Improving Diabetes Care in 75 Minutes. Moderator: Jerry Penso, M.D., M.B.A., President & CEO, AMGA
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1 Improving Diabetes Care in 75 Minutes Moderator: Jerry Penso, M.D., M.B.A., President & CEO, AMGA
2 SESSION OBJECTIVES 1. Identify specific tactics that health care delivery systems can implement to improve a bundle of outcome measures in diabetes 2. Learn novel ways to engage the entire care team and patients in improving health 3. Discover the advantages of joining a national peer-led campaign to improve diabetes care 2016 AMGF
3 DISCLOSURE Presenters and moderator have no relevant financial or nonfinancial relationships to disclose
4 AGENDA TEAM TECH TRANSPARENCY Robert Zimmerman, M.D. Assistant Medical Director C. Todd Staub, M.D. SVP Physician Relations, OptumCare Lori Arnoldussen, RN Clinical Quality Coordinator
5 IMPROVE DIABETES CARE IN 75 MINUTES: ABOUT TOGETHER 2 GOAL Jerry Penso, M.D., M.B.A. President and CEO, AMGA; President, AMGA Foundation
6 ABOUT AMGA
7 ABOUT TOGETHER 2 GOAL
8 THE REACH OF TOGETHER 2 GOAL CAMPAIGN PARTICIPANTS 150 groups in 35 states 61,000 FTE physicians 2.0 million patients with Type 2 diabetes
9
10 CAMPAIGN GOAL Improve care for 1 million people with Type 2 diabetes
11 IMPROVEMENT THROUGH 2017 Q1 Patients with Improved Care Age ,000 Age ,000
12 IMPROVE DIABETES CARE IN 75 MINUTES: TEAM Robert P. Zimmerman, M.D. Assistant Medical Director, Excela Health Medical Group
13 OBJECTIVES Discuss Care Teams Make up Function Must haves Required support Excela Health Medical Group & Team Based Care/ Together 2 Goal Team Based Care Model Form extended teams Engage teams Optimize processes
14 PROVIDING QUALITY CARE IS A TEAM SPORT
15 HEALTH CARE TEAMS Core Team v. Extended Team Core Team Patient Centered PCP Care team Members Daily Interaction Extended Team Members Additional team members to augment Core PCP Care Team Brings limited resources to the table Intermittent interaction
16 HEALTH CARE TEAMS Function to Improve Standard Work to Decrease Variability Support for Quality Improvement Access Education Care Coordination and Delivery Patient Engagement and Self Management Patient and Care Team Satisfaction Patient Safety
17 HEALTH CARE TEAMS Must have PATIENT AT THE CENTER! Common goals (define and track) Members with well-defined roles and responsibilities and awareness / understanding of those roles Authority Responsibility Accountability Open Lines of Communication
18 HEALTH CARE TEAMS Must be given System buy-in Education Resources Time to meet and build relationships, tools, data Structure Process
19 EXCELA HEALTH MEDICAL GROUP: TEAMS & T2G Excela Health Medical Group: Teams & T2G
20 ABOUT EXCELA HEALTH MEDICAL GROUP ABOUT EXCELA HEALTH MEDICAL GROUP The Excela Health Medical Group is a network of integrated, multi-specialty practices and physicians located in Southwestern Pennsylvania. EHMG is part of Excela Health, a non-profit health system formed in locations -120,000 covered lives - Implementing PCMH model with five recognized Level 3 by NCQA Across 14 specialties
21 ABOUT EXCELA HEALTH MEDICAL GROUP Information Technology Outpatient EHR - Allscripts Touchworks Patient Portal Follow My Health IBM Watson Health solutions IBM Phytel Remind / Outreach 2015 IBM Phytel Insight / Coordinate 2016
22 STRUCTURE OF EHMG QUALITY PROGRAM Physician Quality Committee Set strategy Manage clinical quality and satisfaction goals Call out/ set goals for Corporate Quality Measures Teams to support/operationalize strategy Quality Team Quality Coordinators PCP Care Teams Primary Care Quality Work Group Together 2 Goal Team
23 STEPS 1. Implemented Team Based Care Model STEPS 2. Established Extended Teams 3. Engaged Teams 4. Optimized Processes Through Open Communication
24 1 Implemented Team Based Care Model Implementation of Team Based Care Develop Core Teams Roles and responsibilities Develop standard work/ processes Population-based care Panel Ownership
25 2 Established Extended Teams Established Primary Care Quality Workgroup to augment Primary Care Teams Identified MAs, Patient Information Coordinators, other quality champions across 30 practices Connected the dots among frontline patient care, payer quality programs, and financial impact of programs Empowered to problem solve Established Together 2 Goal Diabetes Team
26 3 Engaged Teams Staff engagement by aligning incentives What s the goal? Improve diabetic care to our patients Provider and staff incentives or skin in the game Staff individual merit increases tied to quality measure performance Tied T2G performance to provider compensation Supports culture of team-based care T2G Planks
27 4 Optimized Processes Through Open Communication Created a culture of open communication Provider group leading change Workgroup + T2G teams actively engaged with Core PCP Teams Staff empowered to share what they needed to be successful Staff feel they are making valued contributions Address I can t do this because Staff wanted to be their best and were able to articulate needs Began asking and addressing What is our data? Why is it our data? What can we do about our data?
