Slide 1 Regional Care Collaborative March 25, 2015.

Slide 1 Regional Care Collaborative March 25, 2015 Slide 2 Addressing Managing Competing Priorities PCMH 2014 Workshop Slide 3 PCMH MU $$$ Care Slide 4 Competing Priorities Agenda 1.Context of the HC Environment 2.Critical Thinking & Decision Making 3.Locate Initiative Alignments 4.Activity 1.Context of the HC Environment 2.Critical Thinking & Decision Making 3.Locate Initiative Alignments 4.Activity Slide 5 MULTIPLE INITIATIVE ENVIRONMENT Context of Health Centers Slide 6 Multiple Initiative Environment Health centers have more responsibilities than ever Less payment to do more but still accountable for success UDS HRSA Awards-Nat. Lead/HCQ/CQ/EHR PQRS PCMH-NCQA/TJC/AAAHC/URAC PC Accreditation-TJC/AAAHC/URAC DRP-NCQA HRSA 19 MU (Stage 1 - Stage 2) Slide 7 Many Un-harmonized standards Payment reform Primary care expansion HIT overpromised and under-delivered Provider shortage Insurance expansion Facilities modernization Initiative fatigue Many Un-harmonized standards Payment reform Primary care expansion HIT overpromised and under-delivered Provider shortage Insurance expansion Facilities modernization Initiative fatigue Primary Care Agenda 3/25/15 HC List of Major Concerns Slide 8 Langleys Change Model Eliminate Waste Improve Work Flow Optimize Inventory Change the Work Environment Enhance the Producer/Customer Relationships Manage Time Manage Variation Design Systems to Avoid Mistakes Focus on the Product or Service What will help you succeed in this environment? In a world of rapid continuous change every organization needs some Organizational Endurance Training Congratulations on your Critical Decision Making Skills Slide 9 Executive Decision Making System HEADS lets do it TAILS maybe next time TAILS maybe next time Slide 10 Scale of Challenges ( responsibilities ) Range of Capabilities Levity i.e., lack of serious thought Effective decision making flow Vacillation Automatic Solution Inappropriate or no decisions Hasty/ delayed decisions Indecisiveness COSTS WASTE Slide 11 Cross Walk of Data Workflow Design Documentation Recognition process Established processes Slide 12 Provides electronic care summary to another care facility (for at least 50% of transitions of care and referrals) Cross Walk of Data & Workflow: PCMH/MU Example PCMH Element 5C: Coordinates with facilities and care transitions MU Goal C: Improve care Coordination Measure s Assessing EMR capabilities Process Redesign & Workflow System configuration & upgrades Addressing overlaps between PCMH & MU Producing reports Writing policies & procedures Producing screen shots & documentation Work Plan Slide S TANDARDS A ND E LEMENTS2011 S TANDARDS A ND E LEMENTS Standards Element/ Process Plan Standards Element/ Process Plan PPC1: Access and Communication - The practice provides patient access during and after regular business hours, and communicates with patients effectively. Must pass: PPC 1A: Access and communication processes PCMH 1: Enhance Access and Continuity - The practice provides access to culturally and linguistically appropriate routine care and urgent team-based care that meets the needs of patients/families. Must pass: PCMH 1A: Access during office hours Must pass: PPC 1B: Access and communication results PCMH 1B: After- hours access PCMH 1C: Electronic access PCMH 1D: Continuity PCMH 1E Medical home responsibilities PCMH 1F: Culturally and linguistically appropriate services PCMH 1G: The practice team Total points available 9 Total points available 20 Cross Walk of Recognition Process: MU Stage 1 & 2 Example In this example Standard 1 in PCMH went from 2 -7 Elements Slide 14 Cross Walk of UDS /MU Stage 1 /PCMH Slide 15 Planning for the Multiple initiatives Huddle See 5 columns on a single sheet of paper 1.List all of the programs and initiatives currently active in your health center e.g., HRSA-PCMH, UDS, etc in Column A 2.Review list and with as few words as possible, write in Column B the purpose of the project and or program initiative 3.In Column C down why the initiative is relevant/ important/ beneficial to your