OneCity Health PCMH Learning Collaborative:

Transcription

1 OneCity Health PCMH Learning Collaborative: Quality Improvement and Sustainability Friday, October 20th, 2017

2 Agenda Objectives Quality Improvement: Overview & Tools QI & DSRIP Alignment Practice Panel: Quality Improvement Sustainability: Approach, Methods, and Risks of Inaction Practice Panel: Sustainability Wrap-Up and Next Steps 2

3 Learning Collaborative Objectives Create an understanding of tools and metrics to implement and measure Quality Improvement projects Understand how QI aligns with DSRIP and PCMH goals Gain insight into Quality Improvement in the field Become familiar with strategies for PCMH and QI sustainability Develop short-term and long-term goals for practice sustainability 3

4 What is Quality Improvement? 4

5 the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge Institute of Medicine 5

6 the systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups Health Resources and Services Administration 6

7 The combined and unceasing efforts of everyone healthcare professionals, patients and their families, researchers, payers, planners and educators to make the changes that will lead to better patient outcomes (health), better system performance (care) and better professional development Batalden, P. B. & Davidoff, F. J Quality and Safety in Healthcare

8 Simply put 8

9 Every system is perfectly designed to achieve exactly the results it gets. Dr. Don Berwick, Founder of The Institute for Healthcare Improvement 9

10 RESOURCES (Inputs) People Infrastructure Materials (e.g., vaccines) Information Technology ACTIVITIES (Processes) 1. What is done 2. How it is done RESULTS (Outputs or outcomes) Health services delivered Change in health behavior Change in health status Patient satisfaction 10

11 Is Good Enough Good Enough? An outlook and culture of improving systems and clinical quality Practice versus patient perspective Reflective practice: key to all successful and lasting change Scaling up The business case for improved quality 11

12 Value-Based Payment Payment based on quality aligns with the Quadruple Aim $ Quality Patient Satisfaction Provider Satisfaction Total Cost of Care 12

13 Quality Improvement Alignment with PCMH Standard 6: Quality Improvement A measurement of: Clinical Quality Performance Resource Use and Care Coordination Patient and Family Experience Implementation and Demonstration of: Continued Quality Improvement Examples Monitoring A1C Levels in patients with DM, and working towards frequent lab testing and diet and lifestyle program referrals for patients Using patient surveys to determine patients are unhappy with wait times, and rearranging providers schedules accordingly, as well as improving upon previsit-planning workflows Based on baseline performance metrics Quantify the value of workflow changes 13

14 Enabling Change Strategies for Quality Improvement Project Implementation: Prioritization: Managing competing demands Setting aside time and space to meet Structuring staff scheduling requirements PCMH Team Development Buy-in from all levels Program Alignment DSRIP Goals PCMH Goals MIPS/Meaningful Use/ HEDIS metrics 14

15 Quality Improvement Models

16 Model for Improvement (Part 1): setting goals What are we trying to accomplish? Set goal How will we know change is an improvement? Track measure(s) What changes can we make that will result in an improvement? Identify change concept ACT STUDY PLAN DO 16

17 Setting a S.M.A.R.T. Quality Improvement Goal Specific: Specify area of improvement and patient population Measurable: Select measure to track change Assignable: Consider individuals to hold accountable Realistic: Understand resources and change concept Timely: Set realistic timelines 17

18 S.M.A.R.T. Goal: Example 1 Reduce uncontrolled DM patients by 10% to HA1c levels of <7 by having front desk staff refer them to a local nutrition education program within the next 6 months. Specific: Uncontrolled DM patients Measurable: HA1c levels Assignable: Front desk staff Realistic: Reduce uncontrolled DM by 10% Timely: 6 months 18

19 S.M.A.R.T. Goal: Example 2 Increase number of eligible patients registered to the patient portal by February 28, 2018 by at least 200 patients when registered at the front desk. Specific: all eligible patients Measurable: registrants to patient portal Assignable: Front desk Realistic: register 200 patients to patient portal Timely: by February 28th,

20 Creating a Smart Goal Based on Case Study Please use the handouts to create a goal that is: Specific: Specify area of improvement and patient population Measurable: Select measure to track change Assignable: Consider individuals to hold accountable Realistic: Understand resources and change concept Timely: Set realistic timelines Please also propose an intervention or workflow based on this goal 20

