december 6, 2013 learning session slides

Lead Support Major Support Additional Support

100% Access HealthColumbus

Board & Staff

Individual & Corporate Donations

Patient-Centered Primary Care Collaborative December 6, 2013 Learning Session

Welcome!

Please save the following dates for future learning sessions (8:30-10:30AM): • April 4, 2014 • August 22, 2014 • December 5, 2014

Patient Engagement

Transformation Announcement

OpenNotes is an initiative that invites patients to review their visit

notes written by their doctors, nurses, or other clinicians.

Who will be sharing notes in Greater Columbus starting in Q2 2014?

Evolution of Public-Private

Partnership Announcement

2014 & BEYOND: EVOLUTION OF OUR PUBLIC-PRIVATE PARTNERSHIP 1

Our Vision (aspiration): Optimal Care, Value, and Health for all people in Greater Columbus Our Mission (useful need): To transform healthcare delivery and value for all people in Greater Columbus through collaboration with consumers, providers, and purchasers

www.hcgc.org

2 BOARD OF DIRECTORS

• Ivery Foreman (Board Chair), Vorys, Sater, Seymour & Pease, United Way of Central Ohio Representative

• Mike Stull (Board Vice Chair), Employers Health Coalition, Business Representative

• Bill Wulf, M.D. (Board Treasurer), Central Ohio Primary Care, Columbus Medical Association Representative

• Dianne Radigan (Board Secretary), Cardinal Health, Franklin County Representative

• Jeff Biehl (President), Access HealthColumbus, non-voting, ex-officio

• Doug Anderson, Bailey Cavalieri, City of Columbus Representative

• Dianne Biggs, Labor Representative • Sarah Durfee, RN, Ohio Public Employees

Retirement System, Purchaser Representative • Jerry Friedman, The Ohio State University Wexner

Medical Center, Hospital Representative • Diana Riggsby Gardner, The Dispatch Printing

Company, Purchaser Representative • Jeff Geppert, Battelle, Health Care Representative • Thomas Hadley, Wells Fargo Insurance Services,

Chamber of Commerce Representative • Sister Barbara Hahl, Mount Carmel Health

System, Hospital Representative

• Kevin Hinkle, Anthem Blue Cross & Blue Shield, Health Plan Representative

• Thomas Horan, Columbus Neighborhood Health Center, Community Health Centers Representative

• Isi Ikharebha, Physicians CareConnection, Consumer Representative

• Doug Knutson, M.D., OhioHealth, Hospital Representative

• Teresa Long, M.D., Columbus Public Health, Health Department Representative

• Julie Erwin Rinaldi, Syntero, Behavioral Health Representative

• Valerie Ruddock, Nationwide Children’s Hospital, Hospital Representative

• Olivia Thomas, M.D., Nationwide Children’s Hospital, Community Philanthropic Representative

• Dana Vallangeon, M.D., Lower Lights Christian Health Center, Consumer Representative

• Bruce Wall, M.D., The Ohio State University Health Plan, Columbus Medical Association Representative

• Todd Weihl, D.O., OhioHealth, Columbus Osteopathic Association Representative

WHY: The Need 3 A neutral, trusted organization through which the community can plan, facilitate, and coordinate the many different activities required for successful healthcare system transformation. • One of the greatest challenges facing the nation is making healthcare more affordable while

maintaining and improving its quality and improving population health.

• Evidence is clear that healthcare costs can be significantly reduced by improving the quality and appropriateness of care and engaging community members to work together to improve population health.

• Given the complexity of the healthcare system, the need to coordinate across organizations and sectors, and the barriers to change, coordinated multi-faceted and multi-stakeholder approaches are needed if healthcare reform efforts are to succeed.

• Since all healthcare stakeholders in a community – consumers, providers, purchasers, etc. – will be affected in significant ways, they all need to be involved in planning and implementing change.

• Because there is often considerable distrust and lack of coordination between different stakeholder groups, a neutral facilitator is usually needed to help design true “win-win” solutions.

• Through collaborative leadership and a focus on community benefit, regions can break down silos and promote alignment. Technical assistance and support can further improvement efforts, and measurement and reporting can track progress, identify best practices, and ensure accountability.

