1. PA SPREAD Webinar #2

2. Pre-Work Learning Objectives 1.Understand the concept of empanelment and develop a plan to organize patients into provider panels 2.Develop an aim statement for what and how much you want to improve over the next year. 3.Understand the clinical guidelines and related measures for diabetes. 4.Collect baseline data on the number of diabetes patients in your practice and the number of patients meeting evidence-based diabetes measures.

3. Three Baseline Assessments 1.Practice Facilitator Pre-Work Visit Assessment 2.PCMH Assessment (PCMH-A) 3.Clinical Measures Baselines

4. “MEDICAL HOMENESS” BASELINE PCMH-Assessment (PCMH-A)

5. The PCMH-A Self-assessment tool developed by Qualis and the MacColl Institute for the Safety Net Medical Home Initiative. Assesses current level of “medical homeness.” No right or wrong answers! Just assessment of where you are in each area. Should be completed at the practice level by the team leader or provider champion in consultation with improvement team.

6. PCMH-A Assessment Areas 1.Empanelment (discussed in Webinar #1) 2.Continuous Relationships 3.Patient-Centered Interactions 4.Engaged Leadership 5.Quality Improvement Strategy 6.Enhanced Access 7.Care Coordination 8.Organized, Evidence-Based Care

7. Completing the PCMH-A Emailed to key contacts from PA SPREAD and available online at: http://www.safetynetmedicalhome.org/sites/default/file s/PCMH-A.pdf. http://www.safetynetmedicalhome.org/sites/default/file s/PCMH-A.pdf Answer questions in each assessment area. Send us a copy of your completed PCMH-A by May 11 by email to paspread@hmc.psu.edu or fax it to 717- 531-0182.paspread@hmc.psu.edu We’ll score it for you and send it back to you for your files. It is typical to have low scores at this point! Helpful to identify areas for improvement.

8. INITIAL CLINICAL FOCUS Diabetes

9. Why Start With Diabetes? Prevalence: 9% in PA vs. 8.3% nationally. 1 Cost: $3.6 billion total hospital charges in PA from 2003-2007. 1 Clear, widely accepted evidence-based guidelines. Requires “system of care” to provide: Clinical management of A1C, BP, LDL Screenings for complications Coordination with specialists Patient self-management 1 The Burden of Diabetes in Pennsylvanai, 2010. PA Dept of Health: http://www.portal.state.pa.us/portal/server.pt/community/diabetes/141 60/diabetes_publications___documents/557820.

10. Diagnosing Diabetes HbA1C of 6.5% or higher FBG of 126 or higher Source: American Diabetes Association. Diabetes Care. January 2012 35:S11-S63. http://care.diabetesjournals.org/content/35/Supplement_1/S64.full

11. Clinical Guidelines for Diabetes American Diabetes Association (ADA) guidelines in Diabetes Care January 2012 supplement: http://care.diabetesjournals.org/content/35/Supplement_1/S3.full Evidence for the effectiveness of restructuring systems of chronic care delivery under “Strategies for Improving Diabetes Care.”

12. Improving Diabetes Care Focus of our collaborative work for the next year. Together identify and implement strategies and “best practices” to improve diabetes care. Many ideas for you to test in your practice to see if they work and how you might refine them.

13. CLINICAL QUALITY MEASURES Using and Reporting

14. Importance of Clinical Measures You can’t improve what you don’t measure. Numerous national entities developing and endorsing clinical measures. National Committee on Quality Assurance (HEDIS and PCMH 2011) Centers for Medicare and Medicaid Services (Meaningful Use) National Quality Forum American Medical Association Increasing public accountability demands— need a way to compare apples to apples.

