2018 hccn spring learning session - flux console hccn june 2018... · b1 data quality increase % of...
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2018 HCCN Spring Learning SessionDay 2
June 7, 2018HCCN Learning Session
LSU LOD Cook Hotel
Agenda for Day 2
Louisiana Primary Care Association 2
8:30am – 9:15am HCCN Administrative Updates
9:15am – 10:15am Peer Sharing – Quality Improvement
10:15am – 10:30am BREAK
10:30am – 11:30am Azara Presentation by Missouri PCA
11:30am – 12:00pm Gather lunch and return to meeting room
12:00pm – 1:00pm Azara Presentation and Group Exercise by Missouri PCA
1:00pm – 1:15pm BREAK
1:15pm – 2:15pm Diabetes Quality Improvement Discussion– LSU HCSD
2:15pm – 2:20pm Closing and Evaluations
2:30pm – 3:30pm Clinician's Branch Meeting
Welcome Our 2 New PHCs to HCCN
Louisiana Primary Care Association 3
St. Gabriel Community Health Center
CASSE Dental Health Institute
2018 HCCN OSV May 2-3, 2018
Louisiana Primary Care Association 4
Site Visit Goals
1. Meet with key HCCN staff and board members to discuss the HCCN’s mission, strategic goals, and progress toward meeting the program goals.
2. Discuss successes, challenges, and lessons learned and identify areas of need that will support the advancement of HIT at PHCs
3. Observe demos of HIT tools, resources, services, and solutions provided by the HCCN.
4. Visit PHCs to gain insight on the impact the HCCN has on member organizations.
5. Identify innovative and promising practices that resulted in improved quality of care and/or patient outcomes.
2018 HCCN OSVHighlights
Louisiana Primary Care Association
SUCCESSES• In house infrastructure
development
• Onboard of Azara DVRS
• Project management of HCCN
• Individualized work plans
• QI Dashboards and Reports
• Collaborations and Partnerships
• EHR User Groups
• Learning Sessions (both webinar and face to face)
5
CHALLENGES• Decrease in MU providers
• Changes in MU program
• HIE connectivity
• Limited IT abilities at local level
2018 HCCN OSVPromising Practices Identified
Louisiana Primary Care Association 6
• Individualized annual work plans with PHCs
• Project Management via Smart Sheet
• Quality Improvement Awards – formula and individual award sheets
• Organization of site visit materials
Year 3 HCCN – Individualized PHC Work Plan
Louisiana Primary Care Association 7
Year 3 HCCN – Individualize Work PlanHealth Center Focuses
Louisiana Primary Care Association
• Access to Prenatal Care 1• Low Birth Weight 1• Hypertension Control 11• Colorectal Cancer 13• Cervical Cancer 10• Childhood Immunizations 5• Uncontrolled Diabetes 13• Dental Sealants 4
*** See folder for list of PHCs who have chosen the above***
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Year 3 HCCN – Individualized PHC Work Plan
Louisiana Primary Care Association 9
Quarterly Reporting Schedule
NNOHA Educational Series National Network for Oral Health Access
Louisiana Primary Care Association
• Collaborations with PCAs for 1 year UDS Sealant Measure Learning Community Collaborative
• Sharing of promising practices in data collection and reporting• 4 – 1hr interactive group calls (1 possibly in person at Nat’l Conference)• Potential topics:
• Calculating the UDS Sealant Measure,
• Documenting Exclusions,
• Documenting Sealant Placement,
• Strategies to Improve the UDS Sealant Measure
• Outcomes from participation for health centers:• Improve the accuracy of data collection and reporting for the UDS Sealant Measure
• Gain strategies that will help improve and sustain UDS Sealants Measure outcomes.
• Improve patient outcomes by increasing the number of health center patients ages 6 to 9 who receive dental sealants.
• Assist in the development of state Primary Care Association T/TA capacity
10
NNOHA Educational Series National Network for Oral Health Access
Louisiana Primary Care Association
• Health Centers who have signed up:• Teche Action Center• Access Health• CASSE• SWLA• Morehouse • Daughters of Charity• Outpatient Medical• Iberia• Arbor Family Health
• If interested see Brandi for copy of commitment survey and NNOHA baseline questionnaire• Summary sheet included in packet for additional information
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Louisiana Primary Care Association 12
2018 HCCN Fall Learning Session
Pre-Conference Session
Tuesday, October 9, 2018
2018 LPCA Annual Conference
Registration NOW OPEN!!!
October 10 – 11, 2018(Pre (10/9) and Post Conference (10/12) Sessions also registering)
AZARA DRVS UpdateLPCA HCCN
June 7, 2018HCCN Spring Learning Session
Baton Rouge, LA
Overview of Implementation Process
Louisiana Primary Care Association 14
Overview of Current StateAzara DRVS in LA HCCN
Louisiana Primary Care Association 15
33 Participating Health Centers in HCCN
8 Go Live or Adoption Phase
3 Implementation Phase
10 Connectivity Phase
2 No Services Agreement Received
10 No Services Agreement or BAA Received
ContractingSign BAA and Services Agreement
Louisiana Primary Care Association 16
Final Deadline:
June 30, 2018
(After this HCCN cannot guarantee financial
support)
Connectivity PhaseEstablishing connectivity with EHR
Louisiana Primary Care Association 17
1. Care South 2. Southeast Community Health Systems3. Start Corporation 4. Winn Community Health Center, Inc. 5. Teche Action Clinic 6. Baton Rouge Primary Care Collaborative7. Delhi8. Priority9. Jefferson Community Health Care Centers, Inc.10. Iberia Comprehensive Community Health Center
Implementation PhaseEHR Walkthrough and Assessment; Data and Measure Validation
Louisiana Primary Care Association 18
1. RKM – Primary Care Providers for a Healthy Feliciana 2. Morehouse Community Medical Centers3. David Raines Community Health Center
Go – Live or Adoption PhaseAzara DRVS Available For Use;Post Production Validation and Training
Louisiana Primary Care Association 19
1. Daughters of Charity 2. Out-Patient Medical Center 3. SWLA Center for Health Services 4. NOELA Community Health Center5. Access Health Louisiana 6. Open Health 7. Excelth, Inc. 8. Primary Health Services Center
Features We’re Excited About!
