CHIPRA Quality Demonstration Grant: Felicity Myers, Ph.D.

2 Stating the Obvious…

Stereotypes... Some are true Oregon:  legalized physician assisted suicide  legalized medical marijuana  Cigarette tax is $1.18  Obama received 57% of the vote in 2008 election. South Carolina:  “Second Amendment Weekend” (aka tax free guns)  Cigarette tax increased from $.07 to $.57 in July 2010,  Most mobile homes per capita  “Buckle of the Bible Belt”  Obama received 45% of the vote in 2008 election 3

However, there are some surprising similarities between the states… Roughly the same tax burden per capita Roughly the same voting populace Both have among the highest rates of unemployment 4

Comparing the states on health data Similarities Prevalence of binge drinking Lack of health insurance Prenatal care Differences South Carolina has a higher percentage of immunizations, but Oregon does far better in most health indicators South Carolina has two times the expenditures on public health; however, Oregon has better outcomes. (SC is ranked 46 th and Oregon ranked 13 th ) 5

South Carolina’s Medicaid Program A Conservative program only recently added children from % FPL limited array of optional services limited outreach Medicaid and CHIP are administered within the same agency. Some services are predominately provided by public providers. 6

South Carolina’s Medicaid Program is… Facing challenges:  Relationships are strained with most provider and advocacy groups at this time.  Under numerous legislative constraints.  Facing a significant shortfall in FY11. 7

QTIP 8 Quality through Technology and Innovations in Pediatrics Administered through the South Carolina Health and Human Services $9,2 77,361 grant award The project represents a unique opportunity for South Carolina pediatricians to help develop quality improvement tools that will lead to better health outcomes for current and future generations of patients

Impetus Behind Grant SCAAP chapter saw this grant as a mechanism for strengthening their promotion of the PCMH model in pediatric practices. Our director saw this grant as an opportunity to “jumpstart” the HIT efforts. I saw this as a platform to expand integration of behavioral health into the primary care setting and to test what supports/elements are necessary for making integration successful. 9

What Did South Carolina Propose? to demonstrate the ability to build a provider friendly continuous closed-loop, quality improvement infrastructure focused on pediatric primary care practices. to use the State’s existing health information exchange (HIE) infrastructure, to help participating pediatric practitioners “connect” to other providers to better deliver coordinated care. to work with providers to implement the patient- centered medical home (PCMH) model and the integration of mental health services. 10

South Carolina Chose Categories:  Category A – Experiment with, and evaluate the use of, new measures for quality of Medicaid/ CHIP children’s health care  Category B – Promote the use of Health Information Technology for the delivery of care for children covered by Medicaid/CHIP  Category C – Evaluate provider-based models which improve the delivery of Medicaid/CHIP children’s health care services 11

South Carolina’s Medicaid Program 12 DHHS strengths which will enhance implementation of the CHIPRA grant are:  Reimbursement for pediatric subspecialists and for dentists have greatly improved access to care.  Existing relationships (AAP, USC, Thomson Reuters, CareEvolution)  Existing framework for HIE  DHHS Director is also the State HIE leader.

Grant Partners SCDHHS American Academy of Pediatrics (AAP) Family Connections Federation of Families Department of Health and Environmental Control (DHEC) Department of Mental Health (DMH) South Carolina Primary Health Care Association (SCPHCA) Thomson Reuters Institute for Families in Society (IFS) South Carolina Offering Prescribing Excellence (SCORxE) Care Evolution 13

The South Carolina grant has four key goals: Quality: demonstrate that newly-developed quality indicators can be successfully utilized in pediatric practices; Technology: share key clinical data through a statewide electronic quality improvement network; Innovation: develop a physician-led, peer-to-peer quality improvement network; and Pediatrics: expand the use of pediatric medical homes to address mental health challenges of children in our state. 14

Focus of SC Grant QUALITY  Pursuit of National Committee for Quality Assurance (NCQA) Patient-Centered Medical Home (PCMH) certification by all participating practices.  Collection of CHIPRA Quality Measures.  Utilization of Learning Collaboratives and the Plan, Do, Study, Act quality improvement cycle 15

Focus of SC Grant TECHNOLOGY  providing primary care physicians with HIT tools that will allow them to track their patients outcomes  Technology and the generated reports will allow the practices to compare their performance to others. 16

Focus of SC Grant INNOVATION  Providing behavioral health tools to primary care physicians (such as standardized mental health screening tools, academic detailing, and coordination with mental health providers).  Increasing linkage of family support organizations such as Family Connections and Federation of Families with practices to provide additional resources.  Statewide Learning Collaboratives integrate and support all QTIP initiatives. 17

Focus of SC Grant PEDIATRICS  Selection of pediatric practices of a heterogeneous mix  Working with the pediatric practices on becoming a NCQA medical home  Expanding the mental health services available in a pediatric setting  Establishing a quality improvement team within the pediatric setting to implement and review quality measures. 18

The patient is the focus 19 Patient PCMH model supports the patient and family Grant provides additional supports for physicians

How HIT pieces all ties together 20 Provider sees patients Provider enters data into EMR or EMR-Lite Data travels from SCHIEx to Decision Support System Data travels from SCHIEx to Decision Support System Clinical data is merged with claims data Provider receives quality report feedback CATCH Learning Collaborative Peer to peer review Quality improvement strategies Quality improvement strategies Practice/provider makes adjustments Practice/provider makes adjustments Improved and informed patient care Quality reports are generated PDSA Cycle PDSA Cycle

Progress to Date Staff have been hired and contracts finalized with our principal contractors. Planning & Steering Committee (PSC) has been established and meeting since April 2010 Physician based Learning Collaborative Expert Committee chosen 18 practices (who meet criteria established by the PSC) have been selected. 21

Progress to Date HIT gap analyses has started A conference which focuses on the PCMH model and behavioral health integration is planned for October Our first Learning Collaborative focused in CHIPRA Quality Indicators will be held in January. We have tested the data-mining and reporting process in one site. 22

Challenges 23 1.Scope: SC is trying to tie a lot of components together in this grant. While this creates layers of support and is ultimately anticipated to result in improved quality of care to pediatric patients, this creates issues with evaluation. “Which components contributed to improvements in care?” 2. Ever changing needs – Planning vs. Reality: Budget changes Competing interests

Challenges 24 3.Bureaucracy Within SC Competing Federal interest Competing grants (overlap, duplication, support, timelines) 4. Provider Selection Although heterogeneity was an intentional element in provider selection, this brings challenges with mental health integration, HIT and community resources and supports. Working within existing systems

Challenges 25 5.“Assistance” versus “Burden” to the pediatric practices Too many “helpers” Time with patients Comfort level with technology Advantages of QI not obvious to the average practitioner Not accustomed to working in practice teams 6. Big Personalities and Opinions

Contact Information Felicity Myers, Ph.D., Deputy Director Lynn Martin, QTIP Project Director Myers26