21 PCMH & DSRIP Alignment Yolanda G. Smith, RN, MSN Assistant Vice President Lead Chronic Disease Initiatives & Clinical Performance

22 Evidence-Based Strategies for Disease Management in High Risk/Affected Populations The OneCity Health DSRIP Cardiovascular Disease Management Project (3.b.i - Evidence-Based Strategies for Disease Management in High Risk/Affected Populations) utilizes evidence-based best practices to manage adults with cardiovascular disease. The goal of the Cardiovascular Disease Management project is to support implementation of evidencebased guidelines in ambulatory/primarycare settings to improve management of cardiovascular disease by focusing on treatment guidelines, adoption of quality improvement activities, improvement of patient self-efficacy, self-management adherence and reduce potentially avoidable hospital and Emergency Department (ED) visits. Using strategies form the Million Hearts Campaign, implementation procedures and OneCity Heath Technical Assistance efforts aim to improve management, adopt standardized treatment protocols and blood pressure measurement/control. Currently, implementation of the cardiovascular program is active within the outpatient/primary care adult population. 22

23 Evidence-Based Strategies for Disease Management in High Risk/Affected Populations Integrating DSRIP and PCMH DSRIP Project Requirement Metric Deliverable PCMH Related Standard Project Requirement 1: Implement program to improve management of cardiovascular disease using evidence-based strategies in the ambulatory and community care setting. Metric: PPS has implemented program to improve management of cardiovascular disease using evidence-based strategies in the ambulatory and community care setting. Standard 3D Use Data for Population Health Management 3.D.3. At least annually the practice identifies populations of patients and reminds them of needed care based on patient information, clinical data, health assessments, and evidencebased guidelines, including at least three different chronic or acute care services Standard 4A Identify Patients for Care Management 4.A.3. The practice establishes a systematic process and criteria for identifying patients who may benefit from care management, including patients with poorly controlled or complex conditions Standard 4B - Care Planning and Self-Care Support Standard 4C - Medication Management Standard 4E Support Self-Care and Shared Decision Making Project Requirement 6: Adopt and follow standardized treatment protocols for hypertension and elevated cholesterol. Metric: Practice has adopted treatment protocols aligned with national guidelines, such as the National Cholesterol Education Program (NCEP) or US Preventive Services Task Force (USPSTF). Standard 3E Implement Evidence-Based Decision Support 3.E.4. The practice implements clinical decision support following evidence based guidelines for a condition related to unhealthy behaviors 3.E.2. The practice implements clinical decision support following evidence-based guidelines for a chronic medical condition 23

24 Expansion of Home Based Asthma Self-Management The OneCity Health DSRIP Asthma Program (3.d.ii - Expansion of Home Based Asthma Self-Management) utilizes home-based services to address home environmental trigger management, self-monitoring, medication use, medical follow-up, and coordination with social services. The objective of this project is to improve asthma control and reduce avoidable asthmarelated hospitalizations and emergency department (ED) visits, through an integrated asthma management program that includes home-based services. Pediatric patients with persistent asthma who (1) were admitted to the inpatient unit for asthma exacerbation within the last 12 months, (2) were in the emergency department with an asthma exacerbation two or more times within the last 6 months, (3) received a prescription for a systemic corticosteroid two or more times within the last 6 months and/or (4) have prescription patterns indicating overuse of short acting beta agonists (e.g. albuterol), qualify for enrollment to the DSRIP program regardless of line of business (Medicaid, Commercial Insurance carrier, Uninsured). 24

25 Expansion of Home Based Asthma Self-Management Integrating DSRIP and PCMH DSRIP Project Requirement Metric Deliverable PCMH Related Standard Project Requirement 1: Expand asthma home-based selfmanagement program to include home environmental trigger reduction, selfmonitoring, medication use, and medical follow-up. Metric: PPS has developed a strategy for the collaboration of community medical and social services providers to assess a patient's home and provide self-management education for the appropriate control of asthma Standard 4E Support Self-Care and Shared-Decision Making 4.E.6. Maintains a current resource list on five topics or key community service areas of importance to the patient population Project Requirement 3: Develop and implement evidence-based asthma management guidelines. Metric: PPS incorporates evidence-based guidelines that are periodically evaluated and revised, if necessary, in the design and implementation of asthma management. Standard 2D Team-Based Care 2.D.5. Training and assigning members of the care team to coordinate care for individual patients Project Requirement 4: Implement training and asthma self-management education services, including basic facts about asthma, proper medication use, identification and avoidance of environmental exposures that worsen asthma, self-monitoring of asthma symptoms and asthma control, and using written asthma action plans. Metric: PPS has developed training and comprehensive asthma self-management education, to include basic facts about asthma, proper medication use, identification and avoidance of environmental exposures that worsen asthma, self-monitoring of asthma symptoms and asthma control, and using written asthma action plans. Standard 4B Care Planning and Self-Care Support 25

