PERFORMANCE REPORTING & IMPROVEMENT A GLIMPSE AT THE SCC S PERFORMANCE MEASURES & DASHBOARDS AND ONLINE LEARNING CENTER

Transcription

1 PERFORMANCE REPORTING & IMPROVEMENT A GLIMPSE AT THE SCC S PERFORMANCE MEASURES & DASHBOARDS AND ONLINE LEARNING CENTER Presented by: Kevin Bozza, MPA, FACHE, CPHQ, RHIT Sr. Director, Network Development & Performance Suffolk Care Collaborative 54

2 LEARNING OBJECTIVES 1. Describe the purpose of the SCC Performance Reporting and Improvement Plan 2. Discuss the performance reporting organizational structure and stakeholder roles and responsibilities 3. Explain the performance reporting requirements for Domain I Patient Engagement, Domain I Project Engagement and Domain II & III Performance Outcomes 4. Discuss the Pay-for-Reporting (P4R) and Pay-for-Performance (P4P) model and associated timeline 5. Explain the Gap-to-Goal improvement standards 6. Describe the SCC approach to data aggregation and analysis including the decision support tools used to support the performance reporting program 7. Explain the SCC action planning process 8. Describe the SCC recommended model for performance improvement (IHI Improvement Model) 55

3 PURPOSE & GOAL The purpose of the Performance Reporting and Improvement Plan is: To establish a planned, systematic, organization-wide approach to health care performance reporting, performance measurement, analysis, and improvement across Suffolk Care Collaborative The goal of the Performance Reporting and Improvement Program is: To improve the patient experience of care (quality and patient satisfaction), improve the health of the populations we serve and reduce the per capita cost of providing healthcare services, thus achieving the Triple Aim. 56

4 SCC (PPS) HUB MODEL TABLE OF ORGANIZATION DSRIP Waiver Administrators NYS Department of Health Suffolk PPS Lead (Stony Brook University Hospital) Stony Brook Clinical Network IPA, LLC d/b/a the SUFFOLK CARE COLLABORATIVE HUB Networks CHS NWH SBUH SCC Coalition Partners SCC Coalition Partner Organizations SCC Coalition Partner Organizations SCC Coalition Partner Organizations 57

5 58 SCC (PPS) GOVERNANCE

6 PERFORMANCE REPORTING ORGANIZATIONAL STRUCTURE Each Project Committee has a Clinical Quality Function & reporting responsibility to the Clinical Governance Committee *Two-Way Communication Model 59

7 STAKEHOLDER ROLES AND RESPONSIBILITIES Stakeholder Provider Responsibility Engaged Participant - Fulfill project and patient engagement requirements; meet performance metric goals and targets Knowledgeable Participant - Informed of DSRIP projects and metrics Project Manager Project execution Primary project communicator (SCC Communications Management Plan) Manage day-to-day resources Provide project guidance by monitoring and reporting on applicable metrics Health System Performance reporting and monitoring Corrective action planning Project implementation Sending data feeds in a timely manner (SCC Quarterly Reporting Schedule) SCC Board Oversight of seven SCC subcommittees: Finance; Information Technology (IT)/Biomedical Informatics (BMI); Workforce; Community Needs Assessment (CNA), Cultural Competency & Health Literacy; Compliance, Audit & Clinical 60

8 11 DSRIP PROJECTS Domain 2 Projects: System Transformation Building a Suffolk County Integrated Care Delivery System (IDS) (2ai) Patient Centered Medical Home (PCMH) Practice Transformation Program (2ai) Transition of Care Program for Inpatient & Observation Units (TOC) (2bix & 2biv) Interventions to Reduce Acute Care Transfer (INTERACT ) Program (2bvii) Community Health Activation Program (CHAP) (2di) Domain 3 Projects: Clinical Improvement Programs Primary & Behavioral Health Integrated Care Program (3ai) Cardiovascular Health Wellness & Self-Management Program (CWSP) (3bi) Diabetes Wellness & Self-Management Program (DWSP) (3ci) Promoting Asthma Self-Management Program (PASP) (3dii) Domain 4 Projects: Population-wide Initiatives Substance Abuse Prevention and Identification Initiatives (4aii) Access to Chronic Disease Preventive Care Initiatives (4bii) 61

