UNC Hospitals geriatric specialty clinic (GSC) AT CAROLINA POINTE II COHORT 5 PCIC PRACTICE QI Golden Nuggets For Treating Patients In Their Golden Years: Using an Evaluation Framework to Assess Practice Readiness for QI Initiatives with Aging Populations PCIC Operations Meeting Presented By: Sabrina Vereen, Quality Coach 7/27/17

About Us UNC Hospitals Geriatrics Specialty Clinic (GSC) at Carolina Pointe II Address: 6011 Farrington Rd #101, Chapel Hill, NC 27517 Phone: (984) 974-6599   UNC Division of Geriatric Medicine was established in 2003 to address the growing demand for care of older adults Division consists of 14 board-certified geriatrics, one full-time PhD faculty member, 8 adjunct faculty, and 4 fellows (AY16/17) Geriatric Specialty Clinic at Carolina Pointe II (GSC) is the only UNCHCS outpatient clinic site dedicated solely to geriatric care The GSC inter-professional care team includes clinical staff (CMAs, LPNs), APPs, physical therapist, pharmacist, hospital-based and ACO- assigned case managers. The Geriatric Specialty Clinic also has a joint Memory Disorders Clinic staffed by Geriatric Medicine, Neurology, and Psychiatry. PCIC COHORT 5 (FY18) CONTACTS Medical Director | Steve Kizer MD Nurse Manager and Quality Improvement Lead (QIL) | Lisa Beaver LPN Clinic Manager | James Malley Epic SuperUser | Marvin McBride MD PCIC RESOURCES: Quality Coach | Sabrina Vereen Clinical Improvement Coach | Beth Caviness

Patient Panel: Approximately ~3400 active patients with GSC PCPs Cervical Cancer Screening Breast Cancer Screening CRC Screening Diabetes Measures Statin w/o Prior Hx HTN (Test) Department average: 9% New Patients (91% Established) Non-Age Specific PCIC Clinical Quality Measures: ASCVD Depression Treatment PneumoVax Data Source: Provided by Hunter Gay, 1/19/17 Reporting

Transforming Practice: Train  Gain  Sustain Experience Learning Process CURRENT STATE ANALYSIS Division Presentations and Leadership Meetings with Quality Groups (PCIC, PQI, VCAG, UNC Senior Alliance) Clinic training Clinical Staff Workflow Analyses BPAs Launch and Evaluation Process Redesign and Team Functioning Patient and Provider Surveys Chart Reviews and Documentation Barriers

Improvement Work: 1st Chart Auditing Randomized patient panel provided by PQI analyst with goal to manually chart abstract ~100 – Kizer charts ~100 – All other GSC provider charts Designed audit process with clinical team to evaluate FY17 PCIC and ACO measures What action has to be taken for it to be considered done? (numerator) Who is eligible? (denominator) What are the exclusions? (denominator exclusions) Additional evaluation criteria included: Cognitive impairment/dementia dx (look for=cognitive disorder, dementia, mem loss, delirium, confusion) AAA screening Shingles Tetanus

Chart Audit Results (Feb - Mar 2017) Three types of missed opportunities: Done or potential reasonable exclusion  not charted appropriated Addressed but no follow-up  not done Not addressed in chart

2nd: Identified Opportunities Based On Clinical Workflow Evaluation Specialty vs. Primary Care practice model Do not do “annual wellness visits” ACO patients have received “incentive” letters to schedule and attend an annual wellness visit Providers do not document in structured data fields Unique patient population More cognitive decline Chronic falls Co-morbidities - multiple conditions to manage Providers against more documentation burden Some measures previously/currently done as part of rooming process (i.e. falls)

2nd: Identified Opportunities Based On Clinical Workflow Evaluation Roles/responsibilities of clinic staff (administrative, CMA, LPN, RN care manager, social worker, NPs) Opportunity to work at “top of license” for clinical staff Provider, Staff, Leadership Turnover Uneven patient scheduling Capacity to address upcoming BPAs and evolving metrics

2nd: Identified Opportunities Based On Clinical Workflow Evaluation Roles/responsibilities of clinic staff (administrative, CMA, LPN, RN care manager, social worker, NPs) Opportunity to work at “top of license” for clinical staff Provider, Staff, Leadership Turnover Uneven patient scheduling Capacity to address upcoming BPAs and evolving metrics

3rd: Preparing for Next Steps (FY18) Phase 1: Screening and Immunizations; Advanced Care Planning Decision Points: Depression screening What to do about cognitive impairment and positive screening Fall screening – Epic view has changed Example: Could Kristi uses the problem list to identify chronic falls risk so that BPAs would not continue to fire   Phase 2: Disease Management (cardiovascular, diabetic issues)   Phase 3: Other Quality Initiatives

Questions?