AIDS INSTITUTE NEW YORK PRESBYTERIAN DSRIP AND PRACTICE TRANSFORMATION INITIATIVE

Transcription

1 AIDS INSTITUTE NEW YORK PRESBYTERIAN DSRIP AND PRACTICE TRANSFORMATION INITIATIVE 1

2 Road map What is DSRIP (Delivery System Reform Incentive Payments) Integrating the mission of DSRIP & End the Epidemic Building community based collaborative leadership REACH Collaborative Creating a cross-agency team of community health navigation, peer support and coordination Bringing care out into the community through DSRIP waivers Using information systems as essential tools to support access, integration and care coordination Improving access to clinical care and care coordination through practice transformation

3 What is DSRIP? In 2014, Governor Andrew Cuomo announced that New York State and CMS finalized agreement on the Medicaid Redesign Team Waiver Amendment. $6.42 Billion for Delivery System Reform Incentive Payments (DSRIP) Specific Goals 1. Reduce avoidable hospitalizations and emergency department visits by 25% over 5 years 2. Transform the Medicaid delivery system to be value-based 3. Achieve Triple Aim (improved health, improved quality, lower costs) 3

4 What are we trying to accomplish? End the AIDS Epidemic (PEP, PrEP & TasP) Cure Hepatitis C Projected HCV related deaths without treatment People living with HIV w/ Medicaid are not in care 4

5 REACH Collaborative Ready to End AIDS & Transitions of Care Medical Delivery Health Case On-site System Management Home Reform Incentive Cure Hepatitis Case HIV Hepatitis Management Program Testing C Services (DSRIP) C Pharmacy Services 5

6 Care Coordination through IT integration Health Exchange Resource Mapping Care Coordination 6

7 Care Coordination through IT integration 7

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10 Stimulating Transformation of Technology and Team structure to Reach People Living with HIV A Special Projects of National Significance Project Supported by HRSA

11 Practice Transformation - Susan Olender, MD, MS September 8, 2016 AIDS Institute Quality of Care Clinical Advisory Meeting

12 Objectives Healthcare delivery changes and impact on practice model Support for change CHP Practice transformation Model Quality and Practice Transformation 12

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14 Alphabet Soup of Delivery System Change Affordable Care Act (ACA) Patient Centered Medical Homes (PCMH) Health Homes (HH) Accountable Care Organization (ACO) Delivery System Reform Incentive Payment (DSRIP) ACO Practice Transformation Model (PTM) 14

15 HRSA Recognizes Need for Capacity Building and Creates a SPNS Initiative Trends affecting HIV care: Growing population Aging population with complex medical and psychosocial comorbidities Improved access to care First generation of HIV providers nearing retirement Ongoing changes to the health care system and funding as a result of ACA Lack of full integration of care, silos Outcome: Demand for services is eventually expected to exceed capacity 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT

16 SPNS: System-level Workforce Capacity Building for Integrating HIV Primary Care in Community Healthcare Settings Goal: To identify successful practice transformative models (PTMs) Efficiencies in structural workforce systems that optimize human resources and improve health outcomes PTMs tackle workforce challenges in multiple ways 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT

17 HRSA SPNS Workforce Initiative Project Title: Workforce Capacity Building Initiative 4-Year HRSA-Special Project of National Significance Grant Funded to design, implement, evaluate, and disseminate the intervention Multi-site: 15 demonstration sites across the country Practice Transformation Models or PTMs System level staffing changes Heavily based on Patient Centered Medical Home (PCMH) Improves capacity to care for people living with HIV, valuing efficiency and sustainability Optimizes resources in changing landscape Improves linkage, engagement, retention in care, and suppression rates Cross-site Evaluation UCSF s Evaluation and Technical Assistance Center (ETAC) 17

18 Comprehensive Health Program (CHP) Academic medical center in Upper Manhattan Level II PCMH Provides outpatient & inpatient care to people living with or at-risk for HIV 2200 ambulatory patients and 20 bed inpatient unit Multidisciplinary clinical care Providers, nurses, social workers, care coordinators, nutritionist, psychiatrists, patient navigators, medical and nursing assistants 18