• New relationships across disciplines and sectors to build trust and promote alignment of efforts. Source: Network for Regional Healthcare Improvement www.nrhi.org

http://www.nrhi.org/

Transform Healthcare

in Greater Columbus

with consumers, providers & purchasers

Value-based Healthcare

Delivery

Value-based Healthcare

Literacy

Apply Collaborative

Learning

Value-based Healthcare Reporting

4 WHAT: our strategic areas of focus

Value: quality, cost, and patient experience

Catalyze Collaborative Grant

Applications

Build collaborations with consumers, providers, and

purchasers ~trust~

Catalyze best practices ~awareness~

Convene diverse stakeholders

~exploration~

Coordinate activities that

transform healthcare delivery and value

~commitment~

Measure actionable results

~collective impact~

Apply collaborative learning ~spread knowledge~

HOW: our collaborative process

5

Transform Healthcare

in Greater Columbus

with consumers, providers & purchasers

Source: Network for Regional Healthcare Improvement www.nrhi.org

WHERE: regional healthcare improvement collaboratives

AF4QL South Central PA

Healthcare Collaborative

of Greater Columbus

Better Health Greater

Cleveland

California Quality

Collaborative Center for Improving

Value in HC

Finger Lake Health Systems

Agency & Collaborative of

Western NY

Greater Detroit Area Health

Council

The Health Collaborative

Nevada Partnership for Value-drive HC

Utah Partnership for Value-drive HC

Iowa Healthcare Collaborative

Louisiana Healthcare

Quality Forum

Maine Health

Coalition

Midwest Health

Initiative

Minnesota Community

Measurement Oregon Healthcare

Quality

Pittsburgh Regional Health

Initiative

Puget Sound Health

Alliance

Wisconsin Collaborative

Healthcare Quality

MA Health Quality

Partners

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http://www.nrhi.org/

Sharing Learning from

Patient-Centered Primary Care

Practices in Greater Columbus

OPEN RECORD – The Columbus VA Experience Edward T. Bope MD Chief of Primary Care The Columbus VA

VETERANS HEALTH ADMINISTRATION


The History

• The VA developed an electronic medical record in the 1980s and with that created the largest integrated health system in the world.

• Two years ago the VA created MyHealthyVet and gave record access to the patients.


My HealtheVet

• Admission & DC summaries

• Allergies • Appointments • Demographics • EKG history • Progress notes

• Immunizations • Lab results • Pathology results • Radiology reports • Wellness reminders • Vital signs • DoD Military Service

Information


MyHealtheVet –Track Health

• Allows Veterans to add to their health record in 5 areas – VS – Labs and tests – Health History – Journals – My Goals


Problems Encountered with Open Records

• Unnecessary alarm at near normal labs • Patients reacting emotionally to the notes and

writing letters to protest calling the provider racist and advising the provider should not ever be allowed to see patients again

• Not understanding the medical jargon can lead the patient to believe they have a serious illness.


Problems continued

• Patients are very sensitive about being labelled as obese even when they are morbidly obese. I now use BMI

• I can no longer describe what I see or how they are acting if it is less than complimentary

• I am already busy with phone messages and secure email messages and having to explain the notes adds more calls.


VA advice to Providers

• Be Mindful when writing notes

• Be Professional when choosing language

• Be Open, Listen and Encourage dialogue when patients discuss notes.


Advantages to Open Records

• I have had no conflicts • Overall it is a good thing, at least they are interested

in their health • No conflicts, I tell my patients they can read their

note in MyHealtheVet • A Veteran saw a urinalysis report on his record but

knew that he had not had a urine test. This launched a search for the rightful owner.


Advantages Continued

• I had a patient who is aggressive, big physically, and intimidating. I described his attitude as “offputting” in the note and he came into the clinic very upset at me. I explained how other people saw him and reacted to him, and after that he was more mellow when in the clinic, so that was one incident with a happy ending.


Key Points

• Patients already have access to their records – it is just a cumbersome process to get them

• A focused study of VA patients showed: – Positively affected communication with Dr. – Enhanced knowledge of health – Improved self care – Allowed greater participation in the quality of

their care such as follow up of abnormal tests or decision making on when to seek care


Summary

• The time is now • It is becoming the

standard of care • Both providers and

patients will have to adapt – a change in culture

• We should assess the purpose of the progress note- is it billing, legal or patient care?

FQHC Collaborative Project: Improve Pediatric Immunization Rates

• Deanna Gingrich, RN, Lower Lights Christian Health Center • Morgan Kelley, RN, Heart of Ohio Family Health Centers

• Slessor Fombang, MD, Columbus Neighborhood Health Center,Inc.

