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Session 209 // February 22, 2017
Amy Mechley, MD, Former Medical Director – CPCI and Wellness
Sandra Selman, Director of Care Management
The Role of Technology in Transitioning to a New Care Model
Page 2
Introductions
Amy Mechley, MDFormer Medical Director, CPCI & Wellness The Christ Hospital Health NetworkPrincipal, PYA Consultants
Sandra Selman, RN, WWDirector of Care Management The Christ Hospital Health Network
Page 3
Conflict of Interest
Amy Mechley, MDHas no real or apparent conflicts of interest to report
Sandra SelmanHas no real or apparent conflicts of interest to report
Page 4
Agenda Trigger for change: Where and why we
innovated, local, regional, national impetus
“What is it going to take to get us from here to there?”
Technology served as a pillar, but a bridge was required
Lessons learned and critical success factors for care model transformation initiatives
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Learning Objectives Identify best practices for overcoming EHR integration
challenges and implementing technologies to meet the needs of an organization embarking on a new care model
Discuss learnings through a real-world case study from an advanced comprehensive primary care organization for transitioning to a Patient Centered Medical Home (PCMH) approach to healthcare delivery
Discuss how technological solutions can better facilitate team-based care, resulting in higher clinical quality measures, fewer gaps in care, and increased revenue
Share how data and technology solutions can be customized to accomplish specific organizational goals
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STEPS:™ Satisfaction, Treatment, Electronic, Patient & Population, Savings
Patient experience and provider satisfaction demonstrably improved
Team-based care model (PCMH), significantly outperformed peers in closing treatment gaps
Integrated population health management IT platform with certified EHR technology
Improved key quality performance measures, exceeded advanced primary care benchmarks
Increased Medicare revenue, decreased hospital admissions and readmissions
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Transformation through Patient-Centered Medical Home (PCMH) & the Comprehensive Primary Care Initiative (CPCI)
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The Christ Hospital Health Network
Integrated delivery system based in Cincinnati, OH with a 555-bed acute care hospital, 41 primary care locations, and 100+ ambulatory sites
Recognized national leader in clinical excellence and patient experience
Focused on improving the health of the TCH community and creating patient value by providing exceptional outcomes, affordable care, and the finest experiences
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Do you know about the Comprehensive Primary Care Initiative (CPCI)?
1. Yes, very familiar2. Yes, aware of it, but I do not know any details3. No, happily not a clue…
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2013: CPCI• 2,188 participating providers,
7 regions across the U.S.
• Approximately 2.7M patients
• 38 payers, both public and private
What did we get ourselves into?
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The Evolution of Primary Care
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…the patient-doctor visit is no longer the primary commodity.
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CPCI Core Functions
• Identify patients with chronic conditions and more robust healthcare needs. Deliver intensive care management for patients with high needs.
Risk-Stratified Care Management
•Ensure patients and providers can access patient data tools 24/7 for real-time, patient information necessary to continually provide the highest levels of coordinated care.Access & Continuity
•Proactively manage patients to determine their needs and provide timely preventive care services.
Planned Care for Chronic Conditions & Preventive
Care•Actively engage patients and families in goal setting and decision making to increase patient buy-in and adherence to care plans.
Patient & Caregiver Engagement
•Primary care teams will coordinate with other health providers to effectively communicate key patient information during transitions in care or referring to other providers.
Care Coordination Across the Community
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CPCI: Year 1 Milestones (2013) Budget forecast Care management of high-risk patients 24/7 access by patients Improve patient experience Use data to guide improvement* Care coordination Shared decision making Participation in CPC learning collaborative Meaningful Use Stage 1
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CPCI: Year 1 Milestones (2013) Budget forecast Care management of high-risk patients 24/7 access by patients Improve patient experience Use data to guide improvement* Care coordination Shared decision making Participation in CPC learning collaborative Meaningful Use Stage 1
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Gap Analysis
Patient registry
Care management
EMR interface
Chronic disease management modules
Outcome measures: quality measures and cost analytics
Patient interface (outreach, communications, coaching platform)
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Gap Analysis (cont.)
Global data aggregation (EMR, claims, RX data, HRA, etc.)
Report writing
Coaching platform
Capability for branding and product development
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Team-Based Care Not Designed into EHRs
The EHR user experience is transactional, not actionable
EHRs are designed for data capture, not visualization or knowledge transfer
EHR ill-equipped to address more rigorous 2014 NCQA PCMH certification requirements, or value-based programs like CPCI and CCM
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Team-Based Care, Technology Implementation, & Key Outcomes
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Team-Based CareTeam-based healthcare is the provision of comprehensive health services to individuals, families, and/or their communities by at least two health professionals who work collaboratively along with patients, family caregivers, and community service providers on shared goals within and across settings to achieve care that is safe, effective, patient-centered, timely, and efficient
Naylor MD, Coburn KD, Kurtzman ET, et al. Team-Based Primary Care for Chronically Ill Adults: State of the Science. Advancing Team-Based Care. Philadelphia, PA: American Board of Internal Medicine Foundation; 2010 equitable.
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Team-Based Care (cont.)
Patients come first Every person in the office has responsibility for taking care
of patients As a team, we all take care of patients, even if they never
cross our threshold Patient care happens beyond our office walls
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First StepsAnswering essential questions Can we perform the new functions with the current
staffing? How will we identify the patients in need of the new
services? How will we document the care? How will we track our performance?
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First Steps (cont.)
