3bi cardiovascular disease management project...

3bi Cardiovascular Disease

Management Project

Implementation

March 14, 2018

Agenda and Meeting Objectives

Review DY 3 Actively Engaged Patient Status and Future Targets

Review Cardiovascular Disease Management Performance Outcomes

Review of Health Disparity data- Cardiovascular Measures

Review DY3 Plans- State Milestones, Performance Activities

Review of upcoming performance activity plans

Share best practices and Success stories- Review of Dashboards

Cardiovascular Disease Management Reporting

549645

702

885

1,289

1,045

688731 699

635584 579

471

0

200

400

600

800

1,000

1,200

1,400

Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18

3bi Engaged Patients by Month

Cardiovascular Disease Management Actively Engaged Patients Actively Engaged Patient Contribution by Organization by Month

St. ElizabethMedicalCenter

Faxton-StLuke's

Healthcare

Lewis CountyGeneralHospital

Family CareMedicalGroup

UpstateUniversityHospital

SyracuseCommunity

HealthCenter, Inc.

RomeMemorialHospital

PhysicianCare PC

CommunityMemorialHospital

NOCHSIRegional

Primary CareNetwork

St. Joseph'sHospital

Health Center

AuburnCommunity

Hospital

OneidaHealth

Systems, Inc.

Finger LakesCommunity

Health

LibertyResources

East HillFamily

Medical

RenatoMandanas

OswegoFamily

Physicians

Jan-18 25 61 50 141 1 74 33 28 24 15 4 7 1 7

Dec-17 157 64 54 109 1 25 32 33 16 5 35 10 14 7 14 3

Nov-17 144 67 33 40 35 86 26 37 20 10 20 20 14 12 6 10 4

Oct-17 125 116 55 64 50 62 39 19 22 18 8 18 22 5 2 9 1

Sep-17 166 97 64 50 22 68 48 43 37 19 13 22 14 14 8 2 12

Aug-17 144 108 86 26 74 62 33 54 52 25 14 20 15 11 7

Jul-17 176 132 68 51 72 37 45 27 29 20 14 8 7 2

Jun-17 230 179 103 55 145 109 65 39 31 34 23 6 14 12

May-17 368 258 49 50 211 81 89 32 37 41 17 23 16 17

Apr-17 235 93 105 54 21 118 60 43 48 54 29 17 8

Mar-17 218 150 82 47 65 31 29 26 24 23 4 3

Feb-17 218 133 62 31 24 14 26 30 15 29 23 13 10 17

0

500

1,000

1,500

2,000

2,500

44

DY3 Q4 Targets & Performance January 2018

Total January reporting= 471

Needed On Average each month for DY 3: 100%= 1,060 80% =849

Focus on patient engagement

Partner outreach: Those with opportunity to increase AEP reporting.

Training: Person Centered Self Management goals; Warm Handoffs, Motivational Interviewing;

NCQA Strategies for Success-Lifestyle Management

Community Partnerships: SMBP and CDSMP


DY3 Q4 Target Actual Gap to 80% Goal

Status

100%80%

12,73010,184

7,606 (5,124)(2,578)

At risk $96,914

Future Targets


Quarter 100 % of Target

DY3 Q4 March 2018 12,730

DY4 Q1 6,460

DY4 Q2 12,730

DY4 Q3 19,095

DY4 Q4 25,460

DY5 Q1 6,460

DY5 Q2 12,730

DY5 Q3 19,095

DY5 Q4 25,460

Partner Sharing-

Patient Engagement

Best Practices

Chronic Care Model-Patient Engagement – Person-Centered

Goal Setting

What action plans can be put in place to enhance care teams working with patients to set person-centered goals?

Training- Examples: Person-centered goal setting- available through HW Apps (PA_059); Motivational

Interviewing-coming soon; NCQA Strategies for Success- Lifestyle Management; understand patient’s

readiness to engage: PAM screening and Coaching for Activation (Next training March 23, 2018 at

CNYCC)

Implement clinical decision support tools:patient and clinical decision support tools: (i.e.,SMART

Goals)

Stress importance of documenting self-management goals for the patient and for provider to review

at each relevant visit.

Share best practice- Identify providers/care teams within your organization that are doing it well.

How could CNYCC support this through performance activities? What could that look like?

