National Disparities LAN Event Driving High Performance for Chronic Disease Management Teams. Wednesday, September 13, :00 4:30 PM ET

Transcription

1 National Disparities LAN Event Driving High Performance for Chronic Disease Management Teams Wednesday, September 13, :00 4:30 PM ET

2 Welcome and Reminders Please be prepared for sharing and open discussion. Slides and a recording from today s session can be found on Melanie Wasserman Event Lead Nora Serres Chat Manager

3 Set the Tone Please commit to being Fully present and engaged Open-minded Collaborative and willing to participate Willing to share successes and challenges Ready to value each other s experiences

4 Today s Topics 1. Project Impact: helping low-resource practices meet blood pressure goals 2. Resources for Chronic Care Management teams from the CMS Office of Minority Health

5 Let s Take a Poll Which chronic conditions are you focusing on in your work? Click all that apply. a. Diabetes b. Hypertension/cardiovascular health c. Mental/Behavioral health d. Other (describe in chat)

6 Question to Run On Based on what you hear today, what strategies might you try?

7 Meet Your Panelists Nadia Islam, PhD NYU School of Medicine Joanne Vanterpool, MBA IPRO Corporate Office Jennifer Zanowiak, MA NYU School of Medicine Sonya Karpiak Bowen, MSW CMS

8 Department of Population Health Implementing Million Hearts Using an Integrated Community Health Worker and Provider Model Nadia Islam, PhD Quality Innovation Network National Coordinating Center (QIN NCC) National Disparities Learning Action Network Webinar September 13 th, 2017

9 NYU-CUNY PRC ( ) Mission: To develop and evaluate effective and sustainable community-clinical linkage models for chronic disease prevention in urban areas Goals: 1) Develop, test and evaluate community-clinic-based interventions 2) Develop, test and disseminate a set of CHW and EHR-based tools targeting Million Hearts goals 3) Provide technical assistance to our stakeholder network regarding the population health impact of chronic diseases 4) Develop and implement training programs that build capacity and leadership of public health and clinical practitioners to implement community-clinical linkage strategies CDC-Funded Core Research Project Project IMPACT (Integrating Million Hearts of Provider and Community Transformation) Externally-Funded Research Project HHAP (Harlem Health Advocacy Partners)

10 Background

11 US Million Hearts Campaign Preventing 1 million heart attacks & strokes by 2017 Federal initiative co-led by CDC and CMS (launched 2012) that aims to prevent heart disease and stroke by: Improving access to effective care Improving the quality of care for the ABCS Strategies Scale-up proven community & clinical interventions Foster partnerships Few MH initiatives in immigrant communities or small primary care practice settings >50% of practices in the U.S. are solo, two-physician, or 3-5 physician practices Practices with <5 physicians represent over 40% of the primary care providers in New York City, and many serve low-income residents who are not native English speakers Sources: Casolino 2014; Burke 2015.

12 Burden of Cardiovascular Disease in South Asian Americans South Asian Americans immigrants from India, Bangladesh, Pakistan, Nepal, or Burma Cardiovascular disease is leading cause of death Higher prevalence of obesity and diabetes Similar prevalence of hypertension, but unique risk factors (younger age, BMI) No previous studies developed models for hypertension prevention and management in this population Sources: Hoeffel et al, 2012; Hastings et al., 2015; Yi et al., 2015; Gupta et al., 2011; Gupta et al, 2006; Kanaya et al,

13 Project Overview: Goals, Study Design, & Methods

14 Project IMPACT Implementing Million Hearts for Provider and Community Transformation Overall Goal: Integrate 2 evidence-based strategies for hypertension (HTN) management for South Asian patients in small primary care practice settings Electronic Health Record (EHR) intervention Community Health Worker (CHW) intervention Alerts Registries for uncontrolled HTN patients Improve HTN Control In-language education Perform registry queries Schedule appointments to reduce gaps in care

15 Study Design Modified stepped-wedge design Enrolling 16 small primary care practices All participating practices receive EHR intervention A CHW intervention will be phased after 1 year at all practices Group 1 Practices (sites 1-3) Group 2 Practices (sites 4-6) Group 3 Practices (sites 7-9) Group 4 Practices (sites 10-12) Group 5 Practices (sites 13-16) 15 Baseline and follow-up EHR data collection

16 Practice Recruitment Process and Outcomes Site Identification (n=40) HF practice network HF practice engagement events Other outreach Practice Assessment (n=29) Outreach letters Calls Face to face visits Practice enrollment (n=16)

