Medicine Institute Outcomes

Transcription

1 Medicine Institute 214 Outcomes

2 Measuring Outcomes Promotes Quality Improvement

3 Measuring and understanding outcomes of medical treatments promotes quality improvement. Cleveland Clinic has created a series of Outcomes books similar to this one for its clinical institutes. Designed for a physician audience, the Outcomes books contain a summary of many of our surgical and medical treatments, with a focus on outcomes data and a review of new technologies and innovations. The Outcomes books are not a comprehensive analysis of all treatments provided at Cleveland Clinic, and omission of a particular treatment does not necessarily mean we do not offer that treatment. When there are no recognized clinical outcome measures for a specific treatment, we may report process measures associated with improved outcomes. When process measures are unavailable, we may report volume measures; a relationship has been demonstrated between volume and improved outcomes for many treatments, particularly those involving surgical and procedural techniques. In addition to these institute-based books of clinical outcomes, Cleveland Clinic supports transparent public reporting of healthcare quality data. The following reports are available to the public: Joint Commission Performance Measurement Initiative (qualitycheck.org) Centers for Medicare and Medicaid Services (CMS) Hospital Compare (HospitalCompare.hhs.gov), and Physician Compare (medicare.gov/physiciancompare) Cleveland Clinic Quality Performance Report (clevelandclinic.org/qpr) Our commitment to transparent reporting of accurate, timely information about patient care reflects Cleveland Clinic s culture of continuous improvement and may help referring physicians make informed decisions. We hope you find these data valuable, and we invite your feedback. Please send your comments and questions via to: OutcomesBooksFeedback@ccf.org or scan here. To view all of our Outcomes books, please visit clevelandclinic.org/outcomes.

4 Dear Colleague: Welcome to this 214 Cleveland Clinic Outcomes book. Every year, we publish Outcomes books for 14 clinical institutes with multiple specialty services. These publications are unique in healthcare. Each one provides an overview of medical or surgical trends, innovations, and clinical data for a particular specialty over the past year. We are pleased to make this information available. Cleveland Clinic uses data to manage outcomes across the full continuum of care. Our unique organizational structure contributes to our success. Patient services at Cleveland Clinic are delivered through institutes, and each institute is based on a single disease or organ system. Institutes combine medical and surgical services, along with research and education, under unified leadership. Institutes define quality benchmarks for their specialty services and report on longitudinal progress. All Cleveland Clinic Outcomes books are available in print and online. Additional data are available through our online Quality Performance Report (clevelandclinic. org/qpr). The site offers process measure, outcome measure, and patient experience data in advance of national and state public reporting sites. Our practice of releasing annual outcomes books has become increasingly relevant as healthcare transforms from a volume-based to a value-based system. We appreciate your interest and hope you find this information useful and informative. Sincerely, Delos M. Cosgrove, MD CEO and President 2

5 what s inside Chairman s Letter 4 Institute Overview 5 Quality and Outcomes Measures Quality Performance Measurement Overview 6 At-Risk Population: Hypertension 7 At-Risk Population: Diabetes 8 At-Risk Population: Ischemic Vascular Disease 1 At-Risk Population: Heart Failure 12 At-Risk Population: Coronary Artery Disease 13 Preventive Health 14 Readmissions and Mortality 16 Patient Safety 2 Institute Patient Experience 22 Cleveland Clinic Implementing Value-Based Care 24 Innovations 3 Contact Information 32 About Cleveland Clinic 34 Resources 36 Prefer an e-version? Visit clevelandclinic.org/outcomesonline, and we ll remove you from the hard copy mailing list and you when next year s books are online. 3

6 Chairman s Letter Dear Colleagues: Thank you for your interest in the Medicine Institute s 214 outcomes. This book exemplifies Cleveland Clinic s commitment to measuring and transparently reporting outcomes in an effort to continuously improve patient care. This past year was one of continued growth and achievement for the Medicine Institute. Accomplishments for 214 included: Ongoing clinical transformation of all primary care practices to manage population health Outstanding clinical quality and ambulatory patient experience metrics Successful application to become a CMS Accountable Care Organization effective Jan. 1, 215 Integration of Florida departments and colleagues into the Medicine Institute with recruitment of new leadership Redesign of the main campus Internal Medicine Residency Program with recruitment of new leadership Authorship of more than 23 publications in high-impact journals by staff members Ongoing expansion of the primary care and hospital medicine programs We welcome your feedback, questions, and ideas for collaboration. Please contact me via at OutcomesBooksFeedback@ccf.org and reference the Medicine Institute Outcomes book in your message. Sincerely yours, David L. Longworth, M.D. Chairman, Medicine Institute 4 Outcomes 214

7 Institute Overview Cleveland Clinic s Medicine Institute brings together departments that provide coordinated care across the practices of adult primary care, family medicine (including the care of children and adolescents), consultative internal medicine, geriatrics, hospital medicine, and infectious diseases. From establishing outpatient care with new physicians to ensuring effective inpatient care through hospital medicine and infectious disease consultants, the Medicine Institute has the expertise to deliver outstanding care and achieve superior outcomes. The Medicine Institute strives to be the medical home for accessible, comprehensive, coordinated, high-quality, costeffective care for patients. Based at Cleveland Clinic s main campus, the Medicine Institute has Family Medicine and Internal Medicine physicians at 16 family health centers, 8 regional hospitals, and 13 regional primary care practices. In addition, the Medicine Institute provides primary care services at 4 Florida locations. Key programs include the following: Center for Geriatric Medicine, consistently ranked among the top 1 geriatrics programs in the U.S. News & World Report America s Best Hospitals survey Center for Value-Based Care Research, aimed at studying new models of healthcare Internal Medicine Preoperative Assessment, Consultation and Treatment (IMPACT) Center for preoperative consultation and care Primary Care Women s Health program for gender-specific care, education and research National Consultation Service for out-of-town patients with complex conditions requiring streamlined access to specialists Physicians Primary care Ohio 231 Primary care Florida 38 Infectious disease 22 Hospital medicine 13 National Consult Service 3 International Travel Health Clinics 4 Geriatrics 7 Primary care women s health 12 Residents and fellows 234 Volumes Primary care Ohio 698,4 Primary care Florida 124,64 Infectious disease: outpatient 1,76 Infectious disease: inpatient consults 41,316 Hospital Medicine IMPACT 29,83 Inpatient admissions Ohio 16,788 Medicine Institute 5

