Title Slide Sub Title The Health Collaborative: Current Activities and Capabilities July 13, 2012 Greg Ebel, Executive Director Melissa Kennedy, Director of Operations 1

2 Mission: To employ collaborative leadership in issue identification, program development, outcomes measurement and reporting, with the goal of stimulating meaningful improvement in the health of the people of Greater Cincinnati. The Health Collaborative

Three legged stool of systemic improvement: Measure and report what is important Help people learn how to improve Pay for what is important

Title Points 4 Current Clinical Data Reporting Capabilities in Greater Cincinnati

Title Points I.Your Health Matters public report: Content: clinical outcomes data from providers Outpatient clinical outcomes data: diabetes, vascular disease, colon cancer screening, CHF Hospital Quality Data: July, 2012 Consumer Experience, ACO measures (in discussion): 2013 II.Health Care Stakeholder reporting: Content: Data from multi-payer claims database Patient Center Medical Home evaluation Potentially avoidable complications PACs Data Collection and Reporting Initiatives: initial development based upon AF4Q requirements 5

Current Data Aggregation & Measurement Process Practice Data Push from EHR Electronic Data Extraction Paper Extract (Not Optimal) Health Plan Recognition Programs Practice Dashboard 6

Challenges to Scaling: Policy Implication

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10 Group/Clinic Results

11 QI Optional Results: Monthly PDSA Rapid-Cycle Reporting

% 43% of Primary Care Physicians in the 14 county Area Report on YHM Consists of ~150 Practices & 1.15 Million Patients

Title Points 13 Current Claims Reporting & Plan for Expansion

PCMH Performance Report – Current Report Practice Level Utilization Report Across Chronic Episodes of Care Chronic Episodes of Care include COPD, Asthma, Hypertension, Diabetes, CHF, CAD, and GERD Data are reported at the Chronic Episode Summary level due to small sample size at the practice level within each episode category *Data sources: commercially insured populations from United, Anthem, and Humana GHA Springdale Queen City Physicians Hyde Park Queen City Medical Group - Anderson Queen City Physicians - Western Ridge Queen City Physicians - Maderia Queen City Physicians - Western Hills Average of 17 PCMH practice sites Non PCMH practice sites 1/1/ /31/2010* Episode N Average Age 50th Percentile Risk Factor Count Admits per 1,000 Average Length of Stay (days) Total Bed Days per 1,000 Admits ED visits per 1,000 Potentially Avoidable Complications (PACs) per 1,000 Percent of Patients with at least 1 PAC 2009 D4 Measure 2010 D4 Measure 14

Reporting Expansion Requests from Practices and Health Plans – 33 ACO measures – All patients, not just chronically ill – Measures available for all PCMH-recognized sites – Risk-adjustment of data – Readmission rates – Cost of care measures – Use of Generic Prescription Drugs – Percent of care that remains in a single system and correlations with utilization measures – High cost radiology – ED:OV use ratio

Title Points 16 Successful Implementation of Quality Improvement Programming

Title Points Our Model for Practice Transformation Measureable Quality Improvement Organizational Effectiveness Information Technology for Population Health Patient Centered Medical Home 17

Practice Transformation Success Measurement Begins May 2011 Program Begins JAN Primary Care Practices 53 Physicians 170 Patients 346,600+ ↑ in D5 Score from % points Practices will Achieve PCMH Level 3 Certification 75% Practices will Achieve PCMH Certification 100% 18