Transcript Slide 1

in+care Campaign
Webinar
January 9, 2013
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• Slides and other resources are available on our website
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Agenda
• Welcome & Introductions, 5min
• Sustaining Retention Projects in Unsure Funding
Environments, 30min
• Data Review and Discussion of Retention Strategies
Collected Through the Campaign, 15min
• Q & A Session, 5min
• Updates & Reminders, 5min
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
Quality Measures are a key ingredient in the Continuous Quality Improvement
process and must be compiled for Ryan White, governmental and institutional
reporting requirements including HIVQUAL-US, Meaningful Use and Delivery
System Reform Incentive Payments.

Although Electronic Medical Records collect huge volumes of data, the process of
extracting that data to meet specific reporting requirements or to achieve a
quality improvement activity poses its own challenges.

This lecture will introduce a live experience in the medical home transformation
process which is consolidating quality activities, improving quality reporting,
exploring opportunities to strengthen personnel and infrastructure with attention
to retention and transitions of care.
Amy M. Sitapati, MD
Medical Director, Owen Clinic
Associate Clinical Professor, Department of Medicine
University of California, San Diego
January 9, 2013
Who are we?
Public health mission
Integrated into an
academic medical center
serving as a National
leader in HIV health
delivery. Implementing
new systems of care
relevant to healthcare
reform.
-Ryan White Funded
-Designated Public
Hospital (DPH)
-Low Income Health
Program (LIHP)
-Delivery System Reform
Incentive Payment
(DSRIP) 5 HIV transition
-Meaningful Use (MU)
CY 2011 OSHPD Patient Discharge Data
Where is here?
National leader for HIV
quality care delivery,
excellence in teaching,
workforce capacity
development, designing
patient relevant HIV
research and participating
in national cohort
research.
We empower our HIV
community through
patient advisory meeting,
tools for self-efficacy
(MyUCSDChart), patient
centered web-page, and
on-site computer access.
Patient Centered Medical Home Transformation
-Started with technological build (2 years)
-Now focused on personnel & infrastructure (new)
Web-page
© 2012 Epic Systems Corporation. Confidential.
Patient computer lab
 Create basic level and intermediate computer lessons
 English and Spanish
 Promote on-going e-health literacy and patient chart
access
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My refill:
ritonavir
Viral load
1200
I feel sick
With fever
Call my
therapist
Na low 130
Methadone
refill
Fill out my
Form disability
Flu shot
Testosterone
shot
Appt today?
RPR 1:3
Diarrhea
Letter of
diagnosis
Amoxicillin for
tooth
Dental
referral
Just a hello
Back pain
Mammogr
Trouble with
Medi-cal form
Need lab
orders
AZT refill
More lab
orders
Refills all
out
Headache
Check Vit D

Understanding
the
changes
to
clinic
workload
Monthly Non Office Encounters
5000
4000
3000
2000
1000
0
Dec Jan
2010
Feb Mar Apr May Jun
Jul
Aug Sep Oct Nov Dec Jan
2011
Feb Mar Apr May Jun
Jul
Aug Sep
2012
Telephone
22%
Document/Orders
15%
Non Office Based Encounters Distribution
1/2011 – 9/2012
MyChart
14%
Refill
33%
Orders Only
16%
Ryan White model
to
PCMH HIV model
Patient Centered Medical Home +
Strategy
Category 1: Infrastructure
Development
Category 2: Program
Innovation & Redesign
Category 3: PopulationFocused Improvement
Category 4: Urgent
Improvement in Care
Category 5: HIV Transition
Projects
• Lays the foundation for the delivery system through investments in
people, places, processes and technology.
• Pilots, tests and replicates innovative care models.
• (1) the patient’s experience, (2) the effectiveness of care coordination (3)
prevention and (4) health outcomes of at-risk populations
• Improvement in targeted quality and patient safety measures that are
particularly meaningful to safety net populations
• Support access to high-quality, coordinated, integrated care for HIV/AIDS
patients through delivery system reform

Assigning team members new roles and trying
to determine optimal panel size based on
patient acuity (www.safetynetmedicalhome.org)

HIV empanelment challenges:





Complex set of providers (clear assignment)
Complex funding sources
No HIV patient weight/risk adjustment algorithm
Linkages to a medical home
Team based care
All in one place:
Vitals
History
Labs
Meds
Health Maintenance
Comorbidities

Registries
A collection of information about patients with specific condition
examples: HIV ,(Hep C, Diabetes, Cancer)
May also contain details about their disease status
examples: 6 month gap in care, poor viral control, etc.
Best practice would be to have non MD identify, communicate
and track with an actionable intervention.

