improving diabetes care in 75 minutes - ihi home...

Improving Diabetes Care

in 75 Minutes

Moderator: Jerry Penso, M.D., M.B.A.,

President & CEO, AMGA

SESSION OBJECTIVES

1. Identify specific tactics that health care delivery

systems can implement to improve a bundle of

outcome measures in diabetes

2. Learn novel ways to engage the entire care team

and patients in improving health

3. Discover the advantages of joining a national

peer-led campaign to improve diabetes care

© 2016 AMGF

DISCLOSURE

• Presenters and moderator have no relevant

financial or nonfinancial relationships to disclose

AGENDA

Robert Zimmerman, M.D.

Assistant Medical Director

C. Todd Staub, M.D.

SVP Physician Relations,

OptumCare

Lori Arnoldussen, RN

Clinical Quality

Coordinator

TEAM TECH TRANSPARENCY

©2017 AMGA FOUNDATION

IMPROVE DIABETES CARE

IN 75 MINUTES:

ABOUT TOGETHER 2 GOAL®

Jerry Penso, M.D., M.B.A.

President and CEO, AMGA; President, AMGA Foundation

ABOUT AMGA


ABOUT TOGETHER 2 GOAL®


CAMPAIGN PARTICIPANTS• 150 groups in 35

states

• 61,000 FTE

physicians

• 2.0 million patients

with Type 2 diabetes


THE REACH OF TOGETHER 2 GOAL®

CAMPAIGN GOAL

Improve care for 1 million people with

Type 2 diabetes

IMPROVEMENT THROUGH 2017 Q1

Patients with Improved Care

Age 18–75 503,000

Age 18–89 609,000



IN 75 MINUTES:

TEAM

Robert P. Zimmerman, M.D.

Assistant Medical Director, Excela Health Medical Group

OBJECTIVES

• Discuss Care Teams

– Make up

– Function

– Must haves

– Required support

• Excela Health Medical Group & Team Based Care/

Together 2 Goal®

– Team Based Care Model

– Form extended teams

– Engage teams

– Optimize processes

PROVIDING QUALITY CARE

IS A TEAM SPORT

HEALTH CARE TEAMS

Core Team v. Extended Team

–Core Team

• Patient Centered PCP Care team

–Members

–Daily Interaction

–Extended Team Members

• Additional team members to augment Core PCP Care

Team

–Brings limited resources to the table

– Intermittent interaction

HEALTH CARE TEAMS

Function to Improve

–Standard Work to Decrease Variability

–Support for Quality Improvement

–Access

–Education

–Care Coordination and Delivery

–Patient Engagement and Self Management

–Patient and Care Team Satisfaction

–Patient Safety

HEALTH CARE TEAMS

Must have–PATIENT AT THE CENTER!

–Common goals (define and track)

–Members with well-defined roles and responsibilities and awareness /understanding of those roles

–Authority

–Responsibility

–Accountability

–Open Lines of Communication

HEALTH CARE TEAMS

Must be given

–System buy-in

–Education

–Resources – Time to meet

and build relationships,

tools, data

–Structure

–Process

EXCELA HEALTH MEDICAL GROUP:

TEAMS & T2G

Excela Health Medical Group:

Teams & T2G

ABOUT EXCELA HEALTH MEDICAL GROUP• The Excela Health Medical Group is a network of

integrated, multi-specialty practices and physicians

located in Southwestern Pennsylvania.

• EHMG is part of Excela Health, a non-profit health system

formed in 2004.

30 locations

-120,000 covered lives

- Implementing PCMH

model with five

recognized Level 3

by NCQA

ABOUT EXCELA HEALTH MEDICAL GROUP

Across 14

specialties

ABOUT EXCELA HEALTH MEDICAL GROUP

Information Technology

• Outpatient EHR - Allscripts®

Touchworks

• Patient Portal – Follow My Health

• IBM Watson Health solutions– IBM Phytel Remind™ / Outreach™ – 2015

– IBM Phytel Insight™ / Coordinate™ – 2016

STRUCTURE OF EHMG QUALITY PROGRAM

• Physician Quality Committee

– Set strategy

– Manage clinical quality and satisfaction goals

– Call out/ set goals for Corporate Quality

Measures

• Teams to support/operationalize strategy

– Quality Team

– Quality Coordinators

– PCP Care Teams

–Primary Care Quality Work Group

–Together 2 Goal® Team

STEPS1. Implemented Team Based Care

Model

2. Established Extended Teams

3. Engaged Teams

4. Optimized Processes Through Open

Communication

STEPS

Implementation of Team Based

Care

–Develop Core Teams

• Roles and responsibilities

• Develop standard work/

processes

• Population-based care

–Panel Ownership

Implemented Team Based Care Model

1

• Established Primary Care Quality Workgroup to augment Primary Care Teams

– Identified MAs, Patient Information Coordinators, other quality champions across 30 practices

–Connected the dots among frontline patient care, payer quality programs, and financial impact of programs

–Empowered to problem solve

• Established Together 2 Goal® Diabetes Team

2 Established Extended Teams

Staff engagement by aligning incentives –What’s the goal?