8 Quality Performance Measurement Overview The healthcare landscape continues to change in many ways, providing new and unique challenges to healthcare providers. One clear change is the rise in publicly reported process and outcomes measures. Making results transparent aids both the caregiver and the patient in understanding how a clinician is applying best practices and giving the patient the best opportunity to remain in optimal health. In selecting measures, Cleveland Clinic s Medicine Institute uses standards developed by prominent national organizations, including the National Committee for Quality Assurance (NCQA) and the U.S. Preventive Services Task Force (USPSTF), as well as those adopted by the National Quality Forum (NQF). These measures include: Management of common chronic conditions, such as diabetes, coronary artery disease, and high blood pressure Screening for common preventable or treatable conditions, such as smoking, breast cancer, and colorectal cancer Prevention of infectious diseases with immunizations The patient s safety and hospital experience Hospital readmissions and mortality rates In addition to the results shown in this Outcomes book, these measures are tracked and shared on a regular basis, and physicians are given regular feedback on their practices. This information identifies opportunities to improve performance, which in turn enhances the care the institute provides for patients. Note: The Accountable Care Organization (ACO) outcomes reported for the Medicine Institute population is composed of patients with a primary care physician at Cleveland Clinic main campus, the Northeast Ohio family health centers, Cleveland Clinic Lorain, and Cleveland Clinic Florida. 6 Outcomes 214

9 At-Risk Population: Hypertension ACO 24: Blood Pressure Control in Patients With Diabetes GPRO national mean N = , , ,96 Maintaining blood pressure < 14/9 mm Hg is recommended for most patients with diabetes. Institute physicians make every effort to achieve the best blood pressure control possible in patients. Through consistent monitoring, awareness, and patient education, a high level of success is achieved. The Centers for Medicare & Medicaid Services has retired this measure effective Jan. 1, 215. ACO 28: Hypertension Control (< 14/9 mm Hg) N = , ,27 GPRO national mean ,215 Institute physicians evaluated the percentage of patients aged 18 to 85 who had a documented diagnosis of hypertension and a blood pressure reading of < 14/9 mm Hg at their most recent ambulatory office visit. The institute continues to exceed national averages and is among the best in the country in hypertension control. ACO = Accountable Care Organization, GPRO = group practice reporting option Medicine Institute 7

10 At-Risk Population: Diabetes The epidemic of type 2 diabetes mellitus is of great concern. Institute physicians closely monitor how the care of patients with diabetes adheres to guidelines and targets promoted by prominent organizations, most notably the American Diabetes Association. These targets are often difficult to achieve in actual clinical practice. Given the limitations of currently available treatments and patient factors, controlling diabetes remains a major challenge for patients and their physicians. Results are reported for all patients with diabetes aged 18 to 75. ACO 22: Blood Sugar Control in Patients With Diabetes (HbA 1c < 8%) ACO 27: Blood Sugar Control in Patients With Diabetes (HbA 1c > 9%) GPRO national mean 1 8 GPRO national mean N = 212 a 27, , ,96 N = , , ,96 a There is no 212 GPRO national mean. The percentage of patients with diabetes whose glucose is inadequately controlled (HbA 1c > 9%), as well as the percentage of those patients with good control (HbA 1c < 8%), was examined. Institute performance was compared with established national group practice reporting option (GPRO) benchmarks. The Centers for Medicare & Medicaid Services has retired this measure effective January 1, 215. ACO = Accountable Care Organization, GPRO = group practice reporting option 8 Outcomes 214

11 ACO 23: Lipid (LDL Cholesterol) Control in Patients With Diabetes GPRO national mean N = , , ,96 Aggressive control of high cholesterol, specifically low-density lipoprotein (LDL) cholesterol, has been shown to prevent or delay atherosclerosis and improve outcomes in patients with existing atherosclerosis. Excellent cholesterol control (LDL < 1 mg/dl) is the institute s goal for patients with diabetes. Institute performance was compared with GPRO benchmarks. The Centers for Medicare & Medicaid Services has retired this measure effective January 1, 215. ACO = Accountable Care Organization, GPRO = group practice reporting option Medicine Institute 9

12 At-Risk Population: Ischemic Vascular Disease ACO 29: Ischemic Vascular Disease: Complete Lipid Profile and Low-Density Lipoprotein Control GPRO national mean N = 212 a 29, , ,824 a There is no 212 GPRO national mean. The percentage is reported of patients older than 18 years with ischemic vascular disease who had a complete lipid profile completed within the past year with low-density lipoprotein < 1 mg/dl. The Centers for Medicare & Medicaid Services has retired this measure effective January 1, 215. ACO = Accountable Care Organization, GPRO = group practice reporting option 1 Outcomes 214