9 PERFORMANCE REPORTING REQUIREMENTS Performance Reporting Requirements Domain 1 Patient Engagement Domain 1 Project Engagement Domain 2 & 3 Performance Outcomes 8 of the 11 SCC DSRIP projects require active engagement of patients in the project. Example: 3.b.i Cardiovascular Patient Engagement Metric: Patients (18 and older) with a principal or secondary diagnosis of hypertension or hypercholesterolemia have documented at least one patient selfmanagement goal identified by the patient and reviewed at each visit. All 11 SCC DSRIP projects include specific requirements to demonstrate the provider is actively engaged in the project. Example: 2.ai. Integrated Delivery System Project: Ensure that all safety net providers are actively sharing EHR systems with local health information exchange/rhio/shin-ny and sharing health information among clinical partners, including directed exchange (secure messaging), alerts and patient record lookup. The Domain 2, System Transformation Projects, and the Domain 3, Clinical Improvement Projects, include process and outcome metrics linked to reporting or performance. Pay for Reporting (P4R) Pay for Performance (P4P) 62

10 DOMAIN II AND III PERFORMANCE MEASURES Domain 2 Systems Transformation Projects Domain 3 Clinical Improvement Projects 5 Projects 2ai, 2biv, 2bix, 2bvii & 2di 4 Projects 3ai, 3bi, 3ci, 3dii 26 Measures 32 Measures 63

11 DOMAIN II AND III PERFORMANCE MEASURES 3M Potentially ED Preventable Visits (PPV) Readmissions (PPR) AHRQ Prevention Ambulatory Quality Indicators Sensitive (PQI) Pediatric Conditions Quality Indicators (PDI) HCAHPS -Hospitals Patient CG CAHPS - Satisfaction Physicians Claims HEDIS Medical Record Abstraction Utilization Medicaid Spend 64

12 MEDICAL RECORD ABSTRACTION REQUIREMENT Random Sample Once a Year Across PPS Facilitated by a Medical Record Abstract Vendor Applicable measures for the SCC Screening for Clinical Depression and Follow Up Controlling High Blood Pressure Comprehensive Diabetes Care 65

13 IMPORTANT TERMS Demonstration Year (DY) 12 month period Measurement Year (MY) 12 month period Demonstration /DSRIP Year vs. Measurement Year Pay-for-Reporting (P4R) Pay-for-Performance (P4P) Begins Ends April 1 March 31 July 1 June 30 P4R vs. P4P SCC will receive funds for successfully reporting the measures to NYS DOH within the timeframes for each measurement year (MY) SCC will receive achievement values for results that meet or exceed the annual improvement target. The distribution of funds to coalition partners are based on the SCC collectively achieving improvement targets Note: some measures remain P4R while others flip to P4P later in the DSRIP Program. By DY 5 we are in mostly a P4P payment model 66

14 DSRIP METRIC & MILESTONE DOMAINS Source: Department of Health presentation on April 21, 2015 entitled DSRIP Domain 1 Achievement Values 67

15 ANNUAL IMPROVEMENT TARGETS & HIGH PERFORMANCE GOALS Statewide Performance Goals are fixed throughout DSRIP measurement years. At the beginning of each DSRIP measurement year, an annual improvement target is set for each PPS for all measures in Domain 2 & 3. The Annual Improvement Target is established by determining a small percentage (10%) of the difference between the PPS most recent result and the performance goal, and then adding that value to the most recent performance PPS result. In this example, we add 2.62 to 62.4 and 65.0 is the Annual Improvement Target. The PPS must meet or exceed the annual improvement target by the end of the measurement year. When a PPS achieves High Performance or PPS recent result + 20% for one of the 10 measures eligible for High Performance Fund, the PPS would receive additional payment. 68

16 DOH MAPP PERFORMANCE MEASURE EXAMPLE Baseline Annual Target 10% reduction in the Gap-to-Goal or more or exceeds performance goal Monthly Target Monthly High Performance Target Annual High Performance Goal Reduces Gap-to-Goal by 20% or more or exceeds performance goal 69

