pcmh: learning session meeting #1 american academy of pediatrics – arkansas chapter october 17,...

PCMH: Learning Session Meeting #1

American Academy of Pediatrics – Arkansas ChapterOctober 17, 2014

Objectives• Introductions• SHARE Presentation: Justin Villines, MBA and Janis Bartlett• Overview of PCMH project: Dennis Z. Kuo, MD, MHS

– Primary Care Trends/General Update: Dennis Z. Kuo, MD, MHS– Upcoming Enrollment Metrics: Dennis Z. Kuo, MD, MHS

• Understanding How Data Drives Change: Dennis Z. Kuo, MD, MHS

• PCMH Milestones- Cheryl Arnold, MHSA, FACMPE • Care Plans: Jo Lynne Varner• Medical Neighborhood: Dennis Z. Kuo, MD, MHS• Information on Re-enrollment: Dennis Z. Kuo, MD, MHS• Questions?

Disclosures

• Support provided by Arkansas Medicaid

Introductions

• Arkansas AAP Leadership– Orrin Davis, MD, FAAP- President– Dennis Kuo, MD, MHS, FAAP – Vice-President– Chad Rodgers, MD, FAAP – Secretary– Chris Schluterman, MD, FAAP - Treasurer

• Arkansas AAP staff– Aimee Olinghouse, Executive Director– Kristen Pfeifer, QI specialist

CONNECTING TO SHARE

Arkansas Academy of Pediatrics

Arkansas PCMH

October 17, 2014

Jan Bartlett, Policy Director

Justin Villines, HIT Policy Integrator

Cindy Osment, SHARE Onboarding

Arkansas Office of Health Information Technology

PRESENTATION AGENDA

1. Overview of SHARE

2. How SHARE can help Clinics

3. Provider and Vendor Status

4. Getting started with SHARE

5. SHARE Demo

SHARE OVERVIEW

WHAT IS SHARE?

• Statewide health information exchange (HIE)• Established with Act 891 of 2011, governed by

HIE Council• Funded with public funds and user fees• Infrastructure for providers, labs, pharmacies,

public health, others to share clinical data• Available to any health care entity willing to

follow requirements and pay user fees

Public Health

Payers

Radiology

Centers

Hospitals

Pharmacies

Medicaid

Labs Clinics

Public Health

Payers

Radiology Centers

Hospitals

Pharmacies

Medicaid

Labs Clinics

PATHWAY TO

HEALTH DATA

1. Secure Messaging– Secure, encrypted email exchange

2. Virtual Health Record (VHR) – View patient health data in SHARE securely online– No EMR/EHR needed– Clinical In box for qualified medical professionals

3. Health Information Exchange (HIE)– Integrates with your EMR/EHR system– Send and receive patient health data– View SHARE patient health data online or in EMR/EHR

3 WAYS TO SHARE

3 WAYS TO

SHARE

WHAT DATA CAN BE SHARED?HL-7 Messages, CCDs and Unstructured Documents• Clinical Care Summaries

• Discharge Summaries

• Lab Results

• Radiology Reports

• Medication Histories

• Allergies

• CCDs

• Problem Lists / Diagnoses

• Referrals

• Transcribed Documents

BENEFITS OF USING SHARESave time • Save money •

Improve patient care • Instantly view patient health data from all points of care

• Make better-informed care decisions

• Easily coordinate care with unaffiliated providers

• Reduce administrative costs for gathering health data

• Track acute care events for your patients

• Meaningful Use (MU)

• Patient Centered Medical/Health Home (PCMH)

• Accountable Care Organizations (ACOs)

• Quality Reporting/Monitoring & Measuring Outcomes

SHARE seeks to facilitate meeting collection and data reporting goals for local and national health improvement activities

VALUE OF

SHARE

TRANSITIONS OF CARE

SHARE is a tool for facilitating transitions of care:• Care Coordination and

PCMH– Alerts transmitted through SHARE

between providers and hospitals – Transmission of ED/Inpatient

admits and discharge data

MEANINGFUL USE CRITERIA

Stage 1• Stage 1, Menu

Measure 9: Capability to submit electronic data to immunization registries or immunization information systems

Stage 2• Stage 2, Core

Objective 15: Provide a summary care record for each transition of care or referral where the recipient receives the summary of care record via exchange

• Stage 2, Core Objective 16: Capability to submit electronic data to immunization registries

WHAT’S IN IT FOR CLINICS?

