The Practice Transformation Support Hub. North Central ACH Regional Assessment and Technical Assistance

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1 The Practice Transformation Support Hub North Central ACH Regional Assessment and Technical Assistance

2 The Healthier Washington Practice Transformation Support Hub An investment of Healthier Washington managed by the Washington State Department of Health Helps practices successfully move to whole-person, patientcentered care

3 The Hub: A Four-year, State Innovation Model (SIM) Testing Grant Three separate contracts, funded by DOH Qualis Health provides Practice Coaches and Regional Connectors programs Web Resource Portal offered through partnership with UW Department of Family Medicine Primary Care Innovation Lab

4 Hub Goals Help Providers: To Achieve the Triple Aim Integrate physical and behavioral health Move from volumebased to value-based care Improve population health through clinical and community linkages

Qualis Health Non-profit quality improvement and population

in Seattle, WA Regional offices in five states (Alabama,

District of Columbia Products and services directly

Qualis Health s Mission To generate, apply, and disseminate

5 Qualis Health Non-profit quality improvement and population health management firm Established in 1974, headquartered in Seattle, WA Regional offices in five states (Alabama, Alaska, California, Idaho, and New Mexico), plus the District of Columbia Products and services directly influence care delivered to approximately 13 million people Qualis Health s Mission To generate, apply, and disseminate knowledge to improve the quality of healthcare delivery and health outcomes 2

6 Qualis Health Practice Transformation Support Hub Experience Began in 2008 Safety Net Medical Home Initiative Co-developed an evidence-based framework Supported over 1,000 practices in 24 states Experienced consulting team brings deep knowledge of PCMH content, clinic operations, QI methods, and HIT Focus on building internal capacity to lead, manage, and sustain redesign efforts

7 Objectives Describe the Change Concepts for Practice Transformation and the PCMH-A assessment tool Share a proposal for a regional assessment of primary care practices in North Central Highlight opportunities for a follow up phase of technical assistance Gather feedback and answer questions

8 Change Concepts for Practice Transformation Citation: Wagner EH, Coleman K, Reid RJ, Phillips K, Abrams MK, Sugarman JR. The Changes Involved in Patient-Centered Medical Home Transformation. Primary Care: Clinics in Office Practice. 2012; 39:

9 PCMH Assessment (PCMH-A) Based on 8 Change Concepts for Practice Transformation Well-tested tool sensitive to change Used as a tool for teams to identify opportunities to improve Completed by a multidisciplinary group: Develop consensus scores Used to track progress over time at the individual clinic and cohort levels

10 Scoring No or minimal implementation First stage implementation Basic elements implemented Full implementation

11 Purpose Serve as a standardized measure of progress toward practice transformation to a medical home over time Use as a tool to promote broad-based practice conversations regarding opportunities for improvement Stimulate conversations with other practice sites to learn, share and transform

12 Academic Innovations Collaborative Median PCMH-A Scores by Change Concept Jul 2012-Nov PCMH-A Score Engaged Leadership Quality Improvement Strategy Empanelment Continuous Team-based Healing Relationships Patient-centered Interactions Organized Evidence-based Care Enhanced Access Care Coordination Overall Score AIC: Jul-12 AIC: Jan-13 AIC: Jul-13 AIC: Jan-14 AIC: May-14 AIC: Nov-14

13 Aggregate cohort scores Example of a Regional Comparison Academic Innovations Collaborative AIC Practice Median Score Jul 2012 (N=16) AIC Practice Median Score Oct 2015 (N=16) Difference 2 Change Concept Engaged Leadership Quality Improvement Strategy Empanelment Continuous Team-based Healing Relationships Patient-centered Interactions Organized Evidence-based Care Enhanced Access Care Coordination Overall Score Site scores Site Score Oct 2012 Site Score Oct 2015 Difference 2 Change Concept Engaged Leadership Quality Improvement Strategy Empanelment Continuous Team-based Healing Relationships Patient-centered Interactions Organized Evidence-based Care Enhanced Access Care Coordination Overall Score

14 Practice Assessment Tool Used by CMS Close alignment of assessment content Significant difference in scoring sensitivity: 4-point scale vs.12 Practices with a completed PAT can use that as a tool to make the PCMH-A evaluation process more efficient

15 Behavioral Health Integration MeHAF (Maine Health Access Foundation) 18 questions Wording for both primary care and behavioral health providers 10 point assessment scale, similar to PCMH-A Close alignment of some questions Appropriate for primary care practices already doing some BHI and/or who want to focus on that area of improvement

16 Regional Assessment and Technical Assistance

17 North Central Regional Assessment Engage primary care practices ACH coordination to recruit and engage practices Initial one-hour site call to gather information Facilitated site assessment conducted Two hour site visit PCMH-A for all, additional BHI assessment (MeHAF) for those who are interested/ready Follow-up coaching call or site visit to share results and create action plan Regional PCMH-A data aggregated and shared with practices and ACH to inform next steps

18 Creating Exemplars Begin coaching with a few early adopters Discuss successes and challenges at future ACH meetings Offer coaching services to additional practices, as they feel prepared

19 Supporting Practice Transformation Create an action plan Focus on the practice s priorities Provide education, tools and resources Hold regular, on-site meetings Assist practices with implementation of action plan

20 Supporting Practice Transformation Practice Coaching Building skills Making community-clinical connections Preparing for value-based payment success Improving processes Managing population health Integrating physical and behavioral health

21 Questions and Discussion

22 Thank you or call: (206) or (800) ext. 2540

Transforming Care for Vulnerable Populations:

Transforming Care for Vulnerable Populations: Lessons from the Safety Net Medical Home Initiative Kathryn E. Phillips, MPH July 2015 Safety Net Medical Home Initiative Goals for this Session Describe the