AIMS

• Learn how to effectively utilize practice level data

• Understand the essentials of making data more personal to practices

• Explore creative ways to utilize data in practice transformation

innovations

TEAM

UMMS Facilitation and MA PCMHI Practice Teams

METHODS

DESIGN

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

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

• 49 participating practice sites

• 3-year demonstration; Start: March 2011

DATA

• Self-reported monthly clinical quality measures data from all MA PCMHI practices from June 2011 through November 2013

• Clinical quality measures cover the domains of: adult diabetes, pediatric asthma, care coordination and care management, and adult prevention

ANALYSIS

• Linear Mixed Model and Practice Run Charts

• Data were divided into three-month periods: Time 1 (June - Aug 2011) to Time 10 (Sept - Nov 2013)

• Change over time: Time 1 or Time 2 (Care Coordination and High Risk Care Management measures collection started at later time) vs. Time 10

DISCUSSION

In the first 30 months of the MA PCMHI, participating practices have shown

significantly improvement in:

• Process measures

• New processes and/or newly documented processes

• Measures for specific patient populations

PRACTICE RUN CHARTS

CLINICAL QUALITY MEASURES CHANGE OVER TIME

AGGREGATE RESULTS

CONCLUSIONS

• 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

INTRODUCTION

BACKGROUND

Clinical Data is a key driver in Patient-Centered Medical

Home (PCMH) transformation. Using available data to

make micro (practice) level changes that can result in

macro (system) level changes helps guide the process

and monitor the usefulness of interventions. Data can

be presented in creative ways to practice members to

stimulate their involvement and create a self-reinforcing

QI culture.

Macro and Micro Level Data in the Patient-Centered Medical Home

Center for Health Policy and ResearchCommonwealth Medicine333 South Street, Shrewsbury, MA 01545508.856.6222 l 800.842.9375http://chpr.umassmed.edu

Sai Cherala, M.D., M.P.H.Jaime Vallejos, M.D., M.P.H.

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