CLINICS AND PCMH

PCMH practices are required to participate in SHARE:• Obtain patient admission/discharge data

from affiliated hospitals• EMR integration is not required until 2015• OHIT is working with AFMC, AAP, and

Qualis to ensure practices are properly connected to SHARE for PCMH compliance

SHARE FOR PCMH

Arkansas Medicaid’s PCMH initiative requires providers join SHARE to receive in patient discharge and transfer information. These “event notifications” will alert the practice of ED and hospital admissions, enhancing coordination of care for follow up visits and reducing the cost of care.*

*See Arkansas Medicaid PCMH Handbook, 240.000 – Metrics & Accountability for Incentive Payments, Measure J.

SHARE FOR PCMHWhen a Patient whose providers are connected to SHARE is admitted to or discharged from the hospital:

Participating SHARE providers receive an instant notification of the patient’s hospital status in the EMR inbox or SHARE’s VHR inbox.

This allows timely follow up and care management.

• Cloud-based

• Web-based user interface

• Functions like traditional email

• Facilitates HISP services

• Provides notifications to 3rd party

email systems

• Alerts when a message is successfully or unsuccessfully processed /sent

System with expanded features

SHARE SECURE MESSAGING

IMMUNIZATIONS REPORTING

Automate Immunizations Reporting through SHARE:• SHARE has built an interface with ADH• Send immunizations data directly to ADH through SHARE • Simplify workflow by reducing duplicate data entry• Immunizations Registry is “Live”• ELR and Syndromic Surveillance are “Live”• No additional cost to SHARE participants

PARTICIPATION UPDATE

WHO

SHARES?28

7

Health care sites participate,

including 27 hospitals with

(15) Live and 260 practices

in 99+ cities. *As October 16, 2014

CONNECTED PARTICIPANTS NOW

INCLUDEHOSPITALS PRACTICES

• Family Medicine Clinic• Family Doctors Clinic• Claude Parrish CHC• Main Street Medical• Marshall Family Practice• Ronald Reese, M.D.• Newton County Family Practice• Andrew Coble – General & Specialty Surgeon• Internal Medicine Diagnostics, Inc.• UAMS Regional Center – Pine Bluff; Fort Smith• Boston Mountain Rural Health Center (7 sites)• East Ark Health Center (5 sites)• Jefferson Comprehensive Care (6 sites)• Lee County Cooperative Clinic (4 sites)• Willow Street Health• NEA Baptist (37 sites)• Fonticiella Medical Center

• NARMC• AR Children’s Hospital• UAMS• JRMC• Ashley County• McGehee Hospital• Bradley County• White River Health System• Ark Methodist Medical Center• Stone County Medical Center• Conway Regional• Conway Regional Rehab Hospital • Howard Memorial • Magnolia Regional Med. Center• Saline Memorial Hospital

CONNECTING PARTICIPANTSHOSPIT

ALSPRACTICES• UAMS Regional Centers (4 sites)

• ARcare (23 sites)• Apache Drive Children’s Clinic• Conway / Greenbrier Children’s Clinic • Conway OB/GYN• Cornerstone Clinic for Women• Little Rock Pediatric Clinic• The Pediatric Clinic, NLR• Ozark Internal Medicine and Pediatrics• Pocahontas Medical Clinic• The Children’s Clinic of Jonesboro• Sager Creek Pediatrics• MANA• North Central Arkansas Medical Associates• Community Physical Group• The Breast Center• Paragould Pediatrics

Plus many more…

• North Metro Medical Center

• Chicot Memorial• Izard County• Pinnacle Point Hospital

CONNECTED PARTICIPANTSBehavioral Health

PRACTICES

• Families Inc. Counseling Services Corporate Office • Baptist Health Behavioral Service Community • Counseling Services Inc Cornerstone Community