Louisiana Primary Care Association 20
Diabetes Lab Registry
Features We’re Excited About!
Louisiana Primary Care Association 21
Diabetes Dashboard
Features We’re Excited About!
Louisiana Primary Care Association 22
Pre-Built Reports
Clinical Registries• Adult Female Primary Care• Adult Male Primary Care• Pediatric Primary Care• Immunizations• Asthma Management• Diabetes Labs• Obstetrics• HIV• Hypertension• Depression
Clinical Quality Reports • Meaningful Use• UDS• PCMH• HEDIS• GPRA• OSHPD• Clinical Dashboard & Use
Features We’re Excited About!
Louisiana Primary Care Association 23
Additional Capabilities Available
Operations• Patient Visit Planning / Huddle Report• Transitions of Care• Walk-In/Same-day Scheduled Patient Care• 3rd Next Available• Risk Registry• Uninsured Registry• Referral Management• No Shows• Provider Performance Benchmarking• Center Trend and Performance Comparison
Focus Area AHIT Implementation and MU
Louisiana Primary Care Association 24
Focus Area Objective Baseline Num/Dem Current Goal
A1
Certified EMR
Adoption and
Implementation
Increase the % of
PHC’s with an
ONC-certified
EMR
100% 31/31 100% 100%
A2
Advance
Meaningful
Use
Increase the % of
providers at
PHC’s receiving
MU incentive
payments from
CMS
52% 141/347 41% 75%
Focus Area BData and Quality Reporting
Louisiana Primary Care Association 25
Focus Area Objective Baseline Num/Dem Current Goal
B1 Data Quality
Increase % of PHCs that
extract EMR data to report
UDS CQMs for ALL patients
35% 19/31 61% 100%
B2
Health Center
and Site Level
Data Reporting
Increase % of PHCs
generating QI reports at site
and clinical team level
74% 25/31 81% 100%
B3Health Data
Integration
Increase % of PHCs that
integrate data from different
service types
58% 27/31 87% 85%
Focus Area CHIE and Population Health Management
Louisiana Primary Care Association 26
Focus Area Objective Baseline Num/Dem Current Goal
C1
Health
Information
Exchange
Increase % of
PHCs with
communicating to
HIEs
45% 22/31 71% 90%
C2
Population
Health
Management
Increase % of
PHCs using HIEs
for pop health
mgmt
26% 14/31 45% 90%
Focus Area DQuality Improvement and Patient Centered Medical Home
Louisiana Primary Care Association 27
Focus Area Objective Baseline Num/Dem Current Goal
D1Clinical Quality
Improvement
Increase % of PHCs that meet
or exceed HP2020 goals on
5/8 UDS CQMs
0% 1/31 3% 50%
D2
Operational
Quality
Improvement
Increase % of PHCs that
improved value, efficiency,
and/or effectiveness of service
35% 226/31 84% 90%
D3Advance PCMH
Status
Increase % of PHC sites that
have current PCMH
recognition
56% 93/104 89% 80%
New and High Priority Focus Activities HCCN Grant Year 3
Louisiana Primary Care Association 28
1) PRAPARE Pilot (social determinants of health) - Start & SWLA Center for Health Services
2) Technology & Cybersecurity Webinar Series
3) Re-engagement of state HIEs
4) Become MU Collaborator under State Medicaid
5) Secure clinical champion for HCCN
Peer to Peer Sharing Quality Improvement
Louisiana Primary Care Association 29
• Teche Action Clinic Jennifer Farbe, CIO and QI Director– Diabetes Quality Improvement
– 9:15am – 9:45am (including Q/A)
• NOELA Mily Nguyen, QI Director– Immunization Quality Improvement Utilizing Azara DRVS
– 9:45am – 10:15am (including Q/A)
Diabetes Quality Improvement Activities
Jennifer C Fabre, DNP, APRN, ANP/FNP-C, CDE
CHIO, Director of Quality & Risk Management
Teche Action Clinic
June 7, 2018
2018 HCCN
Spring Learning Session
1
Teche Action Board dba Teche Action Clinic (TAC)Franklin, Louisiana
• 9 Primary Care Clinics
• 4 SBHC
• MUA & HPSA
• Joint Commission & PCMH
• IM, FP, OB/GYN, PEDS, Podiatry, BH, Dental, Pharmacy, Lab, WIC, Certified Application Counselors
• Board Certified Physicians, Nurse Practitioners, & Physician Assistants, LCSW’s & LPC’s
• Clinical Support Staff – Nurses, MA’s, Nutritionists, Pharmacists, Lab Techs
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Diabetes ManagementTAC
Diabetic Adults as a % of estimated adult medical patients ages 18 –75 years
**UDS DM measure changedin 2015 to address uncontrolled diabetes for patients with HgbA1c > 9.0%
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TECHE ACTION CLINIC 2014 2015 2016
% of Patients with DM 18.10% 18.70% 23.20%
DM: Hgb A1c Poor Control (DM Pats with HbA1c > 9%) or No Test 14.29% 5.71% 8.57%
Weight Assessment and Counseling for Nutrition and Physical Activity 95.71% 97.14% 98.57%
Body Mass Index (BMI) Screening and Follow-Up 91.43% 97.14% 95.71%
Controlling High Blood Pressure 91.43% 90.00% 87.14%
Tobacco Use Screening and Intervention 92.86% 97.14% 98.57%
Screening for Clinical Depression and Follow-Up Plan 71.43% 80.00% 92.86%
Lipid Therapy 94.29% 92.59% 100%
Use of Aspirin or Another Antithrombotic 91.43% 71.43% 92.86%
DM Treatment InterventionsTeche Action Clinic
• Follow Evidence-based CPGs
• Staff have access to Up-To-Date imbedded & linked in our EHR reference tab
• Standing Orders: HgbA1c all DM Q 3mos if >7.0%; Q 6mos if <7.0%
• Point-of-Care Testing: DCA analyzers in all exam rooms – nursing completes test before PCP enters room
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DM Treatment InterventionsTeche Action Clinic
• Provide quality standardized care including patient education on appropriate lifestyle changes & interventions to improve health and well-being
• Multi-disciplinary Internal & external referrals
• RDs & CDEs
• Dental
• BH
• Podiatry
• All overweight or obese patients receive bloodwork on an annual basis with includes CMP; Based on Risk factors, ROS, S/S, & Family Hx PCP may order HgbA1c same day
5
DM Treatment InterventionsTeche Action Clinic
• Early intervention with our OB, WIC, & Pediatrics Departments; SBHC’s completing Comprehensive Wellness exams every two years
• Patient access to Onsite lab services & pharmacyservices
• All sites: Certified Application Counselors
• Participate in Pharmaceutical Patient Assistant Programs
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DM Treatment InterventionsTeche Action Clinic
• Partner with pharmaceutical reps who are also CDE’s & offer group education classes
• Partnership with Pennington BioMedical Research Center – PROPEL – one-on-one coaching
• UDS Lunch-N-Learn sessions
7
Teche Action ClinicDiabetes Management
QUESTIONS?
