3bi cardiovascular disease management – 4/19/16 · 2019-09-05 · • recruit work group members...

3bi Cardiovascular Disease Management – 4/19/16

Attendees

Amanda Beattie, Chima Chionuma MD, Dianne DiMeo, Kim Dynka, Thomas Filiak , Margaret Fontenot, D Anthony Gray, Denise Hummer, Daphene Johnson, Stacey Keefe, Diane Loftus, Enedina Marquez, Kim McNamara, Gagan Singh, Dawn Sampson, Tim Scanlon, Michelle Slade, Michael Svendsen, Lynn Vaccaro , Dan Vick, Sherry Willis Buglione, Ann Marie Derecola, Lisa Larkin Partners represented: Northern Oswego County Health Services, Syracuse Community Health Center, Regional Primary Care Network, Family Care Medical Group, Auburn Community Hospital, Onondaga Case Management, Christian Health Services, Community Memorial Hospital, St. Joseph’s Health Center, Lewis County General Hospital, Finger Lakes Center for Health, Upstate University Hospital- Medical Services Group, Rome Medical Group, Oneida Healthcare, Menorah Park CNYCC: Karen Joncas, Shana Rowan, Lauren Wetterhahn

Discussion

Slides reviewed Reporting criteria, Reporting results and future targets

- Eligibility and reporting criteria and payment reviewed - Thank you to partners that reported in DY1. We have exceeded our goal (300 needed, 674

actual) - DY2, Q1 target is 1850. Please continue to report. Twenty organizations are eligible and we will

need all to report to meet these goals. - Targets for actively engaged patients rise significantly each year.

Proposed Workgroup Charge A draft of a new work group charge was presented to partners. Based on the urgency to engage patients in self-management in order to meet our reporting goals, it is suggested that this be the first charge of the work group. Key highlights in the discussion included the work group’s purpose, proposed schedule, proposed scope of work, suggested members, supporting resources, proposed deliverables for project requirement #12-Self-management goals. Also discussed was the proposed format for reporting work group discussions and recommendations (Clinical Work Group Recommendations/Policy Matrix). A slide depicting the Collaborative Care: Cycle of Self-Management Support was briefly discussed as a starting point for developing the standards of care process flow. Some organizations have already implemented self-management goal setting at various levels of patient engagement. It is expected that nursing staff/health coaches/medical assistants in addition to providers will work with patients on this. Their experience would be invaluable to the work group in preparing recommended deliverables. Partners are asked to provide guidance by e-mail or telephone on the following:

- Review the suggested member composition. Suggest work group members from your organization.

- Primary Care practices eligible for reporting should consider who from their organization should commit to the work group to assist in meeting the project goals. Geographic representation and focus on clinical and operational staff is preferred.

Discussion (continued)

- Proposed meeting day and length of session. (11/2 hours every other Wednesday beginning 5/4/16) Would members prefer 7:30-9AM or 8:00-9:30AM? On-site sessions will be held at CNYCC offices. Call-in Webinars will be available but not preferred.

- Review the project deliverables and offer any other suggestions. - Whether a concurrent group (on Wednesdays during the off weeks) could be formed to address

recommendations for smoking related project requirements and blood pressure measurement and equipment maintenance. Should this be same or different representatives from your organization? How would this effect the work group schedule and time commitment?

- PPS is planning a Health Home presentation that will include the role they could serve in the CVDM care coordination team. Who from your organization would benefit from a presentation on Health Homes? What would you like to know?

Attendees offered only positive comments on the proposed work group charge. Karen shared with the PIC attendees some of the activities going on behind the scenes for this project.

• Working with CNYCC counsel regarding copyright issues on evidence-based guideline recommendations for hypertension and elevated cholesterol as well as medication regimes. Hope to have updates on next PIC.

• Working on assessments-will complete over next 6 weeks. Partners not yet assessed should expect a call from Karen to set up an appointment to review their current Cardiovascular Disease Management activities.

• Assessing community resources relevant to this project through conversations with county health and associated departments.

• Pursuing opportunities for smoking cessation training consistent with project requirements. • These activities will be used to complete a current state assessment, gap analysis and strategic

plan for the project. • Evaluating how Insignia’s Patient Activation Measure® tool, for which CNYCC is currently

licensed to use, could also be employed to assess patients’ readiness and confidence in self-management of chronic disease. CNYCC is considering a future presentation to the PIC on this tool.

Partners not receiving planning payments for this project were excused from the last part of the PIC. Draft Planning Template was reviewed and presented for comment. Karen explained that the planning template was built with the project requirements and the Chronic Care Model in mind. Elements of the planning template were highlighted. Dates chosen reflect the level of urgency based on key elements of project implementation, and the state project requirement deadlines. Each element of the planning template references the project requirement (milestone) number in the State’s Project Implementation Plan. Elements related to identifying targeted patients and implementing processes to engage patients have early due dates based on the patient speed requirements reviewed in the PIC. One requirement is the completion of a standardized assessment tool (provided as a link and an attachment) which should be returned to Karen Joncas by e-mail along with the completed planning template. It is expected that partners will be asked to complete this assessment to gauge project progress in subsequent DSRIP years. A slide depicting the components of the Chronic Care Model and the sections of the assessment tool were compared. Other elements include developing the organization’s plan to integrate the project’s performance and

outcome measures and the cardiovascular disease strategies into the organization’s transformation plans. We anticipate a future presentation to the PIC on the State’s baseline assessment of the performance and outcome measures including the source data. (See the attached DSRIP: Measure Specification and Reporting Manual) The project requires that champions be named to help drive change and perhaps train others. These champions include physician champions and blood pressure champions. Organizations are asked to name these individuals in the planning template. Organizations are asked to consider what staff will need to be trained in each activity and implement a process to track staff that are trained. Other elements where project requirements align in functional areas were grouped in the planning template for partner’s ease of use. Once recommended standards of care are developed by the work group, organizations will be asked to implement and integrate them into their organization’s policies and procedures. Partners questions and comments:

• After discussion, it was decided to allow partners to make recommended changes to the planning template through Tuesday of next week. Revisions would then be incorporated and final document posted to the website. Partners requested until May 30, 2016 to complete the assessment tool and the planning template. We want to be as flexible as we can while keeping the urgency of some planning needs in mind.

