Transcript The Rhode Island Chronic Care Sustainability Initiative

The Rhode Island Chronic Care
Sustainability Initiative (CSI-RI)
Presentation for RIBGH
September 21, 2012
Debra Hurwitz, MBA, BSN, RN
David Keller, MD
CSI Co-Directors
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The Rhode Island Chronic Care
Sustainability Initiative (CSI-RI)
Vision
Rhode Islanders enjoy excellent health and quality of life. They are
active participants in an affordable, integrated health care system
that promotes wellness and delivers high quality, comprehensive
primary care.
Mission
To lead the transformation of primary care in Rhode Island. CSI
brings together critical RI payers, providers, purchasers, consumers
and other leaders to develop, implement, evaluate, refine and
spread models to deliver, pay for and sustain high quality
comprehensive primary care.
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Joint Principles of the PCMH
AAP, AAFP, ACP, AOA , March 2007
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Personal physician
Physician-directed medical practice
Whole person orientation
Care is coordinated and/or integrated
Quality and safety
Enhanced access to care
Payment to support the PCMH
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What is CSI-RI?
• Working with all major health care stakeholders to
transform primary care in Rhode Island.
• Promotes the PCMH, a model of primary care that is
patient-centered, coordinated, accessible and teambased. The model focuses on prevention, wellness
and appropriate treatment.
• This will lead to improved care, lower costs and better
health outcomes for Rhode Islanders.
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It Takes a Team…
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CSI-RI Collaboration Partners
Payers
• Medicaid
• All commercial plans
• Medicare
Purchasers
• Self-insured employers
Providers
• Primary care providers (private practices, community health centers,
hospitals and clinics)
State
• Office of the Health Insurance Commissioner, Executive Office of Health
and Human Services, Department of Human Services, Department of
Health
Technical Experts
• Department of Health; QIO
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CSI-RI helps plans and practices build
sustainable Patient-Centered Medical Homes
• Data-driven practice
transformation
• NCQA Level 3
• Nurse Case Manager on
the team
• Common Contract
• All-payers involved
• PMPM paid on
attributable lives
• PMPM based on
performance
Used with permission of Ed Paul MD,
Yuma Regional Medical Center
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CSI-RI is growing
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5 practice in 2008
13 practices in 2010
16 practices on Oct 1
Future:
– Learn and refine model with
RIQI
– More sites in 2013
– Employer engagement (benefit
design)
– Employee engagement (PCP
designation)
Patients in CSI-RI
100000
90000
80000
70000
60000
50000
40000
30000
20000
10000
0
2008 2009
2010
2011
2012
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Key Elements of CSI-RI
PCMH
• Common Contract additional payment PMPM
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Nurse Care Manager at the practice site
Practice coaching for team-based care
Participation in learning collaborative
NCQA recognition Level 3
HIE capacity
Common measures of performance for improved management
of chronic conditions (i.e., diabetes, heart disease, depression,
tobacco cessation)
• Data and reporting on quality measures
• Performance incentives based on PMPM
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Care Management Activities
Nurse Care Manager
lynchpin for success
• Located within practices, regardless of payer
• Care Manager college
• Activities
• Identification of high risk patients
• Patient assessment
• Care coordination (transitions of care; specialist referrals; homeand community-based services and supports)
• Patient/family education
• Engage patients in shared decision-making
• Team communication
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CSI-RI and PCMH:
What’s the Evidence?
Building CSI-RI
• Evolving evidence
– AHRQ
– PCPCC
• Early evaluation
– Practice transformation
– Impact utilization
• Ongoing evaluation
– Quality
– Experience
– Cost
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AHRQ Review
“Overall, these findings are
encouraging … Our horizon scan
identified ongoing studies … that,
when published, should more than
double the size of the published
literature … most are being
conducted with the participation
of a commercial insurer.”
- AHRQ, 2012
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PCPCC
“This report provides significant
evidence that Patient-Centered
Medical Homes around the country
are reducing costs while improving
quality of care, access and patient
satisfaction for both children and
adults.”
- PCPCC, 2012
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PCMH: What works?
• Using Health IT to drive patient care
– Renaissance Medical Management, PA: Patient engagement
reduced hospital admissions and emergency room utilization
• Enhanced access
– Seven projects in VT, ND, CO, UT, WA, NC, PA: Enhanced
communication off hours, reduced preventable hospitalizations
and PMPM costs
• Use of high-value specialist
– Qualitative evaluation of four high-performing practices showed
association with reduced costs
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PCMH: What works?
• Population-based care management programs
– Care Continuum Alliance: Effective use of registries improved risk
factor management
• Patient engagement
– NC: Patient engagement associated with cost savings of 7 – 15%
over four years
• Community health teams to manage and coordinate
care
– VT: CHTs reduce hospital and ER utilization, and enhance
utilization of behavioral health resources
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Evaluating CSI-RI
Patients in CSI-RI
100000
90000
80000
70000
60000
50000
40000
30000
20000
10000
0
2008
2009
2010
2011
2012
Ongoing Measurement
Early Years
Self Attribution
Plan Attribution
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Early Years: 2008-2010
• External evaluation
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Commonwealth Fund
Impact on practice
Impact on quality
Impact on utilization
Comparison group
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NCQA-PPC Improvement
Across Submissions
Based on PPC-PCMH 2008 Standards
Percentages calculated based on formula: points earned / total possible points
From M. Rosenthal, Presentation to CSI-RI Steering Committee, 7/13/2012
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Key Findings
• Small changes in outcomes by year 2
– Improved quality
– Reduced use of ER for ambulatory sensitive
conditions
“CSI-RI evaluation suggests that WITH ADEQUATE
FINANCIAL AND TECHNICAL SUPPORT small practices
can make significant strides in adoption of medical
home structures and processes”
From M. Rosenthal, Presentation to CSI-RI Steering Committee, 7/13/2012
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Pilot Successes
Proactive Population
Management &
Tracking
Improved
Professional
Satisfaction
Overall
Transformation
• “The single most successful piece has been the
ability to record, track and respond to outcomes
data. On a population-level, knowledge is power.”