Population Management
Clinical workflow to manage groups of patients that need similar
health screenings
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 Difficult setup (need interdisciplinary team)
 Regulatory issues (who is allowed to perform bulk orders)
 Must develop protocols for bulk ordering/action
 PCMH team members (personnel and skill)
 Computer performance concerns about system impact of
creating hundreds of orders at once
 Mistakes can be magnified a hundredfold by bulk actions.
Need to develop system of double checking (by another
person) before action takes effect.
HIV Patient Centered Medical Home
Community part….
Community strengthening through
improved care coordination,
Linkages, and service.

Comprehensive services addressing(1):








Primary medical care
Case management
Nutrition
Mental health
Pharmacy
Adherence counseling
Substance abuse counseling
Health reform presents new barriers to
accessing HIV specific wrap-around services
11 Bartlett, EJG HRSA 2004
16 HIVQUAL INDICATORS

Each indicator chart contains
 Provider score
 Clinic score
 HIVQUAL CY 2009 mean score

The indicator sidebar contains
 Indicator definitions
 Provider’s total patient count
 Provider’s compliant patient
count
HIVQUAL/HAB
CMS PQRS
HIV Care has always been ahead of the curve when
it comes to data reporting and analysis.
 Reporting for HIVQual, Ryan White, HRSA, etc…

Owen HIVQUAL Report
Clinic Score
HIVQUAL Facility Mean CY 2009*
-Meaningful Use reports
-Improved monitoring of Open Overdue
Encounters
Current Month
Previous Month
Green (fewer)
Red (more)
An HIV PCMH offers unique challenges related to
volume of prevention measures, prescriptions,
and laboratory testing in medical homes whose
staffing models may not support ease of task
shifting. To approach these challenges we
propose that an HIV PCMH offer:
1. Improved understanding of HIV practice
operations and task shifting
2. Improved patient self-efficacy
3. Population management focused on core
measures
An HIV PCMH
Prevention
Measure/test
New operations
Task shifting
Script volume
Patient selfefficacy
Lab testing
volume
Population
Management
strategies
Delivers wrap-around staff with wrap-around services
In high quality environment with team based care.
1.
2.
3.
4.
5.
6.
Open Access to continuity
provider
Registry of HIV primary care
patients
Retention as care
management goal
Improve patient self-efficacy
through web-site, e-health
literacy, MyUCSDChart.
Track patient’s retention and
coordination of care
Use lessons learned in CQI to
make process more robust
http://www.ncqa.org
Moira Mar-Tang
Militza Bonet-Vazquez
Barbara Berkovich
Pavel Tseytlovskiy
Susan Benson
Dorothea Northcutt
Jan Limneos
Wendy Claproth
Dr. Chris Mathews
CQI committee
UC San Diego
Health System
Administration
Doris Gauff
Yvonne Zazueta
Angela Scioscia
The California HIV/AIDS Research Program
Award number: MH10-SD-640
The Alliance Health Foundation Grant Award
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