• Based on partner feedback, “protocol” will be changed to “recommendation” or “process” where appropriate.

Next Steps

- Please e-mail Karen with proposed changes to draft documents including work group charge and the planning template.

- Please consider appropriate representatives from your organizations for the work group and e-mail member recommendations to Karen by April 29th.

- Proposed First meeting of Work group – May 4, 2016 - Next PIC meeting – May 17, 2016

• Work group report • Insignia presentation possible

Project 3bi: Cardiovascular Disease Management

Agenda April 19, 2016 7:30 – 8:30 am

Join by GoToWebinar

Register for the Webinar Here: https://attendee.gotowebinar.com/register/4150860173747092482

AGENDA & DESCRIPTION

1. Welcome Karen Joncas, PIC Facilitator Email: [email protected]

2. Reporting Update/Recap

Final numbers on DY1Q4 reporting Patient engagement requirements for DY2Q1 Contracting eligible organizations-20 with 91 sites Reporting sites-6

3. Proposed Work Group Charge Proposed scope of work and deliverables for Clinical Workgroup-Focus on self-management goal development and documentation

4. Planning Template

This portion of the meeting will be addressed to those partners receiving incentives under Appendix B that are required to submit organization/practice specific project implementation plans (Planning template and supporting documentation attached)

5. Next Steps:

• Recruit Work group members • Proposed Clinical Workgroup Meeting: May 4, 2016 • Next PIC meeting: May 17, 2016

https://attendee.gotowebinar.com/register/4150860173747092482

mailto:[email protected]

Cardiovascular Disease Management Reporting

Who is Eligible to Report:• Organizations that provide primary care that treat patients with Cardiovascular

Disease or Hypertension

Reporting Criteria:• Adult Medicaid patients with active applicable CVD diagnoses with a documented

self-management goal in their health record• Encounter date where self-management goals are documented

Payment for Reporting• $60.99 (net)/$71.75 (gross) PMPY

Does this sound like your organization?Michele Treinin, Project Manager for Data and Reporting

[email protected]

Cardiovascular Disease Management Reporting Actively Engaged Patients


DY1 Q4 Targets and Final Results

Partners Engaged in Reporting- As of April 15, 2016• Northern Oswego County Health Services• Mohawk Valley Health System• Oneida Healthcare• Port City Family Medicine• Regional Primary Care Network• Upstate University Hospital-Medical Service Group


Q DUE Target Actual Status

DY1 Q4 300 674 GREEN

All listed organizations have submitted rosters for DY1.

DY2 Q1 Targets

Partners Eligible to Report• 20 Organizations• 91 sites


DY2Q1 DUE

Target Actual Status

DY2 Q1 1850 0

Future Targets


Quarter TargetDY2 Q1 1850DY2 Q2 3400DY2 Q3 5100DY2 Q4 6800DY3 Q1 3400DY3 Q2 6800DY3 Q3 10,100DY3 Q4 13,400DY4 Q1 6,800DY4 Q2 13,400DY4 Q3 20,100DY4 Q4 26,800DY5 Q1 6,800DY5 Q2 13,400DY5 Q3 20,100DY5 Q4 26,800

DRAFT 3bi CVDM 4-19-16 KJ

- - - - -DRAFT - - - - - Cardiovascular Disease Management (3bi) Standards of Care Workgroup

Purpose Statement and Objectives This work group is being established to identify standards of care, process workflows, tools, resources and templates that will be recommended to partners implementing the Chronic Care Model and Cardiovascular Disease Management Strategies. Work group schedule and commitment It is suggested that the workgroup will meet every other week on Wednesday mornings, for 1 1/2 hours with an expected start date of 5/4/16. The start time of the work group meeting is to be determined. Wednesday’s are suggested to be consistent with the previous work group meeting schedule. CNYCC seeks partner guidance on whether, on the off-weeks, a concurrent group with the some of the same or different partner representatives could meet to develop protocols for blood pressure measurement and equipment maintenance and smoking cessation. Proposed Scope of Work

• Develop recommendations for standards of care consistent with the project requirements for Cardiovascular

Disease Management and the approved recommendations of the clinical work group. • Prioritize the scope of work to focus on developing and documenting self-management goals to meet the

project reporting criteria and DSRIP targets. • Define minimum required elements of a self-management goal to meet verification requirements. Identify a

standard process for documentation in the medical record to facilitate access across care settings. Develop a patient-centered self-management goal template validating care team and patient collaboration.

• Review Project requirements and evidence-based guidelines as well as published toolkits or other resources to drive process workflows and care standards.

• Achieve consensus around standards of care for the following: developing and documenting patient-centered self-management goals, care coordination team and community linkages, tobacco use protocols, standards of care for use of recommended treatment protocols for hypertension and elevated cholesterol including recommended medication regimes and blood pressure measurement and equipment maintenance.

• Develop recommendations for training to include format and message. Members Facilitator: Karen M. Joncas, MBA, PCMH CCE Email: [email protected] CNYCC Project Manager Desired Composition: Approximately 12 Members Geographic representation from all 6 counties preferred Primary care representation with a focus on both clinical and operational staff Maximum of one representative each from Community based health workers in the area of pharmacy, nutrition, behavioral health, public health and care management (health homes) Representatives may change with the specific focus of the work (i.e. organization blood pressure champions to work on blood pressure related project requirements).