Jennifer C Fabre, DNP, APRN, ANP/FNP-C, CDE
Chief Health Information Officer, Director of Quality & Risk Management
Teche Action Clinic
Email: [email protected]
Phone: 337-355-2309
Web: www.tabhealth.org
Twitter: @techeactionclinic
Facebook: facebook.com/techeactionclinic
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Improving Immunization Rates Utilizing Azara DRVS7 JUNE 2018
Road Map
I. HPV Immunization Quality Improvement Project (2017)
II. Demo: DRVS Immunization Modules/Tools
III. 5 Steps to a Successful QI Project
HPV Immunization Quality Improvement Project (2017)
Small Media
Provider Reminders
Patient Reminder Systems
Staff Reminders
Standing Orders
Provider Assessment
and Feedback
Staff Assessment
and Feedback
HPV VACs Intervention Tree (2017)
Results: Baseline vs. Follow-Up Rates
0%10%20%30%40%50%60%70%80%90% 73%
25%
86%72%
13%
82%
Rat
e (%
)
Females
Baseline (March 2017) Follow-Up (December 2017)
0%10%20%30%40%50%60%70%80%90%
54%40%
90%80%
18%
74%
Rat
e (%
)
Males
Baseline (March 2017) Follow-Up (December 2017)
How can you use DRVS analytics to improve 2 year-old immunization rates at your health center?
Small Media
Provider Reminders
Patient Reminder Systems
Staff Reminders
Standing Orders
Provider Assessment
and Feedback
Staff Assessment
and Feedback
HPV VACs Intervention Tree (2017)
Data Analytics Quality Outcomes
DRVS Module/Tool Action/Intervention
Visit Planning Report Team huddles, Provider/Staff Reminders, Standing Orders
Dashboards Staff/Provider Feedback and Assessment
Measure Analyzer Staff/Provider Feedback and Assessment
Registries Patient Reminders Systems
Pre-Visit Planning (Daily)
Pre-Visit Planning (Daily) Cont’d
Pre-Visit Planning (Daily) Cont’d
2 Year Old Immunization Dashboard
Measure Analyzer
Measure Analyzer (Cont’d)
Measure Analyzer (Cont’d)
Measure Analyzer (Cont’d)
Immunization Registry
Immunization Registry (Cont’d)
Patient Reminder Postcards
DRVS Immunization Mapping
DRVS Immunization Mapping (Cont’d)
DRVS Immunization Mapping (Cont’d)
DRVS Immunization Mapping (Cont’d)
DRVS Immunization Mapping (Cont’d)
A Roadmap to a Successful QI Project
STEP 1
Assemble a Team
• Recruit staff and providers for your QI team
• Identify a provider champion
STEP 2
Make a Plan• Collect
baseline data• Map your
current workflow
• Identify opportunities for improvement
STEP 3
Engage and Prepare
Staff• Train staff
to ensure a consistent message
STEP 4
Perform the
Intervention(s)
• Measure and improve performance.
“Quality is not an act, it is an habit.”
-Aristotle
STEP 5
Data Hygiene
• Get feedback from staff and providers
• Perform data validation on a monthly basis
Questions?
Louisiana Primary Care Association 64
Using Data Analytics to Improve
Population Health:
The Missouri Experience
Angela Herman-Nestor & Noelle Parker
June 7, 2018
MAY 11, 2018 WEBINAR RECAP
Purpose: Trends Affecting Health Centers
• Payer demand for quality and efficiency
• New and developing payment models – ACOs, IPAs,
others
• Transparency/Public Reporting
• Meaningful Use incentives and expectations
• Patient Centered Health Home
• Success will require care delivery transformation:
• New technical tools and methods for measuring
success.
• Rethinking roles and responsibilities.
