Practice Innovation Institute Update 2018 Health Current Summit - - PowerPoint PPT Presentation

Practice Innovation Institute Update

2018 Health Current Summit & Trade Show December 4, 2018

Pii is….

• Arizona’s Practice Transformation Network (PTN)

– a collaboration among Health Current and Mercy Care – funded under the national CMS Transforming Clinical Practice Initiative (TCPI)

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Practice Innovation Institute (Pii)

Executive Sponsors Clinical Faculty Advisors PTN Director Directors Data/Analytics Practice Transformation Consultants HIE Account Management Finance Coordinators Policy Training

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Pii Team

In one word, Pii is UNIQUE

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Pii

Pediatric Clinically Integrated Network Outpatient Behavioral Health FQHC’s

Specialty Practices

Crisis services, Corrections Integrated Health Homes Statewide Health Information Exchange Mercy Care Equality Health Network

AIMs/Goals: Primary & Secondary Drivers

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Progress Towards Commitments – Results as of the end of Year 3

AIM 1 – Enrollment AIM 2 – Improve Health Outcomes AIM 3 - Reduce Unnecessary Hospital Use AIM 4 – Reduce Costs AIM 5 – Reduce Unnecessary Tests & Procedures Commitment– 2,500 Clinicians Commitment – 19,032 improved Commitment - 65,881 avoided Hospitalizations Commitment – $81,549,090 saved Commitment – 2,737 reduction 2,587 Enrolled 100% 17,368 improved 91% 50,036 avoided 76% $124,765,344 saved 153% 3,801 reduction 139%

0% 20% 40% 60% 80% 100%

Enrollment Transformation Clinical Outcomes Reduction in Hospitalizations Cost Savings Reduction in Test & Proc

TCPI Pii

Progress Towards Commitments – Results as of the end of Year 3

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5 Phases of Transformation

Pii Practices That Have Completed the 5 Phases of Transformation

• A New Leaf
• Arizona’s Children’s Association
• Bayless Integrated Healthcare
• Biltmore Ear Nose & Throat
• ConnectionsAZ
• Crazy About Kids Pulmonary Services
• Crisis Preparation and Recovery
• GB Family Care

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Pii Practices That Have Completed the 5 Phases of Transformation

• Horizon Health And Wellness
• Jewish Family & Children’s Service
• LaFrontera EMPACT
• Maricopa County Correctional Health Services
• Mountain Park Health Center
• Native Health
• Neuromuscular Clinic and Research Center
• North Country Healthcare
• Open Hearts Family Wellness

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Pii Practices That Have Completed the 5 Phases of Transformation

• OrthoArizona
• Pendleton Pediatrics
• Phoenix Children’s Medical Group
• Pulmonary Consultants
• Relieve Allergy Asthma & Hives

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LESSONS LEARNED

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Inclusion of the patient voice in practice

• perations

Shared decision- making among clinicians & patients Use of e- technology to engage patients & family Assessment to gauge patient readiness to be “activated” as a partner in their care Measurement of patient health literacy Support for patient medication use

The Importance of Patient & Family Engagement

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• Does the practice use an e-tool that is accessible to both patients

and clinicians and that shares information?

• Does the practice support shared decision-making?

Point of Care

• Does the practice utilize a tool to assess and measure patient

activation?

• Does the practice utilize a tool to assess and measure health

literacy?

• Does the practice promote patient-centric medication

management practices?

Policy & Procedure

• Does the practice have policies, procedures, and actions to support

patient and family participants in governance or operational decision-making?

Governance

TCPI PFE Metrics

The Importance of Patient & Family Engagement

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• Beyond the Metrics

– Measure & Monitor

• Capture current and emerging efforts
• Enhance existing practice and expand efforts

– Evaluate for Best Practice(s)

• Implementation, Change Management
• Most effectual evidence-based interventions/tools in

practice – Scale & Replicate – Build off successful, exemplified implementation practices – Prioritize evidence-based practices with greatest impact

The Importance of Patient & Family Engagement

• Connecting the Dots

– Using technology to build patient registries – Linking clinic and community initiatives to data drive quality improvement projects – Using patient centered design techniques for improvement – Patient and Family Advisory councils

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The Importance of Patient & Family Engagement

Engagement of Patient and Family is highlighted in each transformation plan

Importance of HIT Tools

HIT Platform Services & Applications Data Sources Used by clinicians Used by

• ther staff

CareQuotient

• Population Health &

Analytics

• Predictive Analytics
• Benchmarking
• Risk Stratification
• Claims from

health plan

Care Unify

• Care Management
• Care Pathways
• Risk Stratification
• Patient Panels
• Alerts & Notifications
• Claims from

health plan

• HIE ADTs

Health Current Health Information Exchange (HIE)

• Alerts
• Clinical data aggregation
• Clinical data repository
• Direct secure e-mail
• Provider Portal (query &

response)

• Newly implemented High

Risk Member Report

• Providers, via

direct connection

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Importance of HIT Tools

• Health Current (HIE) - Over 55 Pii organizations are

connected with the HIE either receiving alerts, accessing provider portal and/or sharing data