26 Planned Quality Improvement Select Conditions (4A) PCMH Standard 4: Care Management & Support Element A: Identify patients for Care Management PCMH Standard 6: Performance Measurement & Quality Improvement Element D: Implement Continuous Quality Improvement Element E: Demonstrate Continuous Quality Improvement Act and Improve Quality (6D, 6E) Select Guidelines (3E) PCMH Standard 3: Population Health Management Element E: Implement Evidenced- Based Guidelines Manage Care (3C, 4B, 4C, 4E) PCMH Standard 3: Population Health Management Element D: Use Data for Population Management Outreach for Services (3D) Train Team Members (2D) PCMH Standard 2: Team- Based Care Element D: The Practice Team PCMH Standard 3: Population Health Management Element C: Comprehensive Health Assessment PCMH Standard 4: Care Management & Support Element B: Care Planning & Self-Care Support Element C: Medication Use Element E: Support Self-Care & Shared Decision Making Select Quality Measures (6A, 6B) PCMH Standard 6: Performance Measurement & Quality Improvement Element A: Measure Clinical Quality Performance Element B: Measure Resource Use & Care Coordination 26

27 Breakout Session 27

28 Identify patients who have repeated elevated blood pressure readings in the medical record but do not have a diagnosis of hypertension and schedule them for a hypertension visit. 28

29 Cardiovascular: Milestone # 10 due March 31, 2018 Identify patients who have repeated elevated blood pressure readings in the medical record but do not have a diagnosis of hypertension and schedule them for a hypertension visit. Use THREE Measures Identified in 6A Measure 1: 1. Measure selected for improvement; reason for selection 2./3. Baseline performance measurement;numeric goal for improvement (6D 1) 4. Actionstaken to improve and work toward goal; dates of initiation (6D 2) (Only 1 action required) 5. Remeasureperformance (6E 1,2) Reason: Baseline Start Date: Baseline End Date: Baseline Performance Measurement (% or #): Numeric Goal (% or #): Action: Date Action Initiated: AdditionalActions: Start Date: End Date: Performance Re-Measurement (% or #): 6. Assess actions; describe improvement (6E 1) 29

30 Expansion of Asthma Home Based Self- Management Components of Asthma Management Develop a Doctor-Patient Partnership to achieve guided self-management of asthma giving people the ability to control their own asthma is associated with improved clinical outcomes. Key components include: Joint goal setting Education - teaching by health care team with frequent reinforcement. Key components include: Recognition of early signs of worsening asthma and a prompt symptom response plan Medications (actions, benefits, side effects, difference between Relievers and Controllers ) Proper use of inhalers Home allergen control Self-monitoring (regular use of either symptombased or peak flow monitoring are effective) Regular health care visits to review asthma control, treatment, and self-management skills Written action plan that integrates selfmonitoring with evidence-based management for both long-term control of asthma and treatment of acute exacerbations Control Environmental Factors and Comorbid Conditions that Affect Asthma: avoid tobacco smoke exposure 30

31 Provider & Clinical Team Role: Patient Visit INITIAL VISIT FOLLOW-UP VISIT Diagnose asthma Assess & monitor asthma control Assess asthma severity Initiate medication & demonstrate use Schedule next follow-up appointment Review medication technique & adherence; assess side effects; review environmental control Develop written ASTHMA ACTION PLAN Schedule follow-up appointment Review ASTHMA ACTION PLAN, revise as needed Maintain, step up, or step down medication 31

