From the Frontline of Care Improvement – How to do it Right Webinar #3 - Diabetes Care Improvement Series Chris Cammisa, MD. Medical Consultant, California Quality Collaborative (CQC). Farhan Fadoo, MD, MS. Chief Medical Information Officer, San Joaquin General Hospital (SJGH). David Eibling, MD. Medical Director, Health Plan of San Joaquin (HPSJ). January 18, 2013

Agenda for Todays Webinar Describe a couple of simple improvement models useful to small group practices Provide some improvement strategies from our work in a diabetes collaborative in Southern California Highlight a local best practice How HPSJ supports practices 1

The Model for Improvement An approach promoted by IHI Three basic/key components o Aim Statement – What are we trying to accomplish? o Measure – How will we know if we have accomplished our goal? o Change – What are some interventions we can try to move toward our goal? A really good way to help us focus on the work of improving 2

The Care Model Developed by the Institute for Healthcare Improvement (IHI) Five Key Components o Clinical Information Systems o Delivery System Design o Organization of Health Care o Self management and adherence o Maximizing the use of community resources The two keys are a Prepared Practice Site and an Engaged Patient 3

The Concept of PDSA Stands for plan, do, study, act After setting a goal and a measurement strategy Try an intervention as a small pilot test Then evaluate how it went before spreading the change Implicit in this process is the idea of teamwork 4

The CQC Collaborative Five medical groups/IPAs in the Inland Empire Area Ran over a 15 month period from late 2010 to early 2012 Utilized expert faculty for content Cindi Ardans and I were the co-leads 5

Objectives of CCC Achieve 20% relative improvement in selected diabetes measures Three core measures & four optional to track progress 6

Structure IHI Breakthrough Series College structure Four in-person learning sessions Action periods between LS Coaching calls with CCC co-leads Webinars on related topics TA support as needed Two site visits 7

Action Periods Team leader convenes team periodically Operationalize work plan Conduct PDSA cycles to test changes Measurement cycles to assess progress Communicated & celebrated progress! 8

Outreach Interventions Activity BFMCDOHCEpicNAMMUFC Group/sends letters to patients Group/IPA does outbound calls to patients Site visits/phone calls to practices Gap reports to practices Health ed materials to practices Health ed materials to patients Health educator/CDE consults 9

Other Interventions Activity BFMCDOHCEpicNAMMUFC Registry operational IP Intensive pharmacist intervention Financial incentives to practices Automated lab order entry Use of CPT Category II codes for BP Promote diabetes care at health fairs, etc. Public recognition of high performing physician practices Process to update patient contact info 10

Diabetes Measures Core (all groups) –A1c test last 12 mos –A1c > 9.0 or no test –LDL-C test last 12 mos 11 Optional –A1c <8.0 –Nephropathy monitoring –LDL-C <100 –BP <140/90

Results Goals calculated as relative improvement 20% of gap between Q baseline and benchmark Comparing Q to Q4 2010, 7 of 8 measures met the goal and 1 measure was unchanged Though interventions have not spread to all practices, the grapevine promotes adoption Interventions working – next steps are spread and sustain improvements 12

Lessons Learned Functioning registry is fundamental Good communication plan is essential Small practices may have advantage Using proven QI models = improvement Persistence, follow-up more critical than brilliant ideas Active collaborative participation = motivation 13

Changes You Might Want to Consider for Your Practice 14

Systems and Process Improvement What follows are suggestions to reorganize the practice The practice and the patient visit provide opportunities for improving the care Promoting a more prepared and proactive team Building more informed and engaged patients 15

Office Systems Identify and train clinical and office staff in their role as members of the diabetes care team Implement standing orders for common problems or patient conditions Hold a daily huddle prior to the opening of the practice with the office staff Trained medical assistants 16

Chart Prompts Help patients set self-management goals and provide a goals worksheet and daily log Develop a follow-up system Keep a cheat sheet of the diabetes medication copays in the exam room for health plans common in your practice Ask the patient about medication cost issues 17

Exam Rooms/Waiting Area Post a reminder list of proper procedures for patients with diabetes Post a reminder or checklist, visible to the appointment desk staff, providing procedural reminders for visits of patients with diabetes Implement regular staff meetings Staff conducts messenger activities 18

Building the Diabetes Care Team Attach foot exam results to charts Keep flow sheets and/or visit planners in the medical record Highlight out of range values for blood pressure, glucose and lipids Consider color-coding charts of patients with diabetes Review and update the disease registry regularly Record the patients language and race/ethnicity in the medical record 19

Patient Activation/Support Place educational posters in patients line of sight o The information displayed can empower patients to ask questions and/or remind healthcare professionals of routine care Have a brochure rack including diabetes-focused topics Information should be provided in multiple languages 20

Success in San Joaquin Next it is my pleasure to introduce Dr. Farhan Fadoo, Chief Medical Information Officer at San Joaquin General Hospital who will talk about what his organization is doing to improve care for their members with chronic conditions. 21

Leveraging Population Management Tools to Enhance Data Visibility and Impact Care Quality Farhan Fadoo, M.D., M.S. Chief Medical Information Officer San Joaquin General Hospital January 18, 2013

27 Clinics (4 Primary Care, 2 Peds, 2 OB/GYN, 19 Specialty) 3 Residency Programs (IM, FM, GS) 200k OP encounters/year; ~100 providers (incl. residents) Operational staff = 5 FTE Vulnerable patient population – payer mix tilted towards self-pay and medically indigent, followed by Medi-Cal Challenges with Patient Access and PCP Continuity and Patient Satisfaction Tension between educational mission and patient care in residency clinics Striking appropriate balance with SJGH inpatient priorities Uncertain climate around payment reform 23