Appetite for Data: CHCs who are the greatest consumers
of their data have the best chance of success
on all levels of performance. 68
External Performance
• Regulatory (UDS, MU, P4P)
• PCMH
• Grants, other
QI & Population Management
• Registry & Exception Reporting
• QI PDSAs & Trending
Point of Care•Pre-Visit Planning
•Huddle
•Care Management
•Care Transitions
•Closing Care Gaps
Progression of Vision for Data Warehouse and DRVS
Advocacy
Quality Improvement
Care Coordination
Daily Ops / Visit Planning
Support for $$ Incentives and
IPA
MPCA’s 2010 ARRA Funding Path to DRVS
• Elected to outsource data warehouse,
reporting application – purchased Azara
DRVS
• Initial mapping and data validation
performed
• Originally connected to 13 different EHR
systems, now only 10 different EHRs
• MPCA and FQHC’s able to utilize DRVS
for federal and state reporting initiatives:
• MO HealthNet (Medicaid ACA Section
2703 State Plan Amendment)
• Missouri Department of Health and
Senior Services Chronic Disease
Collaborative (measures reporting and
T/TA)
• Meaningful Use
• UDS
70
MOQuIN
HCCNUDS
(HRSA)
MU(CMS)
PCMHCDC
(DHSS)PCHH(MHN)
2012 – Second HCCN Grant & Health Home
• ACA HCCN 2nd Award
• Continued mapping and data validation
• 2 Health Centers not connected to DRVS
• Quality coaches using DRVS data to monitor and plan interventions
• Measure expansion, data validation, and remapping
• Meaningful Use
• Continued to support CHC’s with attesting for Meaningful Use
• Quality Improvement
• Leverage DRVS to improve quality measures and patient outcomes
• MO HealthNet (State Medicaid) Primary Care Health Home Launched
• Data system broadens to include non-FQHCs
• Creation of new measures (Care Coordination and SBIRT)
• Began exploration of future payment models
• Transitioning advocacy away from “direct” government funding to
value-based payments
2016 Third HCCN Grant
• Health IT Implementation and Meaningful Use
• Certified EHR Adoption and Implementation
• Advance Meaningful Use
• Data Quality and Reporting
• Data Quality
• Health Center and Site Level Data Reports
• Health Data Integration (oral health, behavioral health)
• Health Information Exchange
• Population Health Management
• Quality Improvement
• Clinical
• Operational
• Advance PCMH Status
MPCA’s Data Warehouse- DRVS
73
Vision developed in partnership with Azara: www.azarahealthcare.com | [email protected] | 781.365.2208
Utilizing DRVS To Support Population Health Management
• Point of Care: Care Management, Care Transitions, Closing
Care Gaps
• Internal Quality Monitoring and Improvement
• UDS reporting
• Meaningful Use
• NCQA Patient Centered Medical Home recognition
• Advocacy
• Local, Regional, State, and National Initiatives with Quality
Reporting Components
• Grant applications
Equipping Health Centers for Future Success
Successful Competitive
Health Centers
Robust Data
Systems
Superior Clinical Quality
Excellent Leadership
and Governance
Strong Finance
and Billing
Organizing for
Leverage
75
Outstanding
Customer
Service
Population Health for Leaders, Staff, and Stakeholders
• Foster a high-value culture with clear population health
objectives
• Review quality and utilization performance at all
meetings
• Simplify: Align various programs to create common
goals to drive overall quality and efficiency strategy
• Re-engineer workflow to support population health
management and priority areas
76
Population Health for Leaders, Staff, and Stakeholders
• Provider training on population health management
concepts
• Rethink provider and staff reimbursement models
• Address transformation fatigue
77
POPULATION HEALTH DEFINED
The Challenge: How Can PCAs and CHCs be
Successful in this Shifting Environment?
• Quadruple Aim
79
• Reimbursement Reform Volume to Value
Better Outcomes
Improved Patient
Experience and
Satisfaction
Lower Cost
Improved Provider and
Care Team Satisfaction
Value-Based Care Defined
Measure Value of Care
Report Value of Care
Reimburse providers on value of care
Improve value of care by
reducing costs and improving
quality
Provide healthcare
services
80
Value = Quality Cost
Who is the “Population” in Population Health?
• Defined population
• Geographic areas
• Shared characteristics such as age, race ethnicity,
income level, etc.
• Health conditions
• Insurance type or status
81
Healthy People 2020 SDOH Categories
HP2020 SDOH Categories
Each of these five determinant areas reflects a number of
key issues that make up the underlying factors in the arena
of SDOH.
Populations Served by Missouri Health Centers: Payer Type
84
Private Insurance
MedicaidUninsured
Managed Medicaid
Assigned by MCO, but Unseen
Primary Care Health Home
Established
Adult, Blind, Disabled
Medicare
ACO
Population: By Condition or Factor
Diabetes
Substance Use
Disorder
Multiple Chronic
ConditionsHigh Utilizers
HIV
Hypertension
Pregnancy
Homelessness
High Risk
Episodic vs. Continuous Care
Episodic, Reactive Care Continuous, Planned Care
Patient actively seeks care Care team identifies patient with various needs when care is due via registries and other decision supports
Provider reacts to patient’s complaints Visits are planned and care caps are identified prior patient visit with care team
Interactions are a series of isolated encounters
Monitoring health status overtime with a team-based approach , with self-management support
Sickness is a discreet event Health and sickness lie on a continuum
Patient uses emergency room for avoidable condition
Patient schedules a same day appointment;Care team identifies high utilizers and proactively engages with them
86
Components of Population Health Management
87
Population Assessment
Planned Care
Access to Care
Care Coordination
Risk-Stratified Care Management
Performance Measurement + Quality Improvement
DATA ANALYTICS FOR
POPULATION HEALTH
Population Health Management Data Analytics
People
Processes
Technology
Data at Your Fingertips is Essential
• External
– Who needs/wants the data entrusted to you?
• Funders
• Payers
• Patients
• Government
• Academic institutions/researchers
• Internal
– Business Intelligence at all levels
• Corporate/executive
• Mid-manager
• Providers and front-line staff
90
Data Source in DRVS to Support Population Health
• External Data Sources
– Data from CHC Practice Management & Electronic
Health Record Systems
– Data from external primary care practices
– Attribution lists from payers
– HIE information
– Claims Data
DRVS Population Health Functionality
• Registries: chronic, preventive, social determinants of health
• Pre-Visit Planning Report
• Transitions of Care: Inpatient and ED
• Risk Stratification
• Care Management Passport
• Quality Measures
• Population Specific Reports
• PCMH Reports and Submission
• Payer Integration
92
Progression of Vision for Data Warehouse and DRVS
Advocacy
Advocacy: Scorecard (Demo)
www.azarahealthcare.com | [email protected] | 781.365.2208
Dashboards (DEMO)
www.azarahealthcare.com | [email protected] | 781.365.2208
Progression of Vision for Data Warehouse and DRVS
Advocacy
Quality Improvement
Quality Improvement
• Patient Visit Planner
• Measure Analyzer
• Scorecards
• Registries
• Dashboards
Quality Improvement: Patient Visit Planning Report (Demo)
98
SOGI
Additional cost forReferral Module
www.azarahealthcare.com | [email protected] | 781.365.2208
Quality Improvement: Clinical Quality Measure (DEMO)
99
www.azarahealthcare.com | [email protected] | 781.365.2208
QI: No Show Operational Measures (DEMO)
10
0
www.azarahealthcare.com | [email protected] | 781.365.2208
Data- Driven Process Improvement: Center Comparative Analytics
Break into bite size chunks; focus on one measure at a time
• Order of measures: Pap first in MO because it needed most
work
• Determine how many PDSA cycles per measure
Double-click anywhere in
the bar to drill down.