Project Overview Goal: Improve 2013 pediatric immunization rates

as measured by the 2012 federal Uniform Data System (UDS) metric.

PCMH practice locations: ◦ 5 Columbus Neighborhood Health Centers ◦ 2 Heart of Ohio Family Health Centers ◦ 2 Lower Lights Christian Health Centers

Collaborative met monthly during Q1 2013, then quarterly Quarters 2-4, with monthly conference calls.

Results Health Center 2012

Baseline 2013 Actual

LLCHC 14% 45%

HOH 34% 38%

CNHC 47% 40%

Heart of Ohio Family Health Centers

The child’s Impact/SIIS record is reconciled with EHR vaccine record the day before well child visits. MA checks if needed vaccines are in stock.

MA tracks kids who need vaccines that are not in stock at appointment time. A nurse visit is scheduled once the vaccine is received back in stock.

MA will reschedules “no-show” well child visits immediately, eliminating having to “play catch up”.

Inventory-immunization count is done by RN every other week.

Columbus Neighborhood Health Center

• Increasing access by holding an after-hours immunization clinic.

• Enhanced inventory monitoring and control

• Missed vaccine opportunity is identified through QI data. Appointment rescheduled.

• Immunization opportunities are discussed at staff meetings

0%10%20%30%40%50%60%70%80%90%

100%

2012 2013

Immunization Rate

CNHC success with 2 year old population

Lower Lights Christian Health Center

Data to project ahead, instead of as rear view mirror. ◦ Both clinical and quality staff use tracking tool to

take advantage of all opportunities to immunize.

Set PAR vaccine inventory levels ◦ Stable process in place to determine PAR levels. ◦ Recognition of constraints to having “enough”

serum (e.g. private pay patients – financial; Medicaid patients – permission)

LLCHC Tracking Spreadsheet

Next Steps Maintain the positive change.

Continue to use data to look ahead, instead

of collecting data focused on what didn’t happen in the past.

Through the FCHQ Learning Collaborative, share data transparently.

Look for other process improvement opportunities!

Transitions of Care RN solely dedicated to hospital inpatient and ED follow-up

OSUWMC Family Medicine Elizabeth Beck, MSN(c), RN, Program Manager for Care Coordination Team Janel Grover, MHA, Director of Ambulatory Services Randy Wexler, MD, MPH, Associate Professor & Clinical Vice Chair, Dept of Family Medicine

12.6.13

What are we trying to

accomplish?

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Hire a Care Coordination Team to do the following under PCMH model of care:

Transitions of Care

Population Management

Referral Tracking

Education

Transitions of Care Today’s Focus:

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Reduce 30-day readmission rates. Reduce unnecessary ED visits. Ensure PCP is “in the loop”. Provide better quality and safety for our patients by reviewing medications and ensuring coherence with meds and discharge instructions. Increase patient satisfaction.

In a nutshell…. Close the gap!

37

Care Coordination Team: Elizabeth Beck, RN Program Manager Kathy Maedeker, RN Care Coordinator Sherri McMillan, Care Coordinator Michelle Smith, Care Coordinator Additional RN recruitment

Transitions of Care 4 FTEs hired by Oct, 2012 Buy-in from: Payors and OSU Leadership

Set goals around Transitions of Care Assess current process of receiving/acting upon IP and/or

ER notifications involving our patients. Identify issues and barriers w/ current process:

Timeliness (both internal and external) Continuity and consistency of follow up with patients Timely PCP access for follow up appointments Assumptions about Inpatient case management

Develop new process involving CC team, including standard protocol for communication & dedicated RN.

Educate PCPs and staff. Take it on the road! (Educate Medical Center Leaders and

inpatient Utilization Management departments)

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Transitions of Care Reached out to Medical Center stakeholders

Joined I/P Readmission Reduction Task Force (RRTF) Started regular meetings with Utilization Management Leadership

Team (Medical Director, Department Directors, CMs, LSWs, Navigators)

Participated in Case Management Resource Fair (open to all employees - info on access to our PCPs, how to contact our Care Coordinators, etc.)

Presentations to: Nurse Executive Council; Executive Leadership Council; RRTF. Goal to share our PCMH initiatives and our focus on Transitions of Care.

Developed process for I/P Patient Navigators (high risk patients) to directly contact RN CC.

