Strategy Guide Specialty Care Practice Assessment

Transcription

1 Practice Transformation Network Strategy Guide Specialty Care Practice Assessment 1/20/2017

2 1 Strategy Guide: Specialty Care PAT 2.2 Contents: Demographics Tab: 3 Question 1: Aims... 3 Question 2: Aims... 4 Question 3: Aims... 4 Question 4: Patient & Family Engagement... 5 Question 5: Patient & Family Engagement... 5 Question 6: Team Based Relationship... 6 Question 7: Population Management... 6 Question 8: Community Partner... 7 Question 9: Coordinated Care... 7 Question 10: Coordinated Care... 8 Question 11: Organized Evidenced-Based Care... 8 Question 12: Enhanced Access... 9 Question 13: Engaged & Committed Leadership... 9 Question 14: Quality Improvement Strategy Supporting Culture of Quality Question 15: Quality Improvement Strategy Supporting Culture of Quality Question 16: Transparent Measurement & Monitoring Question 17: Optimize Health Information Technology Question 18: Strategic Use of Revenue Question 19: Workforce Vitality & Joy in Work Question 20: Capability to Analyze & Document Value Question 21: Capability to Analyze & Document Value Question 22: Operational Efficiency Page PFE Metric 1: Active E-Tools PFE Metric 2: Shared Decision-Making PFE Metric 3: Patient Activation... 16

3 2 PFE Metric 4: Health Literacy PFE Metric 5: Medication Management PFE Metric 6: Support for Patient and Family Voices The Compass Practice Transformation Network is supported by Funding Opportunity Number CMS-1L from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the views of the U.S. Department of Health and Human Services or any of its agencies.

4 3 Demographics Tab: Use Compass unique identifier in title. For example: Smith Family Practice IA0123. Issues with not entering the same Practice Name: o The data processing team will be unable to match PAT s to practices and we will be unable to track phases and milestones o Unable to track if the assessment was completed (Baseline or Re-Assessment) Primary Care Practice Type-Must choose the same type every time Issues when not choosing same type o The data processing team is unable to match the baseline PAT s with follow up PAT s o The data team is erroring them and not counting them towards PAT counts TIN-Must include practice TIN with every submission or will get error report from data team and will not get counted towards total PAT s Practice Location Zip Code+4- must enter the four digits following the zip code with every PAT (example: ) Will get error report from data team and will not count the PAT Use if unsure of the zip + 4 Question 1: Practice has met its target and has sustained improvements in practice-identified metrics for at least one year. Aims Ambulatory Quality Measure/Initiative Performance (if applicable) Ambulatory Quality Measure/Initiative Performance Optimal Diabetes Care Controlling High Blood Pressure Use of Appropriate Medications for Asthma Effective Care of Heart Failure Reduction of Imaging Studies for Low Back Pain Appropriate Treatment for Children with Upper Respiratory Infection (URI) Reduction in All-Cause 30-day Readmission Rate Reduction of Overuse of Diagnostic Imaging for Uncomplicated Headache Reduction of Overuse of Diagnostic Imaging for Simple Syncope Avoidance of Unnecessary Use of CT in Immediate Evaluation of Minor Head Injury Reduction of Overuse of Diagnostic Imaging for Uncomplicated Sinusitis

5 4 Does clinic measure performance on any of the above? Are you implementing change strategies and demonstrating improvement? Are you meeting the 2016 goals or had been meeting goals prior to recent increase? o If yes to either, assign score of 3 Question 2: Practice has reduced unnecessary tests, as defined by the practice. Aims Choosing Wisely measures Professional practice guidelines Do your providers follow any guidelines that recommend against use of unnecessary testing? Do your providers follow any of the choosing wisely measures? Do you measure your performance? *Need baseline data, regular monitoring, and demonstrating improvement to assign score of 3 Question 3: Practice has reduced unnecessary hospitalizations. Aims Quality department monitors potentially preventable admissions, readmissions and ER visits Transitions of care improvement work RN Health Coach, high-risk Care Managers, Case Managers, Transitions Coordinators coordinating care, Community Paramedic Program; helping to provide care at the right place and right time Established a baseline around hospitalization and readmission data Are you doing improvement work to improve patient care transitions? Are you doing improvement work to help take care of patients outside of our 4 walls to prevent them from being admitted / readmitted unnecessarily? *Need baseline data, regular monitoring, and demonstrating improvement to assign score of 3