15. The Math of Clinical Measures Performance calculated with a fraction. Numerator = # of Patients Meeting Specification Denominator = # of Patients in Target Population

16. Example Let’s say you have 500 diabetes patients ages 18-75 in your practice. Of those, 250 have an A1C <8.0%. Your performance on this measure of good diabetes control would be 50%. 250 with A1C <8.0% 500 patients in target population = 50%

17. MEANINGFUL USE REQUIREMENTS Clinical Quality Measures THIS INITIATIVE WILL HELP YOU GET THERE!

18. Meaningful Use Requirements To attest for Meaningful Use, must: 1.Meet 15 Core Objectives 2.Meet 5 of 10 “Menu Set” Objectives 3.Report on 3 Core Clinical Quality Measures (or 3 alternate core) 4.Report on 3 More Clinical Quality Measures

19. 15 Core Objectives (we’ll work on) 1.Computerized provider order entry. 2.Drug-drug and drug-allergy interaction checks. 3.E-Prescribing (eRx). 4.Record demographics. 5.Maintain up-to-date problem list. 6.Maintain active medication list. 7.Maintain active medication allergy list. 8.Record and chart changes in vital signs. 9.Record smoking status for patients 13 years or older.

20. 15 Core Objectives (we’ll work on) 10.Implement one clinical decision support rule. 11.Report ambulatory clinical quality measures to CMS or states. 12.Provide patients with electronic copy of their health information upon request. 13.Provide clinical summaries for patients for each office visit. 14.Capability to exchange key clinical information among providers of care and patient-authorized entities electronically. 15.Protect electronic health information.

21. 5 of 10 “Menu Set” Objectives 1.Drug-formulary checks. 2.Incorporate clinical lab test results as structured data. 3.Generate lists of patients by specific condition. 4.Send reminders to patients per patient preference for preventive/follow-up care. 5.Provide patients with timely electronic access to their health information.

22. 5 of 10 “Menu Set” Objectives 6.Use certified EHR technology to identify patient-specific education resources and provide to patient, if appropriate. 7.Medication reconciliation. 8.Summary of care record for each transition of care or referral. 9.Capability to submit electronic data to immunization registries or systems.* 10.Capability to provide electronic syndromic surveillance data to public health agencies.* *Must do either #9 or #10.

23. 3 Core Clinical Quality Measures 1.Hypertension: Blood Pressure Management* 2.Tobacco Use Assessment and Tobacco Use Intervention (Pair)* 3.Adult Weight Screening and Follow-up *We’ll focus on patients with diabetes, but these apply to all patients. Key is to apply the system of care to all patients, all populations.

24. 3 More Clinical Quality Measures 1.Diabetes: HbA1C Poor Control (>9.0%) 2.Diabetes: Blood Pressure Management 3.Diabetes: LDL Management & Control We will also track: 1.Diabetes: HbA1C Control (<8.0%) 2.Diabetes: Urine Screening 3.Diabetes: Eye Exam 4.Diabetes: Foot Exam

25. COLLECTING DIABETES DATA Clinical Measures

26. Diabetes Denominator Count of active patients with diabetes 18-75 years old (includes 75 year olds).* An active patient is one who had two face-to-face encounters with different dates of service in your office or one face-to-face encounter in an acute inpatient or emergency room setting in the past 2 years with a diagnosis of diabetes. Commonly identified using ICD-9-CM codes: 250.xx, 357.2, 362.0, 366.41, 648.0. *Used for all but tobacco cessation intervention measure.

27. More Denominator [Total DM Population] Specifics: FAQ Age range excludes juveniles and frail elderly. Include Type 1 or Type 2 diabetes. Include even patients not seen routinely: Population management! Include patients co-managed with endocrinology. Exclude gestational diabetes, polycystic ovarian syndrome without DM, and steroid-induced diabetes.

28. Diabetes Numerators/Measures HbA1C: Poor Control (>9.0%) HbA1C: Good Control (<8.0%) Blood Pressure: Control (<140/90 mm Hg) LDL Cholesterol: Control (<100mg/dL) Patients Queried on Tobacco Use Tobacco Users Receiving Tobacco Cessation Intervention Screening/Attention for Nephropathy Patients with Yearly Eye Exam Patients with Yearly Foot Exam Patients with Self Management Goal Outcome Measures Process Measures

29. HbA1C: Poor Control (>9.0%) Count of active diabetes patients ages 18-75 whose most recent A1C level tested within last year is >9.0% As documented through automated laboratory data or medical record review.