Counseling • Delta Counseling Associates • Centers For Youth And Families• Life Strategies Counseling Inc (Little Rock) • Life Strategies Counseling Inc (Osceola) • Life Strategies Counseling Inc (Paragould) • Life Strategies Counseling Inc (Piggott) • Life Strategies Counseling Inc (Trumann) • Life Strategies Counseling Inc(Jonesboro) • Life Strategies Counseling Inc • Perspectives Behavioral Health Ma Corp • Counseling & Education Center Inc. • Psychiatric Associates of AR PLLC • Mid-South Health Systems

• Plus many more…

• AR Psychiatric Clinic PA• Behavior Management Systems Inc.

Center For Individual &Family Community Service Inc

• Cooper Clinic – Ozark• Dayspring Behavioral Health• Ascent Children's Health Services Youth

Home Inc.• Outpatient Clinic Southwest AR

Counseling Arkansas• Behavioral Healthcare Counseling

Services Of Eastern AR - Forrest City• Family Psychological Center Health

Resources of AR Hometown Behavioral Health Services Hope Behavioral

• Healthcare Jerry Blaylock MD

Behavioral Health PRACTICES

More than

893,596 patients participate

in SHARE

Help for Providers

Negotiating statewide contracts with EHR vendors THAT:1. Reduce or waive one-time

vendor interface fees to connect to SHARE

2. Shorten the implementation timeline

STATEWIDE AGREEMENTS

SHARE is helping the provider community by:

BASIC PRICING FOR PRACTICES

SHARE Fees Estimated Cost

One-Time Setup Fee Waived

Unlimited VHR and SM (for paper EMR and/or Non Interfaced System practices)

$50 per month

Interfaced System with One VHR Primary Clinical User and Clinical SM

$50 per month

Interfaced System with Unlimited VHR Primary Clinical Users and SM

$75 per month

EMR/EHR Vendor Fees Estimated Cost

One-time Fee Varies per vendor

Monthly or Annual Fees Varies per vendor

HOW TO JOIN SHARE

ONLINE OR BY PHONE

Register online at SHAREarkansas.com

OR

Call 501.410.1999

Thank you! Questions?

Now the

DEMO!

Patient-Centered Medical HomeOverview

.

Arkansas Medicaid PCMH• PCMH: “team-based care delivery model led by PCPs

who comprehensively manage patients’ health needs with an emphasis on health care value”

• Goals– Encourage population health management (all children,

regardless of whether they are coming in or not)– Align financial incentives with good preventive care– Supports primary care physicians as key partners

Terms

• Practice transformation: “adoption, implementation, and maintenance of approaches, activities, capabilities and tools” to encourage team-based care and population management– It’s all about the population management– And being proactive with patient care

• Care coordination: “ongoing work of engaging beneficiaries and organizing their care needs across providers and care settings”– This is particularly valuable for children with disabilities and special

health care needs – i.e. the high resource utilizers

Pediatric Practices

• 47 practices enrolled• Arkansas AAP is assisting 15 practices

– Monthly webinars– Weekly contacts– Listserv– Personal discussions– Review of reports

Completion of activity and timing of reporting

Commit to PCMHMonth 0-3

Start your journeyMonth 6

Evolve your proce-ssesMonth 12Activity

Month 16-18 Month 24

▪ Identify office lead(s) for both care coordination and practice transformation1

1

▪ Assess operations of practice and opportunities to improve (internal to PCMH)

2

▪ Develop strategy to implement care coordination and practice transformation improvements

3

▪ Identify top 10% of high-priority patients (including BH clients)2

4

▪ Identify and address medical neighborhood barriers to coordinated care (including BH professionals and facilities)

5

▪ Provide 24/7 access to care6▪ Document approach to expanding access

to same-day appointments7

▪ Document approach to contacting patients who have not received preventive care

9

▪ Document investment in healthcare technology or tools that support practice transformation

10

▪ Join SHARE to get inpatient discharge information from hospitals

11

▪ Incorporate e-prescribing into practice workflows312

▪ Integrate EHR into practice workflows13

Continue to innovate

Activities

▪ Complete a short survey related to patients’ ability to receive timely care, appointments, and information from specialists (including BH specialists)

8

1 - At enrollment; 2 - Three months after the start of each performance period; 3 - At 18 months

Well?