6 5 Question 4: Patient & Family Engagement Practice can demonstrate that it encourages patients and families to collaborate in goal setting, decision making, and selfmanagement. Patient Centered Medical Home Patient centered care - goal setting Care plan development nothing about me without me Advanced care planning Better Choices Better Health (Iowa Department of Public Health) o Other chronic disease self-management or wellness programs are also included in self-management If you are PCMH certified or following medical home model (i.e. MN Health Care Home, IA Health Home, SD Medicaid Health Care Home) score a 3 Are you routinely implementing goal setting, care plan development and can demonstrate that patients and families collaborate in this goal setting? (even if that means manual chart review) Are you routinely connecting patients with wellness and self-management programs? *Need demonstration/examples (i.e. care plans, documentation of self-managements goals, compacts) Question 5: Patient & Family Engagement Practice has a formal approach to obtaining patient and family feedback and incorporating this into the QI system, as well as the strategic and operational decision made by the practice. Patient and family advisory council Patient experience surveys (Press Ganey, Healthstream, department specific) Patient reps Seven Ways to Give Feedback Do you have a patient and family advisory council?

7 6 Do you review your patient experience data and consistently do performance improvement around identified areas of opportunity? Examples of operational or strategic decisions made around patient feedback: o Open scheduling, opening provider notes, patient portal scheduling o Clinic wait times o Service excellence; friendliness of registration, nursing and physician o PI Based off feedback Question 6: Team Based Relationship Practice sets clear expectations for each team member s functions and responsibilities to optimize efficiency, outcomes, and accountability. Scope of practice work with nursing teams Nursing protocol development and implementation Clinic workflows to improve efficiency Quality measures: o Low performers identified and working with department chairs to improve quality measures o Data reviewed regularly o Physician and quality data displayed by provider Panel management work Have you participated in scope of practice work for nursing? Have you worked internally to improve efficiency in day-to-day processes? o e.g. Smooth patient check-in s/out s, wait time decreases, clinic flow Have you set clear expectations for quality outcomes? o What occurs during the rooming process, what occurs when the provider is present, who else can help improve quality outcomes? Are you holding team members accountable for quality? Question 7: Population Management Practice has a reliable process in place for identifying risk level of each patient and providing care appropriate to the level of risk. Risk identification may be done within the specialty practice or may be obtained from the patient s primary care provider. Practice ensures that patients assessed to be at highest risk receive care management support or have a care plan in place that the practice is following.

8 7 Completion of specialty-specific assessment done prior to clinic visit/ clinic procedure Completion of any socioeconomic assessment to determine best care plan Team collaborate on patient risk Care plan documentation Timely Information sharing with outside facilities Nurse navigators for highest risk population Use of registry to identify risk levels Daily Huddles performed at clinics to plan care for the day Does your clinic staff work with other care management roles to support the care plan for high risk patients? Are reports being run to identify low and intermediate risk patients as well? Does your clinic hold short Huddles to plan daily care, every day? Question 8: Community Partner Practice facilitates referrals to appropriate community resources, including community organizations and agencies, as well as direct care providers. Guide for Available Community Resources Referrals to community agencies (i.e. public health, home health, community paramedic programs, WIC, social services, addiction counseling, etc.) Individualized patient outreach based on risk to follow-up on referrals by care team o Patient Registry & staff message reminders Do you have a community resources inventory (i.e. binder/online resource)? Does your practice consistently link patients with community resources and follow-up on referrals when necessary? Question 9: Coordinated Care Practice works with the primary care practices in its medical neighborhood to develop criteria for referrals for episodic care, co-management, and transfer of care/return to primary care, processes for care transition, including communication with patients and family.