Cervical Cancer Screening
Provider Performance Variation- Chart view (DEMO)
• Provider performance variation can be a factor of practice
preference, staff differences, equipment, or other.
www.azarahealthcare.com | [email protected] | 781.365.2208
Focus on the high performers with
significant denominators to
harvest best practices.
Focus on the tail to
identify rogue
workflows and training
issues.
Patient Detail (DEMO)
104
• Sort by Numerator to identify out of compliance patients
• Export to PDF or Excel. Create an outreach list for staff to
contact as appropriate.
www.azarahealthcare.com | [email protected] | 781.365.2208
Louisiana Primary Care Association 105
Grab lunch and come back to the room!!
Progression of Vision for Data Warehouse and DRVS
Advocacy
Quality Improvement
Care Coordination
Care Coordination: Registries
• SDOH
• Primary Care
• Childhood Immunizations
• Depression
• Risk Registry
• Chronic Pain
• Transitions of Care
– ED & IP Discharge
SDOH Registry (Demo)
Azara Proprietary & Confidential109
4
3
4
6
6
6
5
4
SDOH Risk Tally
• SDOH Risk Tally• SDOH Risk Triggers (same as on PVP & Passport)• Date of the most recent non-demographic SDOH assessment• Raw SDOH responses
Progression of Vision for Data Warehouse and DRVS
Advocacy
Quality Improvement
Care Coordination
Daily Ops / Visit Planning
Daily Ops / Visit Planning
• Care Management Passport
– Assessment
– SDOH
• Transitions of Care
– Care Coordination
• Registries
– Risk Stratification
• Patient Visit Planner
Daily Operations: Care Management Passport (DEMO)
11
2
Diagnostic Values
www.azarahealthcare.com | [email protected] | 781.365.2208
Daily Operations: Transitions of Care (DEMO)
• Care Coordination (CC)
– Identify Hospital and ED Visits
Transition of Care Report Example:
www.azarahealthcare.com | [email protected] | 781.365.2208
Progression of Vision for Data Warehouse and DRVS
Advocacy
Quality Improvement
Care Coordination
Daily Ops / Visit Planning
Support for $$ Incentives and
IPA
Leveraging DRVS Data
Revenue & Partnership Opportunities as a
result of data
• HCCN (Health Center Controlled
Network)
• Medicaid ACA Section 2703 State Plan
Amendment: Primary Care Health Home
• Medicaid Community Health Worker
Program
• State Health Department Chronic
Disease Collaborative
• Meaningful Use
• Medicare ACO
• Million Hearts
• Chronic Pain
• HRSA Quality Improvement Awards
• NCQA PCMH Recognition
11
6
What are the Latest DRVS Enhancements in MO?
• Using Azara Risk Algorithm across all MPCA CHCs
• MPCA’s Chronic Pain Initiative: Dashboard, Scorecard, &
Registry
• Capture of Social Determinants of Health utilizing
PRAPARE to assess and address needs
• Community Health Workers using Data to Improve
Population Health
• Transitions of Care: Integration of HIE data that includes
Admission, Discharge, Transfer (ADT)
• Payer Integration Module: Use of payer enrollment data
to do member matching
• Referral Module
• Controlled Substance Module: Opioid & Substance Use
Reporting
11
7
PCMH Prevalidation
• Azara approved for PCMH Prevalidation
• Thursday, May 31, 2018 @ 1pm CT (recorded)
• Available in the Resource Section of DRVS HELP
• Registration link: https://register.gotowebinar.com/register/1530345754295443202
DATA HYGIENE
11
9
Maintain the Integrity of the Bridge Structure
• Make data hygiene
part of your routine.
• Assign
responsibility and
accountability
for these activities.
• Share results and
celebrate success.
www.azarahealthcare.com | [email protected] |
781.365.2208
Keeping Your Data Healthy
DailyVisit Planning
Tools
WeeklyRegistry &
Care Mgmt Reports
Monthly Quality &
Performance Mapping
Admin
AnnualUDS Reports
& Tables
Sample Data Validation Calendar
Measure Name Targets Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
DM A1c Control (MU CQM)
DM A1c Uncontrolled (HCCN / UDS)
DM A1c Testing (HEDIS)
Cervical Cancer Screening (HCCN / UDS)
Childhood Immunizations (HCCN / UDS)
HTN BP Control (HCCN / UDS)
Child Weight Screening and Counseling
(PCHH)
Colorectal Cancer Screening (HCCN / UDS)
Depression Screening and Follow-up (UDS
/PCHH)
Adult Weight Screening and Follow-up (UDS)
Asthma Pharmacological Therapy (UDS)
UDS Measure Review (UDS)
IVD Use of Aspirin (UDS)
CAD Lipid Therapy (UDS)
Data Hygiene Activities Daily Weekly Monthly Q1 Q2 Q3 Q4
Registries
Visit Planning Report
Review Key Scorecards / Dashboards i.e.,
UDS
Review Mapping Administration
www.azarahealthcare.com | [email protected] | 781.365.2208
Measure Investigation Tool (MIT) – Access (DEMO)
“Right Click” any patient in the Detail List
– Select “Investigate Measure”
122
www.azarahealthcare.com | [email protected] | 781.365.2208
Measure Investigation Tool (MIT) – Example(DEMO)
The MIT displays what parts of the patient’s information meet a
measure’s criteria
123Azara Proprietary & Confidential
www.azarahealthcare.com | [email protected] | 781.365.2208
Measure Investigation Tool (MIT) – Example(DEMO)
Patient Not In Measure Criteria
124
www.azarahealthcare.com | [email protected] | 781.365.2208
Bridging the Quality Chasm
12
5
IT and EHR Experts Clinical, Quality,
Operations, and Front-line staff
Executive
Leadership
Accurate & reliable Data
EHR Documentation of
patients/visits
Performance Data Reflects Quality of Care Delivered, Financial Reward Achieved
Improved Quality Care and Decrease HealthCare CostUse of Data at Point of
Care
P4PValue Based Payment
Manage care and document
to reflect true quality.