• HOW’S IT GOING????

Bodenheimer, Ann Fam Med 2014

Best practices for transformation

• Culture of QI – develop formalized team process and dedicate time

• Family-centered care – recruit and utilize parent partners to motivate and visualize

• Team-based care – play to everyone’s strengths, collaborate

• Care coordination –develop care plans, dedicate time and staff, collaborate to develop patient-centered goals

McAllister et al. Ann Fam Med 2013

Successes• Looking more closely at/tracking specific information (like

24/7 access) helped to provide consistency within offices.• Tracking patients better to see when they need WCCs, PFTs,

etc.• Hired additional nursing positions/PCMH Care

Coordinators.• Monitoring PFSH components filled out by MD on first visit

with new patients.• Adding EMR software.• Better chart documentation by the physicians.• Opening of walk-in clinic model allowing immediate access

Challenges

• Lag in data• Time (webinars & care plans and audits, oh my! ;)• Inconsistencies with what qualifies as meeting metrics

(often based on subjective judgment of reporting form answers)

• Not having resources to track down patients/get them scheduled

• Some [consultants] more helpful than others• Medicaid enhanced payment set to expire at the end

of 2015 (unless reauthorized)

National trends in primary care

• Reminder: ACA – test innovative payment methods

• Projects that focus on children with medical complexity– High value proposition– Co-management

• Payments may be increasingly tied to adoption of EHR, data, and care plans

What’s ahead in 2015?

• Enroll by 11/17/14• Practices may pool with any number of PCMHs

to form a shared savings entity– Statewide pool also an option

• Beneficiary level data available– Cost data: Q4 2014– Metric data: Q1 2015

What’s ahead in 2015?

• Shared savings – likely to be determined by Q2 2015

• Possible changes in targets– Process metrics may all rise a little– Shared savings – a few will rise

• ADHD, Asthma, adolescent wellness visits

• Considering demonstration of extracting data from EHR

Also-

• Enrollment/Re-enrollment opportunity available here today and at the Pediatric Forum held at ACH tomorrow October 18th 2014

• Please see Kristen for more details.

Questions?

• .

Understanding How Data Drives Change: Dennis Z. Kuo, MD, MHS

Data

• Objective measure of performance– Patient– Physician– Practice (or care team)

• Sources– Payer– EMR– Manual review of chart– Measure patient experience

Data, continued

• Use of data for quality improvement– Set targets– Understand if variation

• Time• Between provider

• Understand performance• Communicate findings• Identify areas for improvement

Concept: Model for Improvement

• What are we trying to accomplish?• How do we know that a change is an

improvement?• What change can we make that will result in

an improvement?

Model for Improvement

• What are we trying to accomplish?– Increase the number of children who have their teeth

brushed• How do we know that a change is an improvement?

– Measurable change• What change can we make that will result in an

improvement?– Know your system– Develop SMART Objectives– Plan-Do-Study-Act cycles

Where does data come in?

• Data drives change– Establish where you are now– Establish your target– Tells you if you are making an improvement

• Data can be very complicated or very simple• You need some sort of objective measure

WHY DATA?

• Essential building block for high-performing primary care

• Measure progress• Understand successes and areas for

improvement• Communicate findings to others

What constitutes data?

• Count data – a raw number• Proportions

– Numerator – the number of children for whom the intervention was successful

– Denominator – the total number of children being measured

• Understand the numerator and denominator

Displaying results

• Run chart– Very simple– Very powerful

• Over time

4071442114

5051451914

6021461614

6301471414

7281481114

8251490814

922140%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Median; 34%

Median; 48%

Target

10 daysMedianTarget

1st UnitSecretaries Trained6/10/14

Last Unit Secretaries Trained 9/10/14

% Hospitalized patients discharged and seen within ten days

UpIs

Best

Cards printed for distribution

Hospitalists review data

What about our data reports?

