Kaiser Permanente in the Community: Increasing Access to Care PHASE UPDATE CB Manager Meeting March, 2016

What Do You Want To Know ? Who’s Funded Program Design Evidence Based Program Components 2006-13 Re-design influences Program components Evaluation Design What are we trying to change & how measuring Results/Impact Future thinking – how to link regional and local

LEARNING COLLABORATIVES CONTINUING PHASE GRANTEES NCR Grantees LEARNING COLLABORATIVES Sacramento Cohort of 6 Health Center Corporations Central Valley/Fresno Cohort of 5 Health Center Corporations CONTINUING PHASE GRANTEES Public Hospital/Health Systems Regional Clinic Consortia Alameda Hospital and Health System Community Health Clinic Network (Alameda) San Mateo Medical Centers SF Community Clinic Consortia San Francisco General Hospital Community Health Partnership of Santa Clara Santa Clara Valley Medical Center Redwood Health Network (Sonoma/Marin/Yolo) Three different types of PHASE grantees, 1. Continuing PHASE support “systems” who support their clinics 2. Direct support to health centers requirement to participate in learning collaboratives - Sac cohort learning collaborative focus on QI and PI Skills - CV/F Cohort will focus on data capacity KP is reviewing and evaluation both models which will be part of rationale for how KP funds in future - Wanting to continue to maximize scaling this initiative - Regional and statewide infrasturce critical importance PHASE SUPPORT TEAM Center for Community Innovations * Institute for High Quality Health Center for Excellence in Primary Care * Center for Community Health and Evaluation***

KP Developed Evidence Based Protocol for CVD: PHASE Origins Chronic Care Model Population Health Management Quality Improvement/ Process Improvement KP Developed Evidence Based Protocol for CVD: PHASE (PHASE on a Page) PHASE Community Initiative PHASE is deeply rooted in evidence based strategies which improve health outcomes, increase efficiency and increase patient satisfaction.

Chronic Care Model: Evidence based method of care

Evidence Based Approach to Managing Populations Define Population Identify Care Gaps Stratify Risks Engage Patients Manage Care Measure Outcomes Data Integration Analysis Reporting Communications Based in IHIs “Population Health Management: A Roadmap for Provider-Based Automation in a New Era of Healthcare”

PHASE In The Community 2006-13 $10 million in grants 50 Participating Clinic Site 35,000 People Enrolled Amazing accomplishment! Primary goal during the six years was - on enrolling patients and adopting the protocol How can we do “this” even better - Continuous improvement, even with grant initiatives GOAL: Adopt the clinical protocol

PHASE Redesign: What’s Changing and NCR Leanings May 2014 - Current NCR NEW IS Plan New Clear Goal – Strengthen the SN delivery system Investment Strategy - must have measurable impact, linked to IRS Increase focus on evaluation and program design PHASE Evaluation Results Unintended benefit – grantees reported improved “systemness” Adoption of protocol accelerated with access to training and TA Intensive Review of how grantees spent $$$ Culture change – built QI cultures, established Performance Improvement Strategies and Skills Focus on system improvements – HIT & registries, initiating panel management systems, improving data collection and reporting, workflow improvements, maximizing roles, implementing team based care Readiness characteristics – health centers exhibited vastly different readiness states Health Care Environment SN must move to managing population vs individual patients More patients being seen, and seen more often at SN organizations Payment reform - SN must prove quality IS Plan – Clear directive, new responsibility for regional investments SN must be able to demonstrate quality of care

LONG TERM PHASE SUPPORT STRATEGY PHASE RE-DESIGN Identify/Refine PHASE Building Blocks Readiness and On Boarding Resources and Gap Analysis Evaluation Design Took a step back and asked big questions 1. what have we learned - success factors 2. how can we maximize the impact of the program - how can we spread it more rapidly 3. how can we better measure our impact LONG TERM PHASE SUPPORT STRATEGY

Redesign Accomplishments: We have a Definition! WHAT IS PHASE: A population health management program to care for people with/at risk of cardiovascular disease using KP’s evidence based clinical protocol that, when followed, reduces CVD. Consistent definition of the program with intentional focus on population health management. That was found as success factors in retrospective evalu report. Original Question when spread PHASE to Community – Can a KP, evidence based protocol, be translated into the community Goal – Best Care EVERYWHERE…KP or HC or Public Hospital – doesn't’t matter where you are a patient Focus of grant initiative– ADOPT the protocol

