Transcript PA SPREAD Webinar #3 Robert Gabbay MD, PhD Penn State College of Medicine.

PA SPREAD
Webinar #3
Robert Gabbay MD, PhD
Penn State College of Medicine
Webinar #2
Webinar #1
Pre-Work Learning Objectives
1.Understand the concept of empanelment and
develop a plan to organize patients into provider
panels.
2.Develop an aim statement for what and how
much you want to improve over the next year.
3.Understand the clinical guidelines and related
measures for diabetes.
4.Collect baseline data on the number of diabetes
patients in your practice and the number of
patients meeting evidence-based diabetes
measures.
List of Pre-Work To-Do’s
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Identify a provider champion
Form a multi-disciplinary improvement team
Write an aim statement
Develop a plan to address any issues with
provider panels
Complete and submit the PCMH-A assessment
Collect and report baseline diabetes data on the
monthly practice status report BEFORE your first
learning session
Participate in the 3 pre-work webinars
RSVP attendees for Learning Session #1
Any Questions?
• Writing your aim statement?
• Forming your team?
• Identifying a provider champion?
• Understanding the measure specifications?
• Collecting your baseline data?
• Organizing provider panels?
• Completing the PCMH-A?
• Submitting your baseline report?
• Attending the first learning session?
• Contact your practice coach or email
[email protected].
Going Forward- the BIG PICTURE
• 4 in-person evening Learning Sessions
• May/June
• August/September
• January 2013
• May 2013
• Facilitator visits in each Action Period
• Call or email Patty Stubber (NW) or Sharon Adams (SC) any time!
• Monthly webinars
• Monthly status reports: data and brief written update
• Generally due on the 5th of the month.
• Will get feedback from practice facilitators and data
benchmarking reports from PA AHEC.
• Sharing and networking!
• Practice description/photos for www.paspread.com under
password protected “Participating Practices” section.
• Resources to share on www.paspread.com.
PCMH, Chronic Care, PDSAs
IMPLEMENTING THE MODELS TO
IMPROVE PATIENT CARE
System-for-the-21st-Century.aspx
“Health care harms patients too
frequently and routinely fails to
deliver its potential benefits.
Indeed, between the health
care that we now have and the
health care that we could have
lies not just a gap, but a chasm.”
~Institute of Medicine
Source: http://www.iom.edu/Reports/2001/Crossing-the-Quality-Chasm-A-New-Health-
Driving Force = 2001 IOM Report
Operationalizing the Medical Home
• Chronic Care Model
(or more generally “The Care Model”)
• NCQA PCMH 2011 Standards
http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2
Source:
http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2
Source:
Essential Elements of Good
Patient Care
http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2
• Patient understands the disease process, and
realizes his/her role as the daily self manager.
• Family and caregivers are engaged in the
patient’s self-management.
• The provider is viewed as a partner, guide.
Source:
Informed, Activated Patient
http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2
• At the time of each visit, the team has the
information, decision support, people,
equipment, and time required to deliver
evidence-based care, filling any gaps in care, and
to support patients and their families in ongoing
self-care.
Source:
Prepared, Proactive Practice Team
http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2
• Includes an assessment of self-management
skills and confidence as well as clinical status.
• Collaborative goal-setting and problem-solving
resulting in a shared care plan.
• Active, sustained follow-up.
• Tailoring of clinical management by stepped
protocol.
Source:
How would I recognize a
“productive interaction?”
http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2
By testing changes in these 6 components
of the Chronic Care Model.
Source:
How Do We Get There?
http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2
• Patient registry functionality in your EMR.
• Identify patient subpopulations for proactive outreach
(not seen in 6 months, medication recall, uncontrolled).
• Capture lab and other info in structured data fields that
can be queried for patient care and measurement.
• Prepare for visits and provide reminders/status reports
for patients and care team.
• Use templates to organize patient visits.
• Monitor/measure performance.
