Patient-Centered Primary Care Collaborative December 6, 2013 Learning Session Welcome!
Lead Support
Major Support
Please save the following dates for future learning sessions (8:30-10:30AM): • April 4, 2014 • August 22, 2014 • December 5, 2014
Additional Support 100% Access HealthColumbus Board & Staff Individual & Corporate Donations
Patient Engagement Transformation Announcement
OpenNotes is an initiative that invites patients to review their visit notes written by their doctors, nurses, or other clinicians.
Who will be sharing notes in Greater Columbus starting in Q2 2014?
Evolution of Public-Private Partnership Announcement
2014 & BEYOND: EVOLUTION OF OUR PUBLIC-PRIVATE PARTNERSHIP
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Our Vision (aspiration): Optimal Care, Value, and Health for all people in Greater Columbus Our Mission (useful need): To transform healthcare delivery and value for all people in Greater Columbus through collaboration with consumers, providers, and purchasers www.hcgc.org
BOARD OF DIRECTORS • Ivery Foreman (Board Chair), Vorys, Sater, Seymour & Pease, United Way of Central Ohio Representative • Mike Stull (Board Vice Chair), Employers Health Coalition, Business Representative • Bill Wulf, M.D. (Board Treasurer), Central Ohio Primary Care, Columbus Medical Association Representative • Dianne Radigan (Board Secretary), Cardinal Health, Franklin County Representative • Jeff Biehl (President), Access HealthColumbus, non-voting, ex-officio • Doug Anderson, Bailey Cavalieri, City of Columbus Representative • Dianne Biggs, Labor Representative • Sarah Durfee, RN, Ohio Public Employees Retirement System, Purchaser Representative • Jerry Friedman, The Ohio State University Wexner Medical Center, Hospital Representative • Diana Riggsby Gardner, The Dispatch Printing Company, Purchaser Representative • Jeff Geppert, Battelle, Health Care Representative • Thomas Hadley, Wells Fargo Insurance Services, Chamber of Commerce Representative • Sister Barbara Hahl, Mount Carmel Health System, Hospital Representative
2 • Kevin Hinkle, Anthem Blue Cross & Blue Shield, Health Plan Representative • Thomas Horan, Columbus Neighborhood Health Center, Community Health Centers Representative • Isi Ikharebha, Physicians CareConnection, Consumer Representative • Doug Knutson, M.D., OhioHealth, Hospital Representative • Teresa Long, M.D., Columbus Public Health, Health Department Representative • Julie Erwin Rinaldi, Syntero, Behavioral Health Representative • Valerie Ruddock, Nationwide Children’s Hospital, Hospital Representative • Olivia Thomas, M.D., Nationwide Children’s Hospital, Community Philanthropic Representative • Dana Vallangeon, M.D., Lower Lights Christian Health Center, Consumer Representative • Bruce Wall, M.D., The Ohio State University Health Plan, Columbus Medical Association Representative • Todd Weihl, D.O., OhioHealth, Columbus Osteopathic Association Representative
WHY: The Need
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A neutral, trusted organization through which the community can plan, facilitate, and coordinate the many different activities required for successful healthcare system transformation. •
One of the greatest challenges facing the nation is making healthcare more affordable while maintaining and improving its quality and improving population health.
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Evidence is clear that healthcare costs can be significantly reduced by improving the quality and appropriateness of care and engaging community members to work together to improve population health.
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Given the complexity of the healthcare system, the need to coordinate across organizations and sectors, and the barriers to change, coordinated multi-faceted and multi-stakeholder approaches are needed if healthcare reform efforts are to succeed.
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Since all healthcare stakeholders in a community – consumers, providers, purchasers, etc. – will be affected in significant ways, they all need to be involved in planning and implementing change.
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Because there is often considerable distrust and lack of coordination between different stakeholder groups, a neutral facilitator is usually needed to help design true “win-win” solutions.
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Through collaborative leadership and a focus on community benefit, regions can break down silos and promote alignment. Technical assistance and support can further improvement efforts, and measurement and reporting can track progress, identify best practices, and ensure accountability.
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New relationships across disciplines and sectors to build trust and promote alignment of efforts.