13 ACO 3: Ischemic Vascular Disease: Use of Aspirin or Another Antithrombotic GPRO national mean N = , , ,638 The percentage is reported of patients older than 18 years with ischemic vascular disease who were prescribed aspirin or another antithrombotic during the previous year. ACO = Accountable Care Organization, GPRO = group practice reporting option age of Patients With Ischemic Vascular Disease Prescribed a Statin N = , , ,522 The pharmacological treatment plan for patients with ischemic vascular disease includes statin therapy. The percentage is reported of patients with ischemic vascular disease who were prescribed a statin. No benchmark is available at this time. Medicine Institute 11

14 At-Risk Population: Heart Failure ACO 31: Heart Failure: Beta Blocker Therapy for Left Ventricular Systolic Dysfunction N = GPRO national mean The percentage is reported of patients older than 18 years with a diagnosis of heart failure and a left ventricular systolic dysfunction < 4% who were prescribed beta blocker therapy. The Medicine Institute s performance has been consistent and continues to exceed the national benchmark. ACO = Accountable Care Organization, GPRO = group practice reporting option 12 Outcomes 214

15 At-Risk Population: Coronary Artery Disease ACO 33: Angiotensin-Converting Enzyme Inhibitor or Angiotensin Receptor Blocker Therapy for Patients With Coronary Artery Disease and Diabetes and/or Left Ventricular Systolic Dysfunction N = GPRO national mean The percentage is reported of patients older than 18 years with coronary artery disease, who also have diabetes and/or left ventricular systolic dysfunction, who were prescribed an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker. The Medicine Institute s performance has been consistent and continues to exceed the national benchmark. ACO = Accountable Care Organization, GPRO = group practice reporting option Medicine Institute 13

16 Preventive Health ACO 15: Pneumococcal Immunization for Adults 65 Years GPRO national mean N = 61,384 66,185 84,65 The percentage of adults aged 65 or older showing documentation of pneumococcal immunization was measured. The Medicine Institute consistently surpasses the national benchmark for the administration of the pneumococcal vaccine. ACO 17: Tobacco Use: Screening and Cessation Intervention GPRO national mean a N = 293, , ,759 a There is no available 212 GPRO national mean. The percentage of adults aged 18 or older who were screened for tobacco use and received smoking cessation counseling if identified as a tobacco user was measured. ACO = Accountable Care Organization, GPRO = group practice reporting option age of Cleveland Clinic Medicine Institute Patients Who Smoke, and age Who Quit Smoking Patients Who Smoke (%) N = 27,47 292,323 32,6 The percentage of patients aged 18 and older seen at least once in the past 2 years who were smokers at their last visit was measured. Smokers Who Quit (%) N = 34,376 29,323 4,515 The percentage of patients aged 18 and older who were smokers and quit smoking during the measurement year was tabulated. 14 Outcomes 214

17 ACO 19: Colorectal Cancer Screening GPRO national mean N = 127, ,84 175,29 Completion of appropriate colorectal cancer screening tests leads to earlier detection and reduced risk of death from colorectal cancer. The Medicine Institute evaluated the percentage of patients aged 5 to 75 who had documented colon cancer screening using colonoscopy, flexible sigmoidoscopy, and/or stool occult blood testing. The institute continues to demonstrate an upward trend in performance over the past 3 years. ACO 2: Breast Cancer Screening MI PCWH GPRO national mean 2 MI N = PCWH N = ,618 27, ,241 28, ,845 29,852 The Medicine Institute monitored rates of screening mammography within the past 2 years in women aged 4 to 69. The institute s performance over the past 3 years has been steady and above the national benchmark. The Primary Care Women s Health section performance has been consistently higher than the overall institute and the national benchmark. ACO = Accountable Care Organization, GPRO = group practice reporting option, MI = Medicine Institute, PCWH = Primary Care Women s Health Medicine Institute 15

18 Readmissions and Mortality Standardized Mortality Ratio SMR The standardized mortality ratio (SMR) is observed deaths/expected deaths (1. represents the average mortality rate; < 1. represents a better-than-expected mortality rate). SMR is a commonly used method of representing care and making data comparisons. The All Patient Refined Diagnosis Related Groups (APR DRG) a risk-adjustment method is used in this calculation to make effective comparisons. The institute s SMR remains well below expected. The population is defined as all patients admitted to the Medicine Institute s service. a The 3M All Patient Refined Diagnosis Related Groups (APR DRG) Classification System is used for adjusting data for severity of illness and risk of mortality. solutions.3m.com/wps/portal/3m/en_us/health-information-systems/his/products-and-services/ Products-List-A-Z/APR-DRG-Software 16 Outcomes 214

19 The Medicine Institute hospitalist provides inpatient care, which covers a very wide range of diagnoses and conditions. To better determine readmission rates, the institute leadership continues to focus on the discharge status of the patient and to pair interventions with each of the main modes by which patients are discharged. The three main discharge modes are home, home with home healthcare, and skilled nursing facility. In 214, there was a decrease in the readmission rate for patients being discharged home and patients requiring postdischarge care in a skilled nursing facility. 3-Day All-Cause Readmission Rate for Patients Discharged to Home Day All-Cause Readmission Rate for Patients Discharged to a Skilled Nursing Facility N = N = Day All-Cause Readmission Rate for Patients Discharged to Home With Home Healthcare N = Medicine Institute 17