Adding new roles to address new responsibilities RN Care Managers
Responsible for care management of the high-risk population through disease management and care transitions. This is accomplished through face-to-face and telephone interactions with patients to promote self management skills through education and support.
Care CoordinatorsResponsible for facilitating pre-visit planning, referral management, and proactive outreach for overdue appointments/labs. The care coordinators will also be trained in behavior and lifestyle coaching to help your patients reach their personal health goals.
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First Steps (cont.)Population health technology Develop registries to identify patient cohorts for interventions Develop point-of-care tools to assist the care team in
identifying care opportunities Utilize efficient tracking systems to manage patient cohorts Develop risk stratification methodology Develop discrete fields for documentation in the EMR
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First Steps (cont.)
Reporting Develop reports for milestone
reporting Develop CQM reporting at the
practice level Develop reports for tracking
staff performance
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The WorkRN Care Managers Care transitions: outreach to
patients discharged from the hospital or emergency department
Disease management: diabetics (poor control), COPD, high risk, CHF
Self-management support Shared decision-making
WHAT DO WE NEED? Risk stratification at point of care Discharge Alerts Registries EMR documentation: Docflowsheets, Notewriter templates, Care Management encounter types Patient-centered care plans Discrete fields for self-management support
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The Work (cont.)
Care Coordinators Care Gap Closure Pre-Visit Planning Lifestyle Coaching
WHAT DO WE NEED?
Registries
Note templates
Discrete fields for self-management
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Risk Stratification: Crayons to Computers
•Provider and staff review attribution lists and manually assign high, medium, or low risk based on knowledge of the patient.Phase 1
•Apply HCC algorithm and develop cut points for high, medium, and low risk. Include physician feedback. Create display in patient header for HCC score and risk category. Manual entry.
Phase 2
•Identify patients with HCC score>2.5 with hospital/emergency room utilization or readmission in last 12 months.Phase 3
•Create registry to calculate HCC and identify utilization and automate high, medium, and low risk assignment in patient header.
Phase 4
Technology
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Risk Stratification (cont.)
Page 30
Discharge Workflow
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Registries
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Point-of-Care Tools
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Self-Management
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Care Gap Closure
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Pre-Visit Planning
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Organizing the WorkEvolution of tracking systems Paper calendars Binder systems and paper tracking Outlook calendars Cloud-based tracking system
Technology
Page 37
Care Team Tasking
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Reporting Milestone Reporting
Track all work for submission to program portal eCQM Reporting
Required at the practice level Epic did not have solution Custom report build required
Performance Reporting Outcomes Efficiencies
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Barriers
Resources Validation Lack of documentation
standardization Role clarity Resistance
Page 40
Keys to Success Project managers are vital Inter-disciplinary collaboration essential Innovative out-of-the-box thinking critical Perseverance wins the day
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Outcomes
Quality Measure
% Adherent
4 STAR Compliance Target
5 STAR Compliance Target
Quality Rating
Care of Older Adults - Medication Review 95% ≥77% ≥87% 5- SUPERIOR
Care of Older Adults - Functional Status Review 89% ≥67% ≥86% 5- SUPERIOR
Care of Older Adults - Pain Assessment 95% ≥78% ≥95% 5- SUPERIOR
Diabetes Care - Kidney Disease Monitoring 97% ≥93% ≥97% 5- SUPERIOR
Diabetes Care - Blood Sugar Controlled 87% ≥71% ≥84% 5- SUPERIOR
Rheumatoid Arthritis Management 100% ≥82% ≥86% 5- SUPERIOR
High-Risk Medications 95% ≥92% ≥94% 5- SUPERIOR
Medication Adherence for Diabetes Medications 82% ≥75% ≥82% 5- SUPERIOR
Medication Adherence for Hypertension 81% ≥77% ≥81% 5- SUPERIOR
Breast Cancer Screening 74% ≥74% ≥80% 4- HEDIS
Colorectal Cancer Screening 71% ≥71% ≥78% 4- HEDIS
Medication Adherence for Cholesterol (Statins) 77% ≥73% ≥79% 4- HEDIS
Adult BMI 89% ≥90% ≥96% 3
Osteoporosis Management in Women w/Fracture 44% ≥51% ≥75% 3Diabetes Care - Eye Exam 63% ≥75% ≥82% 2
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All-Payer CPC Hospital Admissions
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All-Payer CPC ACSC Admissions
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All-Payer CPC Total Cost PMPY
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Best Practices & Lessons Learned
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Value-Based Models Emerging New innovation models established by payers, including
government (state and federal) and commercial insurers Difficult to give requirements document to IT,
iterative model with many stakeholders Tenants of gap analysis still relevant in all forms of
value-based care Political transition implies continuation of free market
innovation, transparency, and focus on outcomes
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Focus on Culture“…eats strategy for lunch”
Provider adoption & satisfaction key to ongoing success
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Learn to skate well…
Technology is required to power new risk models…keep the patient (human) always in sight
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94% | 70%
Tobacco Use Assess.Cessation Intervention
ColorectalScreening
60% | 42%
Breast CancerScreening
64% | 41%
Diabetes HemoglobinA1c Poor Control
11% | 12%
Diabetes LDLScreening
80% | 62%
Diabetes LDLControl (< 100)
46% | 42%
Blood PressureControl
73% | 68%
Ischemic VascularDisease Screening
75% | 58%
Ischemic VascularDisease LDL Control
50% | 42%
InfluenzaImmunization
24% | 37%
STEPS: Realizing the Value of HIT - Performance vs. All-CPCI Region