9 8 Specialty and Primary Care practices communicate about care transitions and the role each will play in a patient s care Define the medical neighborhood with which the practice works most closely. Information is shared through the EHR and other avenues with the medical neighborhood/non-sanford facilities Ensure that useful information is shared with patients and families at every care transition, i.e. utilizing the After Visit Summary (AVS). Has your clinic identified your medical neighborhood and do you have formal agreements in place that define the needs of all parties? Do you have strong processes in place for transitions of care in your medical neighborhood? Question 10: Coordinated Care Practice identifies the primary care provider or care team of each patient seen and (when there is a primary care provider) communicates to the team about each visit/encounter Identifying and confirming the patient s PCP at every Specialty visit Communication about care to the PCP occurs after each Specialty visit Does your clinic identify and confirm (in the EHR) the PCP of the patient at each visit? Does your clinic have a process to communicate with the PCP after each Specialty visit? Question 11: Organized Evidenced-Based Care Practice uses evidence-based protocols or care maps when appropriate to improve patient care and safety. Evidence-based Protocols/Guidelines are developed and approved internally Protocols are documented through care/process maps or workflows Protocols are built as a resource into the EHR Condition-specific pathways for chronic condition treatment are guided by protocols Compass PTN Considerations: Can your staff access the clinic protocols/guidelines?

10 9 Do you have a way of monitoring or measuring this to ensure standardization of care? Is your staff consistently using the clinic protocols/guidelines? Question 12: Practice has a system in place for patients to speak with their care team 24/7. Enhanced Access Centralized Call Center to more efficiently manage patient calls. Patient portal is encouraged by staff for patients to utilize. Provide access to patient chart to staff / providers after hours. Provide same-day or next-day access to a consistent provider or care team as needed for urgent care Same Day, Walk in Clinics, Acute Care. 24/7 access to provider or care team for advice about urgent and emergent care. Has your clinic increased the number of patients that are utilizing the patient portal? Does your clinic direct patients on who to contact and when to contact with protocol driven care as an option? Is there a provider accessible to the patient 24/7 for urgent and emergent care? Examples of accessible care 24/7: Same Day, Walk in Clinics, Acute Care Clinic. Have you expanded the hours of the clinic? Question 13: Engaged & Committed Leadership Practice has developed a vision and plan for transformation that includes specific clinical outcomes and utilization aims that are aligned with national TCPI aims and that are shared broadly within the practice. PI Plan that aligns with the goals of the organization Protocol based care, integrated medical home team based-care pilots, clinical practice guidelines Include Quality and Transformation information at staff meetings. Data posted on visibility boards Incorporate Joy in Work strategies Are there dedicated hours for staff to devote to Quality Improvement? Are there meeting minutes that reflect discussions/education on Quality?

11 10 Is the PI Plan and Action Items posted in your clinic? Is your practice implementing clinical services strategies? Has your clinic aligned Quality and/or Clinical Services Strategies with other operational plans? If your clinic has developed and shared a vision and detailed plan that address the goals and how these goals will be achieved, assign a score of 3. Question 14: Quality Improvement Strategy Supporting Culture of Quality Practice uses an organized approach (i.e. use of PDSAs, Model for Improvement, Lean, FMEA, Six Sigma) to identify and act on improvement opportunities. Improvement Model o PDSA, Lean, FMEA, Six Sigma o Project Charter, 100-day plan, Report Out Action plans are posted for staff awareness and assistance with improvement. Interdisciplinary staff committee to lead change and improvement within the organization. Have you provided education to your staff on Process Improvement? Are Process Improvements tools utilized consistently in your clinic? Are staff able to articulate an improvement process that is presently being utilized in the clinic? Does your clinic have an interdisciplinary team to lead change and improvement? Does your clinic use Process Improvement, 100-day plans or an alternative improvement method for projects? Question 15: Quality Improvement Strategy Supporting Culture of Quality Practice builds QI capability in the practice and empowers staff to innovate and improve. PI Plans and Quality Improvement are included in new staff/provider orientation Improvement model education Quality Dashboard and individual provider progress toward goals is accessible. Engage patients and families in improvement via patient and family advisory councils (PFACs) Regular meeting to share information, celebrate success, identify opportunities, and develop improvement plans (i.e. Huddles, Team Meetings)