organization 4.In Column D identify who the HC key players should be to participate in this program 5.In Column E Explore the overlaps Activity 1 Slide 16 COMPETING PRIORITIES ACTIVITY Exercise Slide 17 Column AColumn BColumn CColumn DColumn E Initiative NameProgram/ Project GoalRelevanceCHC Key PlayersAlignment PCMH 2011 Patient Centered Recognition - Through the governance of our leadership we will maintain patient centered quality care delivery by having ideal patient access, provide comprehensive patient care management and patient self - management, use population management to improve patient adherence to preventive and chronic care service needs and measure clinical process and outcomes performance data to assess opportunities to improve our service delivery model and positively affect the patient experience when utilizing our centers High / tied to incentive payment for NYS High / tied to center mission and vision HC Board CEO CMO QI Director Clinic PCMH Champion NCQA DRP HRSA Awards / UDS TJC BCBS Quality Payment NYS PCMH NYS DSRIP BEHAVIORAL HEALTH INTERGRATION HIP in HEALTHCARE / HIV in PC Competing Priorities Worksheet Slide 18 Sample Initiatives HH ICD10 HIPAA 5010 FTCA Healthy People 20/20 CPCI CMMI Workflow Redesign HRSA 19 UDS B2E P4P PQRS TJC MU PCMH ACO Foundation Grants Slide 19 Initiative Questionnaire Activity 2 1.Is your organization currently tracking performance in these major initiative areas? Which categories? Operational? Financial? Clinical? Managerial? Other? 2.Are key performance terms commonly used and understood across the organization? 3.Is performance information collected and quality assured? 4.Is performance information appropriately presented and reported? 5.Is performance information being reported solely to meet external performance reporting requirements or is it also being used internally to support decision-making? 6.What impact is the collection of this data having on performance and decision making? 7.Is the collection, analysis and reporting of this data functioning as intended? 8.Is there opportunity for alignment among the initiatives? Slide 20 Please Reference Your Performance Improvement Worksheets Activity # 2 Slide 21 WRAP UP ON ORGANIZATIONAL DECISION MAKING Slide 22 Step #1 What are the initiatives What is required of the CHC Who (in the org) will need to participate What does it yield the organization Does the Organization have the capacity/capability to perform the required tasks Effective Decision Making Requires Critical Thinking Slide 23 Decision Making Step #2 Now what are the decisions? Which one first? How many can you do at once? Where are the overlaps/alignments? What are organizational changes/impacts? (downstream) What is required upstream Cost/benefit to Patient/Organization/Staff/System Step # 3 Considerations Does it fit with the vision or mission of our strategic plan? Evidence of sustainable success Succession planning Sustainable QI structure Decision Making is Iterative In Change Management Mode It is Continuously Necessary Slide 24 Establishing Sustainable Patient Centered Processes Slide 25 Using and Sorting Data Agenda 1.Define data driven sustainability activities for the practice 2.Maintaining Best Practices: Applying data for monitoring and managing Ongoing Measuring and Monitoring Reviewing outcomes to ensure thresholds are met 3.Aligning work and measures Slide 26 Use Your Data as a Tool Promote the adoption of a comprehensive QI structure Aims, Measures, Systems and Processes QI efforts must be SMART * Use UDS data as a catalyst to: Help staff understand the value of data Use data to support critical decision making Use data to be proactive about patient outcomes vs. reactive (Triple Aim) * up to the end the QI project Slide 27 Our Town Medical CHC Data Cemetery War Stories from the QI Battlefield Deep Dive on Managing Data Ryan White Project 2007 HRSA Disparity Project 2005 PCMH 2008 PCMH 2011 Slide 28 POPULATION MANAGEMENT Sustaining Data Slide 29 Population Management Data Program/ Initiative NCQA PCMHCMS MU STAGE 1TJC 2D: Use Data for Population Management (Must Pass) The