C LINICS AT A T IME : L ESSONS F ROM E VIDENCE NOW PCORI A NNUAL M - - PowerPoint PPT Presentation

ADVANCING PRIMARY CARE A THOUSAND CLINICS AT A TIME: LESSONS FROM EVIDENCENOW

PCORI ANNUAL MEETING

Deborah Cohen, PhD September, 2019

EvidenceNOW Targets | PRACTICE CAPACITY AND ABCS

EVIDENCENOW COOPERATIVES | REGIONAL MAP

CHARACTERISTICS OF EVIDENCENOW PRACTICES

Characteristic, n(%) EvidenceNOW N=1,495 ORPRN N=94 Practice location Urban 951 (63.6) 33 (35.1) Large Town 202 (13.5) 32 (34.0) Rural 235 (15.7) 18 (19.1) Suburban 107 (7.2) 11 (11.7) Classified as Medically Underserved Area 494 (33.0) 41 (43.6) Practice size Solo practice 357 (23.9) 7 (7.4) 2 to 5 clinicians (MD, DO, NP, PA) 699 (46.8) 47 (50.0) 6 to 10 clinicians 205 (13.7) 20 (21.3) 11 or more clinicians 159 (10.6) 20 (21.3) Practice ownership Clinician 605 (40.5) 36 (38.3) Hospital / health system / HMO 342 (22.9) 43 (45.7) Government clinics (FQHC, RHC, IHS) 322 (21.5) 12 (12.8) Other 166 (11.1) 3 (3.2)

BASELINE PRACTICE CAPACITY DISTRIBUTION

BASELINE ABCS PERFORMANCE

Measure Mean (sd) performance Cooperative mean range Smoking 0.55 (0.33) 0.24-0.75 Cholesterol 0.56 (0.24) 0.34-0.68 Blood Pressure 0.63 (0.17) 0.57-0.69 Aspirin 0.60 (0.28) 0.3-0.73

Ono SS, Crabtree BF, Hemler JR, Balasubramanian BA, Edwards ST, Green LA, Kaufman A, Solberg LI, Miller WL, Sweeney SM, Woodson TT, Cohen DJ. Takin ing g Inno novatio ion to S Scale i le in P Prim imary C Care P e Practic ices: T : The F he Func nctio ions o

• f Healt

lth h Care Extensio ion. n. Health Affairs. Febru ruary ry 2018. 2018.

PRACTICE FACILITATOR WORKFORCE

Cooperative 1 Cooperative 2 Cooperative 3 Cooperative 4 Cooperative 5 Cooperative 6 Cooperative 7 Total Number of Practice Facilitator Organizations

9 7 2 2 2 16 2 40

Number of Practice Facilitators

31 17 17 16 19 35 23 158

Mean EN Practice Panel Size*

7.9 13.2 16.1 12.8 11.5 6.9 11.0 11.3±

FACILITATION

DOSE| IN-PERSON PRACTICE FACILITATION

METHODS INTERLUDE

CONFIGURATIONAL COMPARATIVE METHODS

CHANGE IN ABCS | SMOKING

OUTCOME CLUSTERS | SMOKING 1, 2 AND 3

OUTCOME CLUSTERS | SMOKING 4, 5 AND 6

OUTCOME CLUSTERS | SMOKING 7 AND 8

OUTCOME CLUSTERS | SMOKING 9 AND 10

PRACTICE CHANGES|CHANGES REPORTED TO IMPROVE SMOKING

• Documentation
• Process improvement
• Referral resources
• Track referral to quit line
• Outreach
• Staff Education

PRACTICE CHANGES|CHANGES REPORTED TO IMPROVE SMOKING

Practice Change Definition Documentation Evidence that someone in practice learned they were not documenting correctly and reported working with vendor and/or PF to change documentation behavior Process Improvement Changes to practice workflows beyond documentation; might include working with clinicians to make sure they do brief counseling changing workflow so that Mas do something different to provide brief counseling/referral for patients Referral Resources Give information about quit lines and other resources to patients Staff Education Efforts to educate staff in the practice about importance of smoking cessation counseling

SMOKING|NEGATIVE SOLUTIONS

Practices that did not achieve a 5-point gain in smoking performance had:

• Absence of process improvement and a smaller dose of facilitation (less

than 10 hrs.)