20 Readmissions and Mortality Pneumonia All-Cause 3-Day Mortality and All-Cause 3-Day Readmissions July 211 June National rate a Mortality Readmissions N = The Centers for Medicare & Medicaid Services (CMS) calculates 2 pneumonia outcomes measures based on Medicare claims and enrollment information. The most recent risk-adjusted data available from CMS are shown. Although Cleveland Clinic s pneumonia patient mortality rate is slightly higher than the US national rate, CMS ranks Cleveland Clinic s performance as no different than the US national rate. Cleveland Clinic s pneumonia readmission rate is ranked worse than the US national rate. To further reduce avoidable readmissions, Cleveland Clinic is focused on optimizing transitions from hospital to home or postacute facility. Specific initiatives have been implemented to ensure effective communication, education, and follow-up. COPD All-Cause 3-Day Mortality and All-Cause 3-Day Readmissions July 211 June National rate a Mortality Readmissions N = COPD = chronic obstructive pulmonary disease a Source: medicare.gov/hospitalcompare CMS calculates 2 COPD outcomes measures based on Medicare claims and enrollment information. The most recent risk-adjusted data available from CMS are shown. Although Cleveland Clinic s COPD patient mortality rate is lower than the US national rate, CMS ranks Cleveland Clinic s performance as no different than the US national rate. Cleveland Clinic s COPD readmissions rate is slightly higher than the US national rate and also ranked by CMS as no different than the US national rate. To further reduce avoidable readmissions, Cleveland Clinic is focused on optimizing transitions from hospital to home or postacute facility. Specific initiatives have been implemented to ensure effective communication, education, and follow-up. 18 Outcomes 214

21 Heart Failure All-Cause 3-Day Mortality and All-Cause 3-Day Readmissions July 211 June National rate a Mortality Readmissions N = a Source: medicare.gov/hospitalcompare CMS calculates 2 heart failure outcomes measures based on Medicare claims and enrollment information. The most recent risk-adjusted data available from CMS are shown. Although Cleveland Clinic s heart failure patient mortality rate is slightly lower than the US national rate, CMS ranks Cleveland Clinic s performance as no different than the US national rate. Cleveland Clinic s heart failure readmissions rate is slightly higher than the US national rate and also ranked by CMS as no different than the US national rate. To further reduce avoidable readmissions, Cleveland Clinic is focused on optimizing transitions from hospital to home or postacute facility. Specific initiatives have been implemented to ensure effective communication, education, and follow-up. Medicine Institute 19

22 Patient Safety Hospital Unit-Acquired Pressure Ulcers > Stage II Number of Patients N = Cleveland Clinic target Aggressive monitoring of pressure ulcer prevalence, the coordinated initiatives of the clinical nurse specialists, unit-based skin care nurses, and multidisciplinary skin care rounds resulted in a decrease in Medicine Institute hospital unit-acquired pressure ulcers > stage II in Outcomes 214

23 Appropriate Risk Assessment for Venous Thromboembolism Inpatient Falls With Major Injury N = Number of Patients N = Cleveland Clinic target Timely venous thromboembolism risk assessment is a process to prevent deep vein thrombosis and pulmonary embolism for hospitalized patients. By building the risk assessment into the standard Cleveland Clinic admission process, the Medicine Institute has consistently achieved compliance for patients aged 18 and older. Initiatives for reducing the rate of falls during 214 continued to focus on identifying those patients whose fall risk may have changed over the course of their care and treatment, as a result of either their own health status change or new medications/procedures known to increase their risk. The Medicine Institute had great success and improvement in 214 with zero falls with major injury. Medicine Institute 21

24 Patient Experience Medicine Institute Cleveland Clinic is dedicated to delivering excellent clinical outcomes surrounded by the best possible experience for patients and their families. Reported patient experiences are shared with caregivers and used to identify opportunities to improve care. Cleveland Clinic s Office of Patient Experience supports caregivers through education and guidance to help them deliver consistent, patient-centered care. Outpatient Office Visit Survey Medicine Institute CG-CAHPS Assessment a Best Response (%) (N = 12,939) 214 (N = 28,936) CG-CAHPS 213 database average (all practices) b Appointment Access (% Always) c a In 213, Cleveland Clinic began administering the Clinician and Group Practice Consumer Assessment of Healthcare Providers and Systems surveys (CG-CAHPS), standardized instruments developed by the Agency for Healthcare Research and Quality (AHRQ) and supported by the Centers for Medicare & Medicaid Services for use in the physician office setting to measure patients perspectives of outpatient care. b Based on results submitted to the AHRQ CG-CAHPS database from 2172 practices in 213 c Response options: Always, Usually, Sometimes, Never d Response options: Yes, definitely; Yes, somewhat; No Source: Press Ganey, a national hospital survey vendor Primary Care Specialty Care Doctor Communication (% Always) c (% Yes, Definitely) d Doctor Rating (% 9 or 1) 1 Scale Clerical Staff (% Always) c Test Results Communication (% Always) c 22 Outcomes 214

25 Inpatient Survey Medicine Institute HCAHPS Overall Assessment Best Response (%) Hospital Rating (% 9 or 1) 1 Scale Recommend Hospital (% Definitely Yes) b a Based on national survey results of discharged patients, January 213 December 213, from 467 US hospitals. medicare.gov/hospitalcompare b Response options: Definitely yes, Probably yes, Probably no, Definitely no Source: Press Ganey, a national hospital survey vendor 213 (N = 75) 214 (N = 674) National average all patients a The Centers for Medicare & Medicaid Services requires United States hospitals that treat Medicare patients to participate in the national Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, a standardized tool that measures patients perspectives of hospital care. Results collected for public reporting are available at medicare.gov/ hospitalcompare. HCAHPS Domains of Care a Best Response (%) (N = 75) 214 (N = 674) National average all patients b Discharge Information % Yes Doctor Communication Nurse Communication Pain Management Room Clean New Medications Communication % Always (Options: Always, Usually, Sometimes, Never) Responsiveness to Needs a Except for Room Clean and Quiet at Night, each bar represents a composite score based on responses to multiple survey questions. Quiet at Night Source: Press Ganey, a national hospital survey vendor b Based on national survey results of discharged patients, January 213 December 213, from 467 US hospitals. medicare.gov/hospitalcompare Medicine Institute 23

