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How Do You Identify Gaps in Care?
Population Health
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How to Identify Patient Gaps in Care Angela Hale Quality - - PowerPoint PPT Presentation
How to Identify Patient Gaps in Care Angela Hale Quality - - PowerPoint PPT Presentation
How to Identify Patient Gaps in Care Angela Hale Quality Improvement Advisor PHA Physicians April 28, 2017 How Do You Identify Gaps in Care? Population Health Value Driven. Health Care. Solutions. 2 Define Gaps in Care The management of
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Define Gaps in Care
The management of most medical conditions is influenced by gaps in care: the discrepancy between recommended best practices, and the care that’s actually provided Gaps in care can be referred to as gaps in office visits, lab tests, procedures, and pharmaceuticals Gaps are usually the result of obstacles preventing patients and physicians from implementing care recommendations
– Age – Gender – Condition – Complications
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Why Measure Gaps in Care?
Centers for Medicare and Medicaid Services requirements
– MACRA/MIPS – Cost utilization
Value-based care incentives
– HEDIS
Triple Aim
– Improve the health of the population – Enhance the patient experience of care (including quality, access, and reliability) – Reduce, or at least control, the per capita cost of care
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Where Do You Start?
Key to measurement
– Population health – EHR/Registry/Excel
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IT SUPPORT
EHR Capabilities
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EHR Support
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EHR Support
Can your EHR build the reports to pull discrete data?
– A list of patients by age, gender, conditions, preventative services completed
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I Don’t Have an EHR – Now What?
A list of patients by age, gender, conditions, preventative services completed by your billing service OR in an Excel spreadsheet
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EVIDENCE-BASED CARE MEDICINE
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Evidence-Based Care Medicine
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Evidence-Based Care Medicine
Can your EHR build the guidelines to set alerts? Where do the guidelines come from?
– HEDIS reports – Choosing Wisely – United States Preventive Services Task Force (USPSTF) – National Quality Foundation (NQF)
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R
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CARE COORDINATION
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Care Coordination
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Team Responsibilities
- Receptionist
- CMA/roomer
- LPN/RN
- Care manager
- Provider
Team Approach
- Everyone knows
their role
- Routine huddles
NOTE: Not just for primary care providers
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Care Coordination
Planned care visit
– Chart prep work
– Are results received, referral summary in record, due for preventative visits – Tracking tests/referrals
– Outreach
– Ordered tests not completed – Preventatives not done – Missed appointment
Short video on PCV www.improvingchroniccare.org
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PATIENT ENGAGEMENT
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Patient and Family Engagement
Why are they not engaged?
– Patient comments
– “It’s too hard” – “I don’t have time for that”
In the United States, some 3.8 billion prescriptions are written every year, yet over 50% of them are taken incorrectly or not at all
Note: http://www.medscape.com/viewarticle/818850
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Patient and Family Engagement
What is the level of health literacy of the patient/family? Is there a cognitive issue? What other barriers could be there? Is it functional (basic reading/writing) or is it interactive (social/cultural)? How much education have we given the patient?
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Patient and Family Engagement (Cont’d)
Screening for patient barriers
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Health Literacy
- REALM-SF score
- Test of Functional Health
Literacy in Adults (S- TOFHLA)
- Newest Vital Sign (NVS)
Cognition
- Mini-Mental State
Examination (MMSE)
- Montreal Cognitive
Assessment (MOCA)
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Patient and Family Engagement (Cont’d)
Simple message from the primary care provider:
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“Diabetes is a serious condition. There are things you can do to live better with diabetes and things the medical team can do to assist
- you. We are going to work together on this.”
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Patient and Family Engagement (Cont’d)
Patient Action Plans
– Patient sets goals
– What do you want to work on? – What are some barriers you see? – How can you overcome those barriers? – How confident are you in being successful?
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THE ROAD TO CLOSING THE GAP
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Closing the Gap
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Measure the Gaps
What about those non-compliant patients? Specialists who have an point of care (POC) can be a big proponent of closing the gap Is someone besides the insurance carrier looking to see if you are provided good care?
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Closing the Gap
Measure the Gaps
– Run a regular report that shows what is missing – Look at your patient panel
– Who has not been in over 12 months to 24 months
– Start with one condition
– A large population
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Example: Closing the Gap
Diabetic Patient
- 1. Pull report/registry of those patients
- 2. Identify gaps
- 3. Conduct patient outreach
- 4. Prep patient chart
- 5. Track the tests/referrals
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QUESTIONS
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Angela Hale ahale@medadvgrp.com Beth Hickerson bhickerson@medadvgrp.com Kelly Montague kmontague@medadvgrp.com
advgrp.com
Value Driven.Health Care. Solutions.