OUR ROAD TO PCMH RECOGNITION Baldwin Family Health Care

Russ Kolski RN Strategic Projects Director Background in Quality Management Safety and Compliance Accreditation (Joint Commission / AAAHC) Given Medical Home Responsibility in July 2011 PCMH Accreditation Meaningful Use Pay for Performance (Not my only role)

Baldwin Family Health Care Health Center since 1967 Rural Area Serve West Central Michigan 5 Medical Locations 3 Locations with Retail Pharmacies 3 School Based Health Centers 25,000 Annual Medical Visits PCMH Status as of 2011 AAAHC Recognized for PCMH BCBS Recognized for PCMH at 2 of 5 locations

Baldwin Family Health Care Referral Tracking Moved to Registry July 2012 HRSA Quality Funding September 2012 Last Site Live NextGen EHR June 2012 Hired Added Quality Staff May 2012 Education MU Stage 2 April 2012 Report Development Registry Enhancement Oct. 2012 – Feb. 2013 Participation in ACO February 2013 PCMH Steering Comm. October 2011 PCMH Weekly Workgroup August 2012 NCQA PCMH Submission Pt. 2 December 2013 NCQA PCMH Submission Pt.1 June 2013 Pre-Visit Planning for All Patients March 2012 Annual Training PCMH Module November 2012 Implemented i2i Tracks Registry January 2012 Transition to Open Access October 2011 Staff Training (Familiarization) November 2011 MiPCT / CMS Demonstration October 2011 HRSA PCMH Demonstration September 2011 Dedicated Lead Selected June 2011 Trial Staff Huddles/Pre-plan November 2011 LEAN Event Staff Work Flow November 2011 Implemented Quality Dept. January 2012 MiPCT Case Managers Hired January 2012 Submitted MU Year 1 January 2012 First Site Live NextGen EHR December 2011 Road to NCQA PCMH Started 2011

“If we keep doing what we are doing, we will keep getting what we got Yogi Berra

Personal PCMH Learning Limited Understanding at Start Attended PCMH Seminars Local PHO Michigan State Medical Society Obtained Chronic Care Professional Certification Reading LEAN – Toyota Production System TransforMed IHI PATH

Internal Planning EHR Transition (1st site live 12/2011 – last 6/2012) Provider Coordinating Committee Transition Committee Established PCMH Steering Committee Education at all levels Visit Workflow Re-design Transition from Acute Care to Preventative / Wellness Based Care Match pre-EHR Provider Productivity Integrate PCMH Elements into Standard Work

Steering Committee Membership CEO (Ex-Officio) PCMH Lead Quality Manager Chief Medical Officer Physician Lead for EHR Mid-level Provider COO / Privacy Officer Site Facility Manager Finance Representative Dental Representative* Behavioral Health*

“Every system is perfectly designed to get the results it gets.” Paul B. Batalden MD Co-founder Institute for Healthcare Improvement Founding Director Center for Healthcare Improvement and Leadership – The Dartmouth Institute

New Structure Eliminate Medical Support Specialist Role at 5 sites Former Diabetes Registry Coordination (Old PECS System) Centralize Registry Function within Quality Department Added Quality Department Staff PCMH Registry Specialist – May 2012 PCMH Report Generator – May 2012 Care Managers for 2 locations (MiPCT) – January 2012 CMS Muliti-payer Demonstration Project Create PCMH Lead at each site – May 2012 Additional responsibility for selected staff member

Planning Tools Annual Performance Improvement Plan Schedule of Activities Comparison of Clinical Quality Measures for UDS/MU/PCMH/Pay for Performance Measures Crosswalk between NCQA and BCBS PCMH Standards Working examples will be shown at end of presentation

Annual PI Plan Activity

Activity Schedule Clinical Quality Indicator Reporting January UDS ED Visits Open Access Framework for Clinical Portion of Annual PI Plan February Record Audit 7 Day post Hospitalization Visits with PCP March MU Generic Rx Rate Patient Self Mgt. April May June July August September UDS/MU October PH Medications November December Monthly Patient Contact Schedule   Item 1 Item 2 Item 3 Item 4 Item 5 Item 6 Diabetes Well Child - 7-21 Immunizations 7-12 Chlamydia Cardiovascular Smoking Cessation HTN Well Child - Years / Lead Immunizations - 15 Mo Pap/Mam Osteoporosis / RA BMI Asthma Well Child - 3 to 6 Immunizations 3 - 6 Colonoscopy COPD Chronic Kidney

Periodic Assessment - BCBS

What Needs Measured?

Goal Comparisons

Periodic Assessment - NCQA

NCQA Report Priorities

Data Location and Reporting

NCQA Reporting

Evidenced Based Care - MQIC

Protocol Creation / Modification

Staff / Patient Tools PCMH Brochure Care Management / Self Management Documentation Standardized Work Documentation Staff Education Tools

PCMH Brochure

Care Planning

Create Staff Documentation

Success’ NextGen EHR Implementation i2i Tracks Registry Implementation Centralized PCMH Functions Mailings for all sites using fold and seal mailers Report processing and distribution One Time download of all immunization in State Immunization Registry (MCIR) to our EHR PCMH Module in Annual Competency Training Planning Worked Smarter, not Harder Made sure Measures met multiple goals

Weak Areas (Failures) Open Access Scheduling Internal CAHPS Surveying Competing Priorities Internal CAHPS Surveying Costly Time Consuming Interfaces MCIR Upload Identification of Managed Care Population 4 different attempts Too Large – Wrong Measures – Too Small – Just Right Provider Engagement Competing Priorities (Productivity / EHR / PCMH)

Pearls Education Change is Difficult Leadership (Administration and Board) Provider Staff (Clinical and Support) Change is Difficult Changing to the Chronic Care Model is More Difficult than meeting the NCQA PCMH Standards Staff and Providers do not want to give up the old way Competing Priorities Care Management Population Selection What is your time frame to meet goal? – Work Backwards What percent of your proposed patients are seen during that time? Who will do Care Magement?

Pearls Registry Standardize Data Validation How will you measure various aspects of care? Will your registry report on those items? Success is tied to staff proficiency with EHR. Standardize What will be documented where? Who will perform specific ongoing reporting tasks? Adopt the “Everyone works to their highest level of licensure or training” philosophy. Live the “Triple Aim” and immerse yourself in PCMH

Pearls Communication Investment Flexibility Newsletters Reference Materials for Staff Investment Financial (Registry / Licenses / Education / Staffing) Staff Time (Education / New Tasks / Learning Curve) Flexibility Modify timeline as needed Ask for help

Success? NCQA PCMH Designation at all 5 sites Meaningful Use Payments for Stage 2 (2014) Reporting Valid Results Available for all known measures Trending data available Improved Quality Scores UDS Pay for Performance Indicators – All Payers Gain Sharing with our new ACO Initiative