1. SC PA Data Review Robert A. Gabbay, MD, PhD
Professor of Medicine, Penn State College of Medicine

2. PCMH-A (Patient-Centered Medical Home Assessment)
Survey designed to help systems and provide practices move toward the PCMH model
Utilized to help teams identify areas for improvement
A sense of how PCMH like you are

4. PCMH-A Assessment
On average, practices reported an average increase of +2.3/12 points (20%)
The top 3 most improved categories:
Empanelment (+3.3 points)
Quality Improvement Strategy (+3.0 points)
Patient Centered Interactions (+2.6 points)
(All on a scale from 1-12)

5. HEDIS Goals HEDIS & Quality Measurement Goals
90th Percentile of the HEDIS New England or Mid-Atlantic Benchmarks (whichever was higher)
Standardized set of performance measures
HEDIS goals used for PA SPREAD:
% DM pts A1C >9 – 13.63%
% DM pts A1C <8 – 74.70%
% DM pts BP <140/90 – 76.33%
%DM pts LDL <100 – 58.15%
%DM pts tobacco query – 90%
% DM pts nephrology screening – 92.46%
% DM pts eye exam – 90%
% DM pts foot exam – 90%
%DM pts with self-management goals – 90%
% DM pts with tobacco cessation interventions – 90%
*All criteria for goals based on a 12 month period EXCEPT tobacco query & tobacco cessation intervention which are based on a 24 month period

6. Steady Denominators = Good!

7. Excellent Job! Now Part of Planned Care at Every Visit

8. Mean Change in Abs %: Increased +12.0% (statistically significant)

9. Mean Change in Abs %: Increased +8.1% (statistically significant)
*The mean change in percentage points increased +8.1%, making it statistically significant

10. Mean Change in Abs %: Increased +19.5% (statistically significant)
*The mean change in percentage points increased +19.5%, making it statistically significant

11. You Are Likely Doing This – How Do We Track It?

12. Improving As Processes of Care Get Implemented

13. Practices Close To The HEDIS 90% Goal

14. Many Practices Close To The HEDIS 90% Goal

15. Some Practices at HEDIS 90% Goal, Others – More Work To Do

16. Great Work… But More To Do!
All of this was accomplished WITHOUT extra money
Planned care at every visit
Reaching out to high risk
Self-management support
Working as a team
MEETING AS A TEAM

17. In your population of over 11,000 diabetes patients – this is huge!
Why We Have Done This
Each A1C point drop:
Eye disease risk reduced by 76%
Kidney disease risk is reduced by 50%
Nerve disease risk is reduced by 60%
Any cardiovascular disease event risk is reduced by 42%
Stroke by 57%
Better screening nephropathy, feet and eyes reduces ESRD, amputations, and blindness.
In your population of over 11,000 diabetes patients – this is huge!