1. IPC – PCMH Overview (June 4 th, 2014) | IPC Program Office

2. Objectives Summarize the Improving Patient Care (IPC) program pathways for accelerating healthcare improvement within the Indian Health System Describe the IPC Quality & Innovation Learning Network (QILN) approach for system redesign improvements Compare the elements of Patient Centered Medical Home with IPC

3. The IPC National Team Susan Karol, MD Chief Medical Officer Indian Health Service Charlene Avery, MD Director, OCPS Barb Vize, MD, MHA Acting IPC Director Candace Jones, RDH, MPH Administrative Officer Karla Hackett, RN, BSN, MHA Jason Harrington, BSN, MHA Lead Collaborative Director Susan Anderson, MPA Improvement Advisor Sokenunese Myles, BA Data Coordinator Mavis Stephens, Project Manager Kent Jeanotte, Staff Assistant Co-Collaborative Directors Ella Richards, RN, BSN, MS

4. Improving Patient Care Program (IPC) Program Foundations Open to all I/T/U facilities Web-based seminars Introduction to tools and ideas for IPC Learning quality improvement concepts IPC Collaboratives Time limited (15 months) Infrastructure development Learning community Microsystem focus Testing and implementing high leverage changes Building improvement capability QILN Ongoing Quality and Innovation Learning Network Focus on spread/dissemination across the entire system PCMH emphasis Aim Objectives IPC Activities and Pathway Measures Transform the Indian health care system by developing high-performing, innovative health care teams to improve the quality of and access to care. New standards for health care delivery will result in improved health and wellness of the American Indian and Alaska Native people by utilizing a patient-centered medical home model. This will strengthen the positive relationships among the health care system, care team, individual, family, community, and Tribe. Improve quality of care though evidence based practice Enhance access to care across all ages and chronic conditions Improve patient experience of care Build a sustainable infrastructure for the dissemination of innovative improvement Cancer Screening Bundle CVD Bundle DM Comprehensive Health Risk Screening Bundle Outcome Bundle Peds Immunization National Measures Engaged leadership IPC participation PCMH recognition Patient Satisfaction Continuity of care Office Visit Cycle Time Self Management Goal Setting Empanelment Third Next Available Appointment ER and Urgent Care Visits 4

5. Improving Patient Care 5 Opportunity Is Intended For: – All I/T/U organizations that are interested in building improvement capacity and working collaboratively with others to accelerate learning in an action orientated initiative that provides the foundation for continued improvement. Area of Focus: –Interdisciplinary care team –Personal primary care clinician –Comprehensive and continuous care –Patient-centered care –Coordination of care –Enhanced access to care –Access to care and other resources needed to provide care 5

6. 2008-2009

7. 2009-2010

8. 2011-2012

9. 2012-2013

10. IPC V 2014-2015

11. 11 Improved health and wellness for American Indian and Alaska Native individuals, families, and communities Delivery System Design Decision Support Clinical Information Systems Self- Management Support Community Health Care Organization Care Model for the Indian Health System Activated Family and Community Informed Activated Patient Prepared Proactive Care Team Prepared, Proactive Community Partners EFFECTIVE RELATIONSHIPS Efficient Safe Effective Equitable Timely Patient-Centered Chronic Care Model developed by the MacColl Institute.

12. Quality & Innovation Learning Network Continue to advance system wide change improvements across the Indian health system; Care coordination/Care management Advanced access Mobilize tribal and community based health programs Behavioral health integration within the primary care setting Diabetes and CVD Cancer Screening Diabetes Mellitus Comprehensive Care Integrated new measures that align with national I/T/U initiatives to achieve system level performance that can be assessed monthly; and Guide and support QILN teams in achieving recognition as a Patient Centered Medical Home 12

13. High Leverage IPC Changes 1.Engage leadership at multiple levels 2.Build improvement capacity and capability throughout the system 3.Develop mechanisms to listen to and communicate transparently with the community and staff 4.Mobilize, facilitate care coordination, and partner with community resources 5.Ensure opportunities for the community and Tribe to engage in improvement processes, program development, and policy 6.Empower and prepare patients to manage their health and health care 7.Empanel the population served 8.Develop and optimize a multidisciplinary care team 9.Enhance access to care and services with a consistent care team 10.Utilize evidence-based guidelines 11.Optimize the CIS, for proactive, reliable, and coordinated care for patients 13

14. High Leverage Change Concepts 1.Engage leadership at multiple levels 2.Build improvement capacity and capability throughout the system 3.Develop mechanisms to listen to and communicate transparently with the community and staff 4.Mobilize, facilitate care coordination, and partner with community resources 5.Ensure opportunities for the community and Tribe to engage in improvement processes, program development, and policy 6.Empower and prepare patients to manage their health and health care 7.Empanel the population served 8.Develop and optimize a multidisciplinary care team 9.Enhance access to care and services with a consistent care team 10.Utilize evidence-based guidelines 11.Optimize the CIS, for proactive, reliable, and coordinated care for patients 1.Health Care Organization (the Health System) 2.Community 3.Self Management Support 4.Delivery System Design 5.Decision Support 6.Clinical Information Systems IPC Care Model 14