26 Cleveland Clinic Implementing Value-Based Care Overview Cleveland Clinic health system uses a systematic approach to performance improvement while simultaneously pursuing 3 goals: improving the patient experience of care (including quality and satisfaction), improving population health, and reducing the cost of healthcare. The following measures are examples of 214 focus areas in pursuit of this 3-part aim. Throughout this section, Cleveland Clinic refers to the academic medical center or main campus, and those results are shown. Real-time dashboard data are leveraged in each Cleveland Clinic location to drive performance improvement. Although not an exact match to publicly reported data, more timely internal data create transparency at all organizational levels and support improved care in all clinical locations. Improve the Patient Experience of Care Cleveland Clinic Overall Mortality Observed/Expected Ratio O/E Ratio Cleveland Clinic Central Line-Associated Bloodstream Infection ICU Rate per 1 Line Days Rate per 1 Line Days 2.5 Cleveland Clinic Cleveland Clinic target Cleveland Clinic Cleveland Clinic target Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q Source: Data from the UHC Clinical Data Base/Resource Manager TM used by permission of UHC. All rights reserved. Cleveland Clinic s observed/expected (O/E) mortality ratio outperformed its internal target derived from the University HealthSystem Consortium (UHC) 214 risk model. Ratios less than 1. indicate mortality performance better than expected in UHC s risk adjustment model.. Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q Cleveland Clinic has implemented several strategies to reduce central line-associated bloodstream infections (CLABSI), including a central-line bundle of insertion, maintenance, and removal best practices. Focused reviews of every CLABSI occurrence support reductions in CLABSI rates in the high-risk critical care population. 24 Outcomes 214

27 Cleveland Clinic Postoperative Pulmonary Embolism or Deep Vein Thrombosis Risk Adjusted Rate per 1 Eligible Patients Rate per 1 Patients Q1 Cleveland Clinic Cleveland Clinic target Q2 Q3 Q4 Q1 Q2 Q3 Q Source: Data from the UHC Clinical Data Base/Resource Manager TM used by permission of UHC. All rights reserved. Improved screening, risk adjustment, and prevention strategies have supported Cleveland Clinic s continued improvement with respect to perioperative pulmonary embolism and deep vein thrombosis (AHRQ Patient Safety Indicator 12). Embolism/thrombosis prevention remains a safety priority for Cleveland Clinic in 215. Cleveland Clinic Hospital-Acquired Pressure Ulcer Prevalence (Adult) Q1 Cleveland Clinic NDNQI 5 th percentile (academic medical centers) Q2 Q3 Q4 Q1 Q2 Q3 Q Source: Data reported from the National Database for Nursing Quality Indicators (NDNQI ) with permission from Press Ganey. A pressure ulcer is an injury to the skin that can be caused by pressure, moisture, or friction. These sometimes occur when patients have difficulty changing position on their own. Cleveland Clinic caregivers have been trained to provide appropriate skin care and regular repositioning help while taking advantage of special devices and mattresses to reduce pressure for high-risk patients. In addition, they actively look for hospital-acquired pressure ulcers and treat them quickly if they occur. Medicine Institute 25

28 Cleveland Clinic Implementing Value-Based Care Cleveland Clinic is dedicated to delivering excellent clinical outcomes surrounded by the best possible experience for patients and their families. Reported patient experiences are shared with caregivers and used to identify opportunities to improve care. Cleveland Clinic s Office of Patient Experience supports caregivers through education and guidance to help them deliver consistent, patient-centered care. Outpatient Office Visit Survey Cleveland Clinic CG-CAHPS Assessment a Best Response (%) (N = 64,792) 214 (N = 124,521) CG-CAHPS 213 database average (all practices) b Appointment Access (% Always) c a In 213, Cleveland Clinic began administering the Clinician and Group Practice Consumer Assessment of Healthcare Providers and Systems surveys (CG-CAHPS), standardized instruments developed by the Agency for Healthcare Research and Quality (AHRQ) and supported by the Centers for Medicare & Medicaid Services for use in the physician office setting to measure patients perspectives of outpatient care. b Based on results submitted to the AHRQ CG-CAHPS database from 2172 practices in 213 c Response options: Always, Usually, Sometimes, Never d Response options: Yes, definitely; Yes, somewhat; No e Response options: Yes, No Source: Press Ganey, a national hospital survey vendor Primary Care Specialty Care Doctor Communication (% Always) c (% Yes, Definitely) d Doctor Rating (% 9 or 1) 1 Scale Clerical Staff (% Yes, Definitely) d Test Results Communication (% Yes) e 26 Outcomes 214

29 Inpatient Survey Cleveland Clinic HCAHPS Overall Assessment Best Response (%) Hospital Rating (% 9 or 1) 1 Scale Recommend Hospital (% Definitely Yes) b a Based on national survey results of discharged patients, January 213 December 213, from 467 US hospitals. medicare.gov/hospitalcompare b Response options: Definitely yes, Probably yes, Probably no, Definitely no Source: Press Ganey, a national hospital survey vendor 213 (N = 1,73) 214 (N = 1,369) National average all patients a The Centers for Medicare & Medicaid Services requires United States hospitals that treat Medicare patients to participate in the national Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, a standardized tool that measures patients perspectives of hospital care. Results collected for public reporting are available at medicare.gov/ hospitalcompare. HCAHPS Domains of Care a Best Response (%) (N = 1,73) 214 (N = 1,369) National average all patients b Discharge Information % Yes Doctor Communication Nurse Communication Pain Management Room Clean New Medications Communication % Always (Options: Always, Usually, Sometimes, Never) Responsiveness to Needs a Except for Room Clean and Quiet at Night, each bar represents a composite score based on responses to multiple survey questions. Quiet at Night Source: Press Ganey, a national hospital survey vendor b Based on national survey results of discharged patients, January 213 December 213, from 467 US hospitals. medicare.gov/hospitalcompare Medicine Institute 27