17 Protocol Workflow Practice Outreach Practice assessment survey Sign MOU to enroll in the project Establish protocol for baseline and quarterly data collection from EHR Workflow analyses and trainings to Implement EHR Intervention Launch EHR Intervention Integrate CHW-led group and individual counseling protocol after 12 months

18 EHR Component Protocol 3-Day Implementation and Launch Day 1: Workflow Analysis & Baseline Assessment Day 2: Training on Registries, MU, & PCMH Day 3: Training on Order Sets/Alerts 5 Technical Assistance Sessions Quarterly Data pulls

19 Baseline Results: Practice & Patient Characteristics Practices enrolled serve high need immigrant populations ~28% of patients have a HTN diagnosis Practices have been operating for an avg of 7.3 years Avg 2 physicians, 4 staff 75% of patients are South Asian 80% of patients are insured by Medicaid/Medicare

20 Feasibility and Acceptability EHR component is feasible to implement in small practices Providers are enthusiastic Since we were using ECW we never used the Registry and now by using it we are able to extract the Hypertension patients who did not come to our practice since last one year.. now we are working to be PCMH certified. Average Training Time= 4.6 hours Average # of TAs= 4

21 Challenges Practice Context Resource constraints, EHR knowledge Community Context Immigrant, LEP, and diverse populations Partner Context Payer and Vendor to accommodate small practice needs

22 Key Considerations in Working with Small Practices & Implications for Scalability 1) Practice engagement is complex 2) Programmatic needs are unique 3) HIT solutions must accommodate practice and community context 4) CHWs can complement HIT efforts

23 CHW Component Protocol Recruitment of uncontrolled HTN patients using registry lists and tabling by CHWs in practice CHW delivers 5 group educational sessions and 10 follow-up phone calls/in-person visits with patients CHW-clinical integration: CHW participants in clinic staff meetings CHW sends participant action plans and status to clinicians CHWs meet with clinicians as needed

24 CHW Integration into IMPACT Practices: Early Lessons Enhancing EHR capacity of practices to manage hypertension patients cues practices for CHW efforts CHW engagement with practices is just as critical as CHW engagement with patients Acceptability of CHW model is high with patients and practices Challenges

25 IMPACT Products Culturally tailored educational materials and curricula on HTN management Training Manuals on EHR implementation CHW Protocols Policy Briefs/White Papers research2/nyu-cuny%20prc%20- %20Integration%20of%20CHWs%20into%20Primary%20Care%20Systems.pdf

26 Acknowledgements/Contact Information Study Team: Lorna Thorpe, Priscilla Lopez, Anna Divney, Jennifer Zanowiak, Shree Subhedi, MD Uddin, Mursheda Begum, Sidra Zafar, Mamnunal Haq, Susan Beane, Rashi Kumar, Phoebe Laughlin, Adetola Ilegbusi, Ahmad Masoud, Joanne Vanterpool, Susan Hollander, Chau Trinh-Shevrin Funding Source: CDC U48DP Contact: Nadia Islam, PhD NYU School of Medicine

27 Next up Nadia Islam, PhD NYU School of Medicine Joanne Vanterpool, MBA IPRO Corporate Office Jennifer Zanowiak, MA NYU School of Medicine Sonya Karpiak Bowen, MSW CMS

28 Overview of IPRO s Collaboration with Project IMPACT in Engaging Small Practices In Blood Pressure Control Joanne Vanterpool, MBA Senior Clinical Practice Advisor September 13, 2017

29 Atlantic Quality Innovation Network (AQIN) The federally funded Medicare Quality Innovation Network Quality Improvement Organization (QIN-QIO) for New York State, the District of Columbia, and South Carolina Led by IPRO Partners include Delmarva Foundation in the District of Columbia and The Carolinas Center for Medical Excellence in South Carolina. One of 14 QIN-QIOs operating across the U.S.

30 Atlantic Quality Innovation Network (AQIN) Works toward better care, healthier people and communities, and smarter spending Catalyzes change through a data-driven approach to improving healthcare quality Collaborates with providers, practitioners and stakeholders at the community level to share knowledge, spread best practices and improve care coordination Promotes a patient-centered model of care, in which healthcare services are tailored to meet the needs of patients

31 Project IMPACT s EHR-CHS Intervention Program Assist practices to maximize the use of their electronic health records (EHR) Workflow analysis to identify least disruptive method for providing intervention strategies Provide efficient strategies for incorporating EHR solutions in the practice Improving blood pressure control and cardiovascular health 32

