Diabetes Care Trends in the Massachusetts Patient Centered Medical Home Initiative at Mid-Point Sai Cherala1, MD, MPH, Judith Steinberg1, MD, MPH, Stephen Baker 2, MScPH & Christine Johnson1, PhD

1Office of HealthCare Innovation and Quality, Center for Health Policy and Research, Commonwealth Medicine, 2Quantitative Health Sciences, Biostatistics and

Health Services, University of Massachusetts Medical School, 2013

Introduction • Massachusetts Patient Centered Medical Home Initiative

(MA PCMHI) is a multi-payer, statewide initiative, sponsored by MA Health & Human Services

• 45 Participating practices • 3-Year demonstration; Start: March 29, 2011 • Includes payment reform

VISION: All MA primary care practices will be PCMHs by 2015

Aim • Assess data trends of adult diabetes clinical measures

from participating adult practices for first 21 months of the initiative

Design • Quality improvement study using practices’ self-reported

monthly data on adult diabetes clinical quality measures from June 2011 to February 2013 for 38 adult practices

• Diabetes measures include: Blood pressure, LDL cholesterol and hemoglobin A1C control and depression screening

Intervention

• Technical Assistance: Three-year Learning Collaborative, including: learning sessions, regular conference calls, webinars, online courses, support for obtaining NCQA PCMH recognition and practice facilitation

• Financial Incentives: 27/38 adult practices receive incentive payments

Methods • General Linear Mixed Model Analysis of Variance

(ANOVA)

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: Time 1 vs. Time 7

Practice Characteristics Percentage Geography (N=38)

Rural 8% Urban 92%

Practice Size (Based on Number of Full Time Practitioners N=38)

Small (1-6 FTE ) 34% Medium (7-13 FTE) 32% Large (> 13 FTE) 34%

Type of Practice (N=38) Solo Practice 5% Group Practice 24% Residency or Academic Practice 10% Community Health Center 61% Average Payer Mix (Practices with Financial Incentives

N=27) Commercial 7% Health Safety Net 16% Medicaid 76% Medicare 1%

Average Patient Demographics-Age Range (Practices with Financial Incentives N=27)

0-17 years 30% 18-64 years 68% 65+ years 2%

0% 5%

10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80%

1 2 3 4 5 6 7

Perc

enta

ge

Time Period

BP < 140/90 mmHg

HbA1c < 8%

LDL < 100mg/dL

Screened for Depression

HbA1c > 9%

Results • Percentage of diabetic patients

screened for depression measure showed statistically significant improvement (20.5% to 45.9%, p<0.0001)

• Other measures showed no change or improvement without statistical significance

Conclusion

• At midpoint of this 3-year PCMHI demonstration, practices showed statistically significantly improvement in screening adult diabetes patients for depression

Discussion • During the first 21 months of transformation effort, there

has been a significant improvement in the one diabetes process measure

• Process measures may be expected to show improvement earlier than outcome measures

• Given the complexity of the PCMH model and the practice transformation that is required, practices likely need more time to show improvements

• Factors which may impact improvement rates: Payer mix, practice size, financial incentives/resources, practice leadership engagement and adaptive reserve

Next Steps • Analyze the impact of these factors on practice performance

on clinical quality measures • Identify high and low performing practices • Enhance technical assistance by sharing best practices of

high performing practices and identifying barriers to change experienced by low performing practices

Table 1: Practice Characteristics Figure 1. Adult Diabetes Measures Over Time