Performance & Outcomes Measures

Claims based

(Measurement Year 3, (MY3))

July 2016 to May 2017

June 2017 due soon

2

Prevention Quality Indicator #8 – Heart Failure (Rate Per 100,000)

(28.02)Gap to Goal

11

1.3

2

11

3.9

2

12

0.7

7

12

8.9

9

11

8.7

5

12

5.0

1

14

3.6

7

15

1.4

8

15

0.6

4

14

6.0

7

14

8.0

1

14

7.7

3

14

2.7

3

13

7.4

0

13

5.5

1

12

9.0

2

13

3.2

8

15

0.1

7

17

5.6

9

17

3.6

1

17

4.2

7

17

4.6

8

16

6.4

4

16

5.4

9

15

9.8

6

16

2.8

0

16

2.1

6

16

3.1

5

16

8.0

8 140.06

0.00

50.00

100.00

150.00

200.00

Jan

-15

Feb

-15

Mar

-15

Ap

r-1

5

May

-15

Jun

-15

Jul-

15

Au

g-1

5

Sep

-15

Oct

-15

No

v-1

5

Dec

-15

Jan

-16

Feb

-16

Mar

-16

Ap

r-1

6

May

-16

Jun

-16

Jul-

16

Au

g-1

6

Sep

-16

Oct

-16

No

v-1

6

Dec

-16

Jan

-17

Feb

-17

Mar

-17

Ap

r-1

7

May

-17

Measure Result Annual Improvement Target

$510,952.12

$- $100,000.00 $200,000.00 $300,000.00 $400,000.00 $500,000.00 $600,000.00

Measure Worth

32

PQI 8 Heart Failure

202.86

100.89

73.52

180.41

61.49 63.01

0.00

50.00

100.00

150.00

200.00

250.00

Heart Failure Admission Rate Month 9 of 12 MY 3 Results

Measure Result Annual Target

Statin Therapy Measurement Criteria

Statin Therapy for Patients with Cardiovascular Disease-Received Statin Therapy Data Available

Numerator: Number of people who were dispensed at least one high or moderate-intensity statin medication

Yes

Denominator: Number of males age 21-75 or females age 40-75 who have had an MI, CABG or PCI in the year prior or a diagnosis of ischemic vascular disease in both the measurement year and the year prior.

Statin Therapy for Patients with Cardiovascular Disease- Statin AdherenceNumerator: Number of people who achieved a proportion of days covered of 80 percent for the treatment period

Yes

Denominator: Number of males age 21-75 or females age 40-75 who have had an MI, CABG or PCI in the year prior or a diagnosis of ischemic vascular disease in both the measurement year and the year prior.

Statin Therapy for Patients with Cardiovascular Disease – Received Statin Therapy (Per 100)

(2.17)Gap to Goal

76

.59

76

.05

77

.10

77

.03

76

.83

76

.55

77

.48

77

.56

77

.21

77

.37

77

.52

79.69

74.00

75.00

76.00

77.00

78.00

79.00

80.00

Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17


$72,830.85

$- $10,000.00 $20,000.00 $30,000.00 $40,000.00 $50,000.00 $60,000.00 $70,000.00 $80,000.00

Measure Worth

33

Statin Therapy Received

78.0971.03

79.8474.36

81.36

92.86

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

90.00

100.00

Statin Therapy - Received Statin Therapy Month 9 of 12 MY 3 Results


Statin Therapy for Patients with Cardiovascular Disease – Statin Adherence 80% (Per 100)

(6.62)Gap to Goal

$72,830.85

$- $10,000.00 $20,000.00 $30,000.00 $40,000.00 $50,000.00 $60,000.00 $70,000.00 $80,000.00

Measure Worth

55

.80

54

.10

53

.82

54

.25

55

.04

57

.77

56

.98

56

.23

54

.52

54

.66

54

.2

60.82

50.00

52.00

54.00

56.00

58.00

60.00

62.00

Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17


34

Statin Therapy Adherence

55.83 54.37 50.51

58.6262.50

53.85

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

Statin Therapy - Statin Adherence 80% Month 9 of 12 MY 3 Results


Performance & Outcomes Measure

New Dashboards (Measurement Year 3, (MY3))