– Improve diabetic care to our patients

–Provider and staff incentives or “skin in the

game”

• Staff individual merit increases tied to quality

measure performance

• Tied T2G performance to provider compensation

–Supports culture of team-based care

– T2G Planks

3 Engaged Teams

Created a culture of open communication

– Provider group leading change

– Workgroup + T2G teams actively engaged with Core PCP Teams

– Staff empowered to share what they needed to be successful

• Staff feel they are making valued contributions

• Address “I can’t do this because…”

• Staff wanted to be their best and were able to articulate

needs

– Began asking and addressing

• What is our data? Why is it our data?

• What can we do about our data?

4 Optimized Processes Through Open Communication

STEPS1. Implemented Team Based Care

Model

2. Established Extended Teams

3. Engaged Teams

4. Optimized Processes Through Open

Communication

Next:

• Technology

• Transparency

STEPS


IN 75 MINUTES:

TECH

C. Todd Staub, M.D., FACP

SVP Physician Relations, OptumCare

• Founded 1997 – 81 primary care practices

• Two decades of growth and evolution

• Creating a new culture of team empowerment

for primary care

• Moving to value and pop health

• Joined OptumCare December 2015

• 300 physicians – 125 APRNs and PAs

• 400,000 patients – statewide

• Two global cap MA contracts January 2018


OPTUMCARE: BUILDING A NATIONAL

AMBULATORY DELIVERY SYSTEM


• Top performer AMGA Measure Up/Pressure

Down® – groups over 150

• Top ten percent in Together 2 Goal®

• Top ten percent in MSSP quality ranking

• 4 ½ stars MA plan

• Achieved savings in MSSP and commercial

ACO


FIRST GENERATION TOOLS


CREATING BETTER TOOLS TO FIT THE JOB


2ND AND 3RD GENERATION TOOLS


2ND AND 3RD GENERATION TOOLS

• QIS/ProCore fed from data warehouse

• Daily refresh of data

• Combine processes: HCC and care gaps

• Workflow: assign to right team members

• Outreach: delegated team process

• Ongoing monitoring of performance

• Adding in claims data…


CUSTOM FEEDS TO EVERY APP:

A LOT OF PLUMBING MAINTENANCE!


DATA LAKE: UNIFIED FEED WITH

MULTIPLE APPS


TECHNOLOGY & WORKFLOW

TO SUPPORT QUALITY METRICS

• Technology with human centered design

• Workflow – lean and design thinking

• Within EHR environment – user facing

• Just in time – where the clicks need to occur

• Action steps right next to gaps

• Daily refresh – eliminate rework

C. Todd Staub MD FACP

[email protected]



IN 75 MINUTES:

TRANSPARENCY

Lori Arnoldussen, R.N.

Clinical Quality Coordinator, ThedaCare Physicians


Integrated health system in Northeast WI

7 hospitals and 36 primary care clinics throughout 9 counties, with

both rural and urban sites

THEDACARE


LAND OF THE FRIDAY FISH FRY!

GUIDING PRINCIPLE

• Quality and safety for our patients is our #1

priority

• Goal is achieve ZERO defects

• May mean something different inpatient vs

ambulatory

• Missed A1c, for example, is a defect in ambulatory

world

• Must measure to improve (can’t show improvement

on what you are not measuring)


TRANSPARENCY JOURNEY

• Former CEO Dr. John Toussaint was

passionate about transparency before it was

cool

• Touchpoint Health Plan shared provider level

data

• Early adopter of Epic in 1999


WCHQ

www.wchq.org

• Founding member WCHQ: Wisconsin Collaborative

for Healthcare Quality

• Publish on website members’ rates for various

measures

• Our goal is to be in the 90th percentile for each

measure (= #1 or #2 in state)

• Transparent state data has driven up the quality of

all the organizations in our state


http://www.wchq.org/

• Newer generation of sharing data and tactics

to improve health of our communities, by

delivering a consistent and reliable high

quality healthcare, at a lower and more

affordable cost

• 6 major healthcare systems in WI working

together (collabetition)


abouthealth

abouthealth


INTERNAL TRANSPARENCYINTERNAL TRANSPARENCY

• Quality Plan

• 10 metrics

• Compensation for meeting tiered rates, based at group

level

• Data shared on intranet, at provider meetings, staff

meetings, Quality team meetings

• Open to view to whole system

• Drives health competition



MONTHLY QUALITY PLAN

INTERNAL TRANSPARENCY


LEARNINGS


• Initially: “I always check an A1c twice a year”

• Then: mistrust of data “YOUR data is wrong”

• Acceptance: ok, well what do I need to do?

• Not easy/intuitive on how to manage a

population

PROCESS


• Ensure data validity

• Plan-Do-Study-Act

• Share data (assume you are at believing it

at this point)

• Clarification of roles (Med Assistant, RN,

MD)

– We have done this without ambulatory care

managers


• Prioritize measures

• Low hanging fruit to start with

• Builds confidence and experience with the

processes of reading reports and acting upon

them

• Advance to more complicated measures

• Visual management of progress and

success

PROCESS

KEYS TO SUCCESS


• Quality is on every agenda

• Multiple methods of seeing the same data

and communication of that data

• Data is not mine, it’s ours


IN 75 MINUTES:

Q&A

Moderator: Jerry Penso, M.D., M.B.A.

President and CEO, AMGA; President, AMGA Foundation

QUESTIONS


improving diabetes care in 75 minutes - ihi home...

Documents