LOW INCOME HEALTH PROGRAM EVALUATION CONVENING MEETING: HEALTHPAC QI INITIATIVES KATHLEEN CLANON, MD HEALTH PAC MEDICAL DIRECTOR

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1 LOW INCOME HEALTH PROGRAM EVALUATION CONVENING MEETING: HEALTHPAC QI INITIATIVES KATHLEEN CLANON, MD HEALTH PAC MEDICAL DIRECTOR May 9, 2013

2 HealthPAC Provider Network Approximately 90,000 enrollees: includes LIHP and residually uninsured County provides no direct service, contracts with 29 general medical home sites, most FQHCs No direct access to verifiable clinical data HealthPAC QI process focuses on population management

3 HealthPAC P4P Accelerated Quality Improvement Program (AQIP) Funding for clinics is available based on the clinics ability to achieve target outcomes in 3 areas: Access to Care: bringing in enrollees who are assigned to their medical homes but have never been seen. Panel management moving from panel management as a pilot strategy to a routine, sustainable clinic activity Care transitions: Tightening the net in our network by incentivizing realtime communication flow between hospital and medical homes. Action Period 1 Oct-Dec 2012 We are here Action Period 3 Aug-Oct Action Period 2 Apr-Jun /1/14

4 Behavioral Health Population Management P4P Funded separately as a partnership of County Behavioral Health Care Services, HealthPAC and FQHC Consortium Funds to support the creation of panel management systems for behavioral health conditions within primary care including: Creation of a behavioral health panel management plan Identification of mental health professional responsible for managing the panel of patients with behavioral health conditions Completion of a quarterly panel management summary invoice with required elements including baseline assessment (PHQ-9), tracking of contacts and services provided.

5 Behavioral Health Integrated Care Panel Management Pilot Program Funds to support the creation of panel management systems for behavioral health conditions within primary care including: Creation of a behavioral health panel management plan Identification of mental health professional responsible for managing the panel of patients with behavioral health conditions Completion of a quarterly panel management summary invoice with required elements including baseline assessment (PHQ-9), tracking of contacts and services provided.

6 Project Status to Date: 8 out of10 HealthPAC clinic organizations participating 4 clinic organizations currently submitting registry report data to county behavioral health care services Challenges: Integrating registry report capacity within current data systems (i2i)

7 HealthPAC Program Support Met with ED, Medical Director, QM leads at each of the motherships to encourage participation. Provided info about the program through webinars, in person meetings, and a written FAQ Provided on-site TA and coaching. Provided aggregated data, patient reports and support for data analysis. Monthly clinical implementation meetings to go over data and share experiences. These efforts were supported by a Blue Shield grant.

8 Overall Results: the Good Every medical home instituted at least one new program, procedure, or workflow in the goal areas. PM services expanded in the clinics, as indicated by new activities at each clinic (Caveat: No measured baseline.) Overall, 7116 patients received PM interventions. Each medical home was able to produce registry reports for HTN and dyslipidemias as well as diabetes. Care transitions for one high risk group frequent ED users -- were improved through new outreach programs and info sharing. 148 out of 151 frequent ER utilizers had a follow up appointment or staff contact within 60 days of ED visit. The hospital-to-medical home care transitions incentive program began April 1, raising the bar on this measure. $676,667 were distributed to clinic organizations through the program!

9 Overall Results: the Challenge Success was partial. $667,667 represents 58% of the total $ available in the first reporting period. All clinic organizations were successful with at least 2 of the 3 goals (except ACMC) 3 medical home sites were successful with all 3 measures (Axis Pleasanton, La Clinica San Antonio Neighborhood, LifeLong-West Berkeley). A 3 rd Action Period (August-October 2013) has been added to allow clinics to recoup AQIP dollars they did not recover in this first action period. Almost no new activity occurred around the Access goal; Only two sites initiated any change to try to reach this goal. Clearly, clinics overburdened capacity makes working on this goal a difficult sell. We still feel this is an important policy goal and will be working with clinics to encourage innovative access programs (group visits, nurse-run clinics, etc) in the remaining two action periods before 1/1/14. Our baseline in December showed 41% of HealthPAC enrollees had not been seen in any setting (primary or specialty care) in 12 months; in December 2012, if we had reached our goal of <30%, 8,633 individuals would have been more firmly connected to our care system.

10 Access/Utilization: % of HPAC Enrollees with No Outpatient Visits in Prior 12 Months Dec-12 Jan-13 Feb-13

11 Panel Management Work: Observations As they struggled to reach the PM target, several clinics instituted new, centralized PM functions and/or designated a SPOC (single point of contact) Clinics that had EHR already in place found it easier to meet targets. In many (most?) sites, eligibility staff and clinical staff did not have regular contact and that made population management tougher.

12 Care Transitions: How well are we doing? HealthPAC Data February 2013 Total inpatient* admissions: 249 No. of patients receiving outpatient visit within 30 days: % *Highland and John George

13 Care Transitions Interventions (CTI): Acute to Primary Medical Home Transition Record Hand Off Key Questions: What information should be included? How communicated and by whom? To whom at Medical Home? By when? How does Medical Home use information received? 100% of acute care discharges have communication to medical home Transition Crosswalk ID Transition Communication Line Staff Standard Follow-up Protocol Guidelines for care transitions Adoption of standard transition record Q1 Q2 Q3

14 Examples of Successful Practices Utilizing NextGen (Axis, West Oakland) facilitated ease of documentation/review and increased achievement of targets. Tri-City identified a SPOC (Single Point of Contact) early in the action period to conduct outreach to high-er utilizers who was able to successfully contact all patients and/or identify those who are no longer active patients in their system. La Clinica doubled the number of patients seen for medication reconciliation, based on those identified for intervention. Native American Health Center clinic staff initiated Lipid Day for clients due for labs or high levels; 10 pts were seen on the 1 st day and 14 attended the 2 nd session A change in the Panel Manager job description at ACMC allowed for 6,461 or 90% of eligible intervention population to be touched by 4 panel managers across 4 sites.