PHASE: Adoption of Evidence Based Clinical Guidelines Redesign Accomplishments: We have a Program Design! PHASE Domains/Building Blocks PHASE: Adoption of Evidence Based Clinical Guidelines Supportive /Engaged Leadership and Culture Quality Improvement Culture and Process Improvement Methodology Data Driven Decision Making Population/Panel Management Team Based Care Now have SIX domains of PHASE Critical to note 1. We are using PHASE KP evidence based care guidelines as a doorway to develop PHMS. - Core part of PHMS is evidence based care. - Gives a particular clinical/health outcome focus Ultimate goal of PHMS is provision of efficient evidence based care 2. In PHMS there may be more domains but within PHASE there are the ones we will focus on 3. Support services will be inline with the six domains Population Health Management

Redesign Accomplishments: We have an Evaluation Approach! PHASE clinic implementation of the protocol Has the reach of PHASE increased in the safety net? Has the PHASE medication protocol been implemented in clinics? PHASE clinic quality & system outcomes Has PHASE improved clinics’ performance on quality measures? Has PHASE influenced clinics’ ability to engage in population health and chronic care management? PHASE initiative implementation Has the initiative been successfully implemented? Could improvements be made to the initiative to increase impact?

Redesign Accomplishments: We have Standardized Data Reports! Measuring Health Center Capacity to Provide Care Clinical Outcomes Standardized HEDIS clinical measures Standardized UDS lifestyle screening measures Systems Assessment Standardized self assessment tool on each domain/building block PO Institutionalization survey Impact of Support Services PHASE Support Team Services Continuing PHASE Grantee Services

Redesign Result: Notes on Clinical Reporting SPREAD   Number of sites implementing PHASE Of all the sites within your hospital or clinic organization, how many are implementing PHASE? Number of NEW sites implementing PHASE How many sites have started implementing PHASE since January 1, 2015? Total number of clinic sites Total number of sites within your hospital or clinic organization REACH Total number of unduplicated PHASE patients Report the number of individual, unduplicated patients who are considered "PHASE patients" The number of patients with a diagnosis of diabetes (type 1 or type 2) who are aged 18-75 (required) The number of patients with a diagnosis of ASCVD, any age (recommended) Report only if you are including patients with ASCVD in PHASE implementation The number of patients with a diagnosis of hypertension who are aged 18-85 (recommended) Report only if you are including patients with hypertension in PHASE implementation MEDICATION - Prescription Number/% of PHASE patients prescribed a statin # of PHASE patients age 55-75 who have been prescribed a statin, where the medication order is current during the measurement year (denominator is # of PHASE patients age 55-75) Number/% of PHASE patients prescribed an ACE or ARB # of PHASE patients age 55-75 who have been prescribed an ACE/ARB, where the medication order is current during the measurement year (denominator is # of PHASE patients age 55-75) Number/% of PHASE patients prescribed both a Statin and an ACE or ARB # of PHASE patients age 55-75 who have been prescribed BOTH a statin and an ACE/ARB, where the medication order is current during the measurement year (denominator is # of PHASE patients age 55-75) CLINICAL QUALITY (Source: HEDIS) Controlled blood pressure for diabetes (required) The percentage of patients age 18-75 with a diabetes diagnosis whose last blood pressure reading during the past measurement year was ≤ 139/89 Controlled Hemoglobin A1c (required) The percentage of patients age 18-75 with a diabetes diagnosis whose most recent HbA1c reading during the past measurement year was ≤ 9 Controlled blood pressure for hypertension (recommended) The percentage of patients age 18–85 with an outpatient diagnosis of hypertension during the first 6-month period of the measurement year whose last blood pressure reading during the past measurement year was less than or equal to the following thresholds: if < 60 years, BP ≤ 139/89; if ≥ 60 years and has Diabetes, BP ≤ 139/89; if ≥ 60 years and does not have Diabetes, BP ≤ 149/89 LIFESTYLE SUPPORT (Source UDS) Tobacoo screening & counseling Percentage of patients aged 18+ who were screened for tobacco use at least once during the measurement year or prior year AND who received cessation counseling intervention and/or pharmacotherapy if identified as a tobacco user. BMI screening & follow-up plan Percentage of patients aged 18+ with a documented BMI during the most recent visit or within the 6 months prior to that visit AND when the BMI is outside of normal parameters a follow-up plan is documented. Depression screening & follow-up plan Percentage of patients aged 12+ screened for clinical depression using an age appropriate standardized tool AND follow-up plan documented if screened positive for depression. NCR decided to use HEDIS measures Northstar/Gold Standard PHASE clinical protocol linked to HEDIS Some push back from grantees Adherence rates Not possible to collect in SN Using proxy measures, prescription written and some clinical measures Statin Aspirational measure Life style measures Building SN capacity and helping NCR review PHASE program design related to lifestyle