Source: Network for Regional Healthcare Improvement www.nrhi.org
WHAT: our strategic areas of focus
4 Value-based
Healthcare Delivery
Value-based
Healthcare Reporting
Transform Healthcare
in Greater Columbus with consumers, providers & purchasers
Value-based
Healthcare Literacy
Apply
Collaborative Learning
Value: quality, cost, and patient experience
Catalyze Collaborative Grant Applications
HOW: our collaborative process
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Build collaborations with consumers, providers, and purchasers ~trust~
Apply collaborative learning ~spread knowledge~
Measure actionable results
Transform Healthcare
in Greater Columbus with consumers, providers & purchasers
~collective impact~
Catalyze best practices ~awareness~
Convene diverse stakeholders ~exploration~
Coordinate activities that transform healthcare delivery and value ~commitment~
WHERE: regional healthcare improvement collaboratives
Oregon Healthcare Quality
Puget Sound Health Alliance
Wisconsin Collaborative Healthcare Quality
Utah Partnership for Value-drive HC
Minnesota Community Measurement
Greater Detroit Area Health Council
Better Health Greater Cleveland
Finger Lake Health Systems Agency & Collaborative of Western NY
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Maine Health Coalition
Iowa Healthcare Collaborative
MA Health Quality Partners AF4QL South Central PA
Midwest Health Initiative California Quality Collaborative Nevada Partnership for Value-drive HC
Healthcare Collaborative of Greater Columbus
Center for Improving Value in HC
Source: Network for Regional Healthcare Improvement www.nrhi.org
The Health Collaborative Louisiana Healthcare Quality Forum
Pittsburgh Regional Health Initiative
Sharing Learning from Patient-Centered Primary Care Practices in Greater Columbus
OPEN RECORD – The Columbus VA Experience Edward T. Bope MD Chief of Primary Care The Columbus VA
VETERANS HEALTH ADMINISTRATION
The History • The VA developed an electronic medical record in the 1980s and with that created the largest integrated health system in the world. • Two years ago the VA created MyHealthyVet and gave record access to the patients. VETERANS HEALTH ADMINISTRATION
My HealtheVet • Admission & DC summaries • Allergies • Appointments • Demographics • EKG history • Progress notes
VETERANS HEALTH ADMINISTRATION
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Immunizations Lab results Pathology results Radiology reports Wellness reminders Vital signs DoD Military Service Information
MyHealtheVet –Track Health • Allows Veterans to add to their health record in 5 areas – VS – Labs and tests – Health History – Journals – My Goals VETERANS HEALTH ADMINISTRATION
Problems Encountered with Open Records • Unnecessary alarm at near normal labs • Patients reacting emotionally to the notes and writing letters to protest calling the provider racist and advising the provider should not ever be allowed to see patients again • Not understanding the medical jargon can lead the patient to believe they have a serious illness.
VETERANS HEALTH ADMINISTRATION
Problems continued • Patients are very sensitive about being labelled as obese even when they are morbidly obese. I now use BMI • I can no longer describe what I see or how they are acting if it is less than complimentary • I am already busy with phone messages and secure email messages and having to explain the notes adds more calls. VETERANS HEALTH ADMINISTRATION
VA advice to Providers • Be Mindful when writing notes • Be Professional when choosing language • Be Open, Listen and Encourage dialogue when patients discuss notes. VETERANS HEALTH ADMINISTRATION
Advantages to Open Records • I have had no conflicts • Overall it is a good thing, at least they are interested in their health • No conflicts, I tell my patients they can read their note in MyHealtheVet • A Veteran saw a urinalysis report on his record but knew that he had not had a urine test. This launched a search for the rightful owner. VETERANS HEALTH ADMINISTRATION
Advantages Continued • I had a patient who is aggressive, big physically, and intimidating. I described his attitude as “offputting” in the note and he came into the clinic very upset at me. I explained how other people saw him and reacted to him, and after that he was more mellow when in the clinic, so that was one incident with a happy ending.
VETERANS HEALTH ADMINISTRATION
Key Points • Patients already have access to their records – it is just a cumbersome process to get them • A focused study of VA patients showed: – Positively affected communication with Dr. – Enhanced knowledge of health – Improved self care – Allowed greater participation in the quality of their care such as follow up of abnormal tests or decision making on when to seek care VETERANS HEALTH ADMINISTRATION
Summary • The time is now • It is becoming the standard of care • Both providers and patients will have to adapt – a change in culture • We should assess the purpose of the progress note- is it billing, legal or patient care? VETERANS HEALTH ADMINISTRATION
FQHC Collaborative Project: Improve Pediatric Immunization Rates • Deanna
Gingrich, RN, Lower Lights Christian Health Center
• Morgan
Kelley, RN, Heart of Ohio Family Health Centers
• Slessor
Fombang, MD, Columbus Neighborhood Health Center,Inc.