17 HIGH PERFORMANCE MEASURES Potentially Preventable Emergency Room Visits (All Population) Potentially Preventable Readmissions (All Population) Potentially Preventable Emergency Room Visits (BH Population) Potentially Preventable Readmissions (BH Population in SNF) patients Follow-up after Hospitalization for Mental Illness Antidepressant Medication Management Diabetes Monitoring for People with Diabetes and Schizophrenia Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia Controlling High Blood Pressure Medical Assistance with Smoking and Tobacco Use Cessation - Discussion of Cessation Strategies 70

18 Data Aggregation & Performance Improvement Process 71

19 AGGREGATION AND ANALYSIS OF PROCESS AND OUTCOMES DATA Provider Data DATA COLLECTED: Clinical Financial Operational Patient satisfaction Utilize statistical tools/techniques to analyze data Performance dashboards will be used to display data and inform various stakeholders: Providers Project Committees Governance Committees Performance levels, patterns, or trends identified Areas of variation in clinical results or provider performance will be addressed by each health system. Supported by Project Committee Oversight by Clinical Governance Committee 72

20 DECISION SUPPORT TOOLS SOFTWARE USED TO SUPPORT THE PERFORMANCE REPORTING PROGRAM Pay-for-Performance Provider Data Concurrent Monitoring of Performance DOH MAPP/Salient HealtheAnalytics TM Suffolk Care Collaborative (SCC). All rights reserved. This document contains SCC confidential and/or proprietary information belonging to the SCC and/or its related affiliates which may not be reproduced or transmitted in any form or by any means without the express written consent of SCC. 73

21 ACTION PLANNING PROCESS In variance refers to when a partner falls below the agreed-upon standard for one or more metrics Trigger: Partner is in variance for 2 consecutive quarters Corrective Action Plan Action plans may include: Process Redesign Further Trending Implementation of new service or procedure Education Counseling Focused Audit Action Plan Closed and Completed YES Is the metric out of Variance for 2 consecutive quarters? NO Clinical Committee determines next steps 74

22 PERFORMANCE IMPROVEMENT PROCESS Setting Aims Improvement requires setting aims. The aim should be time-specific and measurable; it should also define the specific population of patient that will be affected. Establishing Measures Teams use quantitative measures to determine if a specific change actually leads to improvement. Selecting Changes All improvement requires making changes, but not all changes result in improvement. Organizations therefore must identify the changes that are most likely to result in improvement. Testing Changes The Plan-Do-Study-Act (PDSA) cycle is used for testing a change in the work setting by planning it, trying it, observing the results, and acting on what is learned. 75

23 NEXT STEPS Provide Education to Project Committees re: PI Plan and Project Specific Metrics Analyze MY1 Final Results Identify Opportunities for Improvement e.g. consider trends by patient, provider Develop Care Management, Project Specific Strategies to improve Performance Outcomes 76

24 SCC WORKFORCE TRAINING STRATEGY AND PLAN LEARNING CENTER Presented by: Kevin Bozza, MPA, FACHE, CPHQ, RHIT Sr. Director, Network Development & Performance Suffolk Care Collaborative 77

25 SCC TRAINING STRATEGY & PLAN OVERVIEW SCC aims to ensure individuals feel they have the background, knowledge and skills to perform roles competently. 78

26 SCC TRAINING STRATEGY & PLAN LEARNING APPROACH SCC Training Program reflects a blended learning strategy 79

27 80 SCC LEARNING CENTER

28 SCC LEARNING CENTER Learning Modules are Minutes in length; completed at your own pace Participants complete a brief registration form and post evaluation Participation is tracked for DOH reporting purposes Additional modules in development 81

29 SCC LEARNING CENTER Partner resources page provides access to authoritative resources and potential CEU opportunities by focus area Both the Partner Training and Partner Resources pages do not require a username or password to access content 82

30 SCC TRAINING CURRICULUM COMING SOON Training Module Name New Models of Care & Healthcare Trends DSRIP 101 Community Orientation (Community Needs Assessment) Cultural Competency & Health Literacy Ethics & Professional Boundaries Motivational Interviewing & Health Coaching Care Coordination Methodology, Protocol & Treatment Plans Clinical Improvement Programs Overview Primary & Behavioral Health Integrated Care Program Cardiovascular Health Wellness & Self-Management Program Diabetes Wellness & Self-Management Program Performance Reporting & Improvement Patient Education Opportunities Health Information Technology, Documentation & Confidentiality 83

31 QUESTION & ANSWER 84