Developed process for patients needing specialist appointment that can’t be obtained timely- PCP to bridge care.

Developed Smartphrases for consistent documentation.

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Transitions of Care

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# of inpatient stays and ED visits (patients of our PCPs)

# of PCP f/u appointments made by I/P CM (pre discharge)

# of PCP f/u appointments made by RN CC (post discharge)

Specialty f/u appointments

No show rates for f/u appts

Patient satisfaction

Frequent flyer identification and education

What do we measure?

41

Transitions of Care - Outcomes Eight OSU Family Practices

Arlington Bethel Carepoint East Gahanna Lewis Center New Albany Rardin Worthington

Data collected April – September, 2013 Change in data collection methods implemented in July, 2013 to

include separating inpatient and ED visits and recording 30-day hospital readmissions post discharge.

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Transitions of Care - Outcomes

43

RN Care Coordinator calls to 1542 patients

551 patients IP/ED (prior to July, 2013) 249 IP patients (July – September, 2013) 732 ED patients (July – September, 2013)

487 PCP follow-up appointments made by RN Care Coordinator

25 No Shows for PCP follow-up appointment

18 Readmissions within 30 days of discharge (7.2% rate)

Discharge process inconsistent Inpatient CMs not always making needed f/u appts Patients not always getting education about meds or

understanding discharge instructions- or they aren’t able to remember/comprehend at time of discharge.

F/U appointments made before discharge aren’t always the most convenient for patient, increasing no shows.

Specialty access issues (often unknown to PCP office who could’ve helped bridge care)

Very valuable intervention (quality/safety; patient-centered approach; financial incentive to reduce readmissions)

Patients LOVE this!!!

What did we learn?

44

Trust of providers (switching to a centralized process) Physician leadership critical Transparency (documentation, making sure providers 100%

in the loop) Simply proving ourselves (and going the extra mile on any

provider requests related to coordination of care)

Lack of timely notification / incomplete information Educate providers; reinforce protocol for internal notices Educate staff; set standards for external notices Open discussions w/ Navigators for direct

communication to RN CC on higher risk population

How are we really going to measure this??? I/T can help

Overcoming Obstacles

45

Transitions of Care In July, changed how we look at our metrics

Separated I/P, ED, Observation Look-back of readmissions w/in 30 days w/ identification of

readmit diagnosis Developed process for I/P Patient Navigators (high risk patients)

to directly contact RN CC.

MIDAS system being implemented for Ambulatory Care Coordinators “Real time” view of our patients in OSU hospital or ED/Obs Ability to: develop better work queues; track pts throughout stay;

build assessments (TCM smartphrases) & copy to EMR; track problems and goals; track resources of CC staff; see quick encounter updates (snapshot of svcs relative to PCMH)

Additional RN budgeted for January 2014 Pilot additional approaches

Embedding CC’s physically into practices (vs centralized)

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By developing better relationships and transitions within our own organization, we help patients more easily navigate a very complicated health care system.

Journey to Improvement – Patient Centered Medical Home

Mount Carmel Medical Group

Maria Courser, MD – Chair Quality Committee Michelle Love, RN, MSN, CCM – Manager, Quality and Safety Anna Cluxton, MBA – PCMH Project Manager Mike Anthony – Director of Primary Care Operations


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• Mount Carmel Medical Group (MCMG) is a hospital based employed physician group with more than 120 primary care and specialty physicians, with more than 40 care sites throughout central Ohio

• Member of Catholic Health East-Trinity Health, a Catholic faith based multi-facility healthcare system


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• Mission We believe the relationship between patients and their primary care provider is essential to the assurance of the right care delivery in the right setting, at the right time

MCMG Patient Centered Medical Home Goals/Status

• Achieve NCQA PCMH recognition for all primary care sites by the end of 2015

• One NCQA 2008 recognized practice (Pickerington) site under 2008 guidelines

-submitted recognition for 2011 renewal November 2013

• July 2013 achieved NCQA PCMH Level 3 recognition for MCMG Tri-Village and Upper Arlington sites

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Plan, Do, Study, Act Change Concepts

• Core Focus Areas 1) Preventative Care - pneumonia vaccination 2) Patient Satisfaction – access to care

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Quality Improvement Plans

Aim 1: Improve the rate of Pneumococcal vaccinations in patients 65 years and older by at least 5%. Baseline percentages: MCMG Tri-Village – 61% MCMG Upper Arlington - 55%

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DO-Plans/Tasks Needed to Test Change

Workflow changes: 1) Education to staff and providers 2) Use of population management reports to

identify gaps The rate of pneumonia vaccination for patients

65 and over increased significantly • MCMG Tri-Village - 72% (11% increase) • MCMG Upper Arlington - 69% (14% increase)

54

Quality Improvement Plans

Aim 2: Improve patient satisfaction survey result scores for care delivery to our patient population as a result of practice transformation initiatives.