30 Cleveland Clinic Implementing Value-Based Care Focus on Value Cleveland Clinic is developing and implementing new models of care that focus on Patients First and aim to deliver on the Institute of Medicine goal of Safe, Timely, Effective, Efficient, Equitable, Patient-centered care. Creating new models of Value-Based Care is a strategic priority for Cleveland Clinic. As care delivery shifts from fee-for-service to a population health and bundled payment delivery system, Cleveland Clinic is focused on concurrently improving patient safety, outcomes, and experience. What does this new model of care look like? Integrated Care Model Retail Venues Home Community-Based Organizations Care System Outpatient Clinics Post-Acute (other) Emergency Independent Physician Offices Skilled Nursing Facilities MyChart Rehabilitation Facilities Ambulatory Diagnosis & Treatment Hospitals The Cleveland Clinic Integrated Care Model (CCICM) is a value-based model of care, designed to improve outcomes while reducing cost. It is designed to deliver value in both population health and specialty care. The patient remains at the heart of the CCICM. The blue band represents the care system, which is a seamless pathway that patients move along as they receive care in different settings. The care system represents integration of care across the continuum. Critical competencies are required to build this new care system. Cleveland Clinic is creating disease- and condition-specific care paths for a variety of procedures and chronic diseases. Another facet is implementing comprehensive care coordination for high-risk patients to prevent unnecessary hospitalizations and emergency department visits. Efforts include managing transitions in care, optimizing access and flow for patients through the CCICM, and developing novel tactics to engage patients and caregivers in this work. Measuring performance around quality, safety, utilization, cost, appropriateness of care, and patient and caregiver experience is an essential component of this work. 28 Outcomes 214

31 Improve Population Health Select Accountable Care Organization Performance Measures Measure a 215 ACO 9 th percentile b Lower is better Cleveland Clinic 214 Cleveland Clinic Performance (%) Goal a (%) Pneumococcal vaccination Colorectal cancer screening Mammography screening Hemoglobin b A1c > 9% Hypertension control As part of Cleveland Clinic s commitment to population health and in support of its newly certified Accountable Care Organization (ACO), these primary care ACO measures have been prioritized for monitoring and improvement. Cleveland Clinic is improving performance in these measures through enhanced care coordination, optimizing technology and information systems, and engaging primary care physicians and specialists directly in the improvement work. These pursuits are part of Cleveland Clinic s overall strategy to transform care in order to improve health and make care more affordable. Reduce the Cost of Care Cleveland Clinic All-Cause 3-Day Readmission Rate to Any Cleveland Clinic Hospital of Discharges N a = Q1 CMI = case mix index a Total discharges Cleveland Clinic rate Cleveland Clinic CMI UHC academic medical centers CMI Case Mix Index 3. Q2 Q3 Q4 Q1 Q2 Q3 Q , ,755 Source: Data from the UHC Clinical Data Base/Resource Manager TM used by permission of UHC. All rights reserved. Cleveland Clinic monitors 3-day readmission rates for any reason to any of its system hospitals. Unplanned readmissions are actively reviewed for improvement opportunities. Strategies associated with communication, education, and follow-up have been implemented for several high-risk conditions, including heart failure and pneumonia. These practices are being expanded and enhanced to reduce overall avoidable readmissions. Sicker, more complex patients are more susceptible to readmission. Case mix index (CMI) reflects patient severity of illness and resource utilization. Cleveland Clinic s CMI remains one of the highest among American academic medical centers Medicine Institute 29

32 Innovations Population Health Practice Transformation in Primary Care In 214 Cleveland Clinic s Medicine Institute became the first integrated healthcare delivery system to receive Primary Care Medical Home certification from The Joint Commission after transforming all primary care practices in Northeast Ohio to do population management. Practices moved to top-of-license team-based care with embedded care coordinators to manage high-risk patients, which led to strong performance in multiple quality indicators, top decile performance in patient experience, and significant reductions in hospital admissions, readmissions, and emergency room visits. This transformation culminated in a successful application to become a Centers for Medicare & Medicaid Services Shared Savings Accountable Care Organization, effective Jan. 1, 215, which will manage more than 6, Medicare beneficiaries one of the largest in the US. Population Health Training Program To help caregivers implement solutions that improve quality, safety, and efficiency, the Medicine Institute launched a value-based care population health training program. Teams of physicians, nurses, medical assistants, pharmacists, and administrators met for 12 weeks to learn about quality improvement tools and how to apply them to patient care. These teams have improved processes such as scheduling of follow-up appointments, signing up for MyChart accounts, following up on patients with high blood pressure, ensuring accuracy of patient medication lists, and integrating community services for at-risk seniors. Program graduates continue to apply these tools to subsequent projects. After 2 years implementation in this institute, the program has now spread systemwide and is leading to improved care in other institutes. Internal Medicine Residency Program Redesign The internal medicine residency program is transforming its ambulatory clinic experience to provide increased exposure to outpatient internal medicine. Bound in 1-week blocks that recur every 4 weeks, this new ambulatory experience will promote better patient continuity and will also include a balanced didactic curriculum on important outpatient topics. Embedded within the didactics will be material from FRAME, a discussion-based conference from the Foundations of Resident Assessment Mentorship and Emotional intelligence conference series. With guidance from senior physician faculty, residents will explore novel skills that are becoming increasingly important in the healthcare environment. These curricular elements include change management, leadership, empathic communication, emotional intelligence, and teamwork. Internal Medicine Residency Program icompare Participation The internal medicine residency program is participating in the multicenter icompare duty hour trial, a landmark national study of resident duty hours that is the first of its kind in internal medicine. This trial gives programs the flexibility to craft innovative resident staffing patterns that maximize learning while minimizing unnecessary care transitions, and participation will encourage practices that could lead to a tangible and lasting impact on future graduate medical education policy. Employee Walk-In Clinic In August 214, the Medicine Institute and the Department of Internal Medicine opened a walk-in clinic for Cleveland Clinic caregivers. The clinic is conveniently located at Cleveland Clinic main campus and provides enhanced access to care for minor health concerns in an appropriate and lower-cost setting. 3 Outcomes 214