Operational Delivery System Reform Incentive Program (DSRIP) Patient-Centered Medical Home (PCMH) Changes in rules governing residency programs (ACGME/RRC) Transition to FQHC-LAL (primary care) Future??? An eye towards ACOs… Technological Meaningful Use (MU) and ARRA/HITECH Community HIE ICD-10 Conversion 24

Improved Patient Experience Lower per capita Healthcare Cost Improved Population Health 1 Source: Berwick, D.M., Nolan, T.W., and Whittington, J. (2008) At SJGH: Doing Better, For More, With Less 25

Decrease Overall Disease Burden o Prevention o Wellness o Screening o Immunization Decrease Hospitalizations Decrease Acute Illness Improve Mental Health Expanded Access to Health Care Services 26

Self Management Support 2 Enhanced Communication Decreased Waits/Delays Improved Patient Satisfaction Scores Coordination of Care 2 Source: Patient-Centered Primary Care Collaborative (2010). 27

Decreased ED Utilization Decreased Hospital Admissions Shorter LOS Case Management 28

Unique Vantage Point o Not just about individuals but populations Leverage Multiple Sources of Data Reporting and Dashboards o Daily, Monthly, Quarterly o Provider-specific o Disease-specific Goals/Targets 29

Computerized Chronic Disease Registry Powerful Visible Interfaced Actionable Reporting = Paradigm Shift 30

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i2iTracks DEMOGRAPHICS VISITS CPT ICD-9 APPOINTMENTS POINT OF CARE LAB EHR Clinicals Vitals Pharmacy Imaging 32

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Aggressive empanelment activity Building culture around data o Diabetes and Depression as Use Cases o Office of Panel Management and Specialty Referrals Strong Collaborative Partnership with HPSJ Lean Healthcare Principles o Workflow Standardization / Minimizing Waste o Risk Management / Root Cause Analysis o Care Team Models / Operational Efficiency NCQA Recognition – Diabetes (Aug. 2012) 38

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Deploy Integrated Ambulatory Practice Management System (PMS) and Electronic Health Record (EHR) o Scheduling, Revenue Cycle, Messaging, CPOE/CDS, E-Rx Expand Use of i2iTracks Disease Registry for Population Mgmt. o Asthma/COPD; Womens Health; Immunizations; Pain Management Continue to Foster an Organizational Culture around Data o Deliver Value through Analytics and Business Intelligence o Operational, Financial, and Clinical Dashboards o Participate in Community-Wide HIE Achieve NCQA Recognition for Level 3 PCMH o Advanced Access, Enhanced Continuity, Sophisticated Care Coordination, Population Management 42

Healthcare reform will drive adoption of PCMH-like models of care delivery that heavily leverage care teams Progressive alignment of financial incentives Data visibility is key to managing population health San Joaquin Countys population is poised to receive innovative service delivery from SJGH and its community partners 43

Berwick, D.M., Nolan, T.W., and Whittington, J. (2008). The Triple Aim: Care Health, and Cost. Health Affairs. 27(3), Retrieved on 11/11/12 from California HealthCare Foundation, (2004). Chronic Disease Registries: A Product Review. Retrieved on 11/11/12 from eRegistryReview.pdf eRegistryReview.pdf Institute of Medicine (2012). Primary Care and Public Health: Exploring Integration to Improve Population Health. Retrieved on 11/12/12 from Health/Primary%20Care%20and%20Public%20Health_Revised%20RB_FINAL.pdf Health/Primary%20Care%20and%20Public%20Health_Revised%20RB_FINAL.pdf National Committee for Quality Assurance (2011). Standards for Patient-Centered Medical Home (PCMH). Retrieved on 10/20/12 from Patient-Centered Primary Care Collaborative (2010). Transforming Patient Engagement: Health IT in the Patient Centered Medical Home. Retrieved on 11/12/12 from Robert Graham Center (2007). The Patient Centered Medical Home: History, Seven Core Features, Evidence and Transformational Change. Retrieved on 11/10/12 from MH.pdf MH.pdf 44

HPSJ Meeting Significant Healthcare Needs With Limited Resources

HPSJ Goals Easy Access High Quality of Care Coordinated Care to Achieve 1.Individual Health Improvement 2.Population Health Improvement 3.Cost Savings 46

Integrated Patient Centered Medical Home Patients Hospitalists PCPs Residentialists Nurse Case Managers Social Service Case Managers MH/BH Counselors MA Health Navigators Peer Educators/DM Wellness Educators 24/7 Advice Nurse IHSS Workers 47

Transitional Care Visiting Home Family Nurse Practitioner Physician Home Visits (Residentialists) Home Behavioral Health/Mental Health Counselors Home Monitoring Technology – Glucometers – Blood Pressure Monitors – Scales for congestive heart failure – Oximeters for chronic obstructive pulmonary disease – Medication Dispensing 48

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Fora Care Conversion from TrueTrack 50

Technology to Achieve Goals Home Biometrics Devices Telemedicine Consults Advice Nurse Coordination Ambulance CM/ER Integration Pocket Device with 360 Care Plans Social/Electronic Media DM & ED Programs 51

Presentation Slides Can be found here:

Next Presentation Promoting Patient Self-Management and Medication Adherence Wednesday, January 23 rd 12:15 - 1:15 pm Learn how to help your patients take charge of their health, with a guest speaker from the California Diabetes Program sharing lessons learned from 25 years of on-the-ground improvement work. Dial-in Info: , Passcode ; Webinar link: pbgh.adobeconnect.com/webinar4/pbgh.adobeconnect.com/webinar4/ Please RSVP at: 53