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in+care CampaignWebinar

January 9, 2013

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Ground Rules for Webinar Participation

• Actively participate and write your questions into the chat area during the presentation(s)

• Do not put us on hold• Mute your line if you are not speaking

(press *6, to unmute your line press #6)• Slides and other resources are available

on our website at incareCampaign.org• All webinars are being recorded

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Agenda

• Welcome & Introductions, 5min• Sustaining Retention Projects in

Unsure Funding Environments, 30min• Data Review and Discussion of

Retention Strategies Collected Through the Campaign, 15min

• Q & A Session, 5min• Updates & Reminders, 5min

Health reform, in +care, and Patient Centered Medical Home model

Quality Measures are a key ingredient in the Continuous Quality Improvement process and must be compiled for Ryan White, governmental and institutional reporting requirements including HIVQUAL-US, Meaningful Use and Delivery System Reform Incentive Payments.

Although Electronic Medical Records collect huge volumes of data, the process of extracting that data to meet specific reporting requirements or to achieve a quality improvement activity poses its own challenges.

This lecture will introduce a live experience in the medical home transformation process which is consolidating quality activities, improving quality reporting, exploring opportunities to strengthen personnel and infrastructure with attention to retention and transitions of care.

In +Care approached througha Patient Centered Medical Home model

Amy M. Sitapati, MDMedical Director, Owen ClinicAssociate Clinical Professor, Department of MedicineUniversity of California, San DiegoJanuary 9, 2013

Who are we?

Public health missionIntegrated into an academic medical center serving as a National leader in HIV health delivery. Implementing new systems of care relevant to healthcare reform.

-Ryan White Funded-Designated Public Hospital (DPH)-Low Income Health Program (LIHP)-Delivery System Reform Incentive Payment (DSRIP) 5 HIV transition-Meaningful Use (MU)

CY 2011 OSHPD Patient Discharge Data

Where is here?

National leader for HIV quality care delivery, excellence in teaching, workforce capacity development, designing patient relevant HIV research and participating in national cohort research.

We empower our HIV community through patient advisory meeting, tools for self-efficacy (MyUCSDChart), patient centered web-page, and on-site computer access.

Patient Centered Medical Home Transformation- Started with technological build (2 years)- Now focused on personnel & infrastructure (new)

Web-page

Promoting e-health literacy with basictraining for web-site and chart use

Patient computer lab Create basic level and intermediate computer

lessons English and Spanish Promote on-going e-health literacy and

patient chart access

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My refill: ritonavir

I feel sickWith fever

Call my therapist

Fill out myForm disability

Na low 130

Methadone refill

Appt today?

Amoxicillin fortooth

Viral load 1200

Trouble withMedi-cal form

Dental referral

Back pain

Diarrhea

Testosteroneshot

Flu shot

Just a hello

Refills all out

Need laborders

RPR 1:32

Headache

Letter ofdiagnosis

AZT refill

Mammogram

Check Vit D

More lab orders

Significant increase in workload outside of the visit based encounter Understanding the changes to clinic workload

Dec

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

2010

2011 2012

0

1000

2000

3000

4000

5000Monthly Non Office Encounters

Document/Orders15%

MyChart14%

Orders Only16%

Refill33%

Telephone22%

Non Office Based Encounters Distribution1/2011 – 9/2012

Where are we headed?

Ryan White model to PCMH HIV model

Patient Centered Medical Home +

New strategy:

Provide high-quality comprehensiveand equitable primary HIV carethrough empanelment, casemanagement, and amulti-disciplinary team using a PCMHmodel.

team centricneed directed supportive wraparoundcommunity integrationquality accountable

Originalculture:Stability

Steady growthHard work

IndividualizedPhysician

centricQuality drivenCompassionate

New culture:Innovative

AgileInformativeParticipatory

Team centeredQuality

accountable

Original strategy:

Provide high-quality comprehensiveand equitable primary HIV care througha collaborative and knowledgeablemulti-disciplinary membership using aRWCA model.

physician centricsupportive wrap aroundcommunity leadershipquality driven

Strategy

Delivery System Reform Incentive Payments(DSRIP) Categories:

• Lays the foundation for the delivery system through investments in people, places, processes and technology.

