1. PA SPREAD Webinar #3 Robe rt Gabbay MD, PhD Penn State College of Medicine

2. Pre-Work Learning Objectives 1.Understand the concept of empanelment and develop a plan to organize patients into provider panels. 2.Develop an aim statement for what and how much you want to improve over the next year. 3.Understand the clinical guidelines and related measures for diabetes. 4.Collect baseline data on the number of diabetes patients in your practice and the number of patients meeting evidence-based diabetes measures. Webinar #1 Webinar #2

3. List of 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 BEFORE your first learning session  Participate in the 3 pre-work webinars  RSVP attendees for Learning Session #1

4. Any Questions? Writing your aim statement? Forming your team? Identifying a provider champion? Understanding the measure specifications? Collecting your baseline data? Organizing provider panels? Completing the PCMH-A? Submitting your baseline report? Attending the first learning session? Contact your practice coach or email paspread@hmc.psu.edu. paspread@hmc.psu.edu

5. Going Forward- the BIG PICTURE 4 in-person evening Learning Sessions May/June August/September Facilitator visits in each Action Period Call or email Patty Stubber (NW) or Sharon Adams (SC) any time! Monthly webinars Monthly status reports: data and brief written update Generally due on the 5 th of the month. Will get feedback from practice facilitators and data benchmarking reports from PA AHEC. Sharing and networking! Practice description/photos for www.paspread.com under password protected “Participating Practices” section.www.paspread.com Resources to share on www.paspread.com.www.paspread.com January 2013 May 2013

6. IMPLEMENTING THE MODELS TO IMPROVE PATIENT CARE PCMH, Chronic Care, PDSAs

7. Driving Force = 2001 IOM Report “Health care harms patients too frequently and routinely fails to deliver its potential benefits. Indeed, between the health care that we now have and the health care that we could have lies not just a gap, but a chasm.” ­­~ Institute of Medicine Source: http://www.iom.edu/Reports/2001/Crossing-the-Quality-Chasm-A-New-Health- System-for-the-21st-Century.aspx

8. Operationalizing the Medical Home Chronic Care Model (or more generally “The Care Model”) NCQA PCMH 2011 Standards

9. Source: http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2

10. Essential Elements of Good Patient Care Source: http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2

11. Informed, Activated Patient Patient understands the disease process, and realizes his/her role as the daily self manager. Family and caregivers are engaged in the patient’s self-management. The provider is viewed as a partner, guide. Source: http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2

12. Prepared, Proactive Practice Team At the time of each visit, the team has the information, decision support, people, equipment, and time required to deliver evidence-based care, filling any gaps in care, and to support patients and their families in ongoing self-care. Source: http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2

13. How would I recognize a “productive interaction?” Includes an assessment of self-management skills and confidence as well as clinical status. Collaborative goal-setting and problem-solving resulting in a shared care plan. Active, sustained follow-up. Tailoring of clinical management by stepped protocol. Source: http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2

14. How Do We Get There? By testing changes in these 6 components of the Chronic Care Model. Source: http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2

15. Clinical Information Systems Patient registry functionality in your EMR. Identify patient subpopulations for proactive outreach (not seen in 6 months, medication recall, uncontrolled). Capture lab and other info in structured data fields that can be queried for patient care and measurement. Prepare for visits and provide reminders/status reports for patients and care team. Use templates to organize patient visits. Monitor/measure performance. Source: http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2

16. Decision Support Use evidence-based guidelines to proactively assess patient risk at each visit. Provide stepped care based on the needs of patients (closer follow-up, care management). Activate patients by sharing guidelines (report cards or progress reports) with them. Consult with specialists and integrate their expertise into primary care. Source: http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2

17. Delivery System Design Define roles and delegate tasks across care TEAM using standing orders. Provide care most effectively and efficiently (e.g., group visits, e-visits, care mgmt, phone). Track and document referrals and labs. Schedule visits to assure continuity of care. Provide patient-centered care (interpreters, visits that accommodate special needs, etc.). Source: http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2

18. Self-Management Support Not just education but SUPPORT! Emphasize patients’ central role in managing their wellness/illness. Negotiate self-care behavior change goals with patients. Provide effective behavior change interventions and ongoing support with peers or professionals. Source: http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2