: DRAFT EXAMPLE: Measuring the PHASE Building Blocks Population Health Management System Data Driven Decision Making INDICATORS: Use of performance measures, Registry/panel level data, Use of EHR Leadership dashboards ASSESMENT TOOL: Performance measures are established & provided to individual providers Reports on care processes & outcomes are provided to care teams Registries on panel level data are available & used Registries on individual patients are available & used EHR is meaningful use certified & used to support population management & QI Source: UCSF/CEPC Building Block 2 How do we know we are changing/improving in each building block – needed method to measure change/impact Defining each building block Creating indicators of change for each building block Adapting/creating assessment tools PHASE Support Team is currently building out and testing indicators and the assessment tools for each of the five building blocks. Assessment tools are built on CEPC and BCCQ tools Developed from PHASE grantee experience, KP care delivery experience and models from BCCQ and UCSF/CEPC

What Do Grantees Do? PHASE Support Team/Consultants Provide Support Services, including managing learning collaboratives Evaluation Project Management and logistics Consortia/ Public Health System Provide Support Services to Facilitate Sustaining and Spread of PHASE Data Aggregation & Reporting Grant Management Health Center Site Develop and Implement Improvement Plan (PDSA Cycles) Participation in Learning Collaboratives Care for Patients CPCA/SNI Program Grants (Not “PHASE”) Policy and Advocacy - PRIME and CP3 Pilot learning communities (financing, pop health and data capacity) Resource Management

PHASE Support Team - Services PHASE Support Team - Services *New in 2015-16, Major change from past PHASE grant programs Curriculum Based Training Motivating Change (KP) Health Coaching (CEPC) IHI Communities of Practice Data Health Coaching Team Based Care Learning Collaborative QI/PI (Sacramento) Data Capacity (Central Valley) Lunch and Learns - Integration of mental health Role of consortia services in PHASE Wireside Chats/Webinar - Clinical topics Connections Web site Convenings Coaching - Uniquely designed New 2016 New 2016 New 2016 2015 – Provide a checklist of services/support and allowed grantees to pick and choose - Evaluating demand, impact, cost and sustainability of each type of service 2016 – Discussed this afternoon in detail - Support Team work closer with grantees in matching needs and resources (training navigator) - More services aligned with domains Training navigation service – Using eval & assessment results to develop unique plan for each grantee Support services aligned with PHASE domains Overall evaluating: demand, impact, cost, sustainability

2015 PHASE DATA: Reach 2 Learning Collaboratives 11 Health Center Corporations 4 Public Hospital/Health Systems 25 Outpatient Clinic Sites 4 Regional Health Center Consortia 30 Health Center Corporations 76 Health Center Sites = 112 Sites participating in PHASE, providing care to over 100,000 patients with diabetes and/or hypertension

2015 PHASE DATA: Diabetes – BP & A1c Line is cohort average – still need to add in targets.

2015 PHASE DATA: Hypertension – BP

2015 PHASE DATA: Prescription Data

Lifestyle Measures 81% UDS 2014 Avg

Population Health Management Systems: Institutionalization Efforts related to collecting & using data were mostly likely to continue Efforts that required additional staff resources/care coordination were the least likely to be institutionalized. Source: ALL PHASE Institutionalization Survey, conducted Fall 2015

How to Link Regional with Local My county has the “Hearts of Sonoma” project The possibilities of collaboration are endless……