• “The professional satisfaction now compared to
[before the pilot] is through the roof.”
• It’s hard to believe how far we’ve come. Just the fact
that so much has changed is one of the most important
things about the whole project… The project has given
us both time to think outside of the box and has helped
us develop a meaningful way to get out of the box and
transform our practice to something new.”
From M. Rosenthal, Presentation to CSI-RI Steering Committee, 7/13/2012
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Ongoing Evaluation is driven by
the Common Contract
• Infrastructure
– NCQA Level 3
– Nurse Case Manager on the team
• Quality measures
– Six in 2011-12
– Seven in 2012-13
• Patient experience
– Communication, office staff and access
• Utilization
– ER use and hospitalization
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CSI-RI: Building Infrastructure
NCQA Level 3 Recognized (2011 Criteria)
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Family Health and Sports Medicine (Cranston)
Hillside (Pawtucket)
University Medicine – Governor St. (Providence)
Coastal– Greenville (Smithfield)
Thundermist Health Center (Woonsocket)
NCQA Level 3 Recognized (2008 Criteria)
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Stuart Demirs, MD (Charlestown)
SCH Family Medicine (East Greenwich)
Memorial Hospital Family Care Center (Pawtucket)
Cesario, Kostrzewa, Maguire, Gonzalez (Wakefield)
Coastal Medical, Inc. (Wakefield)
Kristine Cunniff, MD (Wakefield)
South County Internal Medicine (Wakefield)
Thundermist of South County (Wakefield)
Blackstone Valley CHC, (Pawtucket and Central Falls)
East Bay Community Action Program (Newport)
University Family Medicine, (East Greenwich)*
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Ongoing Measurement: Are we
meeting the Triple Aim?
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Population Health:
Setting Quality Benchmarks
• In 2011-12, within our practices:
– Patients with diabetes will:
• Control their sugar
• Control their blood pressure
• Control their LDL ( <100)
– Patient with coronary artery disease will:
• Be treated properly
– Patients will be screened and treated for:
• Depression
• Tobacco use
– Patients will report high level of care in
• Communication, Office Staff
Quality Report Card- 2012
Green = Attained Target Value
Yellow = Within 10% of Target Value
Red =
Not Attained Target Value
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Measuring Patient Experience
Patient Experience Survey- CAHPS PCMH, Spring 2012
Percentage in "usually or always" good)
100%
90%
80%
70%
Communication Composite
Office Composite
60%
50%
40%
30%
P-1
P-4
P-2
P-3
P-5
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Success means growing and
moving on…
Depression Screen
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
P-1
P-2
P-3
P-4
P-5
E-1
Q4 2011
E-2
Q1 2012
E-3
E-4
E-5
E-6
E-7
E-8
Q2 2012
CSI Pilot and Expansion Site Clinical Quality Data
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Raising the bar…
DM LDL Control (<100)
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
50%
40.0%
30.0%
20.0%
10.0%
0.0%
P-1
P-2
P-3
P-4
P-5
E-1
Q4 2011
E-2
Q1 2012
E-3
E-4
E-5
E-6
E-7
E-8
Q2 2012
CSI Pilot and Expansion Site Clinical Quality Data
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And resetting the standards
• In 2012-13, within our practices:
– Patients with diabetes will:
• Control their sugar
• Control their blood pressure
• Control their LDL ( <100)
– Patient with high blood pressure will:
• Be controlled
– Patients will be screened and treated for:
• Obesity
• Tobacco use
– Patients will report high level of care in
• Communication, Office Staff, Access to Care
Utilization as a proxy for cost
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Are we reducing costs?
Health plans think so.
• Blue Cross Blue Shield of R.I. shows directional
reduction (slowing) in inpatient admissions and cost
trends at its PCMH sites.
• United Healthcare’s internal evaluation is
directionally showing a reduction in inpatient
admissions and cost trend.
National, state and internal business metrics are
aligned.
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What about the patient?
“I enrolled in the health plan's medical home option, and
selected this practice as our new provider. … We were
surprised at the time the staff spent with each of us... We
each left the office with a plan, and knew what we needed to
do before the next visit. … Change isn't always easy. But I've
had to get over my "too busy to take care of myself"
mentality. … The patient-centered medical home required
some thought, and some work, on my part. But this change
has been the best decision of my life, and my family's lives as
well.”
Diane @ http://3blmedia.com/theCSRfeed/Dont-Let-Name-Fool-You-MyMedical-Home-Experience
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The future of PCMH
“Why would anyone want to buy anything else?”
- Paul Grundy, IBM
• Expanding the model in Rhode Island
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More practices
Benefit designs focused on PCMH
Preparing for the newly insured
Including pediatrics
• Building block of new systems of care
– ACOs and integration with hospitals
– Community Health Teams and public health
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