12 11 Process in which blame is eliminated when an error occurs (i.e. Just Culture, Safety reporting, Root Cause Analysis/Multi-Cause Analysis) Data posted on visibility boards Reward and Recognition Is Quality included your new staff /provider orientation? Does your clinic provide education /training to staff on how to interpret graphs/data and the steps needed to initiate improvement? Do the job expectations in your clinic include QI? Does your clinic interview and hire based on the organization s quality culture? Does your clinic track the progress of individual physicians on Quality Metrics? Does your clinic train the staff on Sanford Improvement, Lean, PDSA, or other improvement methodologies? Does your clinic post current Quality Data for staff and providers to review? Does your clinic actively engage patients and families in quality improvement? Does your clinic have regular meeting to share information, opportunities for improvements, celebrate successes? Is there a process in place in the clinic that eliminates blame when reviewing errors and allows for individual staff to suggest improvement and lead change? Question 16: Transparent Measurement & Monitoring Practice regularly produces and shares reports on performance at both the organization and provider/care team level, including progress over time and how performance compares to goals. Practice has a system in place to assure follow-up action where appropriate. Annual Performance Improvement Plan Quality Dashboard Physician Portal Ongoing Practice Performance Evaluations Data posted on visibility boards Performance Improvement process utilizing an Improvement Model Standardized process for obtaining patient feedback / satisfaction Are Quality Scores posted in your clinic?

13 12 Does your clinic have methods in place / action plans to improve performance? Do your providers, nurses and clinic teams utilize the physician portal, and/or other reports to review data? Does your clinic have the patient satisfaction scores posted for the staff and community? Do staff meetings routinely include patient satisfaction data and feedback? Question 17: Optimize Health Information Technology Practice uses technology to offer scheduling and communication options that improve patient access by including alternative visit types and electronic communication approaches. Secure /video visits for patients Telehealth visits for patients in rural areas Telehealth visits or video technology for homebound patients Use of patient portal to provide electronic reminders Use of electronic apps Does the team, not just provider, receive messages, and work with the patient portal? Is there a system for ongoing review of workflows and training on updates specific to the patient portal? Does your clinical practice offer alternative visit types? Question 18: Strategic Use of Revenue Practice uses sound business practices including budget management and return on investment (ROI) calculations. Annual Budget Planning Process conducted by all leaders Monthly Budget reconciliation process, all variance is analyzed and explained All new service ideas are presented as a Business Case in front of leadership, including the project ROI associated with the new service Do you manage your budget at all levels (both at the practice level and department level)? Are ROI calculations utilized to make financial decisions?

14 Question 19: Workforce Vitality & Joy in Work Practice has effective strategies in place to cultivate joy in work and can document results. 13 Service Excellence Recognition Nurse Award for the Clinic Clear performance standards and expectations Sharing patient, family or community stories with staff Get staff/provider input at all levels Conduct staff health and wellness initiatives Hold social events together Does your clinic actively participate in any Service Excellence or Nurse Award programs? Does your clinic have an individual recognition or rewards program? Do you routinely celebrate success with staff, or hold social events? Do you share patient stories (positive or otherwise) at staff meetings? Do you promote health or wellness activities for your staff? Question 20: Capability to Analyze & Document Value Practice shares financial data in a transparent manner within the practice and has developed the business capabilities to use business practices and tools to analyze and document the values the organization brings to various types of alternative payment models. Monthly Revenue/Expense Report Daily & Monthly Appointments Kept Report Do you review these reports when you receive them? Are you able to determine how this information impacts your financial performance? Do you share this information with the rest of the practice? Does your clinic know their status in regards to dollars at risk with payment plans?

15 14 Question 21: Capability to Analyze & Document Value Practice considers itself ready for migrating into an alternative based payment arrangement. Submit data for MIPS (Advancing Care Information, Clinical Practice Improvement Activities, Quality) Implement Medical Home Models Pilot Locations for Advanced Medical Home Participate in Bundled Payment Programs Work on initiatives linked to the Value Equation High Quality, Excellence Patient Experience at an Affordable cost Risk arrangements with United Healthcare, Wellmark and CMS, etc. As an organization will move to an Alternative Payment Model and report to CMS accordingly. Question 22: Operational Efficiency Practice uses a formal approach to understanding its work processes, eliminating waste in the processes, and increasing the value of all processing steps. Supports LEAN principles to eliminate waste and identify and strengthen value-added processes. Practice utilizes Continuous Process Improvement Each clinic has a quality improvement team equipped to address process issues. Improve on and optimize use of the EHR and information is distributed to all clinics. Has staff taken any educational courses on process improvement or quality? Has staff been trained in LEAN approaches and the concept of value? Has the clinic worked on Continuous Quality Process Improvement? Do you discuss improvement of workflows to optimize use of the EHR?