July 2016 to May 2017

June 2017 delayed

2

Performance & Outcomes Measure

Non Claims based

2

Controlling Hypertension

Review Measure Definition and Process

Controlling High Blood Pressure Interim Results

Percent of Data Completed Total Sample

Total compliant patients

Total non-compliant patients

MY 3 Interim Results

MY 3 Target

MY 2 Results

State target

91.10% 453 163 184 35.98% 51.94% 49.56% 73.30%

Performance & Outcomes Measures – 2017 Tobacco Use

Measures captured by survey- Results available May/June 2018

The Performance and Outcomes Measures for CVDM captured in patient surveys include:

Medical Assistance with Smoking and Tobacco Use CessationMedical Assistance with Smoking and Tobacco Use Cessation – Advised to QuitNumerator: Number of responses "Sometimes", "Usually" or "Always" were advised to quitDenominator: Number of respondents, ages 18 and older, who smoke or use tobacco some days or every day

Medical Assistance with Smoking and Tobacco Use Cessation – Discussed Cessation MedicationNumerator: Number of responses "Sometimes", "Usually" or "Always" discussed cessation MedicationsDenominator: Number of respondents, ages 18 and older who smoke or use tobacco some days or every day

Medical Assistance with Smoking and Tobacco Use Cessation – Discussed Cessation Strategies Numerator: Number of responses "Sometimes", "Usually" or "Always" discussed cessation methods or strategiesDenominator: Number of respondents, ages 18 and older who smoke or use tobacco some days or every day

Performance & Outcomes Measures – Other- 2017 results

captured by survey-Results available May/June 2018

The Performance and Outcomes Measures for CVDM captured in patient surveys include:

Flu shots for Adults Ages 18-64Had a flu shot or flu spray since September 2016

Aspirin UseTake aspirin daily or every other dayNumerator: Number of responses "Sometimes", "Usually" or "Always" discussed cessation MedicationsDenominator: Number of respondents, ages 18 and older who smoke or use tobacco some days or every day

Aspirin Discussion Doctor has discussed risks and benefits of aspirin to prevent heart attack or stroke.

Health LiteracyProvider usually or always gave easy to understand instructions for caring for illness or health condition.Provider usually or always asked you to describe how you would follow instructions for caring for illness or health condition.Provider usually or always explained what to do if illness or health condition got worse or came back.

Milestones and

Performance Activity

Review

Medication Management-PA_101 (5/31/18)

Cardiovascular Disease Management project- Performance Outcomes for Statin Therapy. How can your organization meet these requirements?

PA_101: For patients prescribed .. And/or statin Therapy (for patients with ischemic heart disease):

1. Track patients to ensure that patient fills prescription and is taking medication properly

2. Reach out to those that are overdue for prescription refill to ensure medication adherence.

Published reasonable guidance focused on behavioral health medications. AMA Medication Adherence

slides.

Best Practice-Who has done medication management for this or other medications effectively?

Medication

AdherenceImprove the health of your patients and reduce

overall health care costs

Patients do not take their medicine as prescribed about

half the time.

25

Why is it important to assess adherence?

=

26

27

Eight steps to improve medication adherence in

your practice

1

2

3

4

Consider medication nonadherence first as the reason a patient’s condition is not under control

Develop a process for routinely asking about medication adherence

Create a blame-free environment to discuss medications with the patient

Identify why the patient is not taking their medicine

28

Eight steps to improve medication adherence in

your practice

5

6

8

Respond positively and thank the patient for sharing their behavior

Tailor the adherence solution to the individual patient

Involve the patient in developing their treatment plan

Set patients up for success

7

Most nonadherence is intentional. Top reasons for

intentional nonadherence include:

29

30

For additional resources,

frequently asked questions

and implementation support,

visit www.stepsforward.org!

http://www.stepsforward.org/

Tobacco Cessation- Beyond State RequirementsCardiovascular Disease Management -Beyond setting up link to New York State Smoker’s Quitline.

Integrated Delivery Systems- How can hospital RT, Pulmonary, Home Care, Care Management, Skilled Behavioral Health

and Primary Care work together?

Warm- Hand-offs to the NYS Smoker’s Quitline. Build Protocols for Follow-up

Survey from NYS Smoker’s Quitline- What would your organization like for feedback from the Quitline?

Who is using the Quitline?

Cayuga County: Finger Lakes Community Health Center; East Hill Medical

Lewis County General Hospital

Oswego County Hospital, Behavioral Services, NOCHSI, Oswego County Health Dept.

