NW PA Data ReviewRobert A. Gabbay, MD, PhDProfessor of Medicine, Penn State College of Medicine

PCMH-A(Patient-Centered Medical Home Assessment)

• Survey designed to help systems and provide practices move toward the PCMH model• Utilized to help teams identify areas for

improvement• A sense of how PCMH like you are

PCMH-A Assessment

• On average, practices reported an increase of +1.8/12 points (15%)• The top 3 most improved categories:• Continuous Team-Based Healing Relationships

(+2.7 points)• Quality Improvement Strategy (+2.6 points)• Organized Embedded Care (+2.4 points)

(All on a scale from 1-12)

HEDIS Goals

90th Percentile of the HEDIS New England or Mid-Atlantic Benchmarks

(whichever was higher)

Steady Denominators = Good!

Baselin

e

June 2012

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0

200

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Count of DM Patients Ages 18-75NorthWest

Seneca

Warren

Oil Valley

MGC

Semeyn - Brookville

Semeyn - Fair Mount

Average

Excellent Job! Now Part of Planned Care at Every Visit

Baselin

e

June 2012

July 2012

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0%

10%

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90%

100%

% DM Patients Tobacco QueryNorthWest

Seneca

Warren

Oil Valley

MGC

Semeyn - Brookville

Semeyn - Fair Mount

Average

Goal

Mean Change in Abs %: Increased +12.0% (statistically significant)

Baselin

e

June 2012

July 2012

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October

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0%

10%

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30%

40%

50%

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80%

90%

100%

% DM Patients with Nephropathy Screening/TreatmentNorthWest

Seneca

Warren

Oil Valley

MGC

Semeyn - Brookville

Semeyn - Fair Mount

Average

Goal

Mean Change in Abs %: Increased +8.1% (statistically significant)

Baselin

e

June 2012

July 2012

August

2012

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ber 2012

October

2012

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0%

10%

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30%

40%

50%

60%

70%

80%

90%

100%

% DM Patients with Dilated Eye Exam Results DocumentedNorthWest

Seneca

Warren

Oil Valley

MGC

Semeyn - Brookville

Semeyn - Fair Mount

Average

Goal

Mean Change in Abs %: Increased +19.5% (statistically significant)

Baselin

e

June 2012

July 2012

August

2012

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ber 2012

October

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November

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ary 2013

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% DM Patients with Foot ExamNorthWest

Seneca

Warren

Oil Valley

MGC

Semeyn - Brookville

Semeyn - Fair Mount

Average

Goal

You Are Likely Doing This – How Do We Track It?

Baselin

e

June 2012

July 2012

August

2012

Septem

ber 2012

October

2012

November

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December

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January

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ary 2013

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% DM Patients with Self-Management GoalsNorthWest

Seneca

Warren

Oil Valley

MGC

Semeyn - Brookville

Semeyn - Fair Mount

Average

Goal

Improving As Processes of Care Get Implemented

Baselin

e

June 2012

July 2012

August

2012

Septem

ber 2012

October

2012

November

2012

December

2012

January

2013

Febru

ary 2013

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April 2013

0%

5%

10%

15%

20%

25%

% DM Patients with A1C>9NorthWest

Seneca

Warren

Oil Valley

MGC

Semeyn - Brookville

Semeyn - Fair Mount

Average

Goal

Practices Getting Closer To The HEDIS 90% Goal

Baselin

e

June 2012

July 2012

August

2012

Septem

ber 2012

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2012

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January

2013

Febru

ary 2013

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0%

10%

20%

30%

40%

50%

60%

70%

80%

% DM Patients with A1C <8NorthWest

Seneca

Warren

Oil Valley

MGC

Semeyn - Brookville

Semeyn - Fair Mount

Average

Goal

Many Practices Close To The HEDIS 90% Goal

Baselin

e

June 2012

July 2012

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2012

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ber 2012

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2012

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2012

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% DM Patients with BP <140/90NorthWest

Seneca

Warren

Oil Valley

MGC

Semeyn - Brookville

Semeyn - Fair Mount

Average

Goal

Getting Closer to Goal – More Work To Do

Baselin

e

June 2012

July 2012

August

2012

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ber 2012

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2012

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2012

December

2012

January

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ary 2013

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April 2013

0%

10%

20%

30%

40%

50%

60%

70%

% DM Patients with LDL <100NorthWest

Seneca

Warren

Oil Valley

MGC

Semeyn - Brookville

Semeyn - Fair Mount

Average

Goal

Great Work… But More To Do!

• All of this was accomplished WITHOUT extra money• Planned care at every visit• Reaching out to high risk• Self-management support• Working as a team• MEETING AS A TEAM

Why We Have Done This• Each A1C point drop:• Eye disease risk reduced by 76%• Kidney disease risk is reduced by 50%• Nerve disease risk is reduced by 60%• Any cardiovascular disease event risk is reduced by 42%• Stroke by 57%

• Better screening nephropathy, feet and eyes reduces ESRD, amputations, and blindness.

In your population of 4,000 diabetes patients – this is huge!