Healthy Patients/Engaged Patients

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1 Healthy Patients/Engaged Patients PRESENTED BY: SUE LING LEE RN, MPA KENNETH FELDMAN, PHD, FACHE CHCANYS 2015 STATEWIDE CONFERENCE AND CLINICAL FORUM

2 FACULTY DISCLOSURE It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. All faculty in a position to control content for this session have indicated they have no relevant financial relationships to disclose. The following Faculty in a position to control content relevant to this session has disclosed the following relevant financial relationships: The content of my material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices. The content of my material/presentation in this CME activity will include discussion of unapproved or investigational uses of products or devices as indicated:

3 Learning Objective At the conclusion of the session, attendees should be able to: Identify strategies needed to develop a Population Health Program Understand the concept of engaging patients and quality outcomes Tie patient engagement and patient experience

4 Paradigm Shift Moving from hospital to ambulatory care Shifting from provider centric model to patient centered model Incorporating patient experience and quality incentives in reimbursement Setting tone on quality standards by National organizations, i.e. NCQA, CMS, TJC Introducing Patient Centered Medical Home

5 Journey of Health Care Old Model Disease oriented and based in the hospitals Hospitals paid for each patient visit and hospital stay No emphasis on preventive health Health care was provider centric

6 Who is Gouverneur Health? Is part of the New York City's Health and Hospitals Corporation s (NYC HHC) $6.7 billion integrated healthcare delivery system. One of the D&TCs of the newly formed Gotham FQHC Largest Diagnostic and Treatment Center in New York State, with 300,000 annual visits. Serves a culturally diverse population in the Lower East Side of Manhattan mainly Spanish and Chinese Primary Care and Specialty Services

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9 Our Approach Based on Quality/Performance Improvement Use of LEAN principles Data driven Use of Evidence Based Practice Tie into managed care quality metrics Link into standards of care for chronic disease and Healthy People 2020 Tie into the HHC mission and 6 Guiding Principles

10 Programs RN Treat to Target for the management of uncontrolled hypertension Public Health Advisors Management of the Diabetes and Cardiovascular Registry patients for quality metrics Transitions of Care RN Telephone Follow Up Post Transfers

11 RN Treat to Target Providers identify and refer patients with uncontrolled hypertension to the RN Treat to Target program Providers provide defined parameters for medication dosing for control Patient scheduled for RN visit for intensive counseling and monitoring of blood pressure Patient graduates when there are two consecutive blood pressures of <140/90 within 3 months in the program

12 % Graduated 43% 60% 57% 60% 64% 70% 70% 76% 75% 81% 79% 83% 81% 81% 88% 86% 91% 100% 100% 100% 100% 100% 100% 100% 100% % Graduated per Team per Quarter 100% 90% 80% 70% 60% Team 1 Team 2 50% 40% 30% Team 3 Team 4 Team 5 20% 10% 0% 2014 Q Q Q Q Q1 Team by Quarter

13 Public Health Advisors Diabetes Project Public Health Advisors (PHA) was a new role conceived for Population Health Assigned to a medical team Worked with the individual providers on their team to review their diabetic patient panel in the Diabetes Registry Indicators Managed Care quality measures Health Care industry standards Corporate indicators for quality reporting NCQA (National Quality Assurance) Diabetes standards

14 Diabetes Registry Follow Up 80% 70% 60% 50% 40% 30% 20% 10% 0% NO MD VISIT (w/in 3 mos ) NO HgbA1 (w/in 6 mos ) HgbA1c >9 BP>140/90 Lipid >100 NO eye exam ( w/in 1 yr ) NO foot exam (w/in 1 yr)

15 PHA Cardiovascular Registry Started mid 2014 utilizing Diabetes Registry Model. Focused on three metrics: Uncontrolled blood pressure >140/90 Lipid result >130 and no MD visit within 6 months No MD visit within 6 months