Sample of Supporting Resources

• Partnering in Self-Management Support: A Toolkit for Clinicians (Institute of Health Care Improvement – 2010)

http://www.ihi.org/resources/Pages/Tools/SelfManagementToolkitforClinicians.aspx

• AHRQ Health Literacy Universal Precautions Toolkit (especially topics related to Self-Management) http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/healthlittoolkit2.pdf

• Self-Management Toolkit for People with Chronic Conditions and Their Families http://www.ihi.org/resources/Pages/Tools/SelfManagementToolkitforPatientsFamilies.aspx

• Self-Management Support Roles and Tasks in Team Care http://www.ihi.org/resources/Knowledge%20Center%20Assets/Tools%20-%20PartneringinSelf-ManagementSupportAToolkitforClinicians_19158315-0e11-4ec3-b531-1003148e54f0/SelfManagementSupport_RolesandTasksinTeamCare.pdf

• Planned Care Video Series http://www.improvingchroniccare.org/index.php?p=Watch_A_Planned_Care_Visit&s=221

• Shared Decision Making Guide http://www.centrecmi.ca/wp-content/uploads/2014/02/Shared_Decision_Making_Guide_2014-02-05.pdf

Reporting Plan The CNYCC Project Manager will provide minutes from each work group session to the work group members as well as monthly updates to members of the PIC. The CNYCC Project Manager will present the work group’s deliverables to the Clinical Governance Committee Meeting for approval. Deliverables

• Work group is expected to develop process flow/standard of care for patient-centered self-management goal development along with the roles and responsibilities of staff and community based workers at each stage of the process.

• Work group will define minimum required elements of a self-management goal and identify standard process for documentation in the medical record to facilitate access across care settings.

• Work group will develop a gold standard patient-centered self-management goal template.

http://www.ihi.org/resources/Pages/Tools/SelfManagementToolkitforClinicians.aspx

http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/healthlittoolkit2.pdf

http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/healthlittoolkit2.pdf

http://www.ihi.org/resources/Pages/Tools/SelfManagementToolkitforPatientsFamilies.aspx

http://www.ihi.org/resources/Knowledge%20Center%20Assets/Tools%20-%20PartneringinSelf-ManagementSupportAToolkitforClinicians_19158315-0e11-4ec3-b531-1003148e54f0/SelfManagementSupport_RolesandTasksinTeamCare.pdf



http://www.improvingchroniccare.org/index.php?p=Watch_A_Planned_Care_Visit&s=221

http://www.centrecmi.ca/wp-content/uploads/2014/02/Shared_Decision_Making_Guide_2014-02-05.pdf


• Work group will recommend tools and resources to support patient-centered self-management goal development and collaborative relationships between the patient and the care team.

• Work group will recommend training format, recommended messaging and staff to be trained.

Institute for Healthcare Improvement Page 9 Partnering in Self-Management Support: A Toolkit for Clinicians

Collaborative Care: Cycle of Self-Management Support

1 CVDM Clinical Workgroup Clinical / Outreach Protocol Matrix

Central New York Care Collaborative, Inc. Cardiovascular Disease Management (CVDM) (Project 3bi)

May 2016 Clinical Work group Recommendations/Policy Matrix

Column 1: Required Deliverable and

Documentation Requirements

Column 2. Summary Description of Protocol or

Link to Additional Information

Column 3. Suggested Work Group charge, Summary of Discussion, Outstanding Decisions, or Additional

Information Required

Workgroup Deliverable and Status

PR # 12: Document patient driven self-management goals in the medical record and review with patients at each (relevant) visit. (DY3Q4)

Metrics:

Self-management goals are documented in the clinical record

PPS provides periodic training to staff on person-centered methods that include documentation of self-management goals.

State Project Deliverables:

Documentation of self-audit of de-identified medical records over project timeframe demonstrating self-management goals documented in the clinical record

List of training dates, focus area or topic of training, training format, number of staff trained; Written training materials

Actively Engaged Patient Definition:

The number of participating patients receiving services with documented self-management goals in medical record (diet, exercise, medication management, nutrition, etc.) that are reviewed at each relevant visit

• Work group is expected to develop process flow/standard of care for patient-centered self-management goal development along with the roles and responsibilities of staff and community based workers at each stage of the process.

• Work group will define minimum required elements of a self-management goal and identify standard process for documentation in the medical record to facilitate access across care settings.

• Work group will develop a gold standard patient-centered self-management goal template.

• Work group will recommend tools and resources to support patient-centered self-management goal development and collaborative relationships between the patient and the care team.

• Work group will recommend training format, recommended messaging and staff to be trained.

• Process to include other project requirement components such as: care coordination team roles, Million Hearts campaign

STATUS:

In process

DELIVERABLES:

1. Process flow/Standard of Care

2. Tools and resources

3. Patient-centered self- management goal template

2 CVDM Clinical Workgroup Clinical / Outreach Protocol Matrix

Column 1: Required Deliverable and

Documentation Requirements

Column 2. Summary Description of Protocol or

Link to Additional Information

Column 3. Suggested Work Group charge, Summary of Discussion, Outstanding Decisions, or Additional

Information Required

Workgroup Deliverable and Status

strategies, evidence-based guidelines, home blood pressure monitoring.