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Clinic based, Moira Mar-Tang
Waiting room: Shutter stock
Computer lab: irvinginstitute.columbia.edu
Vintage care: saviranchauto.com
Vintage repair: buddysautomotivekc.com
Community view: wordpress.com
PCMH home: pcmhelearning.com
Bee hive: en.paperblog.com
Improvement
Strategies Exercise
Michael Hager, MPH MA
NQC Manager
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in+care Campaign National Raw Data Snapshot
Dec 2011 –
Dec 2012
Data
12/11
02/12
04/12
06/12
08/12
10/12
12/12
12/11
02/12
04/12
06/12
08/12
10/12
12/12
Average
Average
Average
Average
Average
Average
Average
Sites
Sites
Sites
Sites
Sites
Sites
Sites
(Patients)
(Patients)
(Patients)
(Patients)
(Patients)
(Patients)
(Patients)
as of 1/8/2013
Measure 1:
Gap Measure
Measure 2:
Visit
Frequency
Measure
Measure 3:
New Patient
Measure
Measure 4:
Viral
Suppression
Measure
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16.26%
209
(126,953)
16.11%
(132,199)
203
14.67%
(132,006)
209
15.00%
(118,969)
188
14.12%
(114,994)
177
15.64%
(116,396)
170
14.70%
(92,505)
145
63.09%
(85,176)
155
65.79%
(90,025)
155
62.33%
(103,954)
176
63.80%
(93,779)
167
65.64%
(94,723)
163
64.70%
(94,627)
155
64.29%
(78,176)
133
56.71%
(7,792)
195
58.41%
(8,957)
193
58.57%
(8,566)
198
59.67%
(7,369)
182
59.63%
(7,277)
174
56.68%
(7,625)
167
57.42%
(6,938)
141
69.56%
(149,699)
195
70.47%
(158,624)
201
71.89%
(143,363)
187
72.15%
(136,059)
174
71.90%
(136,648)
166
72.21%
(106,551)
142
69.80%
200
(137,564)
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Improvement Strategies Discussion
Take Home Points – Amy Sitapati’s work
• Find new payers to make up for expired/lost funding
• Get lean and mean(ingful)
• Find new ways to leverage existing resources (EMR and Meaningful Use)
• Find new ways to integrate work into new or ongoing initiatives (make it a focus of your
PCMH)
• Carefully develop and test bulk actions
• Train teams to task-shift to maximize their levels of licensure
• Find ways to engage patients around self-efficacy including health literacy and computer
competencies to prepare for e-health interactions
• Find new ways to encourage retention activities through your network
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Improvement Strategies Discussion
Take Home Points – Lytt Gardner’s paper
 Theme: “Stay Connected for Your Health”
• Provider messages about importance of regular care and keeping
appointments
•
•
•
•
Working as a team
Keeping you healthy
Best possible care
Staying ahead of the virus
• Brochure
• Posters (waiting room, exam rooms)
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Improvement Strategies Discussion
Take Home Points – Participant Submissions
• Include retention in Quality Management Plan and its work plan
• Integrate retention messaging into all program areas whether or not the
patient is provided primary care at your site, including dinner programs
• Get patients excited about in+care and provide them with links for more info
• Integrate measures of retention into PCMH team “report cards”
• Develop an algorithm to identify patients at high risk of falling out of care and
run it quarterly and deliver to appropriate outreach role
• Prioritize patients who are highest risk for dropping out of care as targets for
patient navigation or intensive outreach
• Linkage agreements through MOUs with other providers in area
• Occasional regional discussions to identify common community barriers to
retention and to identify solutions – sharing of results/progress regionally
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Submit Improvement Updates!
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Announcements
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Upcoming Events
•
Next Campaign Webinar: Mental Health and Retention
January 10, 2013 at 2pm ET
•
Next Meet-the-Author Webinar: M.Vyavaharkar – How Can We
Increase Initiation of and Retention in Care Among People Living
with HIV? January 30, 2013 at 2pm ET
•
Dual Partners in+care and Campaign Webinar: Working with
Individual Patients to Improve Retention
Date Pending – to be announced!
•
Campaign Webinar: Social Service Providers Have a Role in
Retention! Date Pending – to be announced!
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Upcoming Deadlines and Office Hours
•
Campaign Office Hours:
Mondays & Wednesdays 4-5pm ET
•
•
•
•
•
•
•
•
•
Wednesday, January 9 - Patient Experience Evaluation Techniques
Monday, January 14 - Open Space, no set topic
Wednesday, January 16 - Hurdling Over Individual Barriers to Care
Monday, January 21 - Campaign Offices Closed, No Office Hours
Wednesday, January 23 - Building Infrastructure to Personalize Care
Monday, January 28 - Open Space, no set topic
Wednesday, January 30 - Open Space, no set topic
Monday, February 4 - Open Space, no set topic
Wednesday, February 6 - Aligning Care Services Under a Single Message
•
Data Collection Submission Deadline:
February 1, 2013
•
Improvement Update Submission Deadline:
January 15, 2013
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MedScape Retention in HIV Care Series
• Technical Working Group working on articles for a new
Medscape Today News Series.
• We recommend that you subscribe to HIV/AIDS MedPlus
to be informed of new and exciting articles in this series!
• Published Pieces:
•
•
•
•
•
•
•
Implementing QI in HIV Clinics to Improve Retention in Care
Monitoring Rates of Retention in HIV Care Across the State
How Health Departments Promote Retention in HIV Care
Improving Retention in HIV Care: Which Interventions Work?
Engaging in HIV Care: What We Learned from AIDS 2012
How Should We Measure Retention in HIV Care?
Retention In HIV Care: The Scope of the Problem
http://www.medscape.com/index/section_10285_0
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Partners in+care
• Partners in+care Private Facebook Group is live!
• Share tips, stories and strategies
• Join a community of PLWH and those who love them
• Email [email protected] for more details
• Partners in+care website is live!
• http://www.incarecampaign.net/index.cfm/77453
• Join our mailing list (a list-serv version of the FB Group)
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Time for Questions
and Answers
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Campaign Headquarters:
National Quality Center (NQC)
90 Church Street, 13th floor
New York, NY 10007
Phone 212-417-4730
[email protected]
incareCampaign.org
youtube.com/incareCampaign
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