30. HbA1C: Good Control (<8.0%) Count of active diabetes patients ages 18-75 whose most recent A1C level tested within last year is <8.0% As documented through automated laboratory data or medical record review. Virtually everyone should be <8.0%

31. A1C Goal: I thought it was bad to lower A1C too much? All recent studies (i.e., ACCORD) aimed at A1C = 6.5 or lower. No evidence that A1C = 7 is bad. Data says to reduce CVD—it’s not so much about glucose. It’s the Blood Pressure and Cholesterol!

32. Guidelines for A1C Control American Diabetes Association Lowering A1C to below or around 7% has been shown to reduce microvascular and neuropathic complications by as much as 40%. A1C targets below or around 7% in the years soon after a diabetes diagnosis is associated with long-term risk reduction in macrovascular disease. American Geriatric Society A less stringent target (e.g., A1C <8%) is appropriate for frail older adults, persons with <5 year life expectancy, and others with history of severe hypoglycemia. A reasonable A1C goal for older adults with good functional status is 7% or lower.

33. Blood Pressure: Control (<140/90 mm Hg) Count of active diabetes patients ages 18-75 with most recent systolic blood pressure measurement <140 mm Hg and diastolic blood pressure <90 mm Hg, tested within last year. Both systolic and diastolic measurements must be less than the targets noted.

34. Guidelines for BP Control Most important measure to control! A 10 mm Hg reduction in systolic BP reduces the risk of complications by 12%. Good BP control – minimizes CVD and microvascular complications. BP goal should be 130/80. We will track 140/90.

35. Taking and Recording the BP Sitting vs. standing White coat syndrome Right size cuffs Who takes: clinical assistant or provider? Be able to record in EMR visit template 2 or more BP recordings during same visit (so report on most recent).

36. LDL Cholesterol: Control (<100mg/dL) Count of active diabetes patients ages 18-75 whose most recent LDL-C level in the past 12 months is <100 mg/dL, As documented through automated laboratory data or medical record review.

37. Guidelines for LDL Control American Diabetes Association (ADA), American College of Endocrinology (ACE), and American Association of Clinical Endocrinologists (AACE) Recommend aggressive LDL management to achieve goal of <100 mg/dL. STATINS!

38. Patients Queried on Tobacco Use Count of active diabetes patients ages 18-75 who were queried about tobacco use one or more times in the past 24 months. Meaningful Use Core Measure #9 and NCQA PCMH 2011: Tobacco query required for ALL patients ages 13 or older.

39. Tobacco Users Receiving Cessation Intervention DIFFERENT DENOMINATOR: Count of active diabetes patients ages 18-75 who use tobacco that received a cessation intervention one or more times in the past 24 months. Cessation intervention may include smoking cessation counseling (e.g., advice to quit, referral for counseling) and/or pharmacologic therapy. Meaningful Use Preventive/Screening Measure: Tobacco cessation intervention required for ALL patients ages 18 or older who use tobacco.

40. Screening/Attention for Nephropathy Count of active diabetes patients ages 18-75 who have at least one of the following in the past 12 months: Diagnosis of nephropathy Nephropathy-related procedure Laboratory test for urine microalbumin Laboratory test for nephropathy screening Medication order for ACE Inhibitor/ARBs Medication dispensed for ACE Inhibitor/ARBs Active medication list includes ACE Inhibitors/ARBs

41. Why Screen for Nephropathy? Leading cause of kidney failure. Preventable with good glucose and blood pressure control and with ACE/ARB medication. Once macroprotenuria [dipstick positive], it is irreversible.

42. Patients With Documented Eye Exam The count of diabetes patients ages 18-75 who had a retinal or dilated eye exam by an eye care professional in the past 12 months. Results of exams should be documented in the medical records. Requires referral tracking system. Diabetic retinopathy is a leading cause of blindness.