32 Asthma: Milestone # 1 due March 31, 2018 Expand asthma home-based self- management program to include home environmental trigger reduction, self- monitoring, medication use, and medical follow-up using Asthma Action Plan. Use THREE Measures Identified in 6A Measure 1: 1. Measure selected for improvement; reason for selection 2./3. Baseline performance measurement;numeric goal for improvement (6D 1) 4. Actionstaken to improve and work toward goal; dates of initiation (6D 2) (Only 1 action required) 5. Remeasureperformance (6E 1,2) Reason: Baseline Start Date: Baseline End Date: Baseline Performance Measurement (% or #): Numeric Goal (% or #): Action: Date Action Initiated: AdditionalActions: Start Date: End Date: Performance Re-Measurement (% or #): 6. Assess actions; describe improvement (6E 1) 32

33 Questions? Yolanda G. Smith, RN, MSN Assistant Vice President Lead Chronic Disease Initiatives & Clinical Performance Clinical Delivery Redesign Office: (646)

34 Practice Panel: Quality Improvement

35 Children s Aid Background Our Practice: Dually licensed Article 28 and Article 31 clinics Two Community Health Centers located in the Bronx (172 nd St & Southern Boulevard) and Manhattan (118 th St. near 5 th Ave) Six School Based Health Centers, located in the Bronx (Morrisania), Manhattan (Washington Heights) and Staten Island (Northern shore) Our staff: Pediatricians, Nurse Practitioners, Nurse Clinical Managers, License Practical Nurses (LPNs), Medical Office Assistants Dentists and Dental Assistants (+ Dental Hygienist in the SBHC) Behavioral Health Practitioners: Psychiatrists, Psychologists, Therapeutic Social Workers, Health Educators, JAM (Just Ask Me) Peer Educators Administrative Assistants, Referral Coordinators, Financial Screeners Care Coordinators (Children s Health Homes) Our patient panel: What makes our patients unique that we are a pediatric practice, up to age 22 A large component of our unique patients are adolescents ~60% A large component of our visits are for patients in foster care ~40% Our practice values: Our practice value reflects that of our parent company, Children s Aid. Offering children, youth and families the tools and resources they need to realize their fullest potential. Integration of care and services for our patients (offering medical, dental, behavioral health and Care Coordination in one setting) 35

36 Children s Aid QI Project #1 Goal: Increasing the number of patient survey responses and automatizing the process for analysis Intervention: Changed patient survey format from paper based to ipad; instead of offering it for only a few months a year, we are offering it every day, all year, after every visit Challenges: Staff found it difficult at first to fit this in their workflow with a busy waiting area Patients didn t want to fill it out every time Accomplishments: Increased number of survey responses from 505 to 1,145 in a similar period As this is our initial year of conducting the survey, it will provide a baseline for us to use in the upcoming years 36

37 Children s Aid QI Project #2 Goal: Daily Huddle is a meaningful forum for planning and enhanced communication among providers and staff for the benefit of our patients Intervention: Enhanced Daily Huddle agenda and included a spreadsheet with patient s PCP, insurance and other markers regarding multiple visits in the same day Challenges: Additional prepping Ensuring all appropriate staff participate in a daily basis Accomplishments: As a result, staff have increased knowledge of daily expectations and patient needs The patient experience is enhanced, because we have prepped for their visit and can better meet their expectations 37

38 Sustainability at Children s Aid Patient Surveys: Transitioning from paper surveys to surveys on IPads, easier for patients to use and generate survey results Surveying after every visit instead of every six months or once a year Evaluating patient s satisfaction and experience; are expectations being met relating to objective experience Giving patients a constructive outlet to provide feedback on their experience Showing patients that their providers care about their input All staff being on board 38

39 Sustainability at Children s Aid Enhancing Daily Huddles: Huddles are held at the same time daily and staff are required to attend Information reviewed includes: Events from the previous day, outcomes or necessary follow ups Staffing for the current day; who is scheduled off, any call-outs and coverage needed Patient reviews; the list of the scheduled patients for the day are printed and reviewed at the Huddle. The list is color-coded to indicate patients with appointments for different services in the same day (i.e., medical and dental), as-well-as, patients with siblings who are coming in the same day. It also allows for addressing of any special needs. The next day and upcoming events are also reviewed at the Huddle to ensure that everyone is kept abreast of future events or patient needs Reminders are also provided daily (i.e., HIPAA adherence, referrals to Health Connections and other services) Review of referrals to specialty providers, whether patients showed for their specialty appointments, and if the related reports have been received Review of PCP and insurance information to ensure that patients are appropriately scheduled and insurance information is verified 39

