1. 3rd QCIPN Town Hall Meeting
February 4, 2015
Presenters:
Whitney Limm, MD
Daniel Fischberg, MD Ron Morton, MD
Anna Loengard, MD Lori Protzman, RN

2. Agenda 15 II. Specialty Endeavors 10 III. QCIPN Access Policy
TOPIC
TIME(minutes)
Quality and The QCIPN 15
II. Specialty Endeavors 10
III. QCIPN Access Policy
IV. Advance Health Care Directives/POLST
V. Advance Care Planning Clinic and Video
VI. Q&A 30

3. The DHH recently set a timeline for the transition to a fee-for-value reimbursement system. In two years, what percentage of payments to Medicare providers will be based purely on fee for service?
100% of total payments to providers
75% of total payments to providers
25% of total payments to providers
15% of total payments to providers

4. Categories of payment to Medicare providers and targeted percentages:
QCIPN Town Hall
Categories of payment to Medicare providers and targeted percentages:
Category 1: Fee-for-service with no link of payment to quality
Category 2: Fee-for-service with a link of payment to quality
Category 3: Alternative payment models built on fee-for-service architecture
Category 4: Population-based payment

5. ACO: Accountable Care Organization PCMH: Patient Centered Medical Home
All of the following are “Alternative payment models built on fee-for-service architecture”, except:
ACO: Accountable Care Organization
PCMH: Patient Centered Medical Home
Bundle Payment
Capitation

6. QCIPN Path to Quality Anna Loengard MD Chief Medical Officer
Queen’s Clinically Integrated Physician Network
Assistant Professor of Geriatrics
John A. Burns School of Medicine

7. Quality and QCIPN Membership
To be a member in good standing and eligible for compensation, all QCIPN Physicians must:
Support patient -centered care;
Meet high levels of care quality and safety as determined by QCIPN;
Attend at least four QCIPN educational meetings along with additional education required as defined by the Board;
Participate with the QCIPN Referral Process and Procedure;
Support the PCMH practices, recognizing their role for ensuring the coordination and integration of all care
To facilitate communication and non-PHI information sharing, each practice will have in place the following technology:
address for each Physician and provided to the QCIPN
Office Manager address provided to the QCIPN
High speed internet access
Software capable of opening Microsoft and PDF documents

8. Quality and The Clinically Integrated Network
Quality is the foundation upon which a clinically integrated system is built
Federal Trade Commission:
“Clinical integration is a term used to describe certain types of collaborations among otherwise independent health care providers to improve quality and contain costs.”
“Under the program, physicians will be subject to a variety of requirements regarding their performance, including adherence to clinical practice guidelines being developed”
Reply to Tristate Health Partners
This is an unprecedented opportunity to decide what represents best quality/practice rather than have it dictated by CMS or a payer

9. Strive for the best outcomes for our patients
Quality and Our Patients
Strive for the best outcomes for our patients
Board retreat found “quality” and “making a difference” are top reasons for investing in the QCIPN
Increasing transparency when choosing care
Don’t know what the road map looks like to get to this goal. QCIPN here to support.

10. Changing reimbursement mechanisms
Quality
and Payment Reform
Changing reimbursement mechanisms
HHS announced plan for 85% of all Medicare payments to have a quality component by the end of 2016
Also announced 50% of current FFS to value or quality based payments by end of 2018
HMSA and other commercial insurers also tying increases in payment to quality performance
Don’t know what the road map looks like to get to this goal. Major role for QCIPN his to help you be ready for these changes.

11. HHS Announcement
“Many health care providers today receive a payment for each individual service, such as a physician visit, surgery, or blood test, and it does not matter whether these services help – or harm – the patient. In other words, providers are paid based on the volume of care, rather than the value of care provided to patients.” 
Increasingly responsible to demonstrate benefit to patient through improved outcomes
US Department of Health and Human Services
News Release
January 26, 2015

12.                                   
HHS Announcement
“Today’s announcement would continue the shift toward paying providers for what works – whether it is something as complex as preventing or treating disease, or something as straightforward as making sure a patient has time to ask questions.”
CMS has announced these goals but have not given a road map for how we get from here to there. The QCIPN is here to support our physicians as reimbursements change. We need to be sure we are building a system that will be able to demonstrate the desired outcomes.
US Department of Health and Human Services
News Release
January 26, 2015