Home

Cardiovascular Disease Management Requirements CNYCC Due Date Has the partner site completed this action step? If Not, when is the expected completion date? (cannot be

later than column E)

Please list key personnel with title and contact information responsible for this

action step. (Include designated champions where appropriate)

Complete Assessment of Chronic Illness Care Version 3.5 with consideration to Cardiovascular Disease Management project. Submit results to PPS Project Manager. (Survey provided) http://www.improvingchroniccare.org/downloads/acic_v3.5a_copy1.pdf

5/15/2016 Select an option

Develop plans for measurement and improvement of quality measures associated with this project. (Performance Quality Measures provided)


Respond to CNYCC initiated assessment of the specific organization wide activities associated with the CVDM project requirments factors (PR #1)


Implement protocol for identifying targeted patients.(PR #12) (See Appendix C)


Implement protocol for engaging targeted population in patient-centered self-management goal setting with consideration of PPS published standards of care. (PR #12)


Implement a protocol for reporting patients with patient-driven self-management goals reviewed at each relevant visit (PR#12)


Integrate cardiovascular disease management strategies into the practice's PCMH plan and/or practice protocols. Applicable NCQA strategies could include-Safety (evidence-based guidelines and monitoring equipment), Population Management (patient outreach), Care Management, Patient Engagement (self-care support and shared decision making), referral tracking and care coordination, patient access, medication management. (PR #3)


Designate physician champion(s) for cardiovascular disease management project (including hypertension) (PR # 6,11)


Designate practice champion(s) for using correct blood pressure measurement techniques on properly maintained equipment.(PR #9)


Implement PPS approved standardized treatment protocols for hypertension, elevated cholesterol, once daily regimen or fixed combination medications , blood pressure monitoring, home blood pressure monitoring with follow-up support and strategies of the Million Hearts Campaign. (Approved by Clinical Governance Committee, once published). (PR#6,9,11,14, 18)


Identify provider and other staff to be trained in the standards of care associated with project requirements. (PR # 2,3,6,7,12,13,14,16,17,18)


Implement protocol for monitoring ongoing staff training needed for CVDM including date of trainings, focus or topic of training, training format, staff trained and an inventory of training materials used, in order to facilitate completion of CNYCC provided training verification template. (once published) (PR# 2 5 6 7 10 12 13 14 16 17 18)


Care Coordination-Identify members of the practice internal staff care coordination team that will include a PCP, nurse(s), administrative care coordinator, and the internal or external members including care manager (s), pharmacist, dietician and behavioral health specialist (PR #7)


Project Specific Deliverables

Self-management support-Develop processes and protocols and preliminary roles for each team member responsible for care planning and care coordination that addresses patient lifestyle changes, medication adherence, health literacy, self-efficacy, barriers to care and confidence in self-management (PR #7)


Participate in PPS initiative to monitor implementation of care coordination protocol. (PR #7)


Patient Access-Implement a protocol for offering follow-up appointments for practice blood pressure checks without co-pay or scheduled appointment and promote community based availability of blood pressure monitors. Consider group visits for enhanced patient access and peer support. (PR#8,12)


Equipment Safety-Develop a protocol and tracking system for testing accuracy of in-house and home blood pressure monitoring equipment. (PR#9, 14)


Community Linkages-Identify health and community based referral options and implement a mechanism to refer and track patient participation and document any relevant behavioral and/or helath changes. (PR#7, 13, 16,17)


Patient Education-Educate patients on chronic disease self management, home blood pressure measurement and reporting, options for patient access for blood pressure monitoringand provide relevant linguistically and culturally appropriate patient education materials, . (PR #8,14)


Population Health Management-Implement protocols for outreach to targeted patients due for needed services to manage their CVD and/or associated risk factors. (PR #8,10,15,17)


Workflow Automation- Implement clinical decision supports for care planning and self-management goals, evidence based guideline implementation, 5 A's of tobacco control and referrals to NYS smokers Quitline. (PR # 5,6,16)


Identify process to incorporate PPS approved standards of care into the organization's documented policies and procedures. (PR #6, 7, 8, 9,#10, 11, 12, 13, 14, 15,16, 17, 18)


Select an optionSelect an optionSelect an optionSelect an optionSelect an optionSelect an optionSelect an optionSelect an optionSelect an optionSelect an optionSelect an optionSelect an optionSelect an option

Institute for Healthcare Improvement Page 23 Partnering in Self-Management Support: A Toolkit for Clinicians

Sustaining Self-Management Support: The Chronic Care Model In order to sustain changes in care delivery that support self-management, it is helpful to engage the entire system of care. The Chronic Care Model, which includes self- management support as one of six essential elements, can be helpful in planning these system supports. The following adaptation of the Chronic Care Model outlines the key concepts that have been utilized to implement self-management support in many quality improvement initiatives. For more information and examples of key changes see the full Self-Management Support Chronic Care Model Change Package.

Patients engage in effective self-management

Adaptation of the Chronic Care Model:* Using Components to Enhance Self-Management

* Adapted from the Chronic Care Model, developed by Dr. Ed Wagner of the MacColl Institute for Healthcare Innovation in partnership with colleagues at the Improving Chronic Illness Care program. http://www.improvingchroniccare.org/

http://www.ihi.org/resources/Knowledge%20Center%20Assets/Tools%20-%20PartneringinSelf-ManagementSupportAToolkitforClinicians_19158315-0e11-4ec3-b531-1003148e54f0/NHP_SelfMgmtChronicCareModel_ChangePackage2009.pdf

http://www.improvingchroniccare.org/

Copyright 2000 MacColl Institute for Healthcare Innovation, Group Health Cooperative

Assessment of Chronic Illness Care Version 3.5

Please complete the following information about you and your organization. This information will not be disclosed to anyone besides the ICIC/IHI team. We would like to get your phone number and e-mail address in the event that we need to contact you/your team in the future. Please also indicate the names of persons (e.g., team members) who complete the survey with you. Later on in the survey, you will be asked to describe the process by which you complete the survey. Your name:

Date: ________/________/________ Month Day Year Names of other persons completing the survey with you: 1. 2.