Project Overview
Goal: Improve 2013 pediatric immunization rates as measured by the 2012 federal Uniform Data System (UDS) metric.
PCMH practice locations:
Collaborative met monthly during Q1 2013, then quarterly Quarters 2-4, with monthly conference calls.
◦ 5 Columbus Neighborhood Health Centers ◦ 2 Heart of Ohio Family Health Centers ◦ 2 Lower Lights Christian Health Centers
Results Health Center
2012 Baseline
2013 Actual
LLCHC
14% 45%
HOH
34% 38%
CNHC
47% 40%
Heart of Ohio Family Health Centers
The child’s Impact/SIIS record is reconciled with EHR vaccine record the day before well child visits. MA checks if needed vaccines are in stock.
MA tracks kids who need vaccines that are not in stock at appointment time. A nurse visit is scheduled once the vaccine is received back in stock.
MA will reschedules “no-show” well child visits immediately, eliminating having to “play catch up”.
Inventory-immunization count is done by RN every other week.
Columbus Neighborhood Health Center •
Increasing access by holding an after-hours immunization clinic.
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Enhanced inventory monitoring and control
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Missed vaccine opportunity is identified through QI data. Appointment rescheduled.
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Immunization opportunities are discussed at staff meetings
CNHC success with 2 year old population Immunization Rate 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 2012
2013
Lower Lights Christian Health Center
Data to project ahead, instead of as rear view mirror. ◦ Both clinical and quality staff use tracking tool to take advantage of all opportunities to immunize.
Set PAR vaccine inventory levels
◦ Stable process in place to determine PAR levels. ◦ Recognition of constraints to having “enough” serum (e.g. private pay patients – financial; Medicaid patients – permission)
LLCHC Tracking Spreadsheet
Next Steps
Maintain the positive change.
Continue to use data to look ahead, instead of collecting data focused on what didn’t happen in the past.
Through the FCHQ Learning Collaborative, share data transparently.
Look for other process improvement opportunities!
Transitions of Care RN solely dedicated to hospital inpatient and ED follow-up OSUWMC Family Medicine Elizabeth Beck, MSN(c), RN, Program Manager for Care Coordination Team Janel Grover, MHA, Director of Ambulatory Services Randy Wexler, MD, MPH, Associate Professor & Clinical Vice Chair, Dept of Family Medicine
12.6.13
What are we trying to accomplish? Hire a Care Coordination Team to do the following under PCMH model of care:
Transitions of Care Population Management Referral Tracking Education
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Today’s Focus:
Transitions of Care
Reduce 30-day readmission rates. Reduce unnecessary ED visits. Ensure PCP is “in the loop”. Provide better quality and safety for our patients by reviewing medications and ensuring coherence with meds and discharge instructions. Increase patient satisfaction.
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In a nutshell…. Close the gap!
Care Coordination Team: Elizabeth Beck, RN Program Manager Kathy Maedeker, RN Care Coordinator Sherri McMillan, Care Coordinator Michelle Smith, Care Coordinator Additional RN recruitment
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Transitions of Care 4 FTEs hired by Oct, 2012 Buy-in from: Payors and OSU Leadership
Set goals around Transitions of Care Assess current process of receiving/acting upon IP and/or ER notifications involving our patients. Identify issues and barriers w/ current process: Timeliness (both internal and external) Continuity and consistency of follow up with patients Timely PCP access for follow up appointments Assumptions about Inpatient case management
Develop new process involving CC team, including standard protocol for communication & dedicated RN. Educate PCPs and staff. Take it on the road! (Educate Medical Center Leaders and inpatient Utilization Management departments) 38
Transitions of Care Reached out to Medical Center stakeholders Joined I/P Readmission Reduction Task Force (RRTF) Started regular meetings with Utilization Management Leadership Team (Medical Director, Department Directors, CMs, LSWs, Navigators) Participated in Case Management Resource Fair (open to all employees - info on access to our PCPs, how to contact our Care Coordinators, etc.) Presentations to: Nurse Executive Council; Executive Leadership Council; RRTF. Goal to share our PCMH initiatives and our focus on Transitions of Care.