• Learn from them• Shortcomings

– Delay means they do not provide immediate feedback

– Rolling 12 month averages absorb outliers but mean that recent changes will not be reflected

Know your data reports

• Medicaid Q3 data reporting up to March 31, 2014– Dependent on claims– Data cleaning

• Patient-level data– Discussion about making data available on request

• Cost in Q4 2014; Metrics in Q1 2015• Discuss with HP service desk

• Need to produce your own data

PCMH Milestones/Audit: Cheryl Arnold, MHSA, FACMPE

PCMH AuditAFMC

Central Arkansas Pediatric Clinic PA

Cheryl Arnold, MHSA, FACMPE

AAP: Learning Session & Pediatric Forum, October 17, 201467

Pilot Audit with AFMC

Friday, August 29

On-Site Visit: 2 AFMC representatives

Interview

Review of Assessment

Review of Documentation

Take-Aways


Interview

Informal discussion of activities that CAPC has completed or has in process.

“What we are doing” -- daily basis, especially pertaining to HPBs



Completed Assessment

Documented Strategies for Practice Transformation & processes for implementation

Timeline for Practice Transformation Implementation



Documented Strategies for Care Coordination & processes for implementation

Timeline for Care Coordination Priorities Implementation



Documented Barriers to Care

Documented Approaches to Coordinated Care


Proof of Patient Communication for After-Hours Access

Website

Phone Message

Posted on Public Entries


Same Day Appointment Access

Reviewed written process

Reviewed actual schedule – historic and future


Take Aways --

They thought I was doing better than I did!!!

Document everything you are doing!

Rapid Cycle/ Small Change Process for evaluating and continuing to improve (informal).

Medical Neighborhood and Care Plans: Dennis Z. Kuo, MD, MHS

The Chronic Care Model

From Wagner EH. Figure from Antonelli R (2005). Adapted from Bodenheimer (2002)

Medical complexity

• High value proposition– Small # -> High dollars– Reduce preventable ER and inpatient visits– Increase outpatient management?

• Adult models– Identification based on frequent encounters/high

resource use– Intensive outpatient case management

Allocation of Spending Across Groups

Spending Group

Per

cen

tag

e o

f T

ota

l Sp

end

ing

in E

ach

Gro

up

Least 80% Next 15% Next 4% Top 1%0

20

40

60

80

Emergency Care

Hospital Care

Pharmacy CareOutpatient/community Care

Kuo et al. Pediatric Academic Societies abstract, 2014

Outpatient Spending Across Groups

Spending Group

Rel

ativ

e D

iffer

ence

in S

pen

din

gC

om

par

ed w

ith

th

e L

east

80%

Gro

up

Least 80% Next 15% Next 4% Top 1%0

25

50

75

100

125

PharmacySpecialty Care

Primary Care

Kuo et al. Pediatric Academic Societies abstract, 2014

Providing medical homes for children with complex/chronic care needs

• Population management– Primary care may be underutilized– How much investment in additional primary care

would result in a return on that investment?• What are the mutable (i.e. preventable) costs?

– May not get a big “signal” of excessive costs– Need to identify children at risk up front– Proactive management in outpatient setting

• What are the desirable outcomes?

But wait…there’s more

• “New morbidity”• Psychosocial needs also drive health care use

and needs• Care plan can potentially tie all of this

together

Care mapping

• A comprehensive snapshot of all of a family’s needs

• Useful to illustrate the BIG PICTURE and what families face

• Think about broad categories and then fill in the individual providers

• Start with the child and family in the middle

Case

• 1 year old, CHARGE syndrome• Thymus transplant, immunocompromised• Dysphagia, G tube dependent• Bilateral colobomas• Choanal atresia

• ….think about the number of specialists she needs to see, the services she needs and what her family is facing

Care Plans: Jo Lynne Varner

Care plan

• Documentation of Chief Complaint/Current Problems• Plan of care integrating contributions from health care team

(including behavioral health professionals) and from the beneficiary– Problem based detail of plan of care occurring twice during a 12

month time frame

• Instructions for follow-up– Documentation supporting instructions for follow-up

• Assessment of progress to date– Clear documentation identifying the course of a specific problem and

the status

BONUS VIDEO

• W. E. Deming Red Bead Experiment• http://www.youtube.com/watch?