33 If the Walk-In Clinic Didn t Exist, Where Would You Seek Care for Your Medical Concern Today? Schedule With Primary Care Physician Visit Express Care or Retail Clinic Visit the Emergency Department Nothing Schedule With a Specialist Additional benefits include: Decreased time away from work for employees, with cycle times of < 3 minutes per visit Increased patient access for primary care and specialty appointments Increased employee engagement Medicine Institute 31

34 Contact Information Internal Medicine and Family Medicine Appointments/Referrals or , ext National Consultation Service or , ext Infectious Disease Appointments (Main Campus) or , ext Staff Listing For a complete listing of Cleveland Clinic s Medicine Institute staff, please visit clevelandclinic.org/staff. Publications Medicine Institute staff authored 33 publications in 214. For a complete list, go to clevelandclinic.org/outcomes. Center for Connected Care Providing home care, hospice, mobile primary-care physician group practice, home infusion pharmacy, home respiratory therapy, and facility-based (SNF and LTAC) services HOME (4663) or On the Web at clevelandclinic.org/ medicine Locations For a complete listing of Medicine locations, please visit clevelandclinic.org/ medicine. 32 Outcomes 214

35 Additional Contact Information General Patient Referral 24/7 hospital transfers or physician consults General Information Hospital Patient Information General Patient Appointments or Referring Physician Center and Hotline 855.REFER.123 ( ) Or or visit clevelandclinic.org/refer123 Request for Medical Records or , ext Same-Day Appointments CARE (2273) Global Patient Services/ International Center Complimentary assistance for international patients and families or visit clevelandclinic.org/gps Medical Concierge Complimentary assistance for out-of-state patients and families , ext. 5558, or Cleveland Clinic Abu Dhabi clevelandclinicabudhabi.ae Cleveland Clinic Canada Cleveland Clinic Florida Cleveland Clinic Nevada For address corrections or changes, please call Medicine Institute 33

36 About Cleveland Clinic 34 Overview Cleveland Clinic is an academic medical center offering patient care services supported by research and education in a nonprofit group practice setting. More than 32 Cleveland Clinic staff physicians and scientists in 13 medical specialties and subspecialties care for more than 5.9 million patients across the system, performing more than 192, surgeries and conducting more than 497, emergency department visits. Patients come to Cleveland Clinic from all 5 states and more than 147 nations. Cleveland Clinic is an integrated healthcare delivery system with local, national, and international reach. The main campus in midtown Cleveland, Ohio, has a 14- bed hospital, outpatient clinic, specialty institutes, labs, classrooms, and research facilities in 42 buildings on 165 acres. Cleveland Clinic s CMS case-mix index is the second highest in the nation. Cleveland Clinic encompasses more than 9 northern Ohio outpatient locations, including 18 full-service family health centers, 8 regional hospitals, an affiliate hospital, and a rehabilitation hospital for children. Cleveland Clinic also includes Cleveland Clinic Florida; Cleveland Clinic Nevada, which includes the Lou Ruvo Center for Brain Health in Las Vegas, and urology and nephrology services; Cleveland Clinic Canada; and Sheikh Khalifa Medical City (management contract). Cleveland Clinic Abu Dhabi is a full-service hospital and outpatient center in the United Arab Emirates (UAE), which began offering services in spring 215. Cleveland Clinic is the second-largest employer in Ohio, with more than 42,5 employees. It generates $12.6 billion of economic activity a year. Cleveland Clinic Global Solutions supports physician education, training and consulting, and patient services around the world through offices in Canada, China, the Dominican Republic, El Salvador, Guatemala, Honduras, Panama, Peru, Saudi Arabia, Turkey, UAE, and the United Kingdom. The Cleveland Clinic Model Cleveland Clinic was founded in 1921 by 4 physicians who had served in World War I and hoped to replicate the organizational efficiency of military medicine. The organization has grown through the years by adhering to the model set forth by the founders. All Cleveland Clinic staff physicians receive a straight salary with no bonuses or other financial incentives. The hospital and physicians share a financial interest in controlling costs, and profits are reinvested in research and education. The Cleveland Clinic health system began to grow in 1987 with the founding of Cleveland Clinic Florida and expanded in the 199s with the development of 18 family health centers across Northeast Ohio. Fairview Hospital, Hillcrest Hospital, and 6 other regional hospitals have joined Cleveland Clinic over the past 2 decades, offering Cleveland Clinic institute services in heart and neurological care, physical rehabilitation, and more. Clinical and support services were reorganized into 27 patient-centered institutes beginning in 27. Institutes combine medical and surgical specialists for specific diseases or organ systems under unified leadership and in a shared location to provide optimal team care for every patient. Institutes work with the Office of Patient Experience to give every patient the best outcome and experience. A Clinically Integrated Network Cleveland Clinic is committed to providing value-based care, and it has grown the Cleveland Clinic Quality Alliance into the nation s second-largest and Northeast Ohio s largest clinically integrated network. The network comprises more than 54 physician members, both employed and independent physicians from the community. Led by its physician members, the Quality Alliance strives to improve quality and consistency of care; reduce costs and increase efficiency; and provide access to expertise, data, and experience. Outcomes 214