Developed process for I/P Patient Navigators (high risk patients) to directly contact RN CC. Developed process for patients needing specialist appointment that can’t be obtained timely- PCP to bridge care. Developed Smartphrases for consistent documentation. 39
Transitions of Care
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What do we measure?
# of inpatient stays and ED visits (patients of our PCPs) # of PCP f/u appointments made by I/P CM (pre discharge) # of PCP f/u appointments made by RN CC (post discharge) Specialty f/u appointments No show rates for f/u appts Patient satisfaction Frequent flyer identification and education
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Transitions of Care - Outcomes Eight OSU Family Practices
Arlington Bethel Carepoint East Gahanna Lewis Center New Albany Rardin Worthington
Data collected April – September, 2013 Change in data collection methods implemented in July, 2013 to include separating inpatient and ED visits and recording 30-day hospital readmissions post discharge.
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Transitions of Care - Outcomes RN Care Coordinator calls to 1542 patients 551 patients IP/ED (prior to July, 2013) 249 IP patients (July – September, 2013) 732 ED patients (July – September, 2013)
487 PCP follow-up appointments made by RN Care Coordinator 25 No Shows for PCP follow-up appointment 18 Readmissions within 30 days of discharge (7.2% rate)
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What did we learn? Discharge process inconsistent Inpatient CMs not always making needed f/u appts Patients not always getting education about meds or understanding discharge instructions- or they aren’t able to remember/comprehend at time of discharge. F/U appointments made before discharge aren’t always the most convenient for patient, increasing no shows. Specialty access issues (often unknown to PCP office who could’ve helped bridge care) Very valuable intervention (quality/safety; patient-centered approach; financial incentive to reduce readmissions) Patients LOVE this!!! 44
Overcoming Obstacles Trust of providers (switching to a centralized process) Physician leadership critical Transparency (documentation, making sure providers 100% in the loop) Simply proving ourselves (and going the extra mile on any provider requests related to coordination of care)
Lack of timely notification / incomplete information Educate providers; reinforce protocol for internal notices Educate staff; set standards for external notices Open discussions w/ Navigators for direct communication to RN CC on higher risk population How are we really going to measure this??? I/T can help 45
Transitions of Care In July, changed how we look at our metrics Separated I/P, ED, Observation Look-back of readmissions w/in 30 days w/ identification of readmit diagnosis Developed process for I/P Patient Navigators (high risk patients) to directly contact RN CC.
MIDAS system being implemented for Ambulatory Care Coordinators “Real time” view of our patients in OSU hospital or ED/Obs Ability to: develop better work queues; track pts throughout stay; build assessments (TCM smartphrases) & copy to EMR; track problems and goals; track resources of CC staff; see quick encounter updates (snapshot of svcs relative to PCMH)
Additional RN budgeted for January 2014 Pilot additional approaches Embedding CC’s physically into practices (vs centralized) 46
By developing better relationships and transitions within our own organization, we help patients more easily navigate a very complicated health care system. 47
Journey to Improvement – Patient Centered Medical Home Mount Carmel Medical Group
Maria Courser, MD – Chair Quality Committee Michelle Love, RN, MSN, CCM – Manager, Quality and Safety Anna Cluxton, MBA – PCMH Project Manager Mike Anthony – Director of Primary Care Operations
Mount Carmel Medical Group • Mount Carmel Medical Group (MCMG) is a hospital based employed physician group with more than 120 primary care and specialty physicians, with more than 40 care sites throughout central Ohio • Member of Catholic Health East-Trinity Health, a Catholic faith based multi-facility healthcare system 49
Mount Carmel Medical Group • Mission We believe the relationship between patients and their primary care provider is essential to the assurance of the right care delivery in the right setting, at the right time
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MCMG Patient Centered Medical Home Goals/Status • Achieve NCQA PCMH recognition for all primary care sites by the end of 2015 • One NCQA 2008 recognized practice (Pickerington) site under 2008 guidelines -submitted recognition for 2011 renewal November 2013 • July 2013 achieved NCQA PCMH Level 3 recognition for MCMG Tri-Village and Upper Arlington sites 51
Plan, Do, Study, Act Change Concepts • Core Focus Areas 1) Preventative Care - pneumonia vaccination 2) Patient Satisfaction – access to care
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Quality Improvement Plans Aim 1: Improve the rate of Pneumococcal vaccinations in patients 65 years and older by at least 5%. Baseline percentages: MCMG Tri-Village – 61% MCMG Upper Arlington - 55% 53
DO-Plans/Tasks Needed to Test Change
Workflow changes: 1) Education to staff and providers 2) Use of population management reports to identify gaps The rate of pneumonia vaccination for patients 65 and over increased significantly • MCMG Tri-Village - 72% (11% increase) • MCMG Upper Arlington - 69% (14% increase) 54
Quality Improvement Plans Aim 2: Improve patient satisfaction survey result scores for care delivery to our patient population as a result of practice transformation initiatives.