Category 1: Infrastructure Development

• Pilots, tests and replicates innovative care models.Category 2: Program

Innovation & Redesign

• (1) the patient’s experience, (2) the effectiveness of care coordination (3) prevention and (4) health outcomes of at-risk populations

Category 3: Population-Focused

Improvement• Improvement in targeted quality and patient safety

measures that are particularly meaningful to safety net populations

Category 4: Urgent Improvement in Care

• Support access to high-quality, coordinated, integrated care for HIV/AIDS patients through delivery system reform

Category 5: HIV Transition Projects

DSRIP Category 5 Structure

DSRIP5

INFRASTRUCTUREAND

PROGRAM DESIGN(3 projects)

CLINICALAND

OPERATIONALOUTCOMES

(6 required & 4 additional)

Enhance HIV patient-centered medical homes to improve care delivery and coordination

INFRASTRUCTURE

ANDPROGRAMDESIGN

EMPANEL PATIENTSINTO

HIV MEDICAL HOMES

RETENTION PROGRAMFOR

PATIENTS

RYAN WHITEWRAP-AROUND

FOR NEWLIHP PATIENTS

Definition: Empanelment

Assigning team members new roles and trying to determine optimal panel size based on patient acuity (www.safetynetmedicalhome.org)

HIV empanelment challenges: Complex set of providers (clear assignment) Complex funding sources No HIV patient weight/risk adjustment algorithm Linkages to a medical home Team based care

Panel management:

Utilizing the skill sets of medical team to the maximum of licensure

Population Management within the PCMH holds promise

RegistriesA collection of information about patients with specific condition examples: HIV ,(Hep C, Diabetes, Cancer)May also contain details about their disease status examples: 6 month gap in care, poor viral control, etc.Best practice would be to have non MD identify, communicate and track with an actionable intervention.

Population Management Clinical workflow to manage groups of patients that need

similar health screenings

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Challenges with Bulk Actions

Difficult setup (need interdisciplinary team) Regulatory issues (who is allowed to perform

bulk orders) Must develop protocols for bulk ordering/action PCMH team members (personnel and skill) Computer performance concerns about system

impact of creating hundreds of orders at once Mistakes can be magnified a hundredfold by

bulk actions. Need to develop system of double checking (by another person) before action takes effect.

Empanelment in PCMH

HIV Patient Centered Medical Home

DSRIP 5a #1: Empanelment

EMPANELOUTPATIENT

GOALS

DefineMulti-disciplinaryStaffing model

Roles andResponsibility

for Team basedHIV care

ImplementStaffing model

Panel sizerisk adjust

Increaseproportion ofpatients in

continuous care

Seamlesslinkage and care

coordination

Exceed nationalbenchmarks on

core metricsRisk adjustedmethodology for

panelmanagement

Establishbaseline

empanelment

Sharecommunity widelessons learned

Implementempanelment

process

Community part….

Community strengthening through improved care coordination,Linkages, and service.

DSRIP 5a #4: Retention

RETENTIONOUTPATIENT

RETENTIONINPATIENT

GOALS

Create OPCase

Mgt Team

Track,outreach

poorly retained

Algorithmicapproach to

refer services

Increase numberof patients incontinuous

coordinated care

Increaseambulatory

retention rate

Increase carecoordination

Improvecompliance with

med managementand prevention

Create IPCase Mgt

Team

Communityaccess to EMR

Communityparticipation in theInpatient HIV CaseManagement Team

Pharmacymed

reconciliation

Baselineassessment

tool

Weekly HIVdischargemeeting

Scheduled d/cappointment

Definition: Ryan White Wrap-around services

Comprehensive services addressing(1): Primary medical care Case management Nutrition Mental health Pharmacy Adherence counseling Substance abuse counseling

Health reform presents new barriers to accessing HIV specific wrap-around services