Organization & Address:

3.

Your phone number: (______) __ __ __ - __ __ __ __ Your e-mail address:

Directions for Completing the Survey This survey is designed to help systems and provider practices move toward the “state-of-the-art” in managing chronic illness. The results can be used to help your team identify areas for improvement. Instructions are as follows: 1. Answer each question from the perspective of one physical site (e.g., a practice, clinic, hospital, health plan) that

supports care for chronic illness.

Please provide name and type of site (e.g., Group Health Cooperative/Plan) ________________________________

2. Answer each question regarding how your organization is doing with respect to one disease or condition.

Please specify condition ________________________________ 3. For each row, circle the point value that best describes the level of care that currently exists in the site and

condition you chose. The rows in this form present key aspects of chronic illness care. Each aspect is divided into levels showing various stages in improving chronic illness care. The stages are represented by points that range from 0 to 11. The higher point values indicate that the actions described in that box are more fully implemented.

4. Sum the points in each section (e.g., total part 1 score), calculate the average score (e.g., total part 1 score / # of

questions), and enter these scores in the space provided at the end of each section. Then sum all of the section scores and complete the average score for the program as a whole by dividing this by 6.

For more information about how to complete the survey, please contact: Judith Schaefer, MPH tel. 206.287.2077; [email protected] Improving Chronic Illness Care A National Program of the Robert Wood Johnson Foundation Group Health Cooperative of Puget Sound 1730 Minor Avenue, Suite 1290 Seattle, WA 98101-1448

Assessment of Chronic Illness Care, Version 3.5

Part 1: Organization of the Healthcare Delivery System. Chronic illness management programs can be more effective if the overall system (organization) in which care is provided is oriented and led in a manner that allows for a focus on chronic illness care.

Components Level D Level C Level B Level A Overall Organizational Leadership in Chronic Illness Care

Score

…does not exist or there is a little interest. 0 1 2

…is reflected in vision statements and business plans, but no resources are specifically earmarked to execute the work. 3 4 5

…is reflected by senior leadership and specific dedicated resources (dollars and personnel). 6 7 8

…is part of the system’s long term planning strategy, receive necessary resources, and specific people are held accountable. 9 10 11

Organizational Goals for Chronic Care

Score

…do not exist or are limited to one condition. 0 1 2

…exist but are not actively reviewed. 3 4 5

…are measurable and reviewed. 6 7 8

…are measurable, reviewed routinely, and are incorporated into plans for improvement. 9 10 11

Improvement Strategy for Chronic Illness Care

Score

…is ad hoc and not organized or supported consistently. 0 1 2

…utilizes ad hoc approaches for targeted problems as they emerge. 3 4 5

…utilizes a proven improvement strategy for targeted problems. 6 7 8

…includes a proven improvement strategy and uses it proactively in meeting organizational goals. 9 10 11

Incentives and Regulations for Chronic Illness Care

Score

…are not used to influence clinical performance goals. 0 1 2

…are used to influence utilization and costs of chronic illness care. 3 4 5

…are used to support patient care goals. 6 7 8

…are used to motivate and empower providers to support patient care goals. 9 10 11

Senior Leaders

Score

…discourage enrollment of the chronically ill. 0 1 2

…do not make improvements to chronic illness care a priority. 3 4 5

…encourage improvement efforts in chronic care. 6 7 8

…visibly participate in improvement efforts in chronic care. 9 10 11

Benefits

Score

…discourage patient self-management or system changes. 0 1 2

…neither encourage nor discourage patient self-management or system changes. 3 4 5

…encourage patient self-management or system changes. 6 7 8

…are specifically designed to promote better chronic illness care. 9 10 11

Total Health Care Organization Score ________ Average Score (Health Care Org. Score / 6) _________


Part 2: Community Linkages. Linkages between the health delivery system (or provider practice) and community resources play important roles in the management of chronic illness.

Components Level D Level C Level B Level A Linking Patients to Outside Resources

Score

…is not done systematically. 0 1 2

…is limited to a list of identified community resources in an accessible format. 3 4 5

…is accomplished through a designated staff person or resource responsible for ensuring providers and patients make maximum use of community resources. 6 7 8

… is accomplished through active coordination between the health system, community service agencies and patients. 9 10 11

Partnerships with Community Organizations

Score

…do not exist. 0 1 2

…are being considered but have not yet been implemented. 3 4 5

…are formed to develop supportive programs and policies. 6 7 8

…are actively sought to develop formal supportive programs and policies across the entire system. 9 10 11

Regional Health Plans

Score

…do not coordinate chronic illness guidelines, measures or care resources at the practice level. 0 1 2

…would consider some degree of coordination of guidelines, measures or care resources at the practice level but have not yet implemented changes. 3 4 5

…currently coordinate guidelines, measures or care resources in one or two chronic illness areas. 6 7 8

…currently coordinate chronic illness guidelines, measures and resources at the practice level for most chronic illnesses. 9 10 11

Total Community Linkages Score ___________ Average Score (Community Linkages Score / 3) _________


Part 3: Practice Level. Several components that manifest themselves at the level of the individual provider practice (e.g. individual clinic) have been shown to improve chronic illness care. These characteristics fall into general areas of self-management support, delivery system design issues that directly affect the practice, decision support, and clinical information systems. ------------------------------------------------------------------------------------------------------------------------------------------------------------- Part 3a: Self-Management Support. Effective self-management support can help patients and families cope with the challenges of living with and treating chronic illness and reduce complications and symptoms.