19. Community Resources Identify effective wellness and disease management programs and encourage patients to participate in them (e.g., hospital programs, Weight Watchers, walking clubs). Form partnerships with community organizations to support or develop programs (e.g., housing, transportation, food). Advocate for policies to improve care. Source: http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2

20. Health Care Organization Practice/System leaders visibly support quality improvement and include measurable goals in the strategic/business plan. Align incentives (salary increases, performance reviews) to encourage care coordination, team care, quality improvement. Partner with hospitals, health plans, specialists, pharmacies, nursing homes, etc. to coordinate care, share information. Source: http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2

21. NCQA’S OPERATIONAL DEFINITION OF THE MEDICAL HOME NCQA PCMH 2011 Standards, Elements

22. NCQA PCMH 2011 PCMH 1: Enhance Access and Continuity PCMH 2: Identify and Manage Patient Populations PCMH 3: Plan and Manage Care PCMH 4: Provide Self-Care Support and Community Resources PCMH 5: Track and Coordinate Care PCMH 6: Measure and Improve Performance

23. Review of NCQA Standards One “MUST PASS” element in each standard is noted (6 total). “MUST PASS” elements are considered the basic building blocks of a Medical Home. Practices must earn a score of 50% or higher on each of the 6 “MUST PASS” elements. Slides note the key factors in each element that we will address. Some are noted as “critical factors” that must be met for NCQA scoring. NCQA aligns well with Meaningful Use.

24. PCMH 1: Access, Continuity Element A: Access During Office Hours (MUST PASS) Same day appointments (Critical Factor) Timely telephone follow-up Good documentation Element B: After-Hours Access Sharing of clinical information Element C: Electronic Access Visit summaries to patients Web portal or secure email system for Rx refill requests and referral/test results

25. PCMH 1: Access, Continuity Element D: Continuity Patients choose personal clinician Documentation of patient choice Monitor percentage of visits with selected clinician Element E: Medical Home Responsibilities Tell patients about obligations of the medical home and responsibilities of patients/families as partners in care Element F: Culturally and Linguistically Appropriate Services

26. PCMH 1: Access, Continuity Element G: The Practice Team (team-based care) Care teams with defined roles and responsibilities for each team member Regular team meetings, communications (Critical Factor) Use of standing orders Training for team members on care coordination, self-management support, population management, communication skills Team members involved in quality improvement

27. PCMH 2: Population Mgmt. Element A: Patient Information Record name, gender, race, ethnicity, language, contact info, dates of visits, legal guardian/proxy, primary caregiver, advance directives, and health insurance information for each patient Element B: Clinical Data Up-to-date problem and medication lists Documentation of allergies Blood pressure, height, weight, BMI, tobacco use

28. PCMH 2: Population Mgmt. Element C: Comprehensive Health Assessment Age-related immunizations, screenings Family, social, cultural, communications, medical history, behavioral, mental health issues Depression screening Element D: Use Data for Population Mgmt. (MUST PASS) Use of patient information, clinical data, evidence- based guidelines to generate patient lists and proactively remind patients/families and clinicians of needed services.

29. PCMH 3: Plan and Manage Care Element A: Implement Evidence-Based Guidelines Point-of-care reminders At least one condition must be related to unhealthy behaviors (smoking, obesity), substance abuse, or mental health issue (Critical Factor) Element B: Identify High-Risk Patients Develop criteria for high-risk patients and process to identify them Determine percentage of high-risk/complex patients in your practice

30. PCMH 3: Plan and Manage Care Element C: Care Management (MUST PASS) Pre-visit planning Develop individualized care plans in collaboration with patients and review/update them each visit Give patients written plan of care and clinical summary at each visit Assess and address barriers when treatment goals are not met Identify patients needing more support Follow up with patients who miss visits

31. PCMH 3: Plan and Manage Care Element D: Medication Management Review, reconcile meds during care transitions Provide info on new prescriptions Assess understanding of meds, response to meds, and barriers to adherence Document over-the-counter meds, supplements Element E: Use E-Prescribing

32. PCMH 4: Self-Care Support and Community Resources Element A: Support Self-Care Processes (MUST PASS) Education resources to assist in self-management Develop, document collaboratively set self- management goals Document self-care abilities Provide tools for patients to record self-care results Counsel patients to adopt healthy behaviors