13. What is Quality?
The World Health Organization (WHO) and the Institute of Medicine (IOM) define quality similarly:
Safe
Effective
Patient centered
Efficient
Timely
Equitable

14. What is Value?
Value = QUALITY COST

15. Dr. Brent James has led extensive research on health care quality
Intermountain Institute for Healthcare Delivery Research
Dr. Brent James has led extensive research on health care quality
Has studied and designed QI pathways for disease entities and procedures across the healthcare continuum
Has worked with HPH leadership for some years to develop quality program

16. Dr. James and Intermountain have found that:
Intermountain Research
Dr. James and Intermountain have found that:
Most processes in medicine involve great variation
That this leads to:
Decreases Quality
Decreases efficiency
Increases Cost
Focusing on increasing quality outcomes, with few exceptions, will decrease cost
Variation in treatment choices; LOS in hospital, total cost of care, outcomes etc

17. QI Example #1
Intermountain ARDS protocol
Developed a best practice protocol for ARDS patients for ventilator management
Looked at all possible parameters and made recommendations on management
Based on literature available and expert consensus
Protocol was many pages long
James, B. HEALTH AFFAIRS
NO. 6 ( June 2011)

18. When ARDS patients were managed by this protocol:
ARDS Protocol
When ARDS patients were managed by this protocol:
Physicians spent less time managing vent settings
Care was better coordinated (transfer among MDs easier)
Patients left the ICU faster
Protocol followed 24 hours a day
James, B. HEALTH AFFAIRS
NO. 6 ( June 2011)

19. The study ARDS patients showed:
ARDS Protocol
The study ARDS patients showed:
Survival increased from 9.5 to 44%
Saved $120,000 on average/patient
James, B. HEALTH AFFAIRS
NO. 6 ( June 2011)

21. Elective Induction Protocol
QI Example #2
Elective Induction Protocol
In 2001 the pregnancy, labor and delivery leadership dyad focused on induction of labor
Implemented a system whereby the L&D nurses were not allowed to admit a patient who did not fit ACOG criteria without approval of dept chair
Induction without strong clinical indications fell from 28% to less than 2% of total inductions
Total labor time (across 32,000 deliveries) decreased by thirty one days
Now able to deliver 1500 additional babies with no additional beds or staffing
Oshiro B.Obstet Gynecol 2009;113:804–11

22. Elective Induction Protocol
Table 2. Selected Maternal and Neonatal Outcome Data: Before and After Initiation of the Program
(1999–2000 and July 2001 to June 2006)
1999–2000 July 2001 to June 2006 OR 95% CI
Preeclampsia
Postpartum anemia –0.97
Chorioamnionitis –1.24
Endometritis –1.67
Cesarean delivery due to fetal distress –0.92
Meconium aspiration –0.66
1-min Apgar score less than 5
Macrosomia
Stillbirth –0.98
Respiratory distress syndrome –1.13
Ventilator use
Oshiro B.Obstet Gynecol 2009;113:804–11

23. Elective Induction Protocol
Table 2. Selected Maternal and Neonatal Outcome Data: Before and After Initiation of the Program
Outcome:
Rate
Rate
OR(95% CI)
Preeclampsia
0.57
0.83
1.43 (1.18–1.71)
C-section due to fetal distress
0.11
0.06
0.57(0.35–0.92)
Postpartum Anemia
1.58
0.46
0.86 (0.77–0.97)
Still Birth
0.09
0.03
0.59 (0.36–0.98)
Macrosomia
10.9
10.6
0.97 (0.93–1.02)
Ventilator Use
0.42
0.44
1.06 (0.85–1.32)
1 min Apgar < 5
2.99
2.40
0.80 (0.73–0.87)
Oshiro B.Obstet Gynecol 2009;113:804–11

24. Hawaii Surgical Site Infections
QI Example #3
Hawaii Surgical Site Infections
Baseline data :
COLORECT Mortality : 7 observed events and 116 total cases—6%
COLORECT Morbidity : 29 observed events and 116 total cases—25%
COLORECT SSI : 17 observed events and 116 total cases—15%
COLORECT ROR : 12 observed events and 116 total cases--10%