Source:
Clinical Information Systems
http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2
• Use evidence-based guidelines to proactively
assess patient risk at each visit.
• Provide stepped care based on the needs of
patients (closer follow-up, care management).
• Activate patients by sharing guidelines (report
cards or progress reports) with them.
• Consult with specialists and integrate their
expertise into primary care.
Source:
Decision Support
http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2
• Define roles and delegate tasks across care TEAM
using standing orders.
• Provide care most effectively and efficiently (e.g.,
group visits, e-visits, care mgmt, phone).
• Track and document referrals and labs.
• Schedule visits to assure continuity of care.
• Provide patient-centered care (interpreters,
visits that accommodate special needs, etc.).
Source:
Delivery System Design
http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2
• Not just education but SUPPORT!
• Emphasize patients’ central role in managing
their wellness/illness.
• Negotiate self-care behavior change goals with
patients.
• Provide effective behavior change interventions
and ongoing support with peers or professionals.
Source:
Self-Management Support
http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2
• Identify effective wellness and disease
management programs and encourage patients
to participate in them (e.g., hospital programs,
Weight Watchers, walking clubs).
• Form partnerships with community organizations
to support or develop programs (e.g., housing,
transportation, food).
• Advocate for policies to improve care.
Source:
Community Resources
http://www.improvingchroniccare.org/index.php?p=The_Chronic_Care_Model&s=2
• Practice/System leaders visibly support quality
improvement and include measurable goals in the
strategic/business plan.
• Align incentives (salary increases, performance
reviews) to encourage care coordination, team
care, quality improvement.
• Partner with hospitals, health plans, specialists,
pharmacies, nursing homes, etc. to
coordinate care, share information.
Source:
Health Care Organization
NCQA PCMH 2011 Standards, Elements
NCQA’S OPERATIONAL DEFINITION
OF THE MEDICAL HOME
NCQA PCMH 2011
• PCMH 1: Enhance Access and Continuity
• PCMH 2: Identify and Manage Patient
Populations
• PCMH 3: Plan and Manage Care
• PCMH 4: Provide Self-Care Support and
Community Resources
• PCMH 5: Track and Coordinate Care
• PCMH 6: Measure and Improve Performance
Review of NCQA Standards
• One “MUST PASS” element in each standard is
noted (6 total).
• “MUST PASS” elements are considered the basic
building blocks of a Medical Home.
• Practices must earn a score of 50% or higher on
each of the 6 “MUST PASS” elements.
• Slides note the key factors in each element that
we will address.
• Some are noted as “critical factors” that must be
met for NCQA scoring.
• NCQA aligns well with Meaningful Use.
PCMH 1: Access, Continuity
• Element A: Access During Office Hours
(MUST PASS)
• Same day appointments (Critical Factor)
• Timely telephone follow-up
• Good documentation
• Element B: After-Hours Access
• Sharing of clinical information
• Element C: Electronic Access
• Visit summaries to patients
• Web portal or secure email system for
Rx refill requests and referral/test results
PCMH 1: Access, Continuity
• Element D: Continuity
• Patients choose personal clinician
• Documentation of patient choice
• Monitor percentage of visits with selected
clinician
• Element E: Medical Home Responsibilities
• Tell patients about obligations of the medical
home and responsibilities of patients/families as
partners in care
• Element F: Culturally and Linguistically
Appropriate Services
PCMH 1: Access, Continuity
• Element G: The Practice Team (team-based care)
• Care teams with defined roles and responsibilities
for each team member
• Regular team meetings, communications
(Critical Factor)
• Use of standing orders
• Training for team members on care coordination,
self-management support, population
management, communication skills
• Team members involved in quality improvement
PCMH 2: Population Mgmt.
• Element A: Patient Information
• Record name, gender, race, ethnicity, language,
contact info, dates of visits, legal guardian/proxy,
primary caregiver, advance directives, and health
insurance information for each patient
• Element B: Clinical Data
• Up-to-date problem and medication lists
• Documentation of allergies
• Blood pressure, height, weight, BMI, tobacco use
PCMH 2: Population Mgmt.