practice uses patient information, clinical data and evidence based guidelines to generate lists of patients and to proactively remind patients/families and clinicians of services needed for: 2. At least three different chronic care services** MM#3 Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, or outreach MM#4 Send reminders to patients per patient preference for preventive/follow-up care II. OPERATIONAL CHARACTERISTIC: COMPREHENSIVENESS A-4. The organization provides population- based care [PC /EP 4 (A)] Support the continuity of care, and provision of comprehensive & coordinated care & tx or services Document & track care, tx or services Support disease management, including providing patient education Support Slide 30 Sample of Population Management Our Town Clinic maintains several registries for our patient population. The previous file clerks were trained to perform panel management activities. Below is our mammography registry where we recall/ remind all of our female pts. 40 and over to get an annual mammography monthly. We assist in coordinating appointments with the imaging center. Our Town Clinic proactively reminds all patients in our registry via mailing a letter phone call,, text messaging 100% total Slide 31 Challenges for Maintaining Population Mgt. Pop Mgt. was a 1 shot deal No longevity plan No sustained process for creating patient list/ on going registry activity Staff turn over eliminated critical roles in the practice No identified goal /yield expectations Sustainability Issues Checklist Slide 32 POPULATION MANAGEMENT ACTIVITY Exercise Slide 33 Pack a Bag Activity You have 2 Minutes to pack your bag. Your destination is the beautiful island of Population Management. Pack only the items that best fits your destination Copy and cut out the pieces in the next 4 slides. Have participants confirm if the item they have is necessary for population management and why. Slide 34 Staffing Options Option #1 3 FTE MAs .5 FTE Nurse 1 Practice Administrator .5 IT Staff 2.5 FTE providers 1 FTE Front Desk Clerk .5 Admin Support Option #2 1 MAs 2 FTE Nurse 1 Practice Administrator .2 IT Staff 3 FTE Providers 2FTE Front Desk N0 Admin Support Slide 35 Registry of Diabetic Patients Electronic Health Record Patients Overdue for Immunizations Reminder Letters/ s/ Phone Calls Slide 36 Lab and Imaging Tracking Notification from ED when Patients are admitted Exchanging Key Clinical Information Co-managing Patients with Specialists Slide 37 Monitoring Continuity Giving Pertinent Information to Specialist Giving information for New Medications Same Day Appointments Slide 38 Care Plans Addressing Barriers to Treatment Goals Patient Education Printed Materials in Multiple Languages Slide 39 Report Out Time Population Management Activities Slide 40 When choosing clinical measures to improve performance align them with the population management activities and your UDS/TJC/HRSA 19/ Clinical QI activities Slide 41 CARE MANAGEMENT Sustaining Process Slide 42 Care Management Program/ Initiative NCQA PCMH 2011CMS MU STAGE 1TJC 3A Implement Evidence Based Guidelines The practice implements evidence-based guidelines through point of care reminders for patients 3C Care Management The care team performs 1. Conducts pre-visit preparations 2. Collaborates with the patient/family to develop an individualized care plan, 3. Gives the patient/family a written plan of care 4. Assesses and addresses barriers when patient has not met treatment goals 5. Provides patient/family a clinical summary at each relevant visit 6. Identifies patients/families who might benefit from additional care management support 7. Follows up with patients/families who have not kept important appointments CORE REQUIREMENT 13. Provide clinical summaries for patients for each office visit. Clinical summaries provided to patients for more than 50% of all office visits within 3 business days. Exclusion: Any EP who has no office visits during the EHR reporting period. I. Operational Characteristic: Patient- Centeredness C. Focus Area: Patient Involvement in Own Care Decisions II. Operational