2018 hccn spring learning session - flux console hccn june 2018... · b1 data quality increase % of...

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

St. Gabriel Community Health Center

CASSE Dental Health Institute

2018 HCCN OSV May 2-3, 2018

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)

CHALLENGES• Decrease in MU providers

• Changes in MU program

• HIE connectivity

• Limited IT abilities at local level

2018 HCCN OSVPromising Practices Identified

• 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

Year 3 HCCN – Individualize Work PlanHealth Center Focuses

• 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***

Year 3 HCCN – Individualized PHC Work Plan

Quarterly Reporting Schedule

NNOHA Educational Series National Network for Oral Health Access

• 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

NNOHA Educational Series National Network for Oral Health Access

• 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

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

Overview of Current StateAzara DRVS in LA HCCN

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

Final Deadline:

June 30, 2018

(After this HCCN cannot guarantee financial

support)

Connectivity PhaseEstablishing connectivity with EHR

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

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

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!

Diabetes Lab Registry

Diabetes Dashboard

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

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

Focus Area Objective Baseline Num/Dem Current Goal

Certified EMR

Adoption and

Implementation

Increase the % of

PHC’s with an

ONC-certified

100% 31/31 100% 100%

Advance

Meaningful

Increase the % of

providers at

PHC’s receiving

MU incentive

payments from

52% 141/347 41% 75%

Focus Area BData and Quality Reporting

B1 Data Quality

Increase % of PHCs that

extract EMR data to report

UDS CQMs for ALL patients

35% 19/31 61% 100%

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

integrate data from different

service types

58% 27/31 87% 85%

Focus Area CHIE and Population Health Management

Health

Information

Exchange

Increase % of

PHCs with

communicating to

45% 22/31 71% 90%

Population

Health

Management

Increase % of

PHCs using HIEs

for pop health

26% 14/31 45% 90%

Focus Area DQuality Improvement and Patient Centered Medical Home

D1Clinical Quality

Improvement

Increase % of PHCs that meet

or exceed HP2020 goals on

5/8 UDS CQMs

0% 1/31 3% 50%

Operational

Quality

Improvement

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

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

• 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

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

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%

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

• 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

• 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

• 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

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: jfabre@tabhealth.org

Phone: 337-355-2309

Web: www.tabhealth.org

Twitter: @techeactionclinic

Facebook: facebook.com/techeactionclinic

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%

86%72%

Females

Baseline (March 2017) Follow-Up (December 2017)

0%10%20%30%40%50%60%70%80%90%

54%40%

90%80%

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

2 Year Old Immunization Dashboard

Measure Analyzer

Measure Analyzer (Cont’d)

Immunization Registry

Immunization Registry (Cont’d)

Patient Reminder Postcards

DRVS Immunization Mapping

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?

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

MPCA’s 2010 ARRA Funding Path to DRVS

• Elected to outsource data warehouse,

reporting application – purchased Azara

• 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

• Meaningful Use

• UDS

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

• Clinical

• Operational

• Advance PCMH Status

MPCA’s Data Warehouse- DRVS

Vision developed in partnership with Azara: www.azarahealthcare.com | info@azarahealthcare.com | 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

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

Population Health for Leaders, Staff, and Stakeholders

• Provider training on population health management

concepts

• Rethink provider and staff reimbursement models

• Address transformation fatigue

POPULATION HEALTH DEFINED

The Challenge: How Can PCAs and CHCs be

Successful in this Shifting Environment?

• Quadruple Aim

• 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

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

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

Private Insurance

MedicaidUninsured

Managed Medicaid

Assigned by MCO, but Unseen

Primary Care Health Home

Established

Adult, Blind, Disabled

Medicare

Population: By Condition or Factor

Diabetes

Substance Use

Disorder

Multiple Chronic

ConditionsHigh Utilizers

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

Components of Population Health Management

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

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

Advocacy

Advocacy: Scorecard (Demo)

www.azarahealthcare.com | info@azarahealthcare.com | 781.365.2208

Dashboards (DEMO)

Advocacy

Quality Improvement

• Patient Visit Planner

• Measure Analyzer

• Scorecards

• Registries

• Dashboards

Quality Improvement: Patient Visit Planning Report (Demo)

Additional cost forReferral Module

Quality Improvement: Clinical Quality Measure (DEMO)

QI: No Show Operational Measures (DEMO)

Measure Filtering (DEMO)

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

• 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.