43. Diabetic Foot Exam Count of active diabetes patients ages 18-75 who had a foot exam in the past 12 months. Foot exam = visual inspection, sensory exam with monofilament, or pulse exam. Nearly 60-70% of diabetics suffer from mild or serious nervous system damage. Loss monofilament = HIGH RISK Comprehensive foot care programs can lower amputation rates by 45-85%.

44. Patients with Self Mgmt Goal Count of active diabetes patients ages 18-75 who have a documented self-management goal in the chart in the past 12 months. A self-management goal is a behavioral goal that the patient and provider/care team agree upon during a visit or phone conversation. Not a Meaningful Use measure, but needed for NCQA PCMH 2011. Examples: I will walk 10 minutes a day 3 days a week. I will check my glucose twice a day. I will not have more than 2 desserts per week.

45. NCQA PCMH 2011 STANDARDS Becoming Recognized

46. Widespread Application Recording, using, measuring, and reporting data meets many NCQA 2011 Standards: PCMH 2: Identify and Manage Patient Populations PCMH 3: Plan and Manage Care PCMH 4: Provide Self-Care Support and Community Resources PCMH 5: Track and Coordinate Care PCMH 6: Measure and Improve Performance Note: NCQA applies to ALL patients not just diabetes patients!

47. REPORTING YOUR DATA Monthly Status Report

48. Reporting Is Key! VERY helpful to have baseline data before you start testing changes. Important to measure monthly to see if changes you are testing are making a difference. Monthly reporting allows timely feedback to you from practice facilitators. Monthly reporting will help set agenda for monthly conference calls/webinars and future learning sessions.

49. Monthly Reporting Template Use template for both data and written status report. First portion not likely to change much over time.

50. Monthly Reporting Template Double-click on data table to enter baseline data. Note percentages should automatically calculate based on numerators and denominators you enter. Goal % is based on HEDIS 90 th percentile for NE US or Mid- Atlantic US. Used in ongoing PA initiative.

51. Reporting Your Baseline Data We’ll email the reporting template and measure specifications to key contacts this week. Please fill in your (1) team member info, (2) aim statement, and (3) baseline data on the reporting template and submit it BEFORE your first learning session via email to paspread@hmc.psu.edu. paspread@hmc.psu.edu We’ll talk about the rest of the report later. The first update isn’t due until July.

52. Benchmarking Reports Helps you to see how things are going over time. PA AHEC data system will provide monthly run charts and benchmarking reports to facilitate performance assessment/improvement.

53. RESOURCES TO HELP YOU Practice Facilitators

54. Northwest Patricia J. Stubber, MBA Executive Director Northwest PA AHEC 8425 Peach Street Erie, PA 16509-4788 814-217-6029 (phone) 814-594-4740 (cell) 814-864-4077 (fax) pstubber@nwpaahec.org South Central Sharon M. Adams RN, BA Executive Director Southcentral PA AHEC PO Box 509 Carrolltown, PA 15722 814-344-2222 (phone) 814-344-2221 (fax) sadams@scpa-ahec.org Web: www.paspread.comwww.paspread.com Email: paspread@hmc.psu.edupaspread@hmc.psu.edu

55. List of Pre-Work To-Do’s  Identify a provider champion  Form a multi-disciplinary improvement team  Write an aim statement  Develop a plan to address any issues with provider panels  Complete and submit the PCMH-A assessment  Collect and report baseline diabetes data on the monthly practice status report BEFORE your first learning session  Participate in the 3 pre-work webinars  RSVP attendees for Learning Session #1

56. UPCOMING DATES Webinar #3; Learning Session #1

57. Dates for Upcoming Sessions Webinar #2: Baseline Data Measurement May 2: 7-8am May 8: 5-6pm Webinar #3: Introduction to the Models May 16: 7:30-8:30am May 21: 4-5pm NW Learning Session #1: May 23, 5-9pm in Erie SC Learning Session #1: May 22, 5-9pm in Hershey OR June 7, 5-9pm in Altoona Please RSVP the team members who will be attending Learning Session #1 to paspread@hmc.psu.edu by May 11. paspread@hmc.psu.edu