16 % of Patients who showed up for MD visit CVRR Registry Tracking 100% 90% 80% 84% 78% 79% 79% 79% 70% 60% 50% 64% 61% 53% % showed for MD visit where patient had not been seen within 6 months % showed for MD visit where patient has uncontrolled BP 40% 30% 36% % showed for MD visit where patient Lipid>130 without a visit in 6 months 20% 10% 0% Q3 Q4 YTD Time

17 Transitions of Care Developed to meet the standard for Transitions of Care standard for PCMH application Overall goal was to engage patients into care and avoid readmissions 2012 data indicated only 12% of patients transferred from our facility received follow up calls 2013 policy/procedure developed, staff trained on importance of engaging patients into care after discharge from ED/admission RN assigned to contact patient within 3 business days of transfer 2015 started to review data on patients keeping appointments for follow up 2015 Received list of patients discharged from Bellevue for follow up calls

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19 Tips and Strategies KEY to success is to identify your patient population to manage Target a population where you can impact on the quality outcomes, i.e. Better blood pressure control prevents complications Utilize existing resources Think outside the box and utilize strategies such as telephone contacts and RN visits to improve outcomes Develop a team approach to care INVOLVE EVERYONE Share data and success stories. CELEBRATE YOUR SUCCESSES! Don t wait for PERFECT! Frequent huddles/briefs in the beginning to identify barriers and develop solutions

20 QUESTIONS? Sue Ling Lee RN, MPA Associate Executive Director of Nursing; Gouverneur Health Kenneth Feldman PhD, Ed.D., FACHE Associate Executive Director of Ambulatory Care; Gouverneur Health

21 Taking Care of Parents 2 Generation Approach to Pediatric Well Care M A R Y M C C O R D ; J E S S I C A B U O L - F E R G ; M O L LY L O P E Z G O U V E R N E U R H E A LT H S E R V I C E S G O T H A M H E A LT H N E W Y O R K C I T Y

22 FACULTY DISCLOSURE All faculty in a position to control content for this session have no relevant financial relationships to disclose. The content of my material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices.

23 Early Childhood Opportunity for Long Term Impact Brains continue to be built after birth, primarily through interactions with family members and other important adults in a child s life. While the field of child development used to be dominated by debates of nature versus nurture, it is now commonly accepted by the scientific community that individuals are shaped through a dynamic interplay between their genetic makeup and the environments in which they live. This theory of gene-environment interaction has been described as nature dancing with nurture. Jack Shonkoff, Harvard Center for the Developing Child, Neurons to Neighborhoods

24 Early Childhood Opportunity for Long Term Impact

25 It Takes a Village

26 Early Childhood Opportunity for Long Term Impact

27 Early Childhood Opportunity for Long Term Impact

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29 Pediatric Well Care Many Models of Early Childhood Interventions with Long Term Impacts Limited reach Perry Pre-School Project Nurse-Family Partnership Pediatric Care reaches all children with multiple visits in Early Childhood (95% Nationally) = Potential for Public Health impact Multiple visits Trusted advisors Existing Pediatrics models with good evidence for effectiveness Reach Out and Read second only to Immunizations in impact Decrease Language Delay and increases school readiness Healthy Steps > 50% decrease in behavior problems in 3 year olds in Healthy Steps compared to Controls Briggs et al Clinical Practice in Pediatric Psychology. 2014, Vol. 2, No. 2, Next Step 2 Generation Care

30 2 Generation Care - Vision Mother is your patient too Improve Inter-partum care of mothers by integrating maternal and well baby care Support the emotional well being and mental health of mothers Social Determinants of Health identification and intervention Prevention of the inter-generational transmission of trauma

31 2 Generation Care - Vision It Takes a Village Role of Pediatric Practice Identify needs Offer selected, specific supports based on evidence of effectiveness Partner with Community Resources

32 2 Generation Care at Gouverneur 500 mothers receive Prenatal care infants receive WCC yearly GOALS - Pediatrics and Women s Health Collaborate to: Prevent unintended pregnancy for mothers of young children Address Maternal Depression Support positive parenting with focus on Trauma exposed mothers Address Social Determinants of Health

