Using Quality Improvement to Raise Quality Scores in Primary Care

Using Quality Improvement to Raise Quality Scores in Primary Care Continuing Education The Georgia Board of Nursing deems Southwest Georgia Area Health Education Center (SOWEGA-AHEC) as an acceptable provider for continuing education (CE). This activity is approved for 1.0 CE hour toward the continuing education competency requirements for Georgia licensure renewal. Activity #2016-05. Presented by Adrienne Mims, MD MPH, FAAFP, AGSF Vice President, Chief Medical Officer Adrienne.Mims@AlliantQuality.org SOWEGA-AHEC is an approved provider of continuing nursing education by the Alabama State Nurses Association, an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. This activity awards 1.0 contact hour. Activity #2016-05. 2 Disclosures Objectives The following program contains no commercial support. The planners and presenter disclosed that they no have no relationships with commercial companies. At the end of the presentation, each attendee should be able to: 1. Understand how to use quality measures to determine areas of the practice to target for improvement. 2. Describe a method process of improvement to improve care practices. 3. Detail how insurers use quality measures in forming practice networks and adjusting reimbursement Using Quality Improvement to Raise Quality Scores in Primary Care Presented by Adrienne Mims, MD MPH, FAAFP, AGSF Vice President, Chief Medical Officer Adrienne.Mims@AlliantQuality.org 6 1

Accountable Care Organizations Essential Characteristics: Complete and timely information about patients and services received Technology and skills for population management and care coordination Resources for patient education and self-management Culture of teamwork Relationships with specialists and hospitals Ability to measure and report on quality Infrastructure and skills for managing risk Operational accountability and commitment to improve value Adapted from How to Create Accountable Care Organizations, Miller, HD, CHQPR.org 2009 Polling Question Do you currently bill for Medicare FFS patient encounters? Yes No Yes, but plan to retire in less than 5 years Significant changes in Medicare payments are coming in 2019 based on your performance in 2017 Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Repeals 1997 SGR and PFS Updates Bipartisan law signed 4/16/15 392 to 37 House 92 to 8 Senate It will not be repealed. The time to act is now! MACRA aka Quality Payment Program Preferred model MACRA (Medicare Access and CHIP Reauthorization Act )= Quality Payment Program Reforms payment for Medicare reimbursement to more than 600,000 Eligible Clinicians (EC) Serving 55 million Americans on Medicare A major step moving health care to pay for value rather than volume Will continue to evolve over time OR https://qpp.cms.gov/docs/quality_payment_program_overview_fact_sheet.pdf 2

2017 MIPS Performance Weights Quality Performance: Assessment Tools Available Now PQRS Feedback report *No Cost Category for 2017 (NEW) HEDIS Report (Healthcare Effectiveness Data and Information Set) - a tool used by more than 90 percent of America's health plans Specialty Clinical Registry Data * Polling Question PQRS Report - Example * Have you successfully submitted quality measures to PQRS in prior years? Yes No What is this? *Redacted report, some columns are hidden PQRS Quality Measure - #236 HEDIS Report Card - Example Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90mmHg) during the measurement period 3

Improvement Activities Improvement Activities (IA) 15% Groups with < 15 participants or rural or health professional shortage areas: Attest for only 2 select two activities all others 4 activities Select from 93 possible IAs Additional improvements in access as a result of QIN/QIO TA Annual registration in the Prescription Drug Monitoring Program Chronic care and preventative care management for empaneled patients Completion of training and receipt of approved waiver for provision opioid medication-assisted treatments Depression screening Diabetes screening Engagement with QIN-QIO to implement self-management training programs Implementation of antibiotic stewardship program Integration of patient coaching practices between visits Measurement and improvement at the practice and panel level Participation in AAFP MOC Part IV - Hypertension Control Population empanelment TCPI participation Free assistance from QIN/QIO Unhealthy alcohol use Tobacco use Use of telehealth services that expand practice access Increase annual screening for depression using PHQ-2/9 Increase annual screening for risky alcohol use - AUDIT www.alliantquality.org Quality Improvement Steps www.alliantquality.org Obtain leadership commitment Assemble a team with a champion Make X= diagnosis a priority Identify and adopt evidence based guidelines Determine baseline performance Set a goal for improvement Identify baseline clinic workflow (where to improve) Develop policies (new processes) Obtain tools (for staff and patients) Train staff on new roles Implement small tests of change (PDSA) Track your progress Celebrate small successes 4

Model for Improvement PDSA Cycle for Process Improvement ACT What changes are to be made? Next cycle? STUDY Complete the analysis of the data Compare data to predictions Summarize what is learned PLAN Objective Questions and predictions Plan to carry out the cycle (who, what, where, when) Plan for data collection DO Carry out the plan Document the problems and unexpected observations Begin analysis of the data Population-based Approach Identify patients in priority populations and then offer a variety of services to meet their needs Each population-based program has measurable goals and plans for improvement which include: Defining eligibility criteria for the identified population Defining evidence-based guidelines to guide care Defining measures to track performance Developing tools to assist practitioners in caring for these members, such as registries, panel reports, pamphlets, and other self-management tools Improving Hypertension Control Defining the Population of Focus Aim Statement All Clinic Patients Adult Patients Adults on Medicare Hypertension Hypertensio n not controlled Population of Focus Outcome Measure Denominator Outcome Measure Numerator Specific Measureable Attainable Relevant/realistic Timely 5