19 Why Practice Transformation at CHP? Changing healthcare landscape HIV primary care workforce shortages Increasing demand for access to quality HIV, HCV and Prevention services More than 100 staff operating in a variety of settings Inpatient Outpatient Community Home Visits Growing attention to at-risk population through expansion of: Sexual health services (PrEP, PEP, STIs) Hepatitis C care and treatment 19

20 Planning the Practice Transformation: PRECEDE PROCEDE Framework 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT

21 Pre-Implementation Activities HIV Surveillance & Ryan White Program Data (Publicly Available) HIV Care Continuum Indicators Clinic Observation Activities Focus Groups with Clinic Staff STaR Pre-Launch Survey (ie: Teams, Flow, Function, IT) Targeting Members of Clinical Care Teams 21

22 CHP Program Impact Pathway (Logic Model) Inputs Funding & Resources Facilities & Equipment Evidence-Base Policies, Protocols & Guidelines Training & Technical Assistance CHP & NYP Strategic Plans Health Information Technology Monitoring and Evaluation (M&E) Systems Community Partners Activities Clinical & Non-Clinical Services Patient Flow Redesign Expanded Walk-In Capacity & Targeted Coordination of Same Day Services Population Health Management by Clinical Care Teams (CCT) Integrated Clinical & Non-Clinical Care Coordination via CCTs RN & Non-RN Care Coordinator Support of Care Transitions Referrals & Linkages to Community-Based Services Community-Based Outreach & Engagement Consumer Education Consumer Advocacy Outputs Prevention, Care & Support, and Treatment Services Provided Workflow Changes & Quality Improvements Implemented Increase Capacity in Team-Based Care Coordination & Population Health Management Successful Outreach & Engagement of High- Risk Populations and Linkage to Treatment, Care, and Supportive Services Patients Self-Efficacy, Satisfaction & Engagement in Program Development Outcomes (Intermediate Effects) Improvements in Service Delivery: Access Coverage Quality Cost-Effectiveness Staff- & Team-Level Changes in: Knowledge Attitudes Practices Increase Proportion of Patients: Retained in Care & Achieved Viral Suppression Impact (Distal Effects) Psychosocial wellbeing improved among HIV-positive individuals HIV prevalence decreased in the community HIV incidence decreased in the community HIV morbidity & mortality decreased among HIV-positive individuals CHP Quality Improvement, Monitoring & Evaluation of Program 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT

23 Stimulating Transformation: Needs Assessment Care Coordination Inefficiencies in identifying who to follow-up Separate programs for adherence, care coordination, nursing care, medical care Communication Complex communication patterns Multiple staff members in various settings with variable communication Untapped opportunities for efficiencies through HIT 23

24 Stimulating Transformation: Needs Assessment Accessibility Need for strengthening patient access to same-day walk-in care Many providers are not on-site full time (fellows, researchers, etc.) No-shows High no-show rates resulting in lost capacity Staff working at the top of their license Primary Care Nursing 24

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27 Percentage Number and Proportion of Persons with HIV in New York City Engaged in Selected Stages of the Continuum of Care at the End of % 133, % 114,926 80% 60% 40% 20% 0% Estimated HIVinfected 86% of infected Ever HIVdiagnosed 97,940 73% of infected 85% of diagnosed Ever linked to HIV care 72,918 55% of infected 74% of linked to care Retained in HIV care in 2012 Engagement in HIV care 67,624 51% of infected 93% of retained in care Presumed ever started on ART 55,453 41% of infected 82% of started on ART Suppressed viral load ( 200 copies/ml) in 2012 Of all persons estimated to be infected with HIV in NYC, 41% have a suppressed viral load. As reported to the New York City Department of Health and Mental Hygiene by June 30, For definitions of the stages of the continuum of care, see Appendix 2.

