000 members (current HMO membership 700K)

What have we learned so far As we engage provider organizations we find many have efforts towards RCI goals at various levels. And they are all unique…. if you’ve seen one provider group you’ve seen one provider group. RCI synergizes with other programs many groups are already doing – e.g. CDC/CMS Million Hearts, AMGF Measure Up Pressure Down and Together2Goal, AHA Target BP, Know Your Numbers Obtaining Hypertension control in high risk patients has the biggest near term effects on patient outcomes

Partnering with Provider Organizations (POs) Engagement – getting the Groups/IPAs physicians buy in via brief presentation Developed Best Practices self-assessment tool for HTN and DM care based on RCI University of Best Practices (UBP)and other work Done with a BSC clinician Tool has resource links embedded Using Best Practices tool, conduct gap analysis with partner POs and development action plan

Provider Engagement Presentation Brief Presentation emphasizing 3 points: There are some things you can implement rather easily and cheaply that can dramatically effect your outcomes HTN control – basic medical care that can have a meaningful impact (see next slide) You probably aren’t doing as well as you think you are….

Decrease Deaths over 17% (1 in 6) in 2 years Treat them NOW

Best Practices Self Evaluation Tool HTN and DM tabs 3 categories – Leadership, Processes, Patient Engagement; 23 items for HTN, 19 for DM 3 Ratings –yes, no sort of Resource links embedded Hypertension Date: Practice Name:   Best Practice No Sort of Yes Action Items/Comments/Timeline Resources Leadership 1.1 Multidisciplinary team that includes clinical champion(s) No team chartered; no mtgs held. Chartered team but not meeting regularly. Meetings have occurred at least quarterly within last year. Participants include at least 1 Clinical Champion. Best Practice: Zufall Health "Building a Team" 1.2 Engaged all providers and clinical staff through education No provider or staff education occurring. Some staff or provider education has occurred. Leaders engage providers and direct support staff in importance of controlling BP. Information shared from benchmarks such as Million Hearts, AMGF Measure up Pressure Down, AHA and AMA Target: BP RCI Template Presentation 1.3 Internal public reporting of HTN control by provider No reporting in place. Mechanism for reporting available, but not shared with peers. Unblinded provider performance report shared at least quarterly. 1.4 Recognition of providers with excellent performance No recognition program in place. Discussion of recognition program started but not yet implemented. There is a specific future implementation date. Recognition program fully implemented. Processes 2.1 Process map of clinic visit flow to evaluate delivery of care pre-visit, visit and post-visit No process map. Process map under discussion; may have been started. Share a process map or standard workflow based on actual practice. Should have been observed within past 6 months for validation. 2.2 Hypertension is addressed at every primary care visit No chart audits. Sample chart audit shared. May not show action taken. Sample chart audit shared. Demonstrates action taken for at least 80% of patients. 2.3 Consistent Process to ensure HTN measurement part of every visit No process defined. Discussion of a process has started, but has not been implemented. There is a consistent, well-defined workflow that ensures the measurement of blood pressure at every visit. 2.4 Staff trained to take accurate BP No training planned. Plans to train staff are in discussion, but have not started, or training has begun but not completed by all office staff. Training has been completed by all office staff. AMGF measure up pressure down 2.5 BP rechecks done on all patients not in BP control prior to leaving office, and documented in chart BP rechecks are not completed. BP rechecks are completed sometimes, and/or there is no defined process that includes a BP recheck Workflow includes BP rechecks for patients who are not in BP control prior to leaving office. Confirmed via chart audit documentation. 7 Simple steps to ensure ACCURATE reading 2.6 Point of Care reminders in EHR No point of care reminders. Point of care reminders in at least 50% of offices. Point of care reminders in all offices, turned on and viewed regularly. 2.7 Adopt Hypertension Algorithm No algorithm in place. Algorithm agreed upon and available, but not adopted by all providers. All providers trained in algorithm and provider use is monitored. Template from SD RCI 2.8 Intensify treatment every 2-4 weeks until goal reached No protocol in place. Protocol already developed but not used regularly by all providers. Protocol for early and frequent follow up in place to monitor and intensify hypertension management to clinical goal. Evidence of follow-up occurring. Hypertension Team Approach

Pharmacy Programs Expanding BSC Advanced Practice Pharmacist programs Collaborative Practice Agreement Template and expertise in utilizing pharmacists on care team Medication Adherence program ACO funding of Pharmacist and Pharmacy Technician positions

Lean work Utilizing BSC Green teams with Provider Organizations to evaluate supplemental data flow and opportunities for improvement Expanding program

Value add for the Partners Self Evaluation tool with resource links helps develop gap analysis and prioritization of efforts Clinical Assistance Quality expertise Pharmacy Cleaning up the data Financial outcomes – e.g. ACO partners, P4P participants

Where do We Want to Go Continue scaling work - enlisting Provider Organizations in effort Continue to refine approach based on experience with partner Provider Organizations and through participating in UBP and other venues Reach 90th percentile in RCI Metrics Eliminate preventable strokes and heart attacks

Care Worthy of our Family and Friends that is Sustainably Affordable