25. Colorectal Surgery data 2011-12

26. Pre-Op Intra-Op Post-Op
SUSP: CUSP for Safe Surgery Comprehensive Unit-Based Safety Program
Pre-Op
APEC evaluation
Mechanical and antibiotic preparation
Chlorhexidine shower and prep
SCIP IV AB protocol
Intra-Op
Clipping
Antibiotic re-dosing
Separate closing tray
Traffic control
Post-Op
Silver-impregnated dressing
Hyperglycemia protocol
Standardize dressing change
Patient education
Appreciation to Dr. Della Lin for leading this statewide initiative
"No coach has ever won a game by what he knows; it's what his players know that counts."   Paul "Bear" Bryant 

27. Statewide Colorectal SSI Rate Trending Downwards 29%
90% of hospitals reported to 3/2014
20% of hospitals reported to 6/2014
SUSP Project Start 11/27/2012, NHSN data as of 8/2014

28. WHERE DO WE START?

29. Deeper analysis of our population to target efforts Define Targets
Where Do We Start?
Building a quality program to support new community-based clinical network will take time
Deeper analysis of our population to target efforts
Define Targets
high prevalence, high risk, high cost conditions

30. Where Do We Start?
Development/Acceptance Across Network of Clinical Best Practice
IT/data collection resources
Use systems in place to collect data
Build our capacity to demonstrate better outcomes
Look to existing evidence base
Choosing Wisely

31. Quality of the Evidence
I. At least one randomized controlled trial (RCT) II-1. Controlled trails without randomization (quasi-
experimental designs
Cohort or case-control studies
Multiple time series (observational studies) or dramatic results
Agreement among a respected group of
authorities using formal consensus methods
IV. Personal anecdote (“in my experience”)
II-2.
II-3.
III.
Lawrence RS, Mickalide AD. Preventive services in clinical practice: designing the periodic health examination. JAMA 1987; 257:

32. Where Do We Start?
We know that < 20% of what we do has Level I evidence
For majority of patients, we need to agree that expert consensus is better than individual opinion
Need specialists from all fields to help us define quality
Particularly where high level evidence lacking
Determine how our inpatient and outpatient quality efforts are synergistic
Using best practice pathways is a requirement for clinical integration

33. Specialty Endeavors Anna Loengard MD Chief Medical Officer
Queen’s Clinically Integrated Physician Network
Assistant Professor of Geriatrics
John A. Burns School of Medicine

34. QCIPN Membership and Quality
To be a member in good standing and eligible for compensation, all QCIPN Physicians must:
Support patient -centered care;
Meet high levels of care quality and safety as determined by QCIPN;
Attend at least four QCIPN educational meetings along with additional education required as defined by the Board;
Participate with the QCIPN Referral Process and Procedure;
Support the PCMH practices, recognizing their role for ensuring the coordination and integration of all care
To facilitate communication and non-PHI information sharing, each practice will have in place the following technology:
address for each Physician and provided to the QCIPN
Office Manager address provided to the QCIPN
High speed internet access
Software capable of opening Microsoft and PDF documents

35. Join and/or lead a Specialty Specific Endeavor
Role of the Specialists
How can QCIPN Specialists engage and meet the requirements below?
Meet high levels of care quality and safety as determined by QCIPN;
Participate with the QCIPN Referral Process and Procedure;
Support the PCMH practices, recognizing their role for ensuring the coordination and integration of all care
Join and/or lead a Specialty Specific Endeavor

36. What is the purpose of Specialty Endeavors?
Engage QCIPN Specialists in process and performance improvements related to Quality, Cost and Patient experience (Triple Aim)
Identify and standardize high volume, high cost, high variation specialty care
Collaborate with Primary Care Physicians to achieve current/future year HMSA process and performance metrics
How will it work?
The nature of each Specialty Endeavor will vary based on the relevant clinical condition and QCIPN needs
Specialists will join and participate in activities that support the triple aim
The QCIPN Finance Committee/Board will approve the budget for each endeavor to compensate Specialists for their participation, collaboration, and efforts
IN plainer language – specialty endeavors give CIPN physicians, who care for similar patients, the chance to agree on and define quality for this community.
We can help to define where the greatest needs are and bring ideas to specialists
There may be some of you who already have ideas and we would like to support you
We need champions we can support to get this work done. We don’t expect you to do this on your own