16 PFE Metric 1: 15 Active E-Tools Practice uses an e-tool (patient portal or other e-connectivity technology) that is accessible to both patients and clinicians and that shares information such as test results, medication list, vitals, and other information and patient record data. Patient Centered Medical Home Meaningful Use of EHRs OpenNotes Best Practices for Patient Portals - HIMSS Response Considerations: Does your practice use (and makes available to all patients) an e-tool that allows patients to access their medical record and have an easy, direct way to communicate with providers? Do you have a patient portal as part of your EHR? *PFE metric responses do not factor into overall PAT scores. PFE Metric 2: Shared Decision-Making Practice supports shared decision-making by training and ensuring that clinical teams integrate patient-identified goals, preferences, and concerns into the treatment plan (e.g. those based on the individual s culture, language, spiritual, social determinants, etc.). Teach-Back Motivational Interviewing AHRQ Patient Decision Aids Ask Me 3: Good Questions for Your Health Choosing Wisely: 5 Questions to Ask Your Doctor Before You Get Any Test, Treatment, or Procedure Response Considerations: Does your practice use a tool to promote and teach shared decision making in order that patients (and their families according to patient preference) are authentically part of the care team? Do you offer staff and provider trainings and continuing support for shared decision-making methods and tools, i.e. Teach-Back or motivational interviewing training? Does your practice have a protocol or established process that supports use of shared decision-making tools? *PFE metric responses do not factor into overall PAT scores.

17 16 PFE Metric 3: Practice utilizes a tool to assess and measure patient activation? Patient Activation The Patient Activation Measure (PAM)* tool (Insignia Health) Standford Chronic Disease Self-Efficacy Scale Patient Health Engagement Scale AHRQ PFE Primary Care Interventions Tools Response Considerations: Does your practice is using a standard PAM tool to assess and measure patient activation? Does your practice has developed their own tool to assess and measure patient activation? Does your practice is using any of other tools to assess and measure patient activation? *PFE metric responses do not factor into overall PAT scores. PFE Metric 4: Practice utilizes a health literacy patient survey (e.g., CAHPS Health Literacy Item Set). Health Literacy Consumer Assessment of Healthcare Providers and Systems (CAHPS) Health Literacy item set AHRQ Health Literacy Measurement Tools o Short Assessment of Health Literacy Spanish & English o Rapid Estimate of Adult Literacy in Medicine Short Form Health Literacy Tool Shed Response Considerations: Does your practice is using a health literacy patient survey to systematically identify and address health literacy issues? Does your practice assess patient health literacy as part of health coach or care coordinator interactions? Does your practice utilize CAHPS surveys inclusive of the health literacy item set? *PFE metric responses do not factor into overall PAT scores.

18 PFE Metric 5: Medication Management Practice s clinical team works with the patient and family to support their patient/caregiver management of medications? 17 Integrating Comprehensive Medication Management to Optimize Patient Outcomes - Patient-Centered Primary Care Collaborative AHRQ PFE Primary Care Intervention Tools Medication Management Diabetes Self-Management Tools and Resources Sutter Health Partnering in Self-Management Support: A Toolkit for Clinicians Million Hearts Medication Adherence Tools Response Considerations: Does your practice have a systematic, standard method in place to evaluate and support patients and their caregivers in medication self-management? Does your practice have defined processes or protocols to ensure that patients are routinely provided medication self-management support, beyond initial diagnoses to include medication changes throughout their treatment? Does your practice have established appointments for medication self-management education and support? *PFE metric responses do not factor into overall PAT scores. PFE Metric 6: Support for Patient and Family Voices Practice has policies, procedures, and actions taken to support patient and family participation in governance or operational decision-making of the practice (Patient and Family Advisory Councils (PFAC), Practice Improvement Teams, Board Representatives, etc.)? Integrating Comprehensive Medication Management to Optimize Patient Outcomes - Patient-Centered Primary Care Collaborative AHRQ PFE Primary Care Intervention Tools Medication Management Diabetes Self-Management Tools and Resources Sutter Health Partnering in Self-Management Support: A Toolkit for Clinicians Million Hearts Medication Adherence Tools Response Considerations: Does sour practice have a process in place for including the perspective and voice of the patient and family (Patient Family Advisor) in all aspects of the governance of the practice?

19 18 Does your practice have a Patient/Person and Family Advisory Council (PFAC)? Does your practice have a patient representative on a Board, steering committee, or operational team? *PFE metric responses do not factor into overall PAT scores This information is provided by Compass PTN and permits usage of all materials within the Compass PTN.