Document to reflect quality
of care
Follow key standards and
offer feedback
Data at Point of Care for
coordination and QI
BRIDGE ACTIVITY
Bridge Activity Instructions
• Use the blank bridge form to fill in the
answers to the questions asked under the
three pillars that build your foundation
IT, EHR, & Quality Operations & Clinical Leadership
How will your team validate
the accuracy of your data?
Getting Performance Data to Reflects Quality of Care Delivered to Maximize Reward
How do you envision your participation in
the HCCN helping Louisiana CHC’s
achieve the Quadruple Aim?
What PHM tools are you currently using or planning to use
for care coordination team based care?
What does success look like for your health center team?
Are your templates in structured format
and standardized across organization?
How does the HCCN work fit in overall QI
for CHC?
What workflows do we need to
standardize?
What systems do we need in place?
What standing orders are in place or need to be in place?
RESULTS
SYSTEMS
Operations
128
What clinical decision support do you have in
place and are they standardized?
IT, EHR, & Quality Operations & Clinical Leadership
Getting Performance Data to Reflects Quality of Care Delivered to Maximize Reward
RESULTS
SYSTEMS
Operations
129
Report Out of Activity
• Key items identified regarding:
• Systems
• Operations
• Results
13
0
In Summary
• Health and outcomes of entire population served
• Value-based care is the expectation
• Population health management is a framework for
success in achieving value
• Leadership is key
• People and processes are imperative to success
• Louisiana Primary Care Association and Azara will
be important partners to support you in your journey
13
1
MPCA Center for Quality Team
3325 Emerald Lane
Jefferson City, MO 65109
573-636-4222
• Angela Herman-Nestor MPA, CPHQ, PCMH-CCE:
• Noelle Parker, MBA, CMPE, PCMH-CCE:
Louisiana Primary Care Association 134
LPCA HCCN 2018 Spring Learning Session
June 7, 2018
Measuring to Improve vs. Improving to the Measure
Constructing Measures & Using Data to Improve
• What do you want to measure to improve?
• Don’t let the data be the barrier
• A report does not equal improvement
Uses of Quality Measures
• Quality Improvement
• Accountability
• Consumer Decision Making
• Performance-based Payment
• Certification of Professionals or Organizations
• Research
Desirable Attributes of a Quality Measure
importance
scientific soundness
feasibility
Importance of a measure
• Relevance to stakeholders - the topic area of the measure is of significant interest, and financially and strategically important to stakeholders, is important as defined by high prevalence or incidence, and/or a significant effect on the burden of illness.
(i.e., effect on the mortality and morbidity of a population).
• Applicability - to measuring the equitable distribution of health care (for health care delivery measures) or of health (for population health measures) the measure can be stratified or analyzed by subgroup to examine whether disparities in care or of health exist among a diverse population of patients.
Importance of a measure
• Potential for improvement - there is evidence indicating a need for the measure because there is overall poor quality or variations in quality among organizations (for health care delivery measures) or overall poor quality of health or variations in quality of health among populations (for population health measures).
• Susceptibility to being influenced by the health care system -for health care delivery measures, the results of the measure relate to actions or interventions that are under the control of those providers whose performance is being measured, so that it is possible for them to improve that performance. For public health measures, the results should be susceptible to influence by the public health system.
Scientific Soundness: Clinical Logic
• Explicitness of evidence - the evidence supporting the measure is explicitly stated.
• Strength of evidence - the topic area of the measure is strongly supported by the evidence, i.e., indicated to be of great importance for improving quality of care (for health care delivery measures) or improving health (for population health measures).
Scientific Soundness: Measure Properties
• Reliability - the results of the measure are reproducible for a fixed set of conditions irrespective of who makes the measurement or when it is made; reliability testing is documented.
• Validity - the measure truly measures what it purports to measure; validity testing is documented.
• Allowance for patient/consumer factors as required - the measure allows for stratification or case-mix adjustment if appropriate.
• Comprehensible - the results of the measure are understandable for the user who will be acting on the data.
Feasibility
• Explicit specification of numerator and denominator – a measure should usually have explicit and detailed specifications for the numerator and denominator; statements of the requirements for data collection are understandable and implementable. Some measures that do not have explicit and detailed specifications for the numerator and denominator (e.g., measures that have counts or means) can be feasible for quality improvement purposes when used with a specified baseline, benchmark, and/or target.
• Data availability - the data source needed to implement the measure is available and accessible within the timeframe for measurement. The costs of abstracting and collecting data are justified by the potential for improvement in care or health.
DATA
Patient
Payer
HRSA
Improve
&
Research
Learners
Provider
Data Pushback
• Analogous to Kübler-Ross five stages of grief:
• Denial
• Anger
• Bargaining
• Depression
• Acceptance
• Overcome pushback by transparency, engagement, responsiveness, access to data
• Engage in transparent data to move through the stages
“the report is wrong”
“doesn't look right”
“not my fault”
“it’s the systems fault”
“I have sicker patients”
“measures aren't right”
“not adjusted right”
“not my patients”
“using administrative/coding data”
“my patients don’t do
what they are supposed to”
Analytic strategy - business analytics does not equal clinical analytics
Know your patients: panels, registries, rosters, attribution
Work to improve care delivery - not to check boxes
Change from “add work” to “enable improved delivery”
Fight “Data Pushback”
Measurement“a numbers game”
How does a system/provider knowwhich patients they are accountable for?
