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

2. What Do You Want To Know ? Who’s Funded Program Design
Evidence Based
Program Components
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

3. 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***

4. 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.

5. Chronic Care Model: Evidence based method of care

6. 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”

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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?

13. 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

14. 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 (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 (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 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 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 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 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 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

15. : 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

16. 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

17. PHASE Support Team - Services
PHASE Support Team - Services *New in , 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

18. 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

19. 2015 PHASE DATA: Diabetes – BP & A1c
Line is cohort average – still need to add in targets.

20. 2015 PHASE DATA: Hypertension – BP

21. 2015 PHASE DATA: Prescription Data

22. Lifestyle Measures
81% UDS 2014 Avg

23. 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

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