33. PCMH 4: Self-Care Support and Community Resources Element B: Provide Referrals to Community Resources Current resource lists Track referral Arrange or provide treatment for mental health, substance abuse Offer health education programs (group classes, peer support)

34. PCMH 5: Track, Coordinate Care Element A: Test Tracking and Follow-up Track lab/imaging orders until receive results, flag and follow up on overdue results (Critical Factor) Flag abnormal results and make clinician aware Notify patients of normal and abnormal results Electronically order and receive results Record results electronically structured data

35. PCMH 5: Track, Coordinate Care Element B: Referral Tracking and Follow-up (MUST PASS) Give consultant/specialist clinical reason for referral and pertinent information (electronically) Track referrals and follow up to obtain results Establish, document co-management agreements

36. PCMH 5: Track, Coordinate Care Element C: Coordinate with Facilities and Manage Care Transitions Identify patients with hospital admission, ED visit Share clinical info with hospitals, EDs (electronically) Obtain discharge summaries Follow up with patients after discharge

37. PCMH 6: Measure and Improve Performance Element A: Measure Performance Document the measurement period, number of patients represented by the data (at least 75% of eligible population), and patient selection process. Element B: Measure Patient Experience Survey experience related to access, communication, coordination, whole-person care/ self-management support PCMH version of the CAHPS Clinician Group survey Experience of vulnerable groups Qualitative feedback

38. PCMH 6: Measure and Improve Performance Element C: Implement Continuous Quality Improvement (MUST PASS) Set goals and act to improve performance One measure related to disparity in care or for vulnerable populations Involve patients in QI team or advisory council. Element D: Demonstrate Continuous Quality Improvement Track results over time Assess the effect of your actions Improve performance on 1-2 measures

39. PCMH 6: Measure and Improve Performance Element E: Report Performance Within the practice by individual clinician and across the practice Outside the practice to patients or publicly Element F: Report Data Externally To CMS or state To other external entities

40. RAPID CYCLE TESTING OF CHANGES OK… So what do we do now?

41. Improvement Model Write your aim statement What you want to improve, by how much, by when, and generally how you will do it. Use the diabetes measures to know when a change is an improvement. Think of things you can try to change (the tests you will Plan, Do, Study, and Act on).

42. Deciding Which Tests to Try Components of the Chronic Care Model. NCQA PCMH Standards/Elements Areas for improvement in your data. Foundational elements we’d like you to work on. Critical Changes Integrated in Diabetes Population ManagementDate Accomplished Population alert (to visually ID records of all diabetes patients) Use of template/flowsheet with embedded clinical guidelines Use of standing orders for team members Providing planned care at every visit Use of patient report card/progress report Patients setting self-management goals Risk assessment at every visit Follow-up care for high-risk patients (At the bottom of Page 1 of the Monthly Status Report template.)

43. Critical Changes to Make 1.Population alert 2.Use of flow sheet/template embedded with clinical guidelines 3.Standing orders 4.Planned care at every visit 5.Patient report card/progress report 6.Patients setting self-management goals 7.Risk assessment at every visit 8.Follow-up care for high-risk patients Initial Focus

44. Critical Changes to Make Population alert Flag/color/icon to readily see diabetes patients in medical records when they call or visit office (without having to look in problem list). Goal = take advantage of every opportunity you have to provide evidence-based care. Improves patient safety when making medication decisions.

45. Critical Changes to Make Use of flow sheet/template with embedded clinical guidelines Prompts (flags/colors) to identify when services are due/overdue. Prompts (flags/colors) to identify when labs, vitals are out of evidence-based range. Tracking of information in structured data fields that can be queried.

46. Critical Changes to Make Standing orders Grant permission for staff to order, provide, document needed services. Delegate tasks across team. For blood tests, urine test, foot exam, eye exam referral/tracking, blood pressure measurement, height/weight/BMI, tobacco query and counsel, self-management support, etc. Improve efficiency, save provider time.

47. Critical Changes to Make Planned care at every visit Proactive approach to care. Fill any gaps in care, keep current with guidelines at every visit—even sick visits when feasible. Schedule follow-up care for any services still needed or for closer monitoring. Pre-visit planning to ensure all needed info (lab results, referral reports) is available at the visit. Pre-visit lab work, so medication decisions can be made at visits.