Oneida County- Health Dept, MVHS RT, St. E’s Utica Int/Family Med, The Neighborhood Center, Rome Medical

Group, Rome RT and Cardiopulmonary

Onondaga County-St. Joseph’s; SUNY Upstate; Familycare Medical Group

Training- What other training would we like to see?

In-person training on 5 R’s, Pharmacotherapy can be available from Central New York Regional Center for Tobacco

Health Systems (Dr. Beth Gero);

Access through Group Visits, Motivational Interviewing, Brief Action Planning, PAM, Coaching for Activation

Referrals to Community Based

Programs (Milestone 13)

2

Tracking Referrals to Community Based Programs

Milestone 13: Follow-up with referrals to community based programs to document participation and behavioral and health status changes.

Metric 1: PPS has developed referral and follow-up process and adheres to process.

Metric 2: PPS provides periodic training on warm referral and follow-up process.

Metric 3: Agreements are in place with community-based organizations and process in place to facilitate feedback to and from community organizations.

Tracking Referrals to Community Based Programs (PA_047and PA_054*)

Auburn Community Hospital* Oneida Healthcare*

Community Memorial Hospital* Oswego Family Physicians

Compassionate Family Medicine* Physician Care, P.C.*

East Hill Family Medicine* Rome Memorial Hospital*

Family Care Medical Group RPCN*

Faxton St. Luke’s Healthcare St. Elizabeth’s*

Finger Lakes Community Health St. Joseph’s *

Lewis County General Syracuse Community Health Center*

NOCHSI* Upstate University Hospital*

Workflow: Documentation of the

Referral process including warm

transfers

2

Warm transfer and follow-up process

Metric 2: PPS provides periodic training on warm referral and follow-up process.

HW Apps: Conducting Warm Handoffs

Agreements with Community Based Organizations

1. Documentation of the process and workflow demonstrating how agreements and feedback are facilitated between community organizations, including responsible parties at every stage.

2. Agreements in place with: YMCA- Self-Measured Blood Pressure Program Cayuga Community Health Network Madison County Rural Health Network Lewis County Department of Health Oswego County Health Department Arise, Inc. Upstate Medical University OASIS program Any others that you have agreements in place?

Review of Race

Disparity noted in

performance

outcomes

Phase III Funds Flow- Development of

Performance Activities

Work with CMO, Clinical Quality committee, partners to develop next strategies for improving

outcomes with Cardiovascular Disease Management.

Health disparities

Medication Adherence

Align with Chronic Care Model

Promote tobacco cessation-EIP project

Align with Million Hearts 2022 Goals

Work with CMO and Clinical committees to review strategies for long term reductions of heart disease

risk.

Work with CMO and clinical committees to review updates in Evidence-based best practices

Review of performance outcome details for Controlling Hypertension; CG CAHPS report; updated MY

3 performance data

What performance activities would support these goals?

CNYCC Project Next Steps

Next Steps & Wrap Up

Technical Assistance and Validation of March Performance Activities

Quarterly updates due to the State Department of Health

Develop Phase III Funds Flow performance activities

Facilitate community linkages to support patient self-efficacy and confidence and provide

feedback to referring provider.

Cardiovascular Disease Management Reference Guide- Is there a partner need?

CNYCC Project Immediate Next Steps

Provide any internal training materials completed for project milestones to facilitate state reporting

Provide policy/processes for project milestones to support state reporting

Continue pursuit of funding (PA completion) through project implementation activities in CNYCC

Performance Activities

Institute quality initiatives to increase patient engagement and AEP reporting. Partner funding tied to

success.

Measure performance for 3bi outcomes and institute quality initiatives to improve performance. Partner

funding tied to success.

Community linkages to CBOs to support patient self-efficacy and confidence and provide feedback to

referring provider.

In negotiations with MCO’s consider agreements for services for patients at high risk for cardiovascular

disease

Partner Project Next Steps

Upcoming meetings:

NYS PCMH and NYS Medicaid Incentives- March 23rd 10:00AM

PAM Coaching for Activation March 23rd

3bi Implementation meeting- May 16th; June 20th; July 18th 1:00-2:30 PM

Learning Collaborative-April 3, 2018 10:00-12:00 Series 1 Access to Primary Care-

Cardiovascular Care scheduled for later in year (August, September, October).

What topics would you like to see brought to this implementation meeting or learning

collaborative sessions?