32 IPRO s Technical Assistance For Project IMPACT, IPRO assists practices with: Data capture of blood pressure control and electronic reporting Aggregate data extraction for benchmark periods As part of the 11 th SOW cardiovascular health project, IPRO assists practices by providing: Help in data collection, validation, analysis, feedback on the ABCS metrics (anti-platelets, blood pressure, cholesterol, smoking) Patient self-management training in hypertension & diabetes Assistance in patient-centered medical home recognition (PCMH) Staff training in blood pressure measurement, management and quality improvement Sessions on motivational interviewing Assistance with federal incentive programs, e.g., Meaningful and the Quality Payment Program 33

33 IPRO Site visits During site visits to practices, IPRO staff: Train practices on EHR functionality to record structured data for MU Assist practices in pulling data for cardiovascular health project Review meaningful use benchmark data Assist in developing ideas for patient engagement, i.e., patient portal, electronic referrals, and Rx formulary check Provide informational sessions about PCMH 34

34 Barriers to Overcome Practices are not aware of all of the capabilities of their EHR, e.g., reminders, alerts, order sets, templates, registry reporting Some EHRs are limited in the ability to produce reports needed by Project IMPACT Patient engagement, including patient adherence to blood pressure management, is difficult Practices are reluctant to engage in virtual visits 35

35 MU Alignment with EHR-CHS Intervention MU Objective 2: Clinical Decision Support Measure 1: Implement 5 clinical decision support interventions related to 4 or more clinical quality measures at a relevant point in patient care for the entire EHR reporting period Measure 2: Provider has enabled and implemented functionality for drugdrug and drug-allergy interaction checks for the entire EHR reporting period MU Objective 6: Patient-Specific Education Measure: Patient-specific education resources identified by certified electronic health record technology (CEHRT) are provided to patients for more than 10 percent of all unique patients with office visits seen by the provider during the EHR reporting period. 36

36 NCQA PCMH 2014 Standards: Alignment with EHR-CHW Intervention 3.B.3. Blood pressure, with the date of update, for more than 80% of patients 3 years and older (3 month report) 3.D.3. Report identifying patients with at least 3 chronic or acute conditions 3.D.4. Report identifying patients not recently seen by the practice 3.E.2. Implement evidence-based decision support for a chronic medical condition 4.E.2. Provide educational materials and resources to patients

37 NCQA PCMH 2017 Standards: Changes in Structure PCMH 2017 standards have changed, including: Improved focus and flexibility Support of continuous practice transformation Emphasis on comprehensive, integrated care Alignment with Project IMPACT blood pressure control goals: Practice provides access to educational resources, such as self-management tools (Knowing & Managing Your Patients, Competency F; KM 22) Practice systematically identifies patients who may benefit from care management (Care Management and Support; Competency A; CM 01)

38 For more information: Joanne Vanterpool, MBA Senior Clinical Practice Advisor (516) IPRO CORPORATE HEADQUARTERS 1979 Marcus Avenue Lake Success, NY IPRO REGIONAL OFFICE 20 Corporate Woods Boulevard Albany, NY

39 Next up Nadia Islam, PhD NYU School of Medicine Joanne Vanterpool, MBA IPRO Corporate Office Jennifer Zanowiak, MA NYU School of Medicine Sonya Karpiak Bowen, MSW CMS

40 Project IMPACT Community Health Workers Responsibilities of the CHW Supervisor Typical Workday for Project IMPACT CHWs Fostering good relations between CHWs and Primary Care Team Supporting and Engaging CHWs

41 Next up Nadia Islam, PhD NYU School of Medicine Joanne Vanterpool, MBA IPRO Corporate Office Jennifer Zanowiak, MA NYU School of Medicine Sonya Karpiak Bowen, MSW CMS

42 Solutions for Individuals with Disabilities, Patients with Limited English Proficiency, and Duals CMS Office of Minority Health Sonya Bowen, Program Alignment and Partner Engagement September 14, 2017

43 CMS OMH Mission and Vision Mission To ensure that the voices and the needs of the populations we represent (racial and ethnic minorities, sexual and gender minorities, rural populations, and people with disabilities) are present as the Agency is developing, implementing, and evaluating its programs and policies. Vision All CMS beneficiaries have achieved their highest level of health, and disparities in health care quality and access have been eliminated.

44 Path to Equity Understanding, Solutions, Actions (U.S.A.) Our path to equity in Medicare quality consists of three interconnected domains.

