nw pa data review robert a. gabbay, md, phd professor of medicine, penn state college of medicine

NW PA Data ReviewRobert A. Gabbay, MD, PhDProfessor of Medicine, Penn State College of Medicine

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

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)

HEDIS Goals

90th Percentile of the HEDIS New England or Mid-Atlantic Benchmarks

(whichever was higher)

Steady Denominators = Good!

Baselin

e

June 2012

July 2012

August

2012

Septem

ber 2012

October

2012

November

2012

December

2012

January

2013

Febru

ary 2013

March 2013

April 2013

0

200

400

600

800

1000

1200

Count of DM Patients Ages 18-75NorthWest

Seneca

Warren

Oil Valley

MGC

Semeyn - Brookville

Semeyn - Fair Mount

Average

Excellent Job! Now Part of Planned Care at Every Visit

Baselin

e

June 2012

July 2012

August

2012

Septem

ber 2012

October

2012

November

2012

December

2012

January

2013

Febru

ary 2013

March 2013

April 2013

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% DM Patients Tobacco QueryNorthWest

Seneca

Warren

Oil Valley

MGC

Semeyn - Brookville

Semeyn - Fair Mount

Average

Goal

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

Baselin

e

June 2012

July 2012

August

2012

Septem

ber 2012

October

2012

November

2012

December

2012

January

2013

Febru

ary 2013

March 2013

April 2013

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% DM Patients with Nephropathy Screening/TreatmentNorthWest

Seneca

Warren

Oil Valley

MGC

Semeyn - Brookville

Semeyn - Fair Mount

Average

Goal

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

Baselin

e

June 2012

July 2012

August

2012

Septem

ber 2012

October

2012

November

2012

December

2012

January

2013

Febru

ary 2013

March 2013

April 2013

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% DM Patients with Dilated Eye Exam Results DocumentedNorthWest

Seneca

Warren

Oil Valley

MGC

Semeyn - Brookville

Semeyn - Fair Mount

Average

Goal

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

Baselin

e

June 2012

July 2012

August

2012

Septem

ber 2012

October

2012

November

2012

December

2012

January

2013

Febru

ary 2013

March 2013

April 2013

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% DM Patients with Foot ExamNorthWest

Seneca

Warren

Oil Valley

MGC

Semeyn - Brookville

Semeyn - Fair Mount

Average

Goal

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

Baselin

e

June 2012

July 2012

August

2012

Septem

ber 2012

October

2012

November

2012

December

2012

January

2013

Febru

ary 2013

March 2013

April 2013

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% DM Patients with Self-Management GoalsNorthWest

Seneca

Warren

Oil Valley

MGC

Semeyn - Brookville

Semeyn - Fair Mount

Average

Goal

Improving As Processes of Care Get Implemented

Baselin

e

June 2012

July 2012

August

2012

Septem

ber 2012

October

2012

November

2012

December

2012

January

2013

Febru

ary 2013

March 2013

April 2013

0%

5%

10%

15%

20%

25%

% DM Patients with A1C>9NorthWest

Seneca

Warren

Oil Valley

MGC

Semeyn - Brookville

Semeyn - Fair Mount

Average

Goal

Practices Getting Closer To The HEDIS 90% Goal

Baselin

e

June 2012

July 2012

August

2012

Septem

ber 2012

October

2012

November

2012

December

2012

January

2013

Febru

ary 2013

March 2013

April 2013

0%

10%

20%

30%

40%

50%

60%

70%

80%

% DM Patients with A1C <8NorthWest

Seneca

Warren

Oil Valley

MGC

Semeyn - Brookville

Semeyn - Fair Mount

Average

Goal

Many Practices Close To The HEDIS 90% Goal

Baselin

e

June 2012

July 2012

August

2012

Septem

ber 2012

October

2012

November

2012

December

2012

January

2013

Febru

ary 2013

March 2013

April 2013

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% DM Patients with BP <140/90NorthWest

Seneca

Warren

Oil Valley

MGC

Semeyn - Brookville

Semeyn - Fair Mount

Average

Goal

Getting Closer to Goal – More Work To Do

Baselin

e

June 2012

July 2012

August

2012

Septem

ber 2012

October

2012

November

2012

December

2012

January

2013

Febru

ary 2013

March 2013

April 2013

0%

10%

20%

30%

40%

50%

60%

70%

% DM Patients with LDL <100NorthWest

Seneca

Warren

Oil Valley

MGC

Semeyn - Brookville

Semeyn - Fair Mount

Average

Goal

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

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!