Characteristic: Comprehensiveness A. Focus Area: Expanded Scope of Responsibility Slide 43 Care Management Example Example COPD Encounter Slide 44 Example COPD Encounter Slide 45 COPD FLOWSHEET IN ACTION Slide 46 Challenges for Care Management. No risk stratification to identify High Risk patients for CM No IT in place to support risk stratification Partitioned or external CM Staff - touches and feedback not in pt. chart Providers cant do it by themselves No identified goal /yield expectations Sustainability Issues Checklist Slide 47 CARE MANAGEMENT ACTIVITY Exercise Slide 48 Activity Front Desk MANursePCPCDE BH Provider ITOther Identifies risk stratification protocols for patients with Behavioral health conditions High cost/high utilization Poorly controlled or complex conditions Performs a comprehensive health assessment How often? Calls patients to assess their understanding of a new prescription Calls patients to remind them to of their appointments Arranges specialty provider referrals Follows up with patients/families who have not kept important appointments Provides self-management tools to record self-care results in the chart Slide 49 ActivityFront DeskMANursePCPCDE BH Provider ITOther Gives the patient/family a clinical summary at each relevant visit Identifies patients/families who might benefit from additional care management support Assesses and addresses barriers when the patient has not met treatment goals Gives the patient/family a written plan of care Collaborates with the patient/family to develop an individual care plan, including tx goals that are reviewed and updated at each relevant visit Conducts pre-visit preparations Reviews and reconciles the patient medication list Provides patients educational materials and resources Contacts the medical equipment company to order a walker Slide 50 Report Out Time Care Management Activities Slide 51 When choosing to coordinate Care Management Support: 1.Think about High Risk groups of patients that need CM 2.Develop protocols in conjunction with your providers and continue the feedback loop Slide 52 THE LEAP FROM REPORTING QUALITY TO SUSTAINING QUALITY Sustaining Quality Slide 53 SMART RULES Specific Measurable Attainable Relevant, realistic Time bound Slide 54 Best Practice: Sustainability Principles 1.Management Prioritizes Goal 2.Foolproof Change 3.Transparent Feedback Systems 4.Clinic-Wide Understanding of Improvement Process 5.Staff Engaged in a Culture of Improvement 6.Capacity Building Programs Slide 55 Six Principles of Sustainability 1.Management Prioritizes Goal All principles adapted from: 5 Million Lives Campaign. Getting Started Kit: Rapid Response Teams. Cambridge, MA: Institute for Healthcare Improvement; (Available at Slide 56 Six Principles of Sustainability 2. Foolproof Change All principles adapted from: 5 Million Lives Campaign. Getting Started Kit: Rapid Response Teams. Cambridge, MA: Institute for Healthcare Improvement; (Available at Slide 57 Six Principles of Sustainability 3. Transparent Feedback Systems All principles adapted from: 5 Million Lives Campaign. Getting Started Kit: Rapid Response Teams. Cambridge, MA: Institute for Healthcare Improvement; (Available at Slide 58 Six Principles of Sustainability 4. Clinic-Wide Understanding of Improvement Process All principles adapted from: 5 Million Lives Campaign. Getting Started Kit: Rapid Response Teams. Cambridge, MA: Institute for Healthcare Improvement; (Available at Slide 59 Six Principles of Sustainability 5. Staff Engaged in a Culture of Improvement All principles adapted from: 5 Million Lives Campaign. Getting Started Kit: Rapid Response Teams. Cambridge, MA: Institute for Healthcare Improvement; (Available at Slide 60 Six Principles of Sustainability 6. Capacity Building Programs All principles adapted from: 5 Million Lives Campaign. Getting Started Kit: Rapid Response Teams. Cambridge, MA: Institute for Healthcare Improvement; (Available at Slide 61 Takeaways Value based payment is on our heals Difficult to focus on quality Despite best efforts priorities will not be 100% aligned FFS Managed care Slide 62 THANK YOU