37 Cleveland Clinic Lerner College of Medicine Lerner College of Medicine is known for its small class sizes, unique curriculum, and full-tuition scholarships for all students. Each new class accepts 32 students who are preparing to be physician investigators. Cleveland Clinic is building a multidisciplinary Health Education Campus as the new home of the Case Western Reserve University (CWRU) School of Medicine and Cleveland Clinic s Lerner College of Medicine, as well as the CWRU School of Dental Medicine, the Frances Payne Bolton School of Nursing, and physician assistant and allied health training programs. Graduate Medical Education In 214, nearly 18 residents and fellows trained at Cleveland Clinic and Cleveland Clinic Florida, which is part of a continuing upward trend. U.S. News & World Report Ranking Cleveland Clinic is consistently ranked among the top hospitals in America by U.S. News & World Report. It is ranked No. 1 in urology and has ranked No. 1 in heart care and heart surgery since In 214, 4 of its programs were ranked No. 2 in the nation: diabetes and endocrinology, gastroenterology and GI surgery, nephrology, and rheumatology. For more information about Cleveland Clinic, please visit clevelandclinic.org. Cleveland Clinic Physician Ratings At Cleveland Clinic, we believe in transparency. We also believe in the positive influence of the physician-patient relationship on healthcare outcomes. To continue to meet the highest standards of patient satisfaction, we now publish Cleveland Clinic physician ratings, based on nationally recognized Press Ganey patient satisfaction surveys, online at clevelandclinic.org/staff. Medicine Institute 35

38 Resources Referring Physician Center and Hotline Call 24/7 for access to medical services or to schedule patient appointments: 855.REFER.123 ( ), or go to clevelandclinic.org/refer123. The free Cleveland Clinic Physician Referral App, available for mobile devices, gives you 1-click access. Available at the App Store or Google Play. Remote Consults Anybody anywhere can get an online second opinion from a Cleveland Clinic specialist through our MyConsult service. For more information, go to clevelandclinic. org/myconsult, eclevelandclinic.org, or call , ext Request Medical Records or , ext Track Your Patients Care Online Cleveland Clinic offers an array of secure online services that allow referring physicians to monitor their patients treatment while under Cleveland Clinic care, as well as access test results, medications, and treatment plans. my.clevelandclinic.org/online-services DrConnect (online access to patients treatment progress while under referred care): ; drconnect@ ccf.org MyPractice Community (affordable electronic medical records system for physicians in private practice): eradiology (teleradiology consultation provided nationwide by board-certified radiologists with specialty training, within 24 hours or stat): ; starimaging@ccf.org Medical Records Online Patients can view portions of their medical record, receive diagnostic images and test results, make appointments, and renew prescriptions through MyChart, a secure online portal. All new Cleveland Clinic patients are automatically registered for MyChart. clevelandclinic.org/mychart Critical Care Transport Worldwide Cleveland Clinic s fleet of ground and air transport vehicles is ready to transfer patients at any level of acuity anywhere on earth. Specially trained crews provide Cleveland Clinic care protocols from first contact. To arrange a transfer for STEMI (ST-elevation myocardial infarction), acute stroke, ICH (intracerebral hemorrhage), SAH (subarachnoid hemorrhage), or aortic syndrome, call CODE (2633). For all other critical care transfers, call or CME Opportunities: Live and Online Cleveland Clinic s Center for Continuing Education operates the largest CME program in the country. Live courses are offered in Cleveland and cities around the nation and the world. The center s website (ccfcme.org) is an educational resource for healthcare providers and the public. It has a calendar of upcoming courses, online programs on topics in 3 areas, and the award-winning virtual textbook of medicine, The Disease Management Project. Clinical Trials Cleveland Clinic is running more than 21 clinical trials at any given time for conditions including breast and liver cancer, coronary artery disease, heart failure, epilepsy, Parkinson disease, chronic obstructive pulmonary disease, asthma, high blood pressure, diabetes, depression, and eating disorders. Cancer Clinical Trials is a mobile app that provides information on the more than 1 active clinical trials available to cancer patients at Cleveland Clinic. clevelandclinic.org/cancertrialapp 36 Outcomes 214

39 Healthcare Executive Education Cleveland Clinic has programs to teach people from outside the organization how it operates a major medical center. The Executive Visitors Program is an intensive 3-day behind-the-scenes view of the Cleveland Clinic organization for the busy executive. The Samson Global Leadership Academy is a 2-week immersion in challenges of leadership, management, and innovation taught by Cleveland Clinic leaders, administrators, and clinicians. Curriculum includes coaching and a personalized 3-year leadership development plan. Learn more at clevelandclinic.org/executiveeducation. Consult QD Physician Blog A singular blog for physicians and healthcare professionals from Cleveland Clinic. Discover the latest research insights, innovations, treatment trends, and more for all specialties. Join the conversation: consultqd.clevelandclinic.org. Social Media Cleveland Clinic uses social media to help caregivers everywhere provide better patient care. Millions of people currently like, friend, or link to Cleveland Clinic social media including leaders in medicine. Facebook for Medical Professionals facebook.com/cmeclevelandclinic Follow us on Connect with us on LinkedIn Clevelandclinic.org/Mdlinkedin Medicine Institute 37