v=ckBfbvOXDvU

Information on Re-enrollment: Dennis Z. Kuo, MD, MHS

Re-Enrollment Reminder• Enrollment is September 1 through November

17th, 2014 • Current PCMH practices are REQUIRED to re-

enroll.• Please make sure all of your participating

physicians information is up-to-date, if you have new contact leads its important that you update this on the new RE-enrollment forms that will be submitted to HP

New in 2015

• Practices may pool with any number of practices to determine a shared savings entity (5,000 patients)

• Otherwise, statewide pool for shared savings– For those looking for pooling partners, several resources

are available: • List of enrolled PCMH names and locations on the APII

website: http://www.paymentinitiative.org/medicalHomes/Pages/Useful-Links.aspx

• AFMC provider reps

http://www.paymentinitiative.org/medicalHomes/Pages/Useful-Links.aspx

http://www.paymentinitiative.org/medicalHomes/Pages/Useful-Links.aspx

ARKANSAS MEDICAID PATIENT-CENTERED MEDICAL HOME PROGRAM PRACTICE RE-ENROLLMENT AGREEMENT

September 21, 2014 Dear Arkansas Medicaid Provider: Arkansas Medicaid is updating information for current PCMH Providers. Please complete, sign, and return this form to Arkansas Medicaid by email at [email protected] or fax at 501-374-0549. The form must be returned with updated contacts even if there are no changes to your information. Please return this form and any changes attached by 11/17/2014. PCMH ID: <Provider/Group Name, Provider Number>

I wish to stay enrolled as a PCMH Provider with Arkansas Medicaid and have no changes to my current information as shown on the list provided.

I wish to stay enrolled as a PCMH Provider with Arkansas Medicaid, have updates

to my enrollment information, and have completed the remainder of this form. By signing below, the practice, __________________________, hereby agrees to remain enrolled in the PCMH program and agrees to provide the necessary information to update their participation information: _______________________ ______________________ _________________ Authorized Practice Representative Medicaid Billing ID Number Date Your practice lead will be the primary contact for the PCMH program. All notifications will be sent to the information provided below.

Primary Contact Secondary Contact

Name: __________________________ Name: ____________________________

Phone: __________________________ Phone: ____________________________

Email: __________________________ Email: ____________________________

PCMH PRACTICE UPDATE/CHANGE REQUEST FORM ADD PHYSICIANS Please list the required information for the physicians you want to enroll under your practice: NOTE: Please add the date of the recently joined physicians below to be added to your PCMH. 1. Physician Name: ______________________________________

Individual Medicaid Provider ID: ______________________________________

NPI: ______________________________________

Date joined: ______________________________________

Signature: ______________________________________

2. Physician Name: ______________________________________


NPI: ______________________________________

Date joined: ______________________________________

Signature: ______________________________________

3. Physician Name: ______________________________________


NPI: ______________________________________

Date joined: ______________________________________

Signature: ______________________________________ 4. Physician Name: ______________________________________


NPI: ______________________________________

Date joined: ______________________________________

Signature: ______________________________________ 5. Physician Name: ______________________________________

WITHDRAW PHYSICIANS Please list the required information for the physicians you want to withdraw from your practice: NOTE: Please remove only physicians who have recently left your practice, and include the date the

physician left.

1. Physician Name: ______________________________________


NPI: ______________________________________

Date left: ______________________________________

2. Physician Name: ______________________________________


NPI: ______________________________________

Date left: ______________________________________

3. Physician Name: ______________________________________


NPI: ______________________________________

Date left: ______________________________________

4. Physician Name: ______________________________________


NPI: ______________________________________

Date left: ______________________________________

PARTICIPATING PHYSICIANS PCMH ID: <Provider/Group Name, Provider Number> We have provided a list of the physicians currently enrolled in your practice. Please reference this when updating your status. <Insert Excel Table Here>

pcmh: learning session meeting #1 american academy of pediatrics – arkansas chapter october 17,...

Documents

health data slide

share overview slide

share demo slide

transitions of care

overview of share

health care entity

patient care

points of care