48. Other Changes to Test Your biggest frustrations—processes that don’t work well in your office (e.g., test/referral tracking, Rx refills, processing patient forms, scheduling, phone calls, billing). Things that patients have complained about.

49. There’s Value in Knowing How to Make Changes One SE PA practice identified adoption of the PDSA process as its most important lesson learned in Year 1 of its collaborative. Was impetus/focus for weekly meetings. Allowed smooth transitions to new protocols. Gave them “permission” to take chances and try new things. Strengthened their concept of team.

50. How to Test: Plan Step 1: Plan the test State the objective of the test: What are you trying to change? Predict what will happen and why. Develop a plan to test the change (who will do it, what they will do, when they will do it, where they will do it, how they will do it). Identify other data that will be useful (patient feedback, how much time the change added or saved, how it worked for staff). Think ahead what subsequent tests might be.

51. Example of a Plan We will create a new diabetes flow sheet to help us identify gaps in care so we can provide all needed services. Laura will create the new flow sheet in our EMR by Thursday Dr. Gabbay and Erin (his nurse) will use it with the 3 diabetes patients that are scheduled on Friday morning. We expect to be able to meet all of the patients’ unmet needs by using the new flow sheet. We will probably need to revise the flow sheet after we test it.

52. How to Test: Do Step 2: Do the test Try out the test on a small scale: 2 patients, 1 doctor, 1 shift, 1 hour Pick willing volunteers to do. Collect data (time, feedback, etc.)—even on paper. Document problems, unexpected observations.

53. How to Test: Study Step 3: Study results Analyze collected data. Compare the data to your predictions. Summarize and reflect on what was learned (de-brief): What did we expect to happen? What did happen? Were there any unintended consequences? What was the best/worst thing about this change? What might we do next?

54. Studying the Example Laura completed the flow sheet on time and Dr. Gabbay and Erin tested it with the 3 patients as planned. The flow sheet accurately identified the gaps in care for all 3 patients, and Dr. Gabbay and Erin found it helpful, but said it was hard to use because they kept having to go to different screens in the EMR to document other parts of the visit. They were not able to provide all the needed services for 2 of the 3 patients. Dr. Gabbay didn’t have time to do the foot exam on 2 of the patients. They also missed documenting the tobacco query for 1 of the patients.

55. How to Test: Act Step 4: Act on what was learned Determine what modifications are needed. Or decide to try something else. Prepare a plan for the next test: keep the ball rolling! The faster you test, the faster you learn, the faster you change.

56. Acting on the Example Plans for next PDSAs: Laura will integrate the flow sheet into the visit template to facilitate documentation. Laura will revise the flow sheet to make the tobacco query a “must complete” data field so it cannot be missed. Dr. Gabbay will train Erin how to do the foot exams.

57. More on PDSAs to Come! Key topic at first learning session. Focus now on writing your aim statement and collecting your baseline information (PCMH-A and diabetes data). Please submit both your PCMH-A and baseline diabetes data BEFORE your first learning session to paspread@hmc.psu.edu.paspread@hmc.psu.edu

58. WE’RE HERE TO HELP YOU Practice Facilitators

59. 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 Web: www.paspread.comwww.paspread.com Email: paspread@hmc.psu.edupaspread@hmc.psu.edu

60. LEARNING SESSION #1 Plan to Attend!

61. First Learning Sessions NW Learning Session #1: May 23, 5-9pm at PSU Behrend Campus, Erie SC Learning Session #1 (two options): May 22, 5-9pm at Hershey Medical Center Conference Center (West Campus) OR June 7, 5-9pm at PSU Altoona Campus

62. Tentative Agenda Welcome and Introductions “Planned Care at Every Visit” “Process Redesign for Efficiency” “Clinical Diabetes Management” “Review of Aim Statements” “More on PDSAs” Plan your initial PDSAs Sharing of PDSA plans Next steps and send off

63. Who Should Definitely Attend? Provider champion Other members of practice improvement team Any system leaders (IT, administrators, etc.) Please RSVP attendees and meal selections to paspread@hmc.psu.edu ASAP. paspread@hmc.psu.edu

64. List of 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 BEFORE your first learning session  Participate in the 3 pre-work webinars  RSVP attendees for Learning Session #1