• Element C: Comprehensive Health Assessment
• Age-related immunizations, screenings
• Family, social, cultural, communications, medical
history, behavioral, mental health issues
• Depression screening
• Element D: Use Data for Population Mgmt.
(MUST PASS)
• Use of patient information, clinical data, evidencebased guidelines to generate patient lists and
proactively remind patients/families and
clinicians of needed services.
PCMH 3: Plan and Manage Care
• Element A: Implement Evidence-Based Guidelines
• Point-of-care reminders
• At least one condition must be related to unhealthy
behaviors (smoking, obesity), substance abuse, or
mental health issue (Critical Factor)
• Element B: Identify High-Risk Patients
• Develop criteria for high-risk patients and process to
identify them
• Determine percentage of high-risk/complex patients
in your practice
PCMH 3: Plan and Manage Care
• Element C: Care Management (MUST PASS)
• Pre-visit planning
• Develop individualized care plans in collaboration
with patients and review/update them each visit
• Give patients written plan of care and clinical
summary at each visit
• Assess and address barriers when treatment
goals are not met
• Identify patients needing more support
• Follow up with patients who miss visits
PCMH 3: Plan and Manage Care
• Element D: Medication Management
• Review, reconcile meds during care transitions
• Provide info on new prescriptions
• Assess understanding of meds, response to meds,
and barriers to adherence
• Document over-the-counter meds, supplements
• Element E: Use E-Prescribing
PCMH 4: Self-Care Support and
Community Resources
• Element A: Support Self-Care Processes
(MUST PASS)
• Education resources to assist in self-management
• Develop, document collaboratively set selfmanagement goals
• Document self-care abilities
• Provide tools for patients to record self-care
results
• Counsel patients to adopt healthy behaviors
PCMH 4: Self-Care Support and
Community Resources
• Element B: Provide Referrals to Community
Resources
• Current resource lists
• Track referral
• Arrange or provide treatment for mental health,
substance abuse
• Offer health education programs (group classes,
peer support)
PCMH 5: Track, Coordinate Care
• Element A: Test Tracking and Follow-up
• Track lab/imaging orders until receive results, flag
and follow up on overdue results (Critical Factor)
• Flag abnormal results and make clinician aware
• Notify patients of normal and abnormal results
• Electronically order and receive results
• Record results electronically structured data
PCMH 5: Track, Coordinate Care
• Element B: Referral Tracking and Follow-up
(MUST PASS)
• Give consultant/specialist clinical reason for
referral and pertinent information (electronically)
• Track referrals and follow up to obtain results
• Establish, document co-management agreements
PCMH 5: Track, Coordinate Care
• Element C: Coordinate with Facilities and
Manage Care Transitions
• Identify patients with hospital admission, ED visit
• Share clinical info with hospitals, EDs
(electronically)
• Obtain discharge summaries
• Follow up with patients after discharge
PCMH 6: Measure and Improve
Performance
• Element A: Measure Performance
• Document the measurement period, number of
patients represented by the data (at least 75% of
eligible population), and patient selection process.
• Element B: Measure Patient Experience
• Survey experience related to access,
communication, coordination, whole-person care/
self-management support
• PCMH version of the CAHPS Clinician Group survey
• Experience of vulnerable groups
• Qualitative feedback
PCMH 6: Measure and Improve
Performance
• Element C: Implement Continuous Quality
Improvement (MUST PASS)
• Set goals and act to improve performance
• One measure related to disparity in care or for
vulnerable populations
• Involve patients in QI team or advisory council.
• Element D: Demonstrate Continuous Quality
Improvement
• Track results over time
• Assess the effect of your actions
• Improve performance on 1-2 measures
PCMH 6: Measure and Improve
Performance
• Element E: Report Performance
• Within the practice by individual clinician and
across the practice
• Outside the practice to patients or publicly
• Element F: Report Data Externally
• To CMS or state
• To other external entities
OK… So what do we do now?