Components Level D Level C Level B Level A Assessment and Documentation of Self-Management Needs and Activities

Score

…are not done. 0 1 2

…are expected. 3 4 5

…are completed in a standardized manner. 6 7 8

…are regularly assessed and recorded in standardized form linked to a treatment plan available to practice and patients. 9 10 11

Self-Management Support

Score

…is limited to the distribution of information (pamphlets, booklets). 0 1 2

…is available by referral to self-management classes or educators. 3 4 5

…is provided by trained clinical educators who are designated to do self-management support, affiliated with each practice, and see patients on referral. 6 7 8

…is provided by clinical educators affiliated with each practice, trained in patient empowerment and problem-solving methodologies, and see most patients with chronic illness. 9 10 11

Addressing Concerns of Patients and Families

Score

…is not consistently done. 0 1 2

…is provided for specific patients and families through referral. 3 4 5

…is encouraged, and peer support, groups, and mentoring programs are available. 6 7 8

…is an integral part of care and includes systematic assessment and routine involvement in peer support, groups or mentoring programs. 9 10 11

Effective Behavior Change Interventions and Peer Support

Score

…are not available. 0 1 2

…are limited to the distribution of pamphlets, booklets or other written information. 3 4 5

…are available only by referral to specialized centers staffed by trained personnel. 6 7 8

…are readily available and an integral part of routine care. 9 10 11

Total Self-Management Score_______ Average Score (Self Management Score / 4) _______


Part 3b: Decision Support. Effective chronic illness management programs assure that providers have access to evidence-based information necessary to care for patients--decision support. This includes evidence-based practice guidelines or protocols, specialty consultation, provider education, and activating patients to make provider teams aware of effective therapies.

Components Level D Level C Level B Level A Evidence-Based Guidelines

Score


…are available but are not integrated into care delivery. 3 4 5

…are available and supported by provider education. 6 7 8

…are available, supported by provider education and integrated into care through reminders and other proven provider behavior change methods. 9 10 11

Involvement of Specialists in Improving Primary Care

Score

…is primarily through traditional referral. 0 1 2

…is achieved through specialist leadership to enhance the capacity of the overall system to routinely implement guidelines. 3 4 5

…includes specialist leadership and designated specialists who provide primary care team training. 6 7 8

…includes specialist leadership and specialist involvement in improving the care of primary care patients. 9 10 11

Provider Education for Chronic Illness Care

Score

…is provided sporadically. 0 1 2

…is provided systematically through traditional methods. 3 4 5

…is provided using optimal methods (e.g. academic detailing). 6 7 8

…includes training all practice teams in chronic illness care methods such as population-based management, and self-management support. 9 10 11

Informing Patients about Guidelines

Score

…is not done. 0 1 2

…happens on request or through system publications. 3 4 5

…is done through specific patient education materials for each guideline. 6 7 8

…includes specific materials developed for patients which describe their role in achieving guideline adherence. 9 10 11

Total Decision Support Score_______ Average Score (Decision Support Score / 4) _______


Part 3c: Delivery System Design. Evidence suggests that effective chronic illness management involves more than simply adding additional interventions to a current system focused on acute care. It may necessitate changes to the organization of practice that impact provision of care.

Components Level D Level C Level B Level A Practice Team Functioning

Score

…is not addressed. 0 1 2

…is addressed by assuring the availability of individuals with appropriate training in key elements of chronic illness care. 3 4 5

…is assured by regular team meetings to address guidelines, roles and accountability, and problems in chronic illness care. 6 7 8

…is assured by teams who meet regularly and have clearly defined roles including patient self-management education, proactive follow-up, and resource coordination and other skills in chronic illness care. 9 10 11

Practice Team Leadership

Score

…is not recognized locally or by the system. 0 1 2

…is assumed by the organization to reside in specific organizational roles. 3 4 5

…is assured by the appointment of a team leader but the role in chronic illness is not defined. 6 7 8

…is guaranteed by the appointment of a team leader who assures that roles and responsibilities for chronic illness care are clearly defined. 9 10 11

Appointment System

Score

…can be used to schedule acute care visits, follow-up and preventive visits. 0 1 2

…assures scheduled follow-up with chronically ill patients. 3 4 5

…are flexible and can accommodate innovations such as customized visit length or group visits. 6 7 8

…includes organization of care that facilitates the patient seeing multiple providers in a single visit. 9 10 11

Follow-up

Score

…is scheduled by patients or providers in an ad hoc fashion. 0 1 2

…is scheduled by the practice in accordance with guidelines. 3 4 5

…is assured by the practice team by monitoring patient utilization. 6 7 8

…is customized to patient needs, varies in intensity and methodology (phone, in person, email) and assures guideline follow-up. 9 10 11

Planned Visits for Chronic Illness Care

Score

…are not used. 0 1 2

…are occasionally used for complicated patients. 3 4 5

…are an option for interested patients. 6 7 8

…are used for all patients and include regular assessment, preventive interventions and attention to self-management support. 9 10 11

Continuity of Care

…is not a priority.

…depends on written communication between primary care providers and specialists, case managers or disease management

…between primary care providers and specialists and other relevant providers is a priority but not implemented systematically.