11 Bartlett, EJG HRSA 2004

DSRIP 5a #7: Ryan White Wrap Around Services

RYAN WHITEWRAP

AROUNDSERVICES

GOALS

Create an MOUAlgorithmicapproach to

refer services

Improve wraparound servicedelivery duringhealth reform

Use algorithmsto identify high

need

Presentcommunity wideshared learning

Use patient basedmetric screening to

identify need forwrap around services

DSRIP 5: Improvements in Clinical and Operational Outcomes

RequiredCore ClinicalPerformance

Measures

SelectedClinical

PerformanceMeasures

CD4

HAART

Medical Visit

PCPprophylaxis

Viral LoadMonitoring

Viral LoadSuppression

TB ScreeningGonorrhea

testingannually

Chlamydiatesting

annually

Medical Visits forpatients with Medical

Case Managementservices

CMS PQRS

HIVQUAL/HAB

Using performance metrics to change behavior & improve financial performance

-Meaningful Use reports

-Improved monitoring of Open Overdue Encounters

Key ANCHOR Messages

An HIV PCMH offers unique challenges related to volume of prevention measures, prescriptions, and laboratory testing in medical homes whose staffing models may not support ease of task shifting. To approach these challenges we propose that an HIV PCMH offer:

1. Improved understanding of HIV practice operations and task shifting

2. Improved patient self-efficacy3. Population management focused on

core measures

An HIV PCMH

PreventionMeasure/test

Script volume

Lab testing volume

New operationsTask shifting

Patient self-efficacy

PopulationManagementstrategies

Delivers wrap-around staff with wrap-around servicesIn high quality environment with team based care.

PCMH applied to Retention in HIV Primary Care

1. Open Access to continuity provider

2. Registry of HIV primary care patients

3. Retention as care management goal

4. Improve patient self-efficacy through web-site, e-health literacy, MyUCSDChart.

5. Track patient’s retention and coordination of care

6. Use lessons learned in CQI to make process more robust http://www.ncqa.org

Thanks to the OWEN ANCHOR TEAM:

Moira Mar-TangMilitza Bonet-VazquezBarbara BerkovichPavel TseytlovskiySusan BensonDorothea NorthcuttJan LimneosWendy ClaprothDr. Chris MathewsCQI committee

The California HIV/AIDS Research Program

Award number: MH10-SD-640The Alliance Health Foundation Grant

Award

UC San Diego Health SystemAdministration

Doris GauffYvonne ZazuetaAngela Scioscia

Photo credits

Clinic based, Moira Mar-TangWaiting room: Shutter stockComputer lab:

irvinginstitute.columbia.eduVintage care: saviranchauto.comVintage repair:

buddysautomotivekc.comCommunity view: wordpress.comPCMH home: pcmhelearning.comBee hive: en.paperblog.com

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Improvement Strategies Exercise

Michael Hager, MPH MANQC Manager

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in+care Campaign National Raw Data Snapshot

Dec 2011 – Dec 2012 Data as of 1/8/2013

12/11Average

(Patients)12/11Sites

02/12Average

(Patients)02/12Sites

04/12Average

(Patients)04/12Sites

06/12Average

(Patients)06/12Sites

08/12Average

(Patients)08/12Sites

10/12Average

(Patients)10/12Sites

12/12Average

(Patients)12/12Sites

Measure 1: Gap Measure

16.26%(126,953) 209 16.11%

(132,199) 203 14.67%(132,006) 209 15.00%

(118,969) 188 14.12%(114,994) 177 15.64%

(116,396) 170 14.70%(92,505) 145

Measure 2: Visit Frequency Measure

63.09%(85,176) 155 65.79%

(90,025) 155 62.33%(103,954) 176 63.80%

(93,779) 167 65.64%(94,723) 163 64.70%

(94,627) 155 64.29%(78,176) 133

Measure 3: New Patient Measure

56.71%(7,792) 195 58.41%

(8,957) 193 58.57%(8,566) 198 59.67%

(7,369) 182 59.63%(7,277) 174 56.68%

(7,625) 167 57.42%(6,938) 141

Measure 4: Viral Suppression Measure

69.80%(137,564) 200 69.56%

(149,699) 195 70.47%(158,624) 201 71.89%

(143,363) 187 72.15%(136,059) 174 71.90%

(136,648) 166 72.21%(106,551) 142

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Improvement Strategies Discussion