15. 1ENHANCE ACCESS AND CONTINUITY OF CARE4PROVIDE SELF-CARE SUPPORT AND COMMUNITY RESOURCES AAccess During Office Hours4ASupport Self-Care Process6 BAccess After Office Hours4B Provide Referrals to Community Resources 3 CElectronic Access29 DContinuity25TRACK AND COORDINATE CARE EMedical Home Responsibilities2ATest Tracking & Follow-Up6 FCulturally & Linguistically Appr. Services 2 BReferral Tracking & Follow-Up6 GPractice Team4CCoordinate Facility & Care Transitions6 2018 2IDENTIFY AND MANAGE PATIENT POPULATIONS6MEASURE AND IMPROVE PERFORMANCE APatient Information3AMeasure Performance4 BClinical Data4BMeasure Patient/Family Experience4 CComprehensive Health Assessment4C Implement Continuous Quality Improvement 4 DPopulation Management5D Demonstrate Continuous Quality Improvement 3 16EReport Performance3 3PLAN AND MANAGE CAREFReport Data Externally2 AImplement Evidence Based Guidelines4GUse Certified EHR Technology0 BIdentify High-Risk Patients320 CCare Management4 Comparison of NCQA PCMH to IPC DMedication Management3 EUse Electronic Prescribing3 17 Substantially similar to IPCLevel 1 = 35-59 points minimum MUST-PASS ElementsLevel 2 = 60 – 84 points minimum RPMS/iCare/EHRLevel 3 = 85 – 100 points minimum

16. IPC PCMH DDTP Access and Continuity RPMS/CRS iCare Identify and Manage Care Meaningful use Delivery system Design GPRA/ GPRA MA Million Hearts campaign Provide Self Care Support Measure and Improve Performance Division of Behavioral Health Care Teams 16

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18. Successful Strategies There are several factors that have proven to be associated with a successful endeavor and a successful improvement team. They are more likely to be successful if: – Their aim is a priority for the organization, formally connected to their strategies. – Team members have been formally allocated time to work on the improvement effort. – The team’s project report (which includes data for all measures) is reviewed by Senior Leaders at least once a month. – The team has a logical model for approaching change. – The team contains consistent active members. 18

19. Questions 19

20. IPC Area Improvement Support Team (IST) Leads AberdeenJanelle TrottierJanelle.Trottier@ihs.gov AlaskaCharles FagerstromCEFagerstrom@anthc.org Albuquerque Harriet Hosetosavit Neva Kayaani Harriet.Hosetosavit@ihs.gov Neva.Kayaani@ihs.gov BemidjiDr. Dawn WyllieDawn.Wyllie@ihs.gov Billings Charlene Johnson, Carol Strasheim Charlene.Johnson@ihs.gov Carol.Strasheim@ihs.gov CaliforniaHelen MaldonadoHelen.Maldonado@ihs.gov NashvilleKristina RogersKristina.Rogers@ihs.gov NavajoMichael BelgardeMichael.Belgarde@ihs.gov OklahomaJulie Erb-AlvarezJulie.Erb-Alvarez@ihs.gov PhoenixCarol DahozyCarol.Dahozy@ihs.gov PortlandDr. Tom WeiserTweiser@npaihb.org TucsonDiana DeLeonDiana.Deleon@ihs.gov Area Improvement Support Team Leads 20

21. Susan.Karol@ihs.gov Susan.Karol@ihs.gov Chief Medical Officer Charlene.Avery@ihs.govCharlene.Avery@ihs.gov Director, Office of Clinical and Preventive Services Michael.Yanuck@ihs.govMichael.Yanuck@ihs.gov Deputy Director, Office of Clinical and Preventive Services Barbara.Vize@ihs.govBarbara.Vize@ihs.gov Acting Director, IPC Program Candace.Jones@ihs.govCandace.Jones@ihs.gov Administrative Officer Jason.Harrington@ihs.gov Jason.Harrington@ihs.gov Lead Collaborative Director Ella.Richards@ihs.govElla.Richards@ihs.gov IPC Co-Collaborative Director Karla Hacket@ihs.govKarla Hacket@ihs.gov IPC Co-Collaborative Director Susan.Anderson@ihs.govSusan.Anderson@ihs.gov IPC Improvement Advisor Sokenunese.Myles@ihs.govSokenunese.Myles@ihs.gov Data Manager Mavis.Stephens@ihs.govMavis.Stephens@ihs.gov IPC Program Manager Kent.Jeanotte@ihs.govKent.Jeanotte@ihs.gov Staff Assistant Resources: http://www.ihs.gov/ipc/http://www.ihs.gov/ipc/ IHS IPC Website http://www.healthcarecommunities.org/http://www.healthcarecommunities.org/ IPC Portal 21