…is a high priority and all chronic disease interventions include active coordination between primary care, specialists and other relevant


Components Level D Level C Level B Level A

Score 0 1 2

companies. 3 4 5

6 7 8

groups. 9 10 11

(From Previous Page)

Total Delivery System Design Score_______ Average Score (Delivery System Design Score / 6) _______ Part 3d: Clinical Information Systems. Timely, useful information about individual patients and populations of patients with chronic conditions is a critical feature of effective programs, especially those that employ population-based approaches.7, 8

Components Level D Level C Level B Level A Registry (list of patients with specific conditions)

Score

…is not available. 0 1 2

…includes name, diagnosis, contact information and date of last contact either on paper or in a computer database. 3 4 5

…allows queries to sort sub-populations by clinical priorities. 6 7 8

…is tied to guidelines which provide prompts and reminders about needed services. 9 10 11

Reminders to Providers

Score


… include general notification of the existence of a chronic illness, but does not describe needed services at time of encounter. 3 4 5

…includes indications of needed service for populations of patients through periodic reporting. 6 7 8

…includes specific information for the team about guideline adherence at the time of individual patient encounters. 9 10 11

Feedback

Score

…is not available or is non-specific to the team. 0 1 2

…is provided at infrequent intervals and is delivered impersonally. 3 4 5

…occurs at frequent enough intervals to monitor performance and is specific to the team’s population. 6 7 8

…is timely, specific to the team, routine and personally delivered by a respected opinion leader to improve team performance. 9 10 11

Information about Relevant Subgroups of Patients Needing Services

Score

…is not available. 0 1 2

…can only be obtained with special efforts or additional programming. 3 4 5

…can be obtained upon request but is not routinely available. 6 7 8

…is provided routinely to providers to help them deliver planned care. 9 10 11

Patient Treatment Plans

Score

…are not expected. 0 1 2

…are achieved through a standardized approach. 3 4 5

…are established collaboratively and include self management as well as clinical goals. 6 7 8

…are established collaborative an include self management as well as clinical management. Follow-up occurs and guides care at every point of service. 9 10 11


Total Clinical Information System Score_______ Average Score (Clinical Information System Score / 5) ________ Integration of Chronic Care Model Components. Effective systems of care integrate and combine all elements of the Chronic Care Model; e.g., linking patients’ self-management goals to information systems/registries.

Components Little support Basic support Good support Full support Informing Patients about Guidelines

Score

…is not done. 0 1 2

…happens on request or through system publications. 3 4 5

…is done through specific patient education materials for each guideline. 6 7 8

…includes specific materials developed for patients which describe their role in achieving guideline adherence. 9 10 11

Information Systems/Registries

Score

…do not include patient self-management goals. 0 1 2

…include results of patient assessments (e.g., functional status rating; readiness to engage in self-management activities), but no goals. 3 4 5

…include results of patient assessments, as well as self-management goals that are developed using input from the practice team/provider and patient. 6 7 8

…include results of patient assessments, as well as self-management goals that are developed using input from the practice team and patient; and prompt reminders to the patient and/or provider about follow-up and periodic re-evaluation of goals. 9 10 11

Community Programs

Score

…do not provide feedback to the health care system/clinic about patients’ progress in their programs. 0 1 2

…provide sporadic feedback at joint meetings between the community and health care system about patients’ progress in their programs. 3 4 5

…provide regular feedback to the health care system/clinic using formal mechanisms (e.g., Internet progress report) about patients’ progress. 6 7 8

…provide regular feedback to the health care system about patients’ progress that requires input from patients that is then used to modify programs to better meet the needs of patients. 9 10 11

Organizational Planning for Chronic Illness Care

…does not involve a population-based approach.

…uses data from information systems to plan care.

…uses data from information systems to proactively plan population-based care, including the development of self-management programs and partnerships with community resources. 6 7 8

…uses systematic data and input from practice teams to proactively plan population-based care, including the development of self-management programs and community partnerships, that include a built-in evaluation plan to determine success over time.


Components Little support Basic support Good support Full support Score 0 1 2 3 4 5 9 10 11

Routine follow-up for appointments, patient assessments and goal planning

…is not ensured. 0 1 2

is sporadically done, usually for appointments only. 3 4 5

is ensured by assigning responsibilities to specific staff (e.g., nurse case manager). 6 7 8

is ensured by assigning responsibilities to specific staff (e.g., nurse case manager) who uses the registry and other prompts to coordinate with patients and the entire practice team. 9 10 11

Guidelines for chronic illness care

…are not shared with patients. 0 1 2

…are given to patients who express a specific interest in self-management of their condition. 3 4 5

…are provided for all patients to help them develop effective self-management or behavior modification programs, and identify when they should see a provider. 6 7 8

…are reviewed by the practice team with the patient to devise a self-management or behavior modification program consistent with the guidelines that takes into account patient’s goals and readiness to change. 9 10 11

Total Integration Score (SUM items): __________ Average Score (Integration Score/6) = __________


Briefly describe the process you used to fill out the form (e.g., reached consensus in a face-to-face meeting; filled out by the team leader in consultation with other team members as needed; each team member filled out a separate form and the responses were averaged). Description: ___________________________________________________________________________________________ _________________________________________________________________________________________________________________________

Scoring Summary (bring forward scoring at end of each section to this page)

Total Org. of Health Care System Score _______

Total Community Linkages Score _______

Total Self-Management Score _______

Total Decision Support Score _______

Total Delivery System Design Score _______

Total Clinical Information System Score _______

Total Integration Score _______ Overall Total Program Score (Sum of all scores) ______ Average Program Score (Total Program /7) ______


What does it mean? The ACIC is organized such that the highest “score” (an “11”) on any individual item, subscale, or the overall score (an average of the six ACIC subscale scores) indicates optimal support for chronic illness. The lowest possible score on any given item or subscale is a “0”, which corresponds to limited support for chronic illness care. The interpretation guidelines are as follows: Between “0” and “2” = limited support for chronic illness care Between “3” and “5” = basic support for chronic illness care Between “6” and “8” = reasonably good support for chronic illness care Between “9” and “11” = fully developed chronic illness care It is fairly typical for teams to begin a collaborative with average scores below “5” on some (or all) areas the ACIC. After all, if everyone was providing optimal care for chronic illness, there would be no need for a chronic illness collaborative or other quality improvement programs. It is also common for teams to initially believe they are providing better care for chronic illness than they actually are. As you progress in the Collaborative, you will become more familiar with what an effective system of care involves. You may even notice your ACIC scores “declining” even though you have made improvements; this is most likely the result of your better understanding of what a good system of care looks like. Over time, as your understanding of good care increases and you continue to implement effective practice changes, you should see overall improvement on your ACIC scores.