Cardiovascular Disease Management: Next Meetings and Feedback

Questions & Answers

Partner Sharing-

Performance Outcome

Measurement and

Improvement

Measure:

• How can I use CNYCC provided claims data

and/or my own data to assess where I have room

to improve?

• Dashboards by Provider

Develop Quality Initiatives:

• What action plans can I put in place for

improvement?

Best Practices: Partner Insights

What can I do as an organization to improve performance?

Prevention Quality Indicators Measurement Criteria

#7 Hypertension Data Available

Numerator: Number of admissions with a principle diagnosis of hypertensionYes

Denominator: Number of people 18 years and older as of June 30MY

#8 Heart FailureNumerator: Number of admissions with a principle diagnosis of heart failure Yes

Denominator: Number of people 18 years and older as of June 30MY

PA _049 Adopt evidence based guidelines with standardized decision support

PA_61 Chronic Disease Self-Management Program- Milestone 17 and 13

PA_062 Million Hearts initiatives

PA_063 Report on Agreements with MCO for High Risk Patients

PA_082 Coordinated Care Teams

PA_083 Patients Hiding in Plain Site

PA_084 No copay, no advance appointment blood pressure checks

Additional Milestones and Performance Activities Due

Patients Hiding in Plan Sight- Undiagnosed Hypertension

Cardiovascular Disease Management project- Milestone 10. How will your organization meet these requirements?

CNYCC Standards of Care summary Identify: Patients ages 18-59 years of age without a diagnosis of hypertension who have 2 or more BP readings > 140 mmHg SBP or > 90 mmHg

DBP in the medical record, during the past 12 month AND

Patients ages 60-85 of age without a diagnosis of hypertension who have 2 or more BP readings > 150 mmHg SBP or > 90 mmHg DBP in the medical record, during the past 12 months.

Outreach: Partners should have a policy for outreach to patients identified on the reports as due for an office visit. Scheduling a follow-up for patients will be at the discretion of the provider based on all clinical indicators.

Partners can decide on the protocol, frequency and method of outreach

Partners can use tighter blood pressure controls from 2017 AHA Guidelines

Performance Activity (PA_083)- Identify patients with repeated elevated BP, no diagnosis, outreach for needed services and

train 75% of indicated staff. (Due March 31, 2018)

Training- CNYCC sponsored training-Available on HW Apps this week. Please supply CNYCC with materials by March 31, 2018 if

other training is used.

Best Practice-Who has begun this work?

Community Resource Referrals for High Risk Patients

Cardiovascular Disease Management project- Milestone 13 and 17. How can your organization meet these requirements?

Identify how high risk patients are defined for your organization

CNYCC identifying zip codes where patients not meeting performance outcomes reside

Identify what community resources would best fit the needs of these patients

Develop processes and protocols for warm handoffs, where appropriate, and to include closing the referral

loop.

Training on Warm Handoffs- Now available on HW Apps (please promote to help meet milestone)

Performance Activity (PA_061) Bi-lateral Agreements between referring organizations and supplying

organizations of CDSMP. (Due March 31, 2018)

Best Practice-Who has begun this work?

Tobacco Use- Promoting Tobacco CessationCardiovascular Disease Management project- Milestone 5. How will your organization meet these requirements?

CNYCC Standards of Care summary (See Cardiovascular Reference Guide)

Develop policies and procedures for use of 5A’s including use of EHR prompts.

Clinical support must include follow-up at least one time within 1 week of quit date.

Mechanism for referral to NYS Quitline must be put in place with patient follow-up required.

Training required on 5A’s and EHR integration

Training- 5A’s Integration into Electronic Health Record - available through HW Apps (PA_081); In-person training available

from Central New York Regional Center for Tobacco Health Systems (Dr. Beth Gero); provide training materials to CNYCC by

e-mail to Karen Joncas by March 31, 2018

Performance Activity (PA_081)- Implement protocol and procedures for 5A’s and referral process to NYS Quitline, and train

75% of indicated staff. (Due February 28, 2018)

Understand patient’s readiness to engage: 5 R’s included in standards and resources.

Consider group visits to improve access, provide peer support. See resources provided for guidance.

Tobacco use reduction is a self-management goal.

Share best practice- Tracking performance outcomes; Identify exemplary providers/care teams.

3bi cardiovascular disease management project...

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