Take Home Points – Amy Sitapati’s work• Find new payers to make up for expired/lost funding• Get lean and mean(ingful)

• Find new ways to leverage existing resources (EMR and Meaningful Use)

• Find new ways to integrate work into new or ongoing initiatives (make it a focus of your PCMH)

• Carefully develop and test bulk actions• Train teams to task-shift to maximize their levels of licensure• Find ways to engage patients around self-efficacy including health

literacy and computer competencies to prepare for e-health interactions

• Find new ways to encourage retention activities through your network

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Improvement Strategies Discussion

Take Home Points – Lytt Gardner’s paper

Theme: “Stay Connected for Your Health”• Provider messages about importance of regular

care and keeping appointments• Working as a team• Keeping you healthy• Best possible care• Staying ahead of the virus

• Brochure• Posters (waiting room, exam rooms)

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Improvement Strategies Discussion

Take Home Points – Participant Submissions

• Include retention in Quality Management Plan and its work plan

• Integrate retention messaging into all program areas whether or not the patient is provided primary care at your site, including dinner programs

• Get patients excited about in+care and provide them with links for more info

• Integrate measures of retention into PCMH team “report cards”

• Develop an algorithm to identify patients at high risk of falling out of care and run it quarterly and deliver to appropriate outreach role

• Prioritize patients who are highest risk for dropping out of care as targets for patient navigation or intensive outreach

• Linkage agreements through MOUs with other providers in area

• Occasional regional discussions to identify common community barriers to retention and to identify solutions – sharing of results/progress regionally

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Submit Improvement Updates!

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Announcements

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• Next Campaign Webinar: Mental Health and Retention January 10, 2013 at 2pm ET

• Next Meet-the-Author Webinar: M.Vyavaharkar – How Can We Increase Initiation of and Retention in Care Among People Living with HIV? January 30, 2013 at 2pm ET

• Dual Partners in+care and Campaign Webinar: Working with Individual Patients to Improve Retention Date Pending – to be announced!

• Campaign Webinar: Social Service Providers Have a Role in Retention! Date Pending – to be announced!

Upcoming Events

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• Campaign Office Hours: Mondays & Wednesdays 4-5pm ET

• Wednesday, January 9 - Patient Experience Evaluation Techniques

• Monday, January 14 - Open Space, no set topic• Wednesday, January 16 - Hurdling Over Individual Barriers to

Care• Monday, January 21 - Campaign Offices Closed, No Office

Hours• Wednesday, January 23 - Building Infrastructure to

Personalize Care• Monday, January 28 - Open Space, no set topic• Wednesday, January 30 - Open Space, no set topic• Monday, February 4 - Open Space, no set topic• Wednesday, February 6 - Aligning Care Services Under a

Single Message

• Data Collection Submission Deadline: February 1, 2013

• Improvement Update Submission Deadline:January 15, 2013

Upcoming Deadlines and Office Hours

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MedScape Retention in HIV Care Series

• Technical Working Group working on articles for a new Medscape Today News Series.

• We recommend that you subscribe to HIV/AIDS MedPlus to be informed of new and exciting articles in this series!

• Published Pieces:• Implementing QI in HIV Clinics to Improve Retention in Care• Monitoring Rates of Retention in HIV Care Across the State• How Health Departments Promote Retention in HIV Care• Improving Retention in HIV Care: Which Interventions Work?• Engaging in HIV Care: What We Learned from AIDS 2012• How Should We Measure Retention in HIV Care? • Retention In HIV Care: The Scope of the Problem

http://www.medscape.com/index/section_10285_0

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Partners in+care

• Partners in+care Private Facebook Group is live! • Share tips, stories and strategies• Join a community of PLWH and those who love

them• Email michael@nationalqualitycenter.org for

more details• Partners in+care website is live!

• http://www.incarecampaign.net/index.cfm/77453 • Join our mailing list (a list-serv version of the FB

Group)

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Time for Questions and Answers

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Campaign Headquarters:National Quality Center (NQC)90 Church Street, 13th floorNew York, NY 10007Phone 212-417-4730incare@NationalQualityCenter.org

incareCampaign.orgyoutube.com/incareCampaign