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)

• Sort by Numerator to identify out of compliance patients

• Export to PDF or Excel. Create an outreach list for staff to

contact as appropriate.

Grab lunch and come back to the room!!

Advocacy

Quality Improvement

Care Coordination

Care Coordination: Registries

• SDOH

• Primary Care

• Childhood Immunizations

• Depression

• Risk Registry

• Chronic Pain

• Transitions of Care

– ED & IP Discharge

Clinical Patient Registries (Demo)

SDOH Registry (Demo)

Azara Proprietary & Confidential109

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

Advocacy

Quality Improvement

Care Coordination

• Care Management Passport

– Assessment

– SDOH

• Transitions of Care

– Care Coordination

• Registries

– Risk Stratification

• Patient Visit Planner

Daily Operations: Care Management Passport (DEMO)

Diagnostic Values

Daily Operations: Transitions of Care (DEMO)

• Care Coordination (CC)

– Identify Hospital and ED Visits

Transition of Care Report Example:

Advocacy

Quality Improvement

Care Coordination

Support for $$ Incentives and

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

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

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

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 | info@azarahealthcare.com |

781.365.2208

Keeping Your Data Healthy

DailyVisit Planning

WeeklyRegistry &

Care Mgmt Reports

Monthly Quality &

Performance Mapping

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.,

Review Mapping Administration

Measure Investigation Tool (MIT) – Access (DEMO)

“Right Click” any patient in the Detail List

– Select “Investigate Measure”

Measure Investigation Tool (MIT) – Example(DEMO)

The MIT displays what parts of the patient’s information meet a

measure’s criteria

123Azara Proprietary & Confidential

Measure Investigation Tool (MIT) – Example(DEMO)

Patient Not In Measure Criteria

Bridging the Quality Chasm

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

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

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

Report Out of Activity

• Key items identified regarding:

• Systems

• Operations

• Results

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

MPCA Center for Quality Team

3325 Emerald Lane

Jefferson City, MO 65109

573-636-4222

• Angela Herman-Nestor MPA, CPHQ, PCMH-CCE:

aherman@mo-pca.org

• Noelle Parker, MBA, CMPE, PCMH-CCE:

nparker@mo-pca.org

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

• 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.

Patient

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

“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

Disease Management

Medical Home

Population Health

Ambulatory Redesign

Communications

Disease Management

Medical Home

Population Health

Ambulatory Redesign

Communications

Disease Management

Medical Home

Population Health

Ambulatory Redesign

Communications

Disease Management

Medical Home

Population Health

Ambulatory Redesign

Communications

IGG CCC

IGGCCC

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

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

61248393

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

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

16762797

SITES over QUARTERS

Graph uses data from quarters 200801 through 201103

diabetes: A1c<7, LDL<100, BP<140/90denom: PC Sustained, 6/12

52795 136

613 274 201 1910

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

20012002

20032004

20052006

20072008

20092010

20112012

UTIL: ED visits/person (quarter)lowEF pop 3+ mos

Heart Failure Disease Management Program

20012002

20032004

20052006

20072008

20092010

20112012

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

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

jcouk@lsuhsc.edu

Nathan Daigrepont

Clinical Projects Director

ndaigr@lsuhsc.edu

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

gdavis@lpca.net

Christopher Obafunwa, MS, MBA

HIT Director

503 Colonial Drive

(225) 927-7688 ext 211

cobafunwa@lpca.net

Amy Pruim, MPH, CAPM

Data Analyst

503 Colonial Drive

(225) 927-7688 ext 215

aprium@lpca.net

Christine Foerstner

HCCN & Finance Director

503 Colonial Drive

(225) 927-7688 ext 205

cfoerstner@lpca.net

Brandi Bourgeois, MPH, PMP

HCCN Project Manager

503 Colonial Drive

(225) 927-7688 ext 213

bbourgeois@lpca.net

Shannon Robertson, RN, BSN

Clinical Quality Director

503 Colonial Drive

(225) 927-7688 ext 201

srobertson@lpca.net

Dara Stout, PMP

Practice Management Coord.

503 Colonial Drive

(225) 927-7688 ext 202

dstout@lpca.net

Susie Hutchinson, CAPPM, CMSR, PCMH CCE

Practice Management Director

503 Colonial Drive

(225) 927-7688 ext 212

shutchinson@lpca.net

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