28 STEPS 1. Implemented Team Based Care Model 2. Established Extended Teams 3. Engaged Teams 4. Optimized Processes Through Open Communication STEPS Next: Technology Transparency
29 IMPROVE DIABETES CARE IN 75 MINUTES: TECH C. Todd Staub, M.D., FACP SVP Physician Relations, OptumCare
30 Founded primary care practices Two decades of growth and evolution Creating a new culture of team empowerment for primary care Moving to value and pop health Joined OptumCare December physicians 125 APRNs and PAs 400,000 patients statewide Two global cap MA contracts January 2018
31 OPTUMCARE: BUILDING A NATIONAL AMBULATORY DELIVERY SYSTEM
32 Top performer AMGA Measure Up/Pressure Down groups over 150 Top ten percent in Together 2 Goal Top ten percent in MSSP quality ranking 4 ½ stars MA plan Achieved savings in MSSP and commercial ACO
33 FIRST GENERATION TOOLS
34 CREATING BETTER TOOLS TO FIT THE JOB
35 2 ND AND 3 RD GENERATION TOOLS
36 2 ND AND 3 RD GENERATION TOOLS QIS/ProCore fed from data warehouse Daily refresh of data Combine processes: HCC and care gaps Workflow: assign to right team members Outreach: delegated team process Ongoing monitoring of performance Adding in claims data
37 CUSTOM FEEDS TO EVERY APP: A LOT OF PLUMBING MAINTENANCE!
38 DATA LAKE: UNIFIED FEED WITH MULTIPLE APPS
39 TECHNOLOGY & WORKFLOW TO SUPPORT QUALITY METRICS Technology with human centered design Workflow lean and design thinking Within EHR environment user facing Just in time where the clicks need to occur Action steps right next to gaps Daily refresh eliminate rework C. Todd Staub MD FACP
40 IMPROVE DIABETES CARE IN 75 MINUTES: TRANSPARENCY Lori Arnoldussen, R.N. Clinical Quality Coordinator, ThedaCare Physicians
41 THEDACARE Integrated health system in Northeast WI 7 hospitals and 36 primary care clinics throughout 9 counties, with both rural and urban sites
42 LAND OF THE FRIDAY FISH FRY!
43 LAND OF THE FRIDAY FISH FRY!
44 GUIDING PRINCIPLE Quality and safety for our patients is our #1 priority Goal is achieve ZERO defects May mean something different inpatient vs ambulatory Missed A1c, for example, is a defect in ambulatory world Must measure to improve (can t show improvement on what you are not measuring)
45 TRANSPARENCY JOURNEY Former CEO Dr. John Toussaint was passionate about transparency before it was cool Touchpoint Health Plan shared provider level data Early adopter of Epic in 1999
46 WCHQ Founding member WCHQ: Wisconsin Collaborative for Healthcare Quality Publish on website members rates for various measures Our goal is to be in the 90th percentile for each measure (= #1 or #2 in state) Transparent state data has driven up the quality of all the organizations in our state
47 abouthealth Newer generation of sharing data and tactics to improve health of our communities, by delivering a consistent and reliable high quality healthcare, at a lower and more affordable cost 6 major healthcare systems in WI working together (collabetition)
48 abouthealth
49 INTERNAL TRANSPARENCY Quality Plan 10 metrics Compensation for meeting tiered rates, based at group level Data shared on intranet, at provider meetings, staff meetings, Quality team meetings Open to view to whole system Drives health competition
50 MONTHLY QUALITY PLAN
51 MONTHLY QUALITY PLAN
52 MONTHLY QUALITY PLAN
53 INTERNAL TRANSPARENCY
54 INTERNAL TRANSPARENCY
55 INTERNAL TRANSPARENCY
56 INTERNAL TRANSPARENCY
57 INTERNAL TRANSPARENCY
58 INTERNAL TRANSPARENCY
59 INTERNAL TRANSPARENCY
60 LEARNINGS Initially: I always check an A1c twice a year Then: mistrust of data YOUR data is wrong Acceptance: ok, well what do I need to do? Not easy/intuitive on how to manage a population
61 PROCESS Ensure data validity Plan-Do-Study-Act Share data (assume you are at believing it at this point) Clarification of roles (Med Assistant, RN, MD) We have done this without ambulatory care managers
62 PROCESS Prioritize measures Low hanging fruit to start with Builds confidence and experience with the processes of reading reports and acting upon them Advance to more complicated measures Visual management of progress and success
63 KEYS TO SUCCESS Quality is on every agenda Multiple methods of seeing the same data and communication of that data Data is not mine, it s ours
64 IMPROVE DIABETES CARE IN 75 MINUTES: Q&A Moderator: Jerry Penso, M.D., M.B.A. President and CEO, AMGA; President, AMGA Foundation
65 QUESTIONS
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