55

DO-Plans/Tasks Needed to Test Change

Patient satisfaction improvements average of 3 % for: •Access to care - 86.7% to 89.1% •Ease of getting clinic on phone - 82.9% to 87.2% •Convenience of our office hours - 85.7% to 86.7% •Courtesy of registration staff - 91.0% to 94.4%

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STUDY – Lessons Learned • Change is hard!

– Staff, physicians, patients need hands on support and reinforcement

• EMR issues can be distracting • Focused trainings on health literacy fosters

improved patient engagement • Team huddles inclusive of front desk staff

really are critical • A multi-layered attack is best!

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STUDY – Lessons Learned/Successes

• Pre-visit planning – use of population reports,

patient outreach letters, brochure mailings • Patient satisfaction tools: implementation of

AIDET tools and training • Ongoing education for staff/physicians

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ACT –Next Improvement Steps

• Ongoing education and support – Inclusive of non-clinical aspects

• Continued reporting internally and discussion – Implement enhanced patient

population/registry software • Ongoing auditing of medical records for

practice transformation (PCMH) concept workflow

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ACT – Next Improvement Steps

• Ongoing evaluation of patient satisfaction survey results

• Ongoing education, support and evaluation of opportunities for improvement

• Expand and integrate care coordination with ancillary services: – Social/Behavioral Services – Pharmacy

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Contacts

Anna Cluxton, MBA – MCMG Process Improvement Consultant/PCMH Project Manager E-mail: [email protected] Maria Courser, MD – Quality Committee Chair E-mail: [email protected]

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mailto:[email protected]


Contacts

Michelle Love, RN,MSN,CCM-Manager, Quality E-mail: [email protected] Mike Anthony, Practice Operations Director E-mail: [email protected] Vicky Diller, Database Coordinator E-mail : [email protected]

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SNF Initiative

Re-Admission Problem

In 2012, 18.4% of Medicare patients were REHOSPITALIZED within 30 days

Rate can be even higher from a

Subacute Nursing Facility (SNF unit). Range 12-38%

Risks Associated with SNF

Transition failures post hospitalization regarding admission course, diagnosis, medications and treatment plan

Staffing/Skill level Physician limitations Lack of PCP continuity post discharge

Who Needs Post-Acute Care?

CVA for rehabilitation

CHF

Failure to thrive

Falls

Post total joint replacement

General post-op

COPC/SNF Unit Goals

Improve communication between sub-acute facilities (SNF) and the Hospital, ED, OBS unit and PCP Clinics.

Optimize the care of patients in SNF’s and

decrease readmissions. Create a safe next level of care where

hospital physicians and office based physicians are confident about care level.

COPC/SNF Initiatives

2013: Post-Acute Care 2014: Hospital/ER Diversion

2013 Post-Acute Care

COPC patient is cared for by COPC Hospitalist

On-site COPC NP Care delivered within the EHR Communication with COPC PCP

within medical record 5 units in Columbus

Post-Acute Care Results

2 units with COPC Hospitalist and COPC NP

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

#1 (n=600) #2

20122013

UNIT 30 day re-admit

12.9

%

11.5

4%

13.7

% 19.7

%

2014: Hospital/ER Diversion

Avoidable Admissions: 25% per hospitalists

- Pneumonia - CHF - UTI - Dehydration - Weakness - COPD

AVG COST $10,000

2014: Hospital/ER Diversion

Same Scenario COPC patient COPC Hospitalist/NP COPC medical record SNF unit with: • Increased RN:patient ratio

• IV fluids, antibiotics therapy 7 days per week • Respiratory therapy

What is Next?

Visiting physician Care Coordination teams High risk clinics

Home monitoring including telehealth

Lead Supporter

Major Supporters

Individual & Corporate Donations

100% Access HealthColumbus

Board & Staff

Additional Supporters

Funding from the following public-private partners supports our collaborative work in Greater Columbus!

december 6, 2013 learning session slides

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