37. Specialty Endeavor Compensation
ACTION
DELIVERABLE
APPROVAL BODY
RANGE OF HOURS
COMPENSATION
Endeavor Chair
Agendas, Presentations, Documents
Administration
15 to 25
$2,500
Endeavor Meetings
Attendance Records and Minutes
TBD
$125/hr
Clinical Guidelines Development
Document/s
Quality Committee
12 to 20
$2,000
Metric Development
Metric definition, Data requirements and source
2 to 6
$500
Provider Education Development
Presentation, Documents, PowerPoint
Provider Education Facilitation and/or Completion
Document/s and PowerPoint
PO Medical Directors and Administration
Proforma and/or Budget Development
Document/s and Spreadsheet
Board and Administration
Program Implementation Plan
Documents and Process Description
Program Implementation
Meetings, presentations, staff education, mentoring, monitoring, etc
Metric Completion and/or Performance
Outcomes and results on predefined metrics
$500 - $5000
This is an a la carte menu, which includes various activities, deliverables, and outcomes to base compensation on
It is available in the Physician Compensation Policy

38. ESTIMATED Total Budget
Example of Specialty Endeavor
Endeavor: Referral Management System Pilot
Purpose: To Participate in System Testing, Feedback and Optimization
Compensation: All or None
ACTION
COMPENSATION
PARTICIPANTS
ESTIMATED HOURS
ESTIMATED Total Budget
Sign and Submit Data Sharing Agreement
$125 10 4
Complete All Forms and Steps Required for Setup 3
Complete Training for Community Health Record 2
Complete Training for Referral Management 1
Participate in Pilot System Testing and Provide
Feedback 5
COMPLETION OF ALL ACTIONS 15
$18,750

39. Example of Specialty Endeavor
Endeavor: PE Imaging Policy Implementation
Purpose: To reduce the number of CTA’s done in low-risk patients
Compensation: Varies for team members
ACTION
COMPENSATION
PARTICIPANTS
ESTIMATED HOURS
ESTIMATED PAYMENT
Chair
$2500 1
Participate in planning/evaluation meetings
$125/hr 6
$4500
Provide education for front line physicians 4 3
$1500
Data collection and Interpretation 2
$1000
Front line physicians participate in education 30
$3750
Total Budget Needed:
$13,250

40. Patient Access Standards & Decreasing Inappropriate ED Utilization
Ronald Morton, MD
Chief, Department of Medicine

41. Metric Review: Patient Access Standards
Develop/define access standards (i.e. extended/ weekend hours, mid-level integration, office based triage, same day availability)
Achieve a lower than baseline emergency department utilization rate
Achieve improvement on CAHPS survey access questions (baseline collected in November 2014, next survey April 2015)

42. CAHPS Survey Questions
Patient Access Standards
CAHPS Survey Questions
How many days did you usually have to wait for an appointment when you needed care right away?
How long did it take to get an appointment for regular or routine care?
When you phoned the provider’s office, how long did it take for someone to call you back?

43. CAHPS Survey Questions
Patient Access Standards
CAHPS Survey Questions
Access: appointment availability AND answers to phone questions
Timeliness: saw provider within 15 minutes of appointment time
Information: about what to do if you need care on evenings, weekends or holidays.
Reminders: between visits

44. Patient Access Standards
What do I need to do?:
Maintain open slots to address patient panel urgent care needs.
Maintain triage procedures and staff to appropriately determine patients who should be seen in the office and those who should be seen in other settings.
Appropriate referral to Urgent Care Clinics or the Emergency Room for emergent type cases.  

45. Patient Education Materials
Patient Access Standards
Patient Education Materials
Statement from the practice regarding access to care
Availability of same day appointments for urgent issues
Policy regarding after hours care including weekends and holidays
Appropriate use of electronic communication

46. After Hours Phone Message
Patient Access Standards
After Hours Phone Message
How to reach provider
Referral to preferred Urgent Care Center
The message should not state that the office is closed and refer patients to the Emergency Room without first providing the above information.

47. General Access to Care Standards:
Patient Access Standards
General Access to Care Standards:
Primary Care visit available
Urgent Care – same day up to 24 hours
Routine Care – patients should be seen in a timely fashion based on their clinical situation
Specialty Care
At any time that a physician feels a patient needs to be seen urgently, a direct physician to physician communication should ensue
Urgent Consultation – within a week
Non-urgent – 4 weeks
It is expected that a consult note be returned to the PCP in a timely fashion (48 hours is recommended)

48. Patient Access Standards
Transitional Care
Patients should be seen by PCP in a timely manner following discharge
Discharging facility will provide patient discharge regarding PCP follow up

49. Advance Care Planning Documents: Advance Healthcare Directives and POLST
Daniel Fischberg, MD, PhD, FAAHPM
Medical Director, Pain & Palliative Care Department
Professor and Chief, Division of Palliative Medicine
Department of Geriatric Medicine, John A. Burns School of Medicine
University of Hawaii
Welcome
....