• Were hospital or health system owned
• Baseline 90-95%- started at a higher baseline

Ownership – control over QI process

• Health systems voluntold practices
• Facilitators did not always work directly with health system practices
• HS practice, even if they were engaged, didn’t have control of the change

process and the change process was slower and more complex

• Didn’t have the data needed to do data informed QI and slow to get this

from system

• might be told what workflows to implement (which could reduce

engagement, even among the engaged)

• when staff developed their own change plan, these needed system level

approvals.

MEAN CHANGE OVER TIME | BLOOD PRESSURE

OUTCOME CLUSTERS | BLOOD PRESSURE CLUSTER 1 AND 2

OUTCOME CLUSTERS | BLOOD PRESSURE CLUSTER 3 AND 4

OUTCOME CLUSTERS | BLOOD PRESSURE CLUSTER 5

CCM |PRACTICE SAMPLE FOR BLOOD PRESSURE

5% Change Analysis (N=69) 10% Change Analysis (N=76)

Practice Characteristics Number Percent Number Percent Ownership Clinician owned 41 59.4% 44 57.9% Hospital/Health System 15 21.7% 16 21.1% FQHC 9 13.0% 9 11.8% Other 4 5.8% 4 5.3% Parent Organizations Orgs with >1 practice in QCA sample 8 NA 8 NA Practices part of a parent organization 18 26.1% 19 25.0% Practice Size Solo practice 22 31.9% 22 28.9% 2-5 clinicians 37 53.6% 40 52.6% 6-10 clinicians 7 10.1% 8 10.5% 11 or more clinicians 2 2.9% 2 2.6% Geographic Region / Cooperative Midwest (IN, IL, WI) 14 20.3% 14 18.4% North Carolina 6 8.7% 11 14.5% Northwest (OR, WA, ID) 7 10.1% 7 9.2% New York City (five NY boroughs) 15 21.7% 16 21.1% Oklahoma 9 13.0% 9 11.8% Southwest (CO, NM) 11 15.9% 11 14.5% Virginia 7 10.1% 8 10.5% Urbanicity Rural Area 8 11.6% 9 11.8% Large Town 12 17.4% 12 15.8% Suburban 5 7.2% 5 6.6% Urban Core 44 63.8% 50 65.8%

CCM |PRACTICE CHANGES REPORTED TO IMPROVE CMS BLOOD PRESSURE MEASURE

• Blood pressure measurement training
• Patient education
• Registry / outreach
• Subsequent blood pressure check
• Take 2nd blood pressure measure during visit
• Auto blood pressure cuff
• Clinical guidance
• Documentation
• Alert doctor to add blood pressure to agenda

CCM |PRACTICE CHANGE DEFINITIONS

Practice Change Definition Blood pressure measurement training Educating staff in the practice to take a proper blood pressure Patient education Practices using new educational materials directed to patients to teach them about blood pressure control Subsequent blood pressure check Encourage patients to get subsequent blood pressure checks (e.g., free nurse visit to check blood pressure) Take 2nd blood pressure When the intake blood pressure reading is elevated, someone take a second measurement at the end of the visit Documentation Developing system for how a second BP is documented in the EHR

RECIPES FOR CHANGE|BLOOD PRESSURE 5%

RECIPES FOR CHANGE|BLOOD PRESSURE 10%

BLOOD PRESSURE|NEGATIVE SOLUTIONS

Practices that did not achieve a 5-point gain in blood pressure performance had:

• Fewer than 5 visits with a facilitator AN

AND absence of “Take 2nd Blood Pressure”

• Less than 5 hours of facilitation
• 5 to 10 hours of facilitation AND absence of “Blood Pressure Measurement Training”
• 10-25 hours of facilitation AND absence of “Subsequent Blood Pressure Checks” AND

either absence of “Take 2nd Blood Pressure” OR OR absence of “BP Measurement Training”

• 10-25 hours of facilitation AND “Rural Area”
• 25-50 hours of facilitation AND Substantial Presence of “Registry/Outreach”
• More than 50 hours of facilitation AND absence of “Take 2nd Blood Pressure” AND absence
• f “Subsequent Blood Pressure Checks”

THE TEAM

THANK YOU

escalates@ohsu.edu escalates.org @ESCALATESorg