1. NW 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

3. PCMH-A Assessment On average, practices reported an increase of +1.8/12 points (15%) The top 3 most improved categories: Continuous Team-Based Healing Relationships (+2.7 points) Quality Improvement Strategy (+2.6 points) Organized Embedded Care (+2.4 points) (All on a scale from 1-12)

4. HEDIS Goals 90 th Percentile of the HEDIS New England or Mid-Atlantic Benchmarks (whichever was higher)

5. Steady Denominators = Good!

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

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

8. Mean Change in Abs %: Increased +8.1% (statistically significant)

9. Mean Change in Abs %: Increased +19.5% (statistically significant)

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

11. Improving As Processes of Care Get Implemented

12. Practices Getting Closer To The HEDIS 90% Goal

13. Many Practices Close To The HEDIS 90% Goal

14. Getting Closer to Goal – More Work To Do

15. 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

16. 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 4,000 diabetes patients – this is huge!