RAPID CYCLE TESTING OF CHANGES
Improvement Model
• Write your aim statement
• What you want to improve, by
how much, by when, and
generally how you will do it.
• Use the diabetes measures to
know when a change is an
improvement.
• Think of things you can try to
change (the tests you will Plan,
Do, Study, and Act on).
Deciding Which Tests to Try
• Components of the Chronic Care Model.
• NCQA PCMH Standards/Elements
• Areas for improvement in your data.
• Foundational elements we’d like you to work on.
Critical Changes Integrated in Diabetes Population Management
Population alert (to visually ID records of all diabetes patients)
Use of template/flowsheet with embedded clinical guidelines
Use of standing orders for team members
Providing planned care at every visit
Use of patient report card/progress report
Patients setting self-management goals
Risk assessment at every visit
Follow-up care for high-risk patients
(At the bottom of Page 1 of the Monthly Status Report template.)
Date Accomplished
Initial Focus
Critical Changes to Make
1. Population alert
2. Use of flow sheet/template embedded with
clinical guidelines
3. Standing orders
4. Planned care at every visit
5. Patient report card/progress report
6. Patients setting self-management goals
7. Risk assessment at every visit
8. Follow-up care for high-risk patients
Critical Changes to Make
• Population alert
• Flag/color/icon to readily see diabetes patients in
medical records when they call or visit office
(without having to look in problem list).
• Goal = take advantage of every opportunity you
have to provide evidence-based care.
• Improves patient safety when making medication
decisions.
Critical Changes to Make
• Use of flow sheet/template with embedded
clinical guidelines
• Prompts (flags/colors) to identify when services
are due/overdue.
• Prompts (flags/colors) to identify when labs, vitals
are out of evidence-based range.
• Tracking of information in structured data fields
that can be queried.
Critical Changes to Make
• Standing orders
• Grant permission for staff to order, provide,
document needed services.
• Delegate tasks across team.
• For blood tests, urine test, foot exam, eye exam
referral/tracking, blood pressure measurement,
height/weight/BMI, tobacco query and counsel,
self-management support, etc.
• Improve efficiency, save provider time.
Critical Changes to Make
• Planned care at every visit
• Proactive approach to care.
• Fill any gaps in care, keep current with guidelines
at every visit—even sick visits when feasible.
• Schedule follow-up care for any services still
needed or for closer monitoring.
• Pre-visit planning to ensure all needed info (lab
results, referral reports) is available at the visit.
• Pre-visit lab work, so medication decisions can be
made at visits.
Other Changes to Test
• Your biggest frustrations—processes that don’t
work well in your office (e.g., test/referral
tracking, Rx refills, processing patient forms,
scheduling, phone calls, billing).
• Things that patients have complained about.
There’s Value in Knowing How
to Make Changes
• One SE PA practice identified adoption of the
PDSA process as its most important lesson
learned in Year 1 of its collaborative.
• Was impetus/focus for weekly meetings.
• Allowed smooth transitions to new protocols.
• Gave them “permission” to take chances and try
new things.
• Strengthened their concept of team.
How to Test: Plan
• Step 1: Plan the test
• State the objective of the test:
• What are you trying to change?
• Predict what will happen and why.
• Develop a plan to test the change (who will do it,
what they will do, when they will do it, where they
will do it, how they will do it).
• Identify other data that will be useful (patient
feedback, how much time the change added or
saved, how it worked for staff).
• Think ahead what subsequent tests might be.
Example of a Plan
• We will create a new diabetes flow sheet to help us
identify gaps in care so we can provide all needed
services.
• Laura will create the new flow sheet in our EMR by
Thursday
• Dr. Gabbay and Erin (his nurse) will use it with the 3
diabetes patients that are scheduled on Friday
morning.