– Alerts have notified clinicians of ED visits and discharges in

• rder to coordinate appropriate follow-up care

– Connectivity has provided clinicians with patient history information to help reduce unnecessary testing and admissions

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Access to real time information and alerts in

• rder to facilitate care

and care coordination

Importance of HIT Tools

• Population Health Management

– CareQuotient – Implemented at 14 Pii Organizations

• Utilizes Mercy Care claims data
• Provides data on key measures for health plan paneled

patients – HIE High Risk Report

• Utilizes HIE data
• Scores patients on factors

(ED utilization, IP stays, A1c, and radiology)

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Identification of high risk patients is critical to patient care management

• Practices are deploying targeted approaches

– Opioid Management – Diabetes Control – Joy in the Workplace – Breaking down barriers

• Optimizing use of PDSA lifecycle
• Education on management protocols

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Importance of Targeted Approaches

• Education

– Arizona Opioid Epidemic Act signed the into law by Governor Ducey on January 26, 2018 – Provision of one-on-one technical assistance – Collaborative educational sessions ongoing

• Care Coordination

– Intensive care coordination – Development and implementation of Medical Neighborhoods – Leadership Engagement – Adoption of data-driven quality improvement methodology for practice transformation

• Use of HIT Tools

– Use of CareQuotient

• 2 HEDIS measures for tracking/monitoring created in CareQuotient

– PDMP

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Tackling the Opioid Epidemic

Success Story – Opioid Management

• St. Elizabeth’s Health Center
• Medical Director (Dr. Mark Schildt) took on role of champion

to address opioid epidemic within the organization

• Revised policies & procedures
• Identified at-risk population

– Relationships developed – Proper referrals to behavioral health and/or MAT provider utilized – Utilization of PMP for monitoring

Evaluation of 2 HEDIS opioid measures indicates consistent decrease of dosage and length of use since inception of above

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Success Story – Diabetes Control Native Health, Horizon Health & Wellness, St. Elizabeth's Health Center, and Mountain Park Health Center

• 7,977 members with A1c values greater than 9
• Management of these diabetic members showed an 11% (862

members) improvement rate in A1c values

• An 11% improvement in this complex population demonstrates the

effectiveness of focused management of chronic disease members with abnormal lab values

• Of note, this analysis does not include improvement in A1c values for

members whose last value was less than 9

Diabetes A1c > 9 (NQF 59) Commitment– 693 patient that will improve by Year 4 667 patients improved by end of Q11 96% of Commitment

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Success Story – Joy in the Workplace

The MomDoc LEARN! Program was designed to promote opportunities for the personal development of participating employees. Ten different learning modules were

• ffered:

✓ Leadership ✓ MomDoc Culture ✓ Español ✓ Personal Finance ✓ Food & Fitness ✓ The MomDoc Difference ✓ Workplace Skills ✓ Creating Happiness ✓ CPR Certification ✓ MomDoc 2018 Roadmap to Greatness

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GB Family Care

• Implementing a Medical Home partnership through co-location of

the practice with Valle del Sol

• Eliminating the barrier – literally – to behavioral health care for their

patients by remodeling their office to include a connecting door between the two practices

• Integrating leadership meetings and patient co-management into

work flows

• Closing the communication and care coordination loop by sharing

access to their EHR system with their BH partner

Success Story – Breaking down barriers

• AHCCCS Targeted Investment Program (TI)

– Identification of High Risk Membership – Development of operational workflow process (such as validation of eligibility) – Creation of Social Determinants of Health (SDOH) tracking methodologies – Alignment with Health Information Exchange activities – Leverage national resources for training and operational process flow development *such a trauma informed care – Cultivate relationships between practices (connections of BH and PH practices)

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Importance for Preparing for Value- Based Programs

• Establishing a Medical Neighborhood which tracks and refers

patients to regular screening examinations

• Using the Health Information Exchange to track and respond

to ADT notices

• Creating leadership support for and implementation of

innovation throughout the organization

• Adopting an integrated model of medicine
• Adding patient activation questions to member survey
• Integrating leadership meetings and patient co-management

into work flows

• Engaging members in integrated treatment plans
• Implementing a process for recording depression and

smoking screening in visit notes to provide tracking data leading to improved treatment and follow-up

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Reported Key Factors of Success

• Implementing a Family Advisory Council
• Using a practice-based Care Management team to review

ADTs, engage patients to schedule follow-up appointments and, ultimately, reduce hospital re-admissions

• Identifying high risk patients through the population

management tool and existing Electronic Medical Record

• Utilizing intake and discharge processes to capture, measure

and respond to changes in patient or family quality of life and to achieve individual service goals

• Creating clinical assessment processes to identify patients for

same-day appointments or immediate BH coaching

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Reported Key Factors of Success

• Coordinating care delivery through primary care physicians

and community resources in their Medical Neighborhood

• Adoption of practices to track and use data in the

management of patient population including high risk / high cost members

• Successful engagement of patients and family in the decision

making and care plan development and modifications

• Inclusion of all level of staff in the quality improvement

process

• Employs documented evidence based protocols to support

improved clinical outcomes that are scalable

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Reported Key Factors of Success

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Questions