51. A process of preparing for future health decisions
Advance Care Planning (ACP)
A process of preparing for future health decisions
Outcomes of the process may include
Selection of a decision-maker (agent or surrogate)
Reflection on priorities for care in case of advanced illness
Completion of documents: Advance Healthcare Directive and, if appropriate, a POLST form

52. Advance Healthcare Directive
Names a healthcare agent (+/- alternate)
Provides guidance for advanced illness
Prolong/Not prolong life?
Artificial nutrition/hydration?
Pain relief if risk of shortened life?
Requires witnesses or notary

53. Regarding Provider Orders for Life- Sustaining (POLST)-which ONE is NOT accurate?
Distills advance directives into valid provider orders
Appoints the healthcare agent
Guides treatment decisions in the emergency department
Guides actions by emergency medical personnel

54. POLST: The “Now” Directive
Provider orders for life-sustaining treatments
Distills ACP process into a medical order to guide first responders
Fast becoming the national standard to document out of hospital DNAR
In general, for patients that desire some limitation of their care now

56. Attempt Resuscitation Do Not Attempt Resuscitation / DNR
Must select Full Treatment in section B
Do Not Attempt Resuscitation / DNR
Allow Natural Death
Section in effect when no pulse or respirations

57. Limited Interventions: Full Treatment:
Comfort Measures Only
“Keep me comfortable. Let me stay home”
Limited Interventions:
“Hospital if I need, but I don’t want ICU”
Full Treatment:
“Hospital if I need. ICU is OK!”

60. For which patient would POLST generally NOT be appropriate?
Terminally ill
35 year old with stage IIB breast cancer
Chronically ill person with progressive debilitating disease
A patient for whom you would issue an inpatient DNAR order

61. Who Needs POLST? Chronic, progressive illness Serious health condition
Medically frail
Consider the “surprise question”:
“Would you be surprised if this patient died within the next year?”

62. Advance Care Planning Continuum
Where Does POLST Fit In?
Advance Care Planning Continuum
Age 18
Complete an Advance Directive C O N V E R S A T I
Update Advance Directive Periodically
Diagnosed with Serious or Chronic, Progressive Illness (at any age)
Complete a POLST Form
End-of-Life Wishes Honored

63. POLST AHCD For seriously ill/frail, at any age
POLST vs. Advance Healthcare Directive
POLST
AHCD
For seriously ill/frail, at any age
For everyone 18 and older
Specific orders for current treatment
General instructions for future treatment
Can be signed by decision-maker
Appoints decision-maker
POLST:
Though anyone can have a POLST form, it is designed for those who are seriously ill or very frail – at any age.
Is a medical order that documents wishes for treatment at this point in time; usually completed in a medical setting.
Can be signed by the patient’s decisionmaker if the patient lacks decision-making capacity; can also be completed by the patient’s decisionmaker in consultation with the patient’s physician.
There is one, standard form for California.
Advance Healthcare Directive:
Encourage everyone 18 years and older to have an AHCD.
Is a legal document completed in advance that allows you to:
make general statements about your healthcare wishes in the future, and
appoint a healthcare decisionmaker to speak on your behalf.
There is no universal AHCD form.

64. Advance Care Planning Clinic - A support resource
Lori Protzman, RN
ACP Coordinator
office fax

65. Screen patients for appropriate ACP clinic Introduce the ACP topic and
Referral
Screen patients for appropriate
ACP clinic
Introduce the ACP topic and
clinic
Fax referral form to ACP Clinic
Schedule a follow-up visit

66. ACP Clinic
Provide patient/family education on ACP
ACP decisions videos
Go Wish Cards
Help complete appropriate ACP
documents (e.g. AHCD and/or POLST)

67. ACP Clinic
Communicate outcome back to provider
Perform phone follow-up with patient
Track outcome measurements for
appropriate ACP clinic referral

68. Goals Of Care For Advanced Disease
ACP Video
Goals Of Care For Advanced Disease
ACP Decisions Video
Dr. Elizabeth Tam

70. Closing & Questions
Contact Information:
General Inquiries:
Whitney Limm, MD:
Anna Loengard, MD:
Amita Goyal: