Download - 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!