40 Callen-Lorde Community Health Center Background Our location: 3 clinical sites in Chelsea, 1 in the Bronx, 1 coming to Brooklyn soon! Our staff: 300 staff, about 30 medical providers, 30 mental health providers Largest stand alone LGBT health center in the world 40

41 Callen-Lorde Community Health Center About Us Callen-Lorde is the global leader in LGBTQ healthcare. Since the days of Stonewall, we have been transforming lives in LGBTQ communities through excellent comprehensive care, provided free of judgment and regardless of ability to pay. In addition, we are continuously pioneering research, advocacy and education to drive positive change around the world, because we believe healthcare is a human right. Our Mission Callen-Lorde Community Health Center provides sensitive, quality health care and related services targeted to New York s lesbian, gay, bisexual, and transgender communities in all their diversity regardless of ability to pay. To further this mission, Callen-Lorde promotes health education and wellness, and advocates for LGBT health issues. Callen-Lorde is a: New York State Department of Health Article 28 Diagnostic and Treatment Center New York State Office of Mental Health Article 31 Outpatient Mental Health Treatment Clinic Federally Qualified Health Center 41

42 Callen-Lorde Community Health Center Patient and visit volume In 2016, the health center provided services for 17,812 unique patients, who made 107,002 visits for our comprehensive and integrated services. Total Clinical Visits *Callen-Lorde underwent major renovations in 2013, reducing usable clinical space for the year. 42

43 Callen-Lorde Community Health Center Services Offered All of services are provided in a sensitive, nonjudgmental environment and, in keeping with the agency s mission, are offered regardless of ability to pay. Services Patients Visits Primary Medical Services 14,974 53,488 Mental Health Services 2,742 25,815 Dental Services 2,389 9,093 HIV Specialty Care 4,165 19,269 Enabling Services (Including Care Coordination and Health Education) 6,921 15,654 Other Services Total Prescriptions Filled 107,355 Rapid HIV Screening 8,300 Insurance Assistance and Enrollment 2,671 43

44 Callen-Lorde Community Health Center Patient Demographics: Geography Many of Callen-Lorde s patients particularly those that do not openly identify as LGBTQ - report not feeling safe receiving care in their own communities, and so many of Callen- Lorde s patients do not solely come from the health center s immediate vicinity. Outside NYC 13% Manhattan 36% Queens 12% Bronx 9% Staten Island 1% Brooklyn 29% Patient Geographic Origin,

45 Callen-Lorde Community Health Center Patient Demographics: Race & ethnicity Callen-Lorde s patients continue to be diverse in terms of race and ethnicity. 1% 9% 5% 3% White Hispanic/Latino 17% 43% Black/African American Asian/Pacific Islander American Indian/Alaska Native Unreported/Refused 22% More than 1 Race UDS race/ethnicity,

46 Callen-Lorde Community Health Center Patient Payor Mix Callen-Lorde s patients are payer-diverse, with 6,091 covered by private insurance, 6,232 covered by Medicaid and other public coverage, 904 covered by Medicare and 4,583 uninsured. With the implementation of the ACA marketplace in New York, Callen-Lorde saw a 20% decrease in the uninsured and an increase in patients covered by Medicaid and private ACA plans. 34% 28% 26% 7% 5% Private Insurance Medicaid Non/Insured Other Public Insurance (ADAP) Medicare UDS insurance type,

47 Callen-Lorde Depression Screenings, the WHY Depression disproportionately affects our LGBT community, which faces stigma, harassment and discrimination. Moreover, our patients living with HIV must cope with many social, psychiatric, and medical issues that are best addressed through a patient centered, multi disciplinary approach to the disease. Depression is known to impair adherence to HIV medications and increase the risk of transmission. Once evaluated for depression, these factors can be managed through Callen-Lorde s supportive and behavioral health services. Before we began this project, we infrequently documented use of a standardized depression screening tool and appropriate follow-up. While our internal reports captured some form of depression screening administered to most patients, we did not screen and document in a standardized format, making external reporting and meaningful quality improvement efforts difficult. 47

48 Callen-Lorde The Intervention The Director of Nursing developed a plan with the Manager of Patient Administrative Services and the Manager of Mental Health. They made a work flow then hired two Mental Health Providers for our medical clinic. DSRIP was only concerned with Medicaid patients but we decided we can t just screen patients with certain insurance types. So we started universal screening at every medical visit. We then moved to annual screening. Now at time of rooming the LPN/MA looks in the patient s chart for the date of the last screening. The PHQ2 is a test of two questions asked verbally. The PHQ9 is done if the patient screens positive on the PHQ2. Then the provider discusses the PHQ9 with the patient. If further assessment is needed, a warm hand-off is done by MA to PCA for a same-day / walk-in appointment with a licensed clinical social worker who assesses the patient. 48

49 QI Project Depression Screening Callen-Lorde wanted to increase our depression screenings Baseline Start Date: 1/1/15 Baseline End Date: 12/31/15 Baseline Performance Measurement (% or #): 2031/14765 = 16% Numeric Goal (% or #): 30% Intervention -The Nursing Department started screening patients for depression at more appointment types, and started screening behavioral health patients who did not have an active depression diagnosis. Our screening rates continued to increase since over the course of the year. Challenges Some of the issues we found when working on this project were: It could be challenging to complete a warm hand-off of patients requiring further assessment from clinical staff to Behavior Health staff. We wanted to ensure patients did not slip between the cracks when assessed. In order to address this we have MAs walk patients directly to the 6 th floor to ensure the warm hand off was completed. Accomplishments The team, which included PCP, MH providers, and a psychiatrist, accomplished the following success: A patient who had not disclosed to her PCP or anyone else she was feeling depressed, isolating from friends and family, and no longer enjoying her job, was administer a PHQ by her PCP. A positive depression screen led her medical provider to refer her to our MH assessment clinicians where she received a same day, walk-in MH assessment. The patient was referred internally for comprehensive MH treatment. This patient, who is now being treated for major depressive disorder and PTSD, is in weekly therapy and monthly psychiatry at our clinic. 49

50 Callen-Lorde Screening for Clinical Depression (NQF 0418 Modified) Improvement! When the Nursing Department started screening patients for depression at more appointment types, and screening mental health patients, our screening rates went up. Keep up the good work, Nursing! 50

51 Sustainability at Callen-Lorde Most successful workflow change or portion of PCMH at your practice: enhanced same day, walk in mental health assessment. We realized a real time warm hand off was important in addressing the MH needs of our patients. In addition we are uncovering many examples of undiagnosed depression we would not have found it if weren t for the screenings. How you made sustainable changes:(examples: do you still have staff meetings to discuss PCMH workflow changes? Did the culture of the organization change?) For this project (depression screenings) we have highlighted constantly with Nursing and Medical Providers the importance of depression screening where this may not be on their mind as much as our behavioral health staff. This is important especially given disproportionately high rates of suicidality in the LGBTQ community. 51

52 Practice Background The Door Our Location: The Door A Center of Alternatives, Inc. is located in Lower Manhattan at 555 Broome Street, New York, NY Our Values: The Door s mission is to empower young people to reach their potential by providing comprehensive youth development services in a diverse and caring environment. The Door serves 10,000 young people with a wide range of services all for free and under one roof. Our Practice: The Door s Adolescent Health Center offers comprehensive health services including primary care, reproductive health care, dental services, eye care including eyeglasses, mental heath services, dermatology, nutrition, health education, and entitlements counseling. Our Patients: The Door s Adolescent Health Center serves a diverse population of young men and women, ages 12 to 24, from all five boroughs of NYC. As part of this program, the AHC targets young people most in-need. Our Staff: The Door s Adolescent Health Center has a diverse staff include MDs, NPs, Optometrist, Dentist, Dental Hygienist, Nutritionist, Social Workers, Nurses, Clinical Support Staff, Management, Coordinators, Billers, Receptionists, Health Educators, and Peer Educators. 52

53 QI Project Patient Portal The Door worked to increase active users on the health center s Patient Portal over three months Baseline Start Date: Baseline End Date: Baseline Performance Measurement (% or #): Numeric Goal (% or #): 50% Intervention -The project team included a multidisciplinary group, including: the Operations Manager, Clinical Manager, and Health Center Coordinator.The team utilized technical support from Patient Relationship Management (PRM) team at eclinicalworks. The PRM team provided onsite staff training, template design, and patient education tools during the process during the project roll out. Challenges Accomplishments Some of the issues we found when working on this project were: Slow patient enrollment (educating patients on benefits, easy use) Provider resistance (assumed increase in administrative work) Work flow issues with managing incoming messages Staff training needed on patient portal features The team accomplished the following successes: Implementation of the Kiosk and elimination of paper at check-in Secured communication between patients and providers Increased patient utilization of online resources Maximized the use of our EHR system Remediation to address challenges: The project team monitored activities, offered ongoing support, and helped with troubleshooting during the project implementation. Overall Successes: The Door had an 82% increase in active users since the start of the patient portal project 53

54 Sustainability at The Door Adolescent Health Center Most successful workflow change or portion of PCMH at your practice: Implementation of care coordination teams, team meetings, and daily huddles were well received and a major success. How you made sustainable changes: Care coordination teams, team meetings, and daily huddles empowered staff to share ideas and suggestions for QI projects. As a result, data collection and reporting improvements were made because staff were interested in seeing results and successes 54

55 Sustainability

56 A 3 Phased Approach Implementation: This is the learning phase What is required? What infrastructure do we need? Cultural shift in organization Allocation of resources to support program goal Engage staff: administrative staff to leadership Meet all PCMH requirements and submit Evolution: This is the adoption phase Processes, resource allocation and culture evolve to fit PCMH model for value-based care Place emphasis on continuous improvement The Triple/Quadruple Aim (improve patient care/experience, better manage population health, reduce or control costs) Integration: This is the owning phase Integration with internal and external medical providers, community resources and other stakeholders 56

57 PCMH 2017 and Sustainability The new PCMH Model changes significantly to support sustainable change. It includes 3 Phases Commit: Complete assessment, develop evaluation schedule Transform: Evaluator checks practice documentation on iterative basis and assists practice with challenges Succeed: Practice demonstrated continued high quality performance through annual check-ins with the NCQA. Those renewing from level 3 in 2014 can go right to the Succeed QI now called: Performance Measurement & Performance Improvement Different Competencies: A,B, and C Elective and Core Criteria Generally the same as QI in 2014, with a focus on Clinical, Cost, Coordination and Patient Experience data, stratified by vulnerable populations. Yearly reviews will create incentives for continuous monitoring Phase. 57

58 Methods for Sustainability Tools and Tricks for Maintaining the PCMH Model: Know why you re measuring what you re measuring The more specific you can be, the better Avoiding temptation to change everything Continue to use real metrics, rather than general perceptions of success Share improvements on ongoing basis 58

59 Quality Improvement Sustainability Avoid Change Fatigue for Long Term Success Avoid the temptation to do too much, too soon: pick the most valuable workflows and work on maintaining these Reflect on accomplishments and best practices Be realistic with time-bound goals Use LEAN thinking to avoid temptation to abandon PCMH workflows Continue regular meetings, even after PCMH recognition has been achieved 59

60 SWOT Analysis for Sustainability A SWOT Analysis: Strengths, Weaknesses, Opportunities, Threats What did we/are we doing well? What can we improve upon during this process? Where can we determine further opportunities? What are the threats to our success? 60

61 Risks of Not Maintaining The PCMH Model Missed incentives and cost-saving opportunities in the future PCMH 2017 Missed payment for value based care and clinical outcomes MIPS, Meaningful Use Private payor incentives for PCMH-like initiatives Missed billing opportunities for PCMH workflows Chronic Care Management Transitional Care Management Inadequate monitoring and coordination of care can result in lost opportunities 61

62 Sustainability: Activity Goal Setting: Please use the handout on your table to develop a goal for your practice s PCMH Sustainability. Long term goal Something you can work towards in the following months or years. Short term goal Something you can implement or hope to incorporate into your practice tomorrow. 62

63 Recap Healthcare landscape is shifting beginning to reward based on value rather than volume Focused attention to quality throughout the institution is vital Problem identification is half the battle use the Fishbone Analysis as route-cause analysis to determine the source of the challenge Small, iterative changes lead to big results Work to support ongoing QI efforts in your department or to begin your own 63

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