February 25, 2016: Measurement Year 1 FINAL 37

± A lower rate is desirable. * High Performance Eligible measure # Statewide measure ^ Performance Goal is a system default and will be changed following Measurement Year 1 results.

DELIVERY SYSTEM REFORM INCENTIVE PAYMENT (DSRIP): MEASURE SPECIFICATION AND REPORTING MANUAL

Measure Name Specification Version

NQF #

Projects Associated with Measure

Numerator Description Denominator Description

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resident demonstrates little interest or pleasure, or feeling down or depressed or hopeless in half or more of the days over the last 2 weeks and a staff assessment interview total severity score indicates the presence of depression

Prevention Quality Indicator # 7 (Hypertension) ±

AHRQ 4.4 0276 3.b.i – 3.b.ii

Number of admissions with a principal diagnosis of hypertension

Number of people 18 years and older as of June 30 of measurement year

12.32 per 100,000

Medicaid Enrollees

1 if annual improvement target or performance goal met or exceeded

NYS DOH

P4P P4P

Prevention Quality Indicator # 13 (Angina without procedure) ±

AHRQ 4.4 0282 3.b.i – 3.b.ii

Number of admissions with a principal diagnosis of angina without a cardiac procedure

Number of people 18 years and older as of June 30 of measurement year

2.75 per 100,000

Medicaid Enrollees


NYS DOH

P4P P4P

Cholesterol Management for Patients with CV Conditions retired. NYS DOH may introduce a

TBD TBD 3.b.i – 3.b.ii





NQF #



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cholesterol management measure in future

Controlling High Blood Pressure

HEDIS 2015 0018

3.b.i –

3.b.ii, 3.h.i

Number of people whose blood pressure was adequately controlled as follows:

below 140/90 if ages 18-59;

below 140/90 for ages 60 to 85 with diabetes diagnosis; or

below 150/90 ages 60 to 85 without a diagnosis of diabetes

Number of people, ages 18 to 85 years, who have hypertension

73.3% (2012 Data)

*High Perf Elig


PPS and NYS DOH

P4R P4P

Aspirin Use HEDIS 2015 NA

3.b.i –

3.b.ii

Number of respondents who are currently taking aspirin daily or every other day

Number of respondents who are men, ages 46 to 65 years, with at least one cardiovascular risk factor; men, ages 66 to 79 years, regardless of risk factors; and women, ages 56 to 79 years, with at least two cardiovascular risk factors

100%^

0.5 if annual improvement target or performance goal met or exceeded

NYS DOH

P4R P4P





NQF #



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Discussion of Risks and Benefits of Aspirin Use

HEDIS 2015 NA

3.b.i –

3.b.ii

Number of respondents who discussed the risks and benefits of using aspirin with a doctor or health provider

Number of respondents who are men, ages 46 to 79 years, and women, ages 56 to 79 years

100%^


NYS DOH

P4R P4P

Medical Assistance with Smoking and Tobacco Use Cessation – Advised to Quit

HEDIS 2015 0027

3.b.i –

3.b.ii, 3.c.i –

3.c.ii, 3.e.i,

3.h.i

Number of responses ‘Usually’ or ‘Always’ were advised to quit

Number of respondents, ages 18 years and older, who smoke or use tobacco some days or every day

100%^

0.33 if annual

improvement

target or

performance

goal met or

exceeded

NYS DOH

P4R P4P

Medical Assistance with Smoking and Tobacco Use Cessation – Discussed Cessation Medication

HEDIS 2015 0027

3.b.i –

3.b.ii, 3.c.i –

3.c.ii, 3.e.i,

3.h.i

Number of responses ‘Usually’ or ‘Always’ discussed cessation medications


100%^

0.33 if annual

improvement

target or

performance

goal met or

exceeded

NYS DOH

P4R P4P

Medical Assistance with Smoking and Tobacco Use Cessation – Discussed Cessation Strategies

HEDIS 2015 0027

3.b.i –

3.b.ii, 3.c.i –

3.c.ii, 3.e.i,

3.h.i

Number of responses ‘Usually’ or ‘Always’ discussed cessation methods or strategies


100%^ *High Perf Elig

0.33 if annual

improvement

target or

performance

NYS DOH

P4R P4P





NQF #



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goal met or

exceeded

Flu Shots for Adults Ages 18 – 64

HEDIS 2015 0039

3.b.i –

3.b.ii, 3.c.i –

3.c.ii, 3.h.i

Number of respondents who have had a flu shot

Number of respondents, ages 18 to 64 years

100%^


NYS DOH

P4R P4P

Health Literacy (QHL13) 2357a_ C&G CAHPS Adult Supplement

NA 3.b.i – 3.b.ii, 3.c.i – 3.c.ii

Number responses ‘Usually’ or ‘Always’ that instructions for caring for condition were easy to understand

Number who answered they saw provider for an illness or condition and were given instructions

100%^


NYS DOH

P4R P4P


NA 3.b.i – 3.b.ii, 3.c.i – 3.c.ii

Number responses ‘Usually’ or ‘Always’ that provider asked patient to describe how the instruction would be followed

Number who answered they saw provider for an illness or condition and were given instructions

100%^


NYS DOH

P4R P4P


NA 3.b.i – 3.b.ii, 3.c.i – 3.c.ii

Number responses ‘Usually’ or ‘Always’ that provider explained what to do if illness/condition got worse or came back

Number who answered they saw provider for an illness or condition

100%^


NYS DOH

P4R P4P

3bi cardiovascular disease management – 4/19/16 · 2019-09-05 · • recruit work group members...

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