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DO-Plans/Tasks Needed to Test Change Patient satisfaction improvements average of 3 % for: •Access to care - 86.7% to 89.1% •Ease of getting clinic on phone - 82.9% to 87.2% •Convenience of our office hours - 85.7% to 86.7% •Courtesy of registration staff - 91.0% to 94.4%
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STUDY – Lessons Learned • Change is hard! – Staff, physicians, patients need hands on support and reinforcement • EMR issues can be distracting • Focused trainings on health literacy fosters improved patient engagement • Team huddles inclusive of front desk staff really are critical • A multi-layered attack is best! 57
STUDY – Lessons Learned/Successes • Pre-visit planning – use of population reports, patient outreach letters, brochure mailings • Patient satisfaction tools: implementation of AIDET tools and training • Ongoing education for staff/physicians
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ACT –Next Improvement Steps • Ongoing education and support – Inclusive of non-clinical aspects • Continued reporting internally and discussion – Implement enhanced patient population/registry software • Ongoing auditing of medical records for practice transformation (PCMH) concept workflow 59
ACT – Next Improvement Steps • Ongoing evaluation of patient satisfaction survey results • Ongoing education, support and evaluation of opportunities for improvement • Expand and integrate care coordination with ancillary services: – Social/Behavioral Services – Pharmacy 60
Contacts Anna Cluxton, MBA – MCMG Process Improvement Consultant/PCMH Project Manager E-mail: acluxton@mchs.com Maria Courser, MD – Quality Committee Chair E-mail: mcourser@mchs.com
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Contacts Michelle Love, RN,MSN,CCM-Manager, Quality E-mail: mlove@mchs.com Mike Anthony, Practice Operations Director E-mail: manthony@mchs.com Vicky Diller, Database Coordinator E-mail : vdiller@mchs.com 62
SNF Initiative
Re-Admission Problem In 2012, 18.4% of Medicare patients were REHOSPITALIZED within 30 days Rate can be even higher from a Subacute Nursing Facility (SNF unit). Range 12-38%
Risks Associated with SNF Transition failures post hospitalization regarding admission course, diagnosis, medications and treatment plan Staffing/Skill level Physician limitations Lack of PCP continuity post discharge
Who Needs Post-Acute Care? CVA for rehabilitation CHF Failure to thrive Falls Post total joint replacement General post-op
COPC/SNF Unit Goals Improve communication between subacute facilities (SNF) and the Hospital, ED, OBS unit and PCP Clinics. Optimize the care of patients in SNF’s and decrease readmissions. Create a safe next level of care where hospital physicians and office based physicians are confident about care level.
COPC/SNF Initiatives
2013: Post-Acute Care 2014: Hospital/ER Diversion
2013 Post-Acute Care COPC patient is cared for by COPC Hospitalist On-site COPC NP Care delivered within the EHR Communication with COPC PCP within medical record 5 units in Columbus
Post-Acute Care Results 2 units with COPC Hospitalist and COPC NP 25.00%
UNIT 30 day re-admit
20.00%
2013
12.9% 11.54%
5.00%
2012
13.7%
10.00%
19.7%
15.00%
0.00% #1 (n=600)
#2
2014: Hospital/ER Diversion  Avoidable Admissions: 25% per hospitalists - Pneumonia - CHF - UTI - Dehydration - Weakness - COPD
AVG COST $10,000
2014: Hospital/ER Diversion Same Scenario COPC patient COPC Hospitalist/NP COPC medical record SNF unit with: • Increased RN:patient ratio
• IV fluids, antibiotics therapy 7 days per week • Respiratory therapy
What is Next? Visiting physician Care Coordination teams High risk clinics Home monitoring including telehealth
Funding from the following public-private partners supports our collaborative work in Greater Columbus! Lead Supporter
Major Supporters
Additional Supporters 100% Access HealthColumbus Board & Staff
Individual & Corporate Donations