• We expect to be able to meet all of the patients’
unmet needs by using the new flow sheet.
• We will probably need to revise the flow sheet
after we test it.
How to Test: Do
• Step 2: Do the test
• Try out the test on a small scale:
2 patients, 1 doctor, 1 shift, 1 hour
• Pick willing volunteers to do.
• Collect data (time, feedback, etc.)—even on paper.
• Document problems, unexpected observations.
How to Test: Study
• Step 3: Study results
• Analyze collected data.
• Compare the data to your predictions.
• Summarize and reflect on what was learned
(de-brief):
•
•
•
•
•
What did we expect to happen?
What did happen?
Were there any unintended consequences?
What was the best/worst thing about this change?
What might we do next?
Studying the Example
• Laura completed the flow sheet on time and Dr. Gabbay
and Erin tested it with the 3 patients as planned.
• The flow sheet accurately identified the gaps in care for
all 3 patients, and Dr. Gabbay and Erin found it helpful,
but said it was hard to use because they kept having to
go to different screens in the EMR to document other
parts of the visit.
• They were not able to provide all the needed services for
2 of the 3 patients. Dr. Gabbay didn’t have time to do the
foot exam on 2 of the patients.
• They also missed documenting the tobacco query for 1 of
the patients.
How to Test: Act
• Step 4: Act on what was learned
• Determine what modifications
are needed.
• Or decide to try something else.
• Prepare a plan for the next test:
keep the ball rolling!
• The faster you test, the faster you learn, the faster
you change.
Acting on the Example
Plans for next PDSAs:
• Laura will integrate the flow sheet into the visit template
to facilitate documentation.
• Laura will revise the flow sheet to make the tobacco
query a “must complete” data field so it cannot be
missed.
• Dr. Gabbay will train Erin how to do the foot exams.
More on PDSAs to Come!
• Key topic at first learning session.
• Focus now on writing your aim statement and
collecting your baseline information (PCMH-A
and diabetes data).
• Please submit both your PCMH-A and baseline
diabetes data BEFORE your first learning session
to [email protected].
Practice Facilitators
WE’RE HERE TO HELP YOU
Practice Facilitators
• Northwest
• South Central
Patricia J. Stubber, MBA
Executive Director
Northwest PA AHEC
8425 Peach Street
Erie, PA 16509-4788
814-217-6029 (phone)
814-594-4740 (cell)
814-864-4077 (fax)
[email protected]
Sharon M. Adams RN, BA
Executive Director
Southcentral PA AHEC
PO Box 509
Carrolltown, PA 15722
814-344-2222 (phone)
814-344-2221 (fax)
[email protected]
Web: www.paspread.com
Email: [email protected]
Plan to Attend!
LEARNING SESSION #1
First Learning Sessions
• NW Learning Session #1:
• May 23, 5-9pm at PSU Behrend Campus, Erie
• SC Learning Session #1 (two options):
• May 22, 5-9pm at Hershey Medical Center
Conference Center (West Campus)
OR
• June 7, 5-9pm at PSU Altoona Campus
Tentative Agenda
• Welcome and Introductions
• “Planned Care at Every Visit”
• “Process Redesign for Efficiency”
• “Clinical Diabetes Management”
• “Review of Aim Statements”
• “More on PDSAs”
• Plan your initial PDSAs
• Sharing of PDSA plans
• Next steps and send off
Who Should Definitely Attend?
• Provider champion
• Other members of practice improvement team
• Any system leaders (IT, administrators, etc.)
• Please RSVP attendees and meal selections to
[email protected] ASAP.
List of Pre-Work To-Do’s








Identify a provider champion
Form a multi-disciplinary improvement team
Write an aim statement
Develop a plan to address any issues with
provider panels
Complete and submit the PCMH-A assessment
Collect and report baseline diabetes data on the
monthly practice status report BEFORE your first
learning session
Participate in the 3 pre-work webinars
RSVP attendees for Learning Session #1