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29 Community Outreach

30 Stimulating Transformation of Technology and Team structure to Reach People Living with HIV

31 STaR Practice Transformation Model: Providing More Care Through Harmonious Redesign (without sacrificing quality) Enhanced Communication Efficient Use of Clinical Space - Patient flow redesign Integrating Health Information Technology for Population Health Management - Designing IT dashboard to summarize key indicators for each team LTFU, High Acuity, etc. Panel-Based Clinical Care Team - Organizing staff into dedicated teams for specific groups of patients - Engaging Teams in Quality Coordinated Care Across Settings - Developing the role of the RN Clinical Care Coordinator to provide support transitions, facilitate CCTs and support navigators 31

32 STaR Practice Transformation Activities Practice Operations and Systems Practice Staff Consumers Pre- Implementation Implementation Evaluation 32

33 Panel-Based Care

34 Building the Clinical Care Teams 600 Provider (PCP)-Social Worker (SW) Team Alignment 300 Social Worker Distribution by Team A Provider PCP Team A PCP Team B PCP Team C PCP Team D PCP Team E 0 No SW Assigned SW Team E SW Team D SW Team C SW Team B SW Team A Salcedo Rojas Pudil Hidalgo Cruz Cella- Shackelford Cabrera Cabreja Campos 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT

35 Panel-Based Clinical Care Teams & Coordinated Care Across Settings CCT A STaR Clinical Care Coordinator at the Comprehensive Health Program CCT B CCT C CCT D STaR Clinical Care Coordinator: Provides CCT structure and training Supports Navigators, Community Health Workers and Peer Educators Crosses settings and program boundaries Social Worker(s) Registered Nurse Clinicians Care Coordinators Patient Navigators Social Worker Registered Nurse Clinicians Care Coordinators Patient Navigators Social Worker Registered Nurse Clinicians Care Coordinators Patient Navigators Social Worker(s) Registered Nurse Clinicians Care Coordinators Patient Navigators Adherence Supervisor, Community Health Worker, Peer Educator, Nutritionist, Psychiatrist, Patient Financial Advisors, & Other Staff Care Enhancements: Better communication Social Worker co-lead Clinical Care Teams Medication adherence through Primary Care RN Integration of HIV Prevention Coordinated Services for People with Complex Co-Morbidities Integration of Behavioral Health 35

36 Coordinating Weekly Care Team Meetings RN Care Coordinators send out daily reminders Pre-meeting planning between RN Care Coordinators and Social Worker (Team Co-Captains) Theme-based discussion calendar Review of Dashboard indicators 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT

37 Patient Discussion Structure 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT

38 Population Health Through HIT

39 Accesible Health Information Technology Improve registry functions Search for patients based on key indicators Uncontrolled HIV? Recent hopsitalizations? Recent visit? Lost to follow-up Accessible access to data summaries 39

40 Integration of Health Information Technology (HIT) for Population Health Management Updates to HIT to support team discussions (population health) and create efficiencies Collaboration with RDE Systems Dashboard design Adding additional key clinical indicators 40

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43 CCT New Clients 43

44 Clinical Care Teams from the Patient Perspective

45 Patient Clinical Care Team Sheet Improving Communication with Clients Clinical Care Team Provider names Photos Accurate contact information

46 How does this transformation occur in the clinic and how can stakeholders drive the process? 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT

47 Quality

48 Practice Transformation and Quality Improvement If we want safer, higher-quality care, we will need to have redesigned systems of care, including the use of information technology to support clinical and administrative processes. Committee on the Quality of Health Care in America (Institute of Medicine, Crossing the Quality Chasm, 2001) 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT

49 NYP QPS Goals and Metrics Nursing QPS CHP Goals and Metrics ACN QPS CHP Quality Program Implementing Practice Transformation through a Quality Framework QI (or Patient Care Improvement ) Teams PDSAs STaR Work Groups Program Monitoring Monthly Review of Program Performance Quality Assurance & Regulatory Compliance Outcome Measures Review (CHP/State/Regional) Program Outcomes Evaluation Staff Surveys & Focus Groups Patient Surveys 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT

50 Integrating Quality Improvement into Clinical Care Team Include all practice members Support development of PDSA cycles Provide data and administrative support to develop ideas Place Clinical Care Teams at the center so that team members explore shared goals and shared solutions 50

51 Care Teams QI Projects Timeline 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT

52 TEAM A Project

53 Facilitating Transformation: Updating the Treatment Adherence Program Jumpstart Adherence Program defunded Pre-poured pillboxes paired with education are essential adherence support intervention for patients Opportunities to use Nursing expertise in medications and patient education Prevention of Medication errors Nurses as an integral part of the Clinical Care Teams 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT

54 CCT Dashboard: Primary Care Nursing 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT

55 STaR Working Group on Medication Distribution & Adherence Support Working Group consisted of representatives from each of the stakeholder groups with interest: Registered Nurses Nurse Administrator Clinicians Adherence Supervisor Operations Manager STaR Team facilitated the creation of the Working Group and participated in the meetings 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT

56 Building on a Strength and Engaging Stakeholders for Transformation 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT

57 Planning Implementation of New Treatment Adherence Program Review the old process and policies with the following goals: Identify issues Medical errors Reconciliation issues Large number of patients pick-up medication (~200 patients) Identify opportunities for transformation Nursing expertise in medication and education Nursing now committed to dedicated Clinical Care Team (CCT) Solutions Shrink pick-up list Move medication reconciliation and adherence pick-up under Nursing Nursing will be able to guide CCT meetings with up to date knowledge 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT

58 Pre-Implementation Activities: Pilot & Evaluation Practice Transformation Interest Group Meeting September 58

59 Updating Protocol & Workflows 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT

60 Changes to the Medication Distribution & Adherence Program Workflow First Work Group Meeting on Medication Distribution, Reconciliation, & Adherence 2 Week Pilot New Medication Distribution via RNs April 2015 August 2015 September 2015 Clinical Care Teams Review Program Enrollment & Proposes Graduation from Program Medication Distribution Shifts to RNs, Updates to Adherence Program Policy and Workflow Finalized 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT

61 Treatment Adherence Program QI Team Clinical Care Team A Treatment Adherence Supervisor All RNs (4) STaR Project Director /Quality Manager 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT

62 QI Project AIM Increase, over a period of three months initially, the proportion of patients outreached, re-engaged and/or referred to other internal resources (e.g., Treatment adherence educator, Medical Case Management, or peer education) by those directly involved in implementing adherence support for CHP clients out of those patients enrolled in the program and who are failing to pick-up their medication or need additional adherence support NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT

63 Intermediate AIMS Regulatory Decrease number of medications returned to Pharmacy. Intervention Monitoring Achieve real-time monitoring of missed medication pick-ups Improve care coordination among those involved in treatment adherence monitoring and support Care Teams at Clinic, Community Partner Staff, Nursing Team 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT

64 Number of Patients CHP Adherence Program Population (February 2016): Viral Suppression (<200copies/mL) Rates by Teams N=150 47% 32% 32% 15% 12% 5% A B C D Clinical Care Teams Unsuppressed Overall, 64% viral suppression rate. Suppressed 6% 1% 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT

65 CHP Adherence Program Population (February 2016): Last Viral Load > 6 month N=23 Unsuppressed Suppressed 17% 83% 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT

66 PDSA Work Plan Action Step Details When Who 1) Develop and maintain Adherence Program population report through ecompas Get an updated list from AHF of patients picking-up at CHP; and Enroll patients in the Program in ecompas and maintain list so it is up-to-date Ongoing STaR Data Coordinator 2) Develop med pick-up tracking system Develop medication pick-up patient list and tables for monitoring missed medication pick-ups End of May Treatment Adherence Supervisor (TAS) 3) Medication pick-up weekly afternoon huddle Implement Friday afternoon huddle with RN and TAS to further refine weekly reports of missed medication pick-ups and protocol; identify patients to be outreached and discussed at CCT meetings Beginning of July RNs, TAS, and other team members as needed 4) Identify patients for CCT meeting discussion Patient discussion might result in an intervention including but not limited to: 1) referral to peer program, 2) referral to TAS, 3) referral to MCM, 4) need to be outreached and scheduled for PC visit. Beginning of July RNs, TAS, and other team members as needed 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT

67 TAS often excluded from day-to-day patient encounters and pick-ups Peer referrals dropped off Nurses with many responsibilities and less time for intensive cases TAS able to attend team meetings RN variable team meeting attendance TAS not aware of who is picking up/not (prev based on individual patient interactions) Team QI PDSA (Where we lost ground) 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT

68 Changes to the Medication Distribution & Adherence Program Workflow Primary Care Nursing Panels in CCT Dashboard Updated December 2015 March 2016 July 2016 Start of QI Discussions at CCTs Meetings, and Team A Proposes PDSA Nursing Panel Reviews at CCT Weekly Meeting Start PDSA Implementation Starts: Weekly Friday Afternoon Huddles, Meds put on Hold, and Targeted Patient Outreach 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT

69 Team QI PDSA Progress (What We Have Accomplished) Coordinated with Pharmacy - accurate master list of patients picking up med Reviewed Master Medication Delivery logs for teams Conducted four afternoon Adherence QI huddles in July with RNs, TAS, and Quality Manager Patient tracking list TAS coordinating with pharmacy to reduce med returns Weekly Huddles assure improved RN- TAS communication proper med returns Identified and reached out to patients who need more support referred for peer, MCM, TAS support via Team structure 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT

70 Meds Missed Pick-up & Viral Load Suppression Tracking Tool Tables

71 Creating Efficiencies Adherence Program Indicators in the CCT Dashboard Adherence Program 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT

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75 Secure Data Transfer 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT

76 Summary Involving stakeholders in all the stages of process improvement and transformation Building trust Using HIT solutions to achieve efficiencies and enhance communication Employing QI approaches or tools allow for systematic assessment of changes Leveraging Clinical Care Team to support continuous quality improvement 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT

77 Examination of organizations that have achieved and sustained substantial performance improvements reveals that lasting transformation requires the relentless hard work of local operational redesign. 77

78 STaR Team Susan Olender - PI Mila Gonzalez - Project Director Audrey Perez - Clinical Care Coordinator Marilena Lekas - Evaluator James Beltran - Data Manager Jesse Thomas - HIT Consultant, RDE Anusha Dayananda - HIT Consultant, RDE Peter Gordon Medical Director 78

79 Questions 2016 NATIONAL RYAN WHITE CONFERENCE ON HIV CARE & TREATMENT

80 Efficient Use of Clinical Space

81 Current CHP Patient Flow Model Reg & DC Meds NA Waiting Room RN PCP 81

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83 HP6 Proposed Patient Flow Model Patient Arrives Pt checks in at front desk Pt Presents insurance card Patient is Registered PFA Arrives Patient in Eagle and updates Pt Status in XA. PFA verifies pts insurance PFA updates demographic information PFA prints label and room assignment on encounter form. PFA updates Pt Status to read r for vitals, SW, JS, CASAC, RD, etc. Vital Signs Conducted NA takes pt to exam room assigned (on encounter form) NA conducts vital signs NA updates pt status list r for PCP. In exam room PCP sees Patient PCP informed pt is ready via pt status column. PCP sees pt; updates pt status; completes documentation including orders; updates pt status: r for RN, r for D/C, DC by MD PCP exits exam room and visits next pt. RN sees Patient RN notified to see pt via pt status and by monitoring doctors orders RN gets pt; updates status w/ RN, sees pt; when finished, updates status r for D/C. Patient Checks Out Pt exits exam room (either after PCP or RN) and proceeds to front desk. PFA completes any PCP orders PFA discharges patient OR Patient uses mynyp.org and checks on appts from home. CRD 2/08/11