45 What is a Health Care Disparity? Clinical Appropriateness and Need Patient Preferences Quality of Health Care Group A Group B Difference The Operation of Healthcare Systems and Legal and Regulatory Climate Discrimination: Biases, Stereotyping, and Uncertainty Disparity SOURCE: Figure 1. Differences, Disparities, and Discrimination: Populations with Equal Access to Healthcare. Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, Summary. Brian Smedley, Adrianne Stith, and Alan Nelson, Eds. Washington, DC. Institute of Medicine, 2002.

46 Health Disparities among People with Disabilities Health Indicator People With Disabilities (%) People Without Disabilities (%) Data Source Health care access In past year, needed to see doctor but did not because of cost a BRFSS 2010 Women current with mammogram a BRFSS 2010 Women current with Pap test a BRFSS 2010 Health behaviors Adults who are obese a,b NHANES Adults who smoke (100 cigarettes in lifetime and currently smoke) a NHIS 2010 Annual no. of new cases of diagnosed diabetes (per 1000 persons) a NHIS Adults with cardiovascular disease y NHIS y NHIS Adults reporting sufficient social and emotional support a BRFSS 2010 Social determinants of health Internet access NOD 2010 Household income < $ NOD 2010 Inadequate transportation NOD 2010 a Age-adjusted. b Obesity defined as a body mass index of 30 kg/m 2. BRFSS = Behavior Risk Factor Surveillance System; CPS = Current Population Survey; NCVS = National Crime Victimization Survey; NHANES = National Health and Nutrition Examination Survey; NHIS = National Health Interview Survey; NOD = National Organization on Disabilities Survey of Americans with Disabilities; All differences reported are statistically significant. Source: Krahn GL, Walker DK, Correa-De-Araujo R. Persons With Disabilities as an Unrecognized Health Disparity Population. American Journal of Public Health. 2015;105(Suppl 2):S198-S206. doi: /ajph

47 CMS Equity Plan Priorities Priority 1: Expand the Collection, Reporting, and Analysis of Standardized Data Priority 4: Increase the Ability of the Health Care Workforce to Meet the Needs of Vulnerable Populations Priority 2: Evaluate Disparities Impacts and Integrate Equity Solutions Across CMS Programs Priority 5: Improve Communication & Language Access for Individuals with LEP & Persons with Disabilities Priority 3: Develop and Disseminate Promising Approaches to Reduce Health Disparities Priority 6: Increase Physical Accessibility of Health Care Facilities

48 Communication and Language Access Resources Understanding Communication and Language Needs of Medicare Beneficiaries (Apr CMS OMH issue brief at go.cms.gov/omh) CMS OMH resources coming soon: How Healthcare Providers Meet Patient Language Needs: Highlights of a Medscape Provider Survey Building an Organizational Response to Health Disparities series: Guide to Developing a Language Access Plan Approaches to Providing Communication and Language Services to Diverse Populations: Lessons from the Field

49 Physical Accessibility Resources Increasing the Physical Accessibility of Health Care Facilities (May 2017 CMS OMH issue brief at go.cms.gov/omh) CMS OMH resources coming soon: Provider toolkit for identifying and removing accessibility barriers in health care settings, and understanding and meeting patient accommodation needs Beneficiary education materials on understanding rights for accessible health care services and how to ask for needed accommodations

50 RightNow Tool: QIN-QIOs Can Ask CMS Questions RightNow is an application Supports answering and posting of answered questions Website: Create a Login Ask a disparities or health equity question or Look Up an answer

51 Resources for Integrated Care for Providers Serving Duals CMS Medicare-Medicaid Coordination Office provides technical assistance to expand provider capacity to serve dually eligible enrollees through the Resources for Integrated Care: RIC provider resources: Webinar series exploring facets of Disability Competent Care (DCC) model DCC Self-Assessment Tool DCC Self-paced Training Assessment Review Tool

52 Connected Care Resource Hub Information for Health Care Professionals Access resources and tools explaining the benefits of CCM and how to implement this service Information for Patients Access easy-to-read information on the benefits of CCM for Medicare beneficiaries living with two or more chronic conditions Campaign Partnership Resources Access information about partnering to bring awareness to CCM through the Connected Care campaign Visit the Connected Care Hub at: go.cms.gov/ccm Contact CMS with CCM questions:

53 Facilitated Discussion Q: What are the demographics, specifically ages, types of comorbidities, and disabilities, of the patient population included in the program? A: It is a research program; There are some eligibility requirements: (18-80 years old, HTN, uncontrolled HTN reading within last 6 months). The population is largely Medicaid with high rates of DM and HTN. Q: What role did the CHW play with self-management in the program? A: CHWs provide group sessions that cover topics such as healthy diet, physical activity, risk factors (CHO, smoking), how to communicate with doctors, and medication adherence. CHWs have bi-weekly follow-up calls to set goals with the patients.

