Massachusetts Patient-Centered Medical Home Initiative: Impact on Clinical Quality at Midpoint

Judith Steinberg, MD, MPHSai Cherala, MD, MPH Christine Johnson, PhD Ann Lawthers, SM, ScD

Commonwealth Medicine UMass Medical School

Background: Massachusetts Patient-Centered Medical Home Initiative (MA PCMHI)

Multi-payer, statewide initiative, sponsored by MA Health & Human Services

45 Participating Practices• 35 adult practices• 7 pediatric practices • 3 adult and pediatric practices

3-Year Demonstration; Start: March 29, 2011 Vision: All MA primary care practices will be

PCMHs by 2015

MA PCMHI Interventions

Technical Assistance Three year Learning Collaborative ‐

• Periodic Learning Sessions• Monthly conference calls or webinars • Online courses • Monthly submission and review of practice‐

level performance data • Support for obtaining NCQA PCMH

recognition Practice Facilitation

MA PCMHI Interventions

Financial Incentives 31/45 practices receive incentive payments Incentives:

• Start-up funding, 2 prospective payment streams, shared savings

Massachusetts Patient Centered Medical Home Initiative

InputsOutputs

Activities Results (1 – 2 years)

Outcomes – ImpactShort Term Long Term (1-2 years) (3-5 years)

*Fewer ED visits*Fewer Hospitalizations*Improved chronic disease management*Improved acute problem management*Improved delivery of preventive care*Better patient experience*Better practice experience*Slowed growth of cost

Stakeholder Groups· Massachusetts

Patient-Centered Medical Home Initiative Council (includes multiple stakeholders)

· EOHHS

· Residents of the Commonwealth of Massachusetts

Payment Reform

EVALUATION

Situation

Fragmented, discontinuous care that harms patient health status and increases costs

Increased prevalence of chronic disease, and suboptimal management of chronic disease

Shortage of PCPs

Priorities

Implement and evaluate the PCMH model as a means to achieve accessible, high quality primary care

Demonstrate cost-effectiveness to justify and support the sustainability and spread of the model

Attract and retain primary care clinicians in Massachusetts

AssumptionsTransformation of primary care practices will change patient behavior (how they access care & manage their own health).

External FactorsWorking relationships across state agencies.

Available resources

*Sustained reduction in cost growth*Improved primary care provider retention

Practices haveCore Competencies in:

· Consumer engagement

· Practice redesign

· Clinical care management and coordination

Key Activities

External to Practice· Learning

Collaboratives· Practice

coaching· Feedback of

data

Within the Practice· Team

meetings· Care Manager· Registry with

reporting capability

· Linkages to medical neighborhood

Payers

Patients

January 2010MA PCMHI Logic Model

Aim And Study Design

Aim: To assess data trends of 12 clinical quality measures from participating practices for first 21 months of the initiative

Design: Quality improvement study using self-reported monthly clinical quality measures data from all PCMHI practices from June 2011 through February 2013

Clinical Quality MeasuresAdult Diabetes

HbA1c Control (<8%) HbA1c Control (>9%) BP < 140/90 mmHg LDL Control < 100mg/dL Screened for Depression

Adult Prevention Adult Weight Screening and

Follow-Up Tobacco Use Assessment Tobacco Cessation

Intervention

Pediatric Asthma Use of Appropriate Medications

for Asthma Persistent Asthma Patients with

Action Plan

Care Coordination/ Care Management Follow-up after Hospital

Discharge Highest Risk Patients with Care

Plan

Methods• Linear Mixed Model

Analysis• Data were divided into three-month periods:

• Time 1 (2011-June, July and August)….. to Time 7 ( 2012-December, 2013- January and February)

• Analysis of Change over Time: Baseline (Time 1 or Time 2) vs. Time 7

Methods And Analysis

Results: Study Participants Practice Characteristics Percentage

GeographyRural (<10,000 town population) 9%

Suburban (Between 10,000 and 50,000) 20%Urban (>= 50,000) 71%

Practice Size (Based on Number of Full Time Practitioners) Small (< 6 FTE practitioners) 31%

Medium (Between 6 and 11 FTE practitioners) 29%Large (> 11 FTE practitioners) 40%

Type of PracticeCommunity Health Center 56%

Residency or Academic Practice 11%Group Practice 29%Solo Practice 4%

Payer Mix (Practices with Financial Incentives N=31)Commercial 12%

Health Safety Net 15%Medicaid 72%Medicare 1%

Results

3 measures showed statistically significant improvement from Baseline to Time 7:• Diabetic patients screened for depression

(25.8% to 42.4%, p=0.0009)• Action plan for children diagnosed with

persistent asthma (19.6% to 50.7%, p=0.0076)• Highest risk patients with care plan (36.5% to

54.2%, p=0.0147) All other measures showed a non-significant

trend towards improvement or no change

Adult Diabetes Measures: Change over Time

* Values met the study’s definition of statistical significance p<.05.

BP < 140/90 mmHg

HbA1c > 9% HbA1c < 8% LDL Control < 100mg/dL

Screened for Depression

0

10

20

30

40

50

60

70

80

71.3

16.2

61.7

47.7

25.8

68.7

15.2

61.6

45.842.4*

BaselineTime 7

Measure

Perc

ent

Adult Prevention Measures: Change over Time

* Values met the study’s definition of statistical significance p<.05.

Adult Weight Screening and Follow-Up

Tobacco Use Assessment Tobacco Cessation Interven-tion

0

10

20

30

40

50

60

70

80

90

100

35.1

80.9

45.139.2

86.3

50.1

BaselineTime 7

Measure

Perc

ent

Pediatric Asthma Measures: Change over Time

* Values met the study’s definition of statistical significance p<.05.

Use of Appropriate Medications for Asthma Persistent Asthma Patients With Action Plan

0

10

20

30

40

50

60

70

80

90

76.1

19.6

77.6

50.7*

BaselineTime 7

Measure

Perc

ent

Care Coordination/Care Management Measures: Change over Time

* Values met the study’s definition of statistical significance p<.05.

Hospital discharge Management of Highest-Risk Patient: Developing Care Plan

0

10

20

30

40

50

60

70

80

66.9

36.5

70.6

54.2*

BaselineTime 7

Measure

Perc

ent

In the first 21 months of the MA PCMHI, participating practices have significantly improved:• Diabetes care delivery by more consistently

screening patients for depression• Pediatric asthma care by more consistently

developing action plans for patients with persistent asthma

• Care management by more consistently developing care plans for highest risk patients

Discussion I

Discussion II Factors which may impact improvement rates:

• Payer mix• Practice size• Financial incentives/resources • Practice leadership engagement• HIT functionality and use • Practice “adaptive reserve”

Next steps:• Analyze effect of factors on practice performance• Use results in sharing best practices and addressing

barriers to change

Limitations

Quality Improvement study • Small sample size • Short follow-up period • No comparison group

Conclusion and Implications for Policy and Practice Primary care practice transformation takes time Processes of care are more likely to improve

before outcomes are impacted Use of a clinical quality measures set is important

for:• Developing practices’ skillset in QI, a PCMH

component• Evaluating the impact of implementing PCMH

processes on patient care and outcomes

Acknowledgements

We would like to acknowledge the MA Executive Office of Health and Human

Services (EOHHS), the MA PCMHI Leadership and Medical Home Facilitator

Teams, as well as MA PCMHI participating practices without whom this work

would not be possible.

Contact Information:

Judith Steinberg, MD, MPH

Deputy Chief Medical Officer

Commonwealth Medicine, UMass Medical School

Judith.Steinberg@umassmed.edu