• Identify best practice clinics and providers… and emulate
• Standardize = level setting for basic processes
- not cookbook, every patient needs the minimum
• Clinical staff want transparent & actionable data
• “Taking the same test” - with national measures,
need local/site operation measures
Measurement“a numbers game”
Components of LSU Healthcare Effectiveness
• Engaged Patients• Informatics Support
• Actionable Patient Goals• Evidence-Based Guidelines
• EBG Knowledgeable Providers• Information at the point of care• Medication Assistance Program
• Transparent Outcome Measurement• Infrastructures for Improvement & Learning• Seamless transitions throughout the systems
A few simple “LEAN” tools
• Concept of waste – necessary and unnecessary • Transport
• Inventory
• Motion
• Waiting
• Over-Processing
• Overproduction
• Defects
• 5 Why’s
• Fishbone Diagram
• PDSA / PDCA
Fishbone Diagram(Cause and Effect, Ishikawa)
Performance Improvement CyclesPDSA / PDCA
Plan
Do
Check
or
Study
Act
“K
no
w w
ha
t.”
“Wisdom in determining ends and the means of attaining them.”
Disease Management
Medical Home
Population Health
Ambulatory Redesign
Communications
Operational Improvement
Disease Management
Medical Home
Population Health
Ambulatory Redesign
Communications
Operational Improvement
Disease Management
Medical Home
Population Health
Ambulatory Redesign
Communications
Operational Improvement
Disease Management
Medical Home
Population Health
Ambulatory Redesign
Communications
Operational Improvement
Disease Management
Medical Home
Population Health
Ambulatory Redesign
Communications
Operational Improvement
Disease Management
Medical Home
Population Health
Ambulatory Redesign
Communications
Operational Improvement
CCC
IGG CCC
IGG
CCC
IGG
CCC
IGG
CCC
IGG
CCC
IGGCCC
IGG
CCC
IGG
CCC
IGG
CCC
IGG
CCC
IGG
CCC
IGG
"W
e c
an
kn
ow
mo
re t
ha
n w
e
ca
n t
ell
."
AprilOperational
Review
JulyOperational
Review
OctoberOperational
Review
February Leadership Meeting• Review past years results• Organizational goal setting and objectives for year• Align positive-change initiatives with strategy and organizational
goals• External concepts and design innovations
• Empathetic Engagement and Radical Collaboration
March Healthcare Effectiveness• Translate goals – problem reframing, design
opportunities• Review and revise previous measures• Review clinical and process issues• Develop new metrics
• Empathetic Engagement and Radical Collaboration
August Leadership Meeting• Validate alignment of initiatives with strategy and
organizational goals• Codification of new work boundaries, structural and policy
changes• Socialization of design improvements
• Rapid Prototyping and Radical Collaboration
September Healthcare Effectiveness• Demonstrated meeting Quadruple Aim• Codification of new work boundaries, structural and policy
changes• Socialization of design improvements
• Rapid Prototyping and Radical Collaboration
May Leadership Meeting• Link positive-change initiatives with strategy and
organizational goals• Action steps for positive change with goals, strategies,
tactics, timelines, metrics, and accountability
• Radical Collaboration and Rapid Prototyping
November Leadership Meeting• Focus on best practices• Focus on measurement• Focus on identifying barriers and solutions
• Rapid Prototyping and Empathetic Engagement
June Healthcare Effectiveness• Internal execution with trended team-metric reporting• Teams activity reporting and target accountability• Variation and cost reduction• LEAN rapid improvement events
• Radical Collaboration and Rapid Prototyping
December Healthcare Effectiveness• Quadruple Aim gap analysis, patient and community links• Storytelling• Ramp and Scale Prototypes into Production Platform
• Rapid Prototyping and Empathetic Engagement
January Winter ForumJanuary Operational Review
• Recognition of achievement• Positive reflections• Voice of workforce and patients for design opportunities
• Broad Engagement and Stakeholder Collaboration
HCE
Q1 data
Q2 data
Q3 data
Q4 data
Measure Construction Approachattribution – analytics - panels
1/12 visit group
3/12 visit group
6/12 visit group
>12+ months group
5511
9275
4855
8909
61248393
7018
50085
.2
.25
.3
.35
.4
.45
.5
BM
CEKL
LAK
LJC
MCL
UM
C
WOM
_TO
T
SITES over QUARTERS
Graph uses data from quarters 200901 through 201301AWARD criterion = 0.27, 25th and 75th percentiles: see lines on graph
mhstandards: Last BP > 140/90, Totaldenom: MedHm sustained 6/12
1508
2354
1353
3054
1453
2024
1788
13534
.45
.5
.55
.6
.65
.7
.75
BM
CEKL
LAK
LJC
MCL
UM
C
WOM
_TO
T
SITES over QUARTERS
Graph uses data from quarters 200901 through 201302AWARD criterion = 0.60, 25th and 75th percentiles: see lines on graph
diabetes: last BP <= 140/90denom: MedHm sustained 6/12
1557
2698
16762797
2317
2939
1759
15743
.15
.2
.25
BM
CEK
LLA
KLJ
CM
CL
UM
C
WOM
_TO
T
SITES over QUARTERS
Graph uses data from quarters 200801 through 201103
diabetes: A1c<7, LDL<100, BP<140/90denom: PC Sustained, 6/12
64
52795 136
613 274 201 1910
0
.1
.2
.3
.4
.5
.6
.7
.8
.9
1
BM
CEKL
LAK
LJCM
CL
UM
C
WOM
_TOT
SITES over QUARTERS
Graph uses data from quarters 200701 through 201104AWARD criterion = 0.80, GOAL = 0.80, see lines on graph
hiv: STDs, Gonorrhea test in past 15 mos [R]denom: HIV clinic 3/12 sustained
.15
.2
.25
.3
.35
.4
.45
.5
.55
20012002
20032004
20052006
20072008
20092010
20112012
year
UTIL: ED visits/person (quarter)lowEF pop 3+ mos
Heart Failure Disease Management Program
.05
.1
.15
.2
.25
20012002
20032004
20052006
20072008
20092010
20112012
year
UTIL: IP stays per person (quarter)lowEF pop 3+ mos
Heart Failure Disease Management Program
From feedback to impact
Report Card
Trust actionability of feedback
Aggregate data from
silos
Recognize gaps
Opportunity information at the point
of care
Understand data and measure
constraints
Which patients fall into which
measures and what do they need based
on criteria
Who are “my/our” patients and how are “they/we” doing?