54 Facilitated Discussion Q: What are some things to promote patient engagement in the program? A: There is a letter from the provider that promotes the program and gives the CHW contact information, provides pictures of the CHW. There are sessions at multiple times, including Saturdays. We hold sessions at community based organizations (community centers, libraries). We also provide metro cards to help with transportation. Q: Do the CHW have any educational requirements? A: It is more important that they have a connection to the community. The job description includes attributes that CHWs need. We also work with community leaders. We do ask that CHWs have a HS or GED diploma, but not always necessary if have desired characteristics. We train CHWs on core competencies.

55 Facilitated Discussion Q: Could you address problems identified at the beginning? A: We didn t have capacity to standardize equipment across practices. We did partner with IPRO to implement BP protocols. Practices needed help with EMR capabilities. We helped with that. Now, practices have incorporated components from the trainings; Meaningful Use reports show that practices have better understanding and are incorporating changes. Q: Did you have trouble recruiting CHWs if they are not paid? A: We feel that CHWs have a professional identity and are a part of the clinical team. It is difficult to have volunteer CHW model. Through Medicaid expansion, there are opportunities to pay CHW. There are payment incentive models that exist; have to determine most effective models.

56 Facilitated Discussion Q: Can you tell us about your grant and CHW payment? A: The grant covers CHW pay. NYU has community service plan that supports CHWs. Q: Is there a sustainability piece? A: Impact work: The EHR component enhanced practice capacity. IPRO: Practices continue to work with us on other initiatives. IPRO will provide assistance on other federal models.

57 Facilitated Discussion Q: Are there resources for practices to adapt for people who use wheelchairs? A: There are different resources available for health care providers; through the Administration for Community Living s ADA National Network there are regional centers that can help. The ADA National Network website is adata.org. Information and technical assistance are also available through the following Federal websites: Department of Justice ( and HHS Office for Civil Rights ( Practices can use available selfassessment tools that can help inform the development and implementation of an accessibility plan and timeline. CMS OMH is developing a provider tool-kit that will provide a framework to facilitate the process. OMH CMS has mailbox for participants to ask questions: healthequityta@cms.hhs.gov

58 Facilitated Discussion Q: How did you develop your relationship with HealthFirst and develop relationship with vendors? A: HealthFirst engages with communities/practices and minority communities. We met with them after grant opportunity presented itself. They had experience with self-management model. Leadership is engaged and committed to this type of model. They are willing to share data with research team. Medicaid expansion helps bring population health into health management. Vendors: Practices needed to run a report that is accurate. We worked with them to develop a report that would help with the study and help practices track uncontrolled HTN patients. Another vendor we worked with pulled data using our parameters. We built the cost of working with vendors into the grant. Practices do not have these resources. We could help negotiate prices to run the report.

59 Facilitated Discussion Q: Do you encounter any issues with privacy and sharing patient data? A: At IPRO, we only take numerator and denominator information; do not gather patient level data Q: How did you get practice staff engaged? A: We went out to practices. We identified practices that were members of HealthFirst and served our target population. HealthFirst provided language data on providers. We went to the offices to provide brief overview to staff and we invited providers to a 15 minute PowerPoint presentation that explained our two-pronged approach (EMR and CHW); IPRO accompanied on practice visits. This material was prepared by Telligen, the Quality Innovation Network National Coordinating Center, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-QINNCC /27/17

60 Let s Take a Poll To what degree do you agree with this statement: I would recommend an event like this one to a colleague. a. Totally Agree b. Agree c. Neither Agree or Disagree d. Disagree e. Totally Disagree

61 Call to Action Identify one strategy you heard today that you can implement immediately (post in chat!) Complete the post-event assessment upon exiting WebEx:

62 Call For Future Topics We want to hear from you! Do you have a need or desire to hear about a certain topic? Submit your ideas in chat or the QIN NCC at: QINNCC@area-d.hcqis.org

63 Save the Date! 10/11/17 Medication Safety LAN Event A Review of Patient Activation and Prescription Drug Monitoring: Resources to Enhance Medication Management with Patients Registration Required: 7f4212a2b200bdbf0a 11/8/17 National LAN Event Engaging Physicians & Care Teams to Prevent & Manage Diabetes Registration Required: fc3129e1d75574c6e This material was prepared by Telligen, the Quality Innovation Network National Coordinating Center, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-QINNCC /31/17

64 Q&A: Peer-to-Peer Sharing