33 Preventing Unintended Pregnancy Intensive focus in first 4 months on effective contraception Start in Delivery room or prior to discharge when feasible All staff trained - ask the One Key Question Do you intend to get pregnant in the next year? => What are your plans for your family? Are you planning more children? In the next year? Same Day access to Women s Health for Contraceptive Care Same Day access in Pediatrics for Mothers 21 and under

34 Preventing Unintended Pregnancy Metrics Counseling for contraception counseling coded in Infant chart Health Educator Referrals for Newborn counseling Effective contraception, Post Partum Depression screen, Breast Feeding Maternal uptake of effective contraception - harder

35 Two patient stories 21 yo mother at 4 mo Well Child visit talks herself into the implant and has it done that day by the Pediatric provider Mother of 11 sees Health Educator who asks One Key Question leading to a clear answer, request for IUD => inserted by Women s Health an hour later.

36 Addressing Maternal Depression Screening for Post Partum Depression Current screening in Women s Health at Post Partum visit - ~30% don t go to this visit 16% positive don t know percent who engage in care Health Educator screens mother Percent seen by Health Educator varies 25-50% Pediatric Medical Assistants to be trained to administer PHQ9 at 2 mo visit Addressing Maternal Depression most do not follow up on referrals Bring Treatment to Pediatric Care Train staff - collaboration with NYU Behavioral Health team All nurses and Providers to train in one session psycho-educational support Selected staff to train in 3 session scripted intervention High risk referred out (10-20% of positive screens)

37 Addressing Maternal Depression Quality Metrics Screen done Rate of detection of Depression Compliance with intervention visits

38 Unified Registry for Mother and Infant care MS Access Database used for PCAP tracking Infants entered at time Newborn appointment made at Gouverneur Link to mother s demographic info helps with Newborn No Shows SW identifies mothers with high psycho-social risk (ACS involved, history of depression or other mental illness) => risk communicated to Peds team

39 2 Generation Mother and Infant care What are you doing? Is this a current Family Practice Model? Is Mother-Infant data integrated by EMR in Family Practices?

40 Links to Community Partners Early Childhood Services - Resource guide Early Intervention for those with Developmental Concerns Early Head Start, Head Start and Pre K for all Pre-natal and Newborn referral to Nurse family Partnership or Healthy Families America Growing number of parent support program models

41 Positive Parenting Prevent Inter-generational transmission of trauma Healthy Steps Early Childhood Specialist integrated into practice Providers and staff trained in positive parenting support All families supported - Becomes primary focus of anticipatory guidance Ongoing coaching from specialist to increase staff skills Families screened for risk => high risk followed by specialist Risk screen => more intensive support for higher risk families Teen mothers, homeless, hx of parental mental illness or substance abuse Other models are possible

42 Screening for Psycho-Social Risk Many approaches Geo mapping to high risk census tracts Maternal ACE s Specific needs food, housing Child behavior and Development Maternal Depression Specific risks - DV, Substance abuse, other mental illness, Homeless

43 Screening for Risk What are you doing?

44 Strength Based Model of Primary Care Apply chronic disease model to supporting Early Childhood Make Positive Parenting the focus of Anticipatory Guidance Risk stratify Define Care Bundles for different risk levels and follow with registry CHW s to work closely with high risk mothers Develop systematic linkages with Community Based EC services:

45 Challenges Too much to do, too Little time Need to prioritize this agenda Has to be a team approach Link to WH don t do double work MA s and nursing roles in health education Standardize for limited number of critical items Focus Quality Agenda here PCMH and Practice Transformation resources not allocated to Pediatric care but should be if long term outcomes are considered Outreach Workers QI data resources Screening effectively ALL patients secure follow up plan confidence that follow up is effective Coding Maternal care in infant chart

46 2 Generation Pediatric-Maternal Care What are you doing now? What can you do next?

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