Aim Statement Examples A. We will increase the amount of patients with blood pressure under control among our clinic patients. (weak) B. In three months, patients who have uncontrolled blood pressure will be requested to perform self monitoring of blood pressures. (better) C. By December 2017, we will increase the number of people with hypertension who have a normal blood pressure from 50% to 65% by utilizing a nurse visit protocol (strong) Receptionist Nurse Physician Lab Health Education Referrals Billing Desk Work Flow Swim Lanes Swim Lanes Check In Vitals taken performs exam performs UA, A1C rooms patient reviews labs, writes orders education provided process referral pays bill books next appt 32 Diagnosis of Hypertension Clinic Visit Population Segmentation Blood Pressure Measured On Medications Blood Pressure Under Control Measure in 6 Months Quantifiable Data Segment : used to monitory change in improvement Track When Next Due Root Cause Analysis Example Aim Statement BP monitored Aim Statement On medication 90% of Population of Focus will have an clinic By the end of December, 2017, the 65% of patients visit within the next 6 months with blood pressure under control Baseline 61% Baseline 50% under control Root Cause Analysis BP monitored Root Cause Analysis On a medication Short Staff Failure to keep appointments/take meds/follow diet Availability of equipment Transportation Lack of standing orders Provider inertia Provider inconsistency Family support patient stubbornness Not maximizing the use of pt. Adherence alerts/notifications Lack of training (MAs) Lack of home monitoring Lack of exercise Psychological depression, anxiety Environmental Financial limitations Patient denial Personal habits smoking/illicit drug use Quality Improvement Process Primary care physicians receive monthly lists of their patients with elevated blood pressure with out diagnosis of hypertension (from EHR) Physicians exclude patients who: died, left the practice, lack of mobility, mental illness, or multiple co-morbidities Patients are contacted by staff: Via telephone using a script Mailed letters signed by the physician Promoted use of SMBP and diary Appointment reminders Scheduled nurse visits (no co-pay). Successful use of a Hypertension Protocol 3 MA s 2 LPN s 1 RN 1 FNP 2 MD s 1 Behaviorist (part-time) 1 Nutritionist (part-time) 6

Population Report II. Monthly Hypertension Report HTN Goal Working Document Successful use of a Hypertension Protocol Providers agree on JNC-8 protocol Providers agree on preferred medications Standard Goals Standard Follow up Standard Documentation for nurse visits Recommended Elements of Effective Hypertension Protocols http://millionhearts.hhs. gov/docs/hypertension- Protocol.pdf Clarity and simplicity Lifestyle modification Treatment by stage of hypertension Time interval to titration and reassessment Use of low-cost 1st-line treatment Exclusions and suggestions for medications based on concurrent medical conditions Recommended lab tests Implementing a Hypertension Protocol Make hypertension control a priority Fully use the expertise and scope of practice of every member of the health care team Include the patient and family as key team members Conduct pre-visit planning care Learn about community resources and Recommend them to patients Look for opportunities to check in with patients and adjust medication dose as needed Protocol Implementation: How Can A Practice Get Started? Make decisions about roles, content, meds, more Workflow of BP measurement and recording What lifestyle advice will you give? By whom? When? How? Which medications will you use and at what dosages? What are your target goals and for what ages? How often to re-check and titrate? Who does this? How? How will you define and manage resistance? Track implementation weekly; share monthly control rates Celebrate your success along the way 7

Nurse Visit Protocol Self-Measured Blood Pressure Monitoring: Action Steps for Clinicians http://www.alliantquality.org/sites/default/files /materials/blood_blood_pressure_tracker_10 SOW-GA-IHPC-13-01.pdf Guidance for clinicians on SMBP Teach patients to use monitors Check home machines for accuracy Suggested protocol for home monitoring Guidance on establishing a patientclinician feedback loop http://millionhearts.hhs.gov/ Docs/MH_SMBP_Clinicians.pdf Addressing Adherence Final Advice Team is Critical Use QI tools for structure and documentation Go for Low Hanging Fruit Celebrate and Recognize Remind everyone why we are here for Patients! WHO-HCT team. World Health Organization. Adherence to Long Term Therapies: Evidence for Action. (2003). 8

Where do I go for help? Alliant Quality CMS contracted Quality Innovation Network-Quality Improvement Organizations (QIN- QIO) www.alliantquality.org Transforming Clinical Practice Initiative https://innovation.cms.gov/initiatives/ Transforming-Clinical-Practices/ Adrienne Mims, MD MPH Vice President, Chief Medical Officer 678-527-3492 Adrienne.Mims@AlliantQuality.org Quality Performance Program https://qpp.cms.gov/ Questions? This material was prepared by GMCF, for Alliant Quality, the Medicare Quality Innovation Network Quality Improvement Organization for Georgia and North Carolina, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents Evaluation Attended Live Activity on 12.08.16 Evaluation Link: https://www.surveymonkey.com/r/primarycarecqi Attended On-Demand Activity 12.09.16 or later Evaluation Link: https://www.surveymonkey.com/r/primarycarecqi2 9