HARP – Diabetes Indicators
Want more info? Click “Run HARP Now”
= Process Measure
= Outcome Measure
Indicator Indicator
BP most recent <= 130/80 Pneumococcal immunization ever
BP most recent <= 140/90 Prescribed a high intensity statin
Eye exam in past 2 years Prescribed a moderate or high intensity statin
Foot exam in past 15 months HbA1C in past 6 months
Hep B immunization ever HbA1C <= 7 in past 12 months
LDL in past 15 months HbA1C > 9 in past 12 months
LDL <= 100 in past 15 months
HARP – HbA1c in past 6 mos
HARP – HbA1c >= 9
Tips for Effective Measuring• Plot data over time. Tackling a few key measures
over time is a useful tool.
• Seek usefulness, not perfection. Measurement is not the goal – improvement is.
• Use sampling if needed. It’s a simple and easy way to understand how a system is performing. Don’t wait months for data. Create a simple way to capture data in real time, if nothing else is available.
• Use qualitative and quantitative data. Asking staff, patients and family for input is highly informative.
LAK “Total Care” Project
• Problem: Data reporting indicated a substantial portion of outpatient patients were not receiving recommended screenings, procedures, lab testing and/or immunizations.
LAK “Total Care” Project
An improvement intervention was proposed in a single clinic, as a pilot, to identify care gaps prior to the encounter and address these gaps during the encounter.
Measures of Success• Monitor platform (HARP) indicators to
reflect change in those items being addressed.
• Additional “ad hoc” reports/data for items that have no indicator.
• Reduction of care gaps for completed encounters
Pilot Summary - Plan• Identify a provider for the pilot• Run the pilot long enough to show
improvement through current reporting system(s).
• Issues with EMR health notifications prevented using total electronic solution
• Rules, completeness, build resources
• Review charts of patients prior to encounter and report findings to the clinic staff to be acted upon
Pilot Summary - Do• Identified a provider
• Created a “review” team (3 RNs) to manually review charts prior to encounter day and fill out a “checklist” for the provider to use to place orders
• Ran the pilot for 10 weeks, to include two complete months of data for reporting
Data Capture Tool
Data Capture Tool (cont’d)
Pilot Summary - Study• 776 encounters were scheduled during the
pilot period.
• 483 encounters were completed
• The average care gap per patient was 5
• Only five patients had NO care gaps identified
• 26% of patients had multiple encounters over the pilot period.
• Of these, nearly half (45%) had a decrease in the number of care gaps reported.
Performance Comparison – Pre and PostProv BP <=
140/90Colon Cancer Scrng
Flu 65+
Mammo2yr, 40-75
PAP 3yr21-29
PneumoEver 65+
PSA 2yr50-75
PilotProvider
76% 66% 30% 85% 50% 58% 97%
Pilot Clinic (All Prov)
78% 62% 34% 80% 37% 63% 90%
Facility 77% 56% 37% 77% 59% 68% 84%
Prov BP <=140/90
Colon Cancer Scrng
Flu 65+
Mammo2yr, 40-75
PAP 3yr21-29
PneumoEver 65+
PSA 2yr50-75
PilotProvider
79% 66% 37% 86% 56% 59% 97%
Pilot Clinic (All Prov)
79% 62% 38% 81% 36% 64% 90%
Facility 78% 56% 40% 77% 58% 68% 86%
Pilot Performance – Ad Hocs
* From the LAK CDW Query
Pilot Period
Procedure Orders Over TimePilot Clinic ONLY
•Data Limitations• Patient Reported• Facility Data• External (Payer) Data
• Internal Resources• Staff Time• Cancellations
Pilot Summary – Lessons (Study)
Moving Forward (Act)• Phase I – Replace manual review with
daily reports to clinic staff, expand effort to all PC clinics. (Started Apr2018)
• Phase II – Introduce additional data sources from payer (Medicaid initially) sources. (Information Exploration)
• Phase III – Create an automated solution that compiles data from multiple sources for real-time reporting to providers. (Early Prototype Dev)
Contact Information
John Couk, MD
Chief Medical Officer
Nathan Daigrepont
Clinical Projects Director
THANK YOU from the LPCA HCCN Staff
Visit our website at www.LPCA.net
Gerrelda Davis, MBA
Executive Director
503 Colonial Drive
Baton Rouge, LA 70821
(225) 927-7688 ext 207
Christopher Obafunwa, MS, MBA
HIT Director
503 Colonial Drive
Baton Rouge, LA 70821
(225) 927-7688 ext 211
Amy Pruim, MPH, CAPM
Data Analyst
503 Colonial Drive
Baton Rouge, LA 70821
(225) 927-7688 ext 215
Christine Foerstner
HCCN & Finance Director
503 Colonial Drive
Baton Rouge, LA 70821
(225) 927-7688 ext 205
Brandi Bourgeois, MPH, PMP
HCCN Project Manager
503 Colonial Drive
Baton Rouge, LA 70821
(225) 927-7688 ext 213
Shannon Robertson, RN, BSN
Clinical Quality Director
503 Colonial Drive
Baton Rouge, LA 70821
(225) 927-7688 ext 201
Dara Stout, PMP
Practice Management Coord.
503 Colonial Drive
Baton Rouge, LA 70821
(225) 927-7688 ext 202
Susie Hutchinson, CAPPM, CMSR, PCMH CCE
Practice Management Director
503 Colonial Drive
Baton Rouge, LA 70821
(225) 927-7688 ext 212
Turn BLUE evaluations into the
registration table or LPCA Staff!!!!!!