Framework for Sustainability: Perspectives from CHIPRA State Grantees

Transcription

1 Framework for Sustainability: Perspectives from CHIPRA State Grantees Facilitated by Henry T. Ireys Senior Fellow, Mathematica Policy Research Director, National Evaluation of the CHIPRA Quality Demonstration Program The CMS Healthcare Quality Conference Baltimore, MD December 2 4, 2014 Follow us on Tweet with our conference hashtag: #QualityNet14

2 Agenda National Evaluation of the CHIPRA Quality Demonstration Grants: Strategies for Sustaining Success Henry Ireys From Innovation to Sustainment: Pennsylvania s CHIPRA Demonstration Grant Experience David Kelley Systems Building, Reliability, and Sustainability: The North Carolina CHIPRA Quality Demonstration Grant Marian F. Earls 2

3 National Evaluation of the CHIPRA Quality Demonstration Grants: Strategies for Sustaining Successes Henry T. Ireys Senior Fellow, Mathematica Policy Research Director, National Evaluation of the CHIPRA Quality Demonstration Program

4 Sustainability: Definitions The endurance of systems and processes (Wikipedia) Continuation of programs and practices after initial implementation efforts or funding is over (Blasinsky et al. 2006) 4

5 Sustainability: How Do You Get There? What contributes to sustainability? Specific contributing factors vary by location States and regions Local communities Organizations and practices 5

6 From Innovation to Sustainment: A Conceptual Framework NEW PROGRAM OR PROCESS Political, Economic, Legislative Trends Refinements made Evidence (or not) of successful implementation or outcomes FACTORS INFLUENCING SUSTAINABILITY Extent of mutual adaptation between program & institutional home Alignment with new or emerging priorities & initiatives ADOPT OR ADAPT PROGRAM? YES REVISED PROGRAM OR PROCESS FUNDING ENDS Marketing effort of program champions/leaders Strength of evidence for positive effects Presence & role of stakeholders Workforce characteristics New funding is found Existing funding is re-allocated Key activities, components become institutionalized Staff is retained or retrained PROGRAM OR PROCESS ENDURES IN SOME FORM 6

7 Questions for Discussion Groups During Later Breakout Session What steps can you take to move the project or key components toward mutual adaptation? How can you align your efforts to emerging initiatives, such as the Innovation Accelerator Program (IAP) or new statebased programs? What information or evidence can help market key activities? 7

8 Mutual Adaptation: An Example from the CHIPRA Demonstrations 11 of 12 practices in Utah committed to finding funds in operating budgets to keep medical home coordinators (MHCs) Mutual adaptation at practice level: Use MHCs for both quality improvement (QI) work and care coordination 8

9 Alignment: An Example from the CHIPRA Demonstrations Georgia s certified peer specialists (CPSs) likely to continue Peer support aligns with recovery-oriented shift in state s behavioral health system Aligns with definition of parent peer support in Georgia s Medicaid State Plan 9

10 Marketing: An Example from the CHIPRA Demonstrations Illinois launched perinatal quality collaborative Numerous meetings, conferences, webinars, boot camps fill information gaps Collaborative has become valuable to many stakeholders 10

11 Beyond Examples: Experiences from Two Demonstration States David Kelley, MD, MPA Chief Medical Officer, Pennsylvania Department of Public Welfare, Office of Medical Assistance Programs Marian Earls, MD, MTS, FAAP Director of Pediatric Programs, Community Care of North Carolina 11

12 From Innovation to Sustainment: Pennsylvania s CHIPRA Demonstration Grant Experience David Kelley Chief Medical Officer, Pennsylvania Department of Human Services Office of Medical Assistance Programs

13 Reporting the Core Set of Children s Healthcare Quality Measures Pennsylvania s seven grantees electronically reported between eight and fourteen of the core quality measures Quality measure data was extracted directly from patient electronic health records (EHRs) Data was collected in a standardized flat file format which remained consistent across health systems and various EHR vendors Flat files contained demographic data as well as measure specific data 13

14 Reporting the Core Set of Children s Healthcare Quality Measures Moving from the EHR to a useable format: Alignment of data extraction with institutional priorities Meaningful Use Importance is placed on cataloging all updates to data variables such as payer mapping tables and data groupers Ensuring appropriate quality measure data is stored in discrete fields which can be queried Quality Dashboards Extraction of EHR data is being used to support real-time practice level quality improvement Physicians are able to view their quality related performance 14

15 Electronic Developmental Screening Electronic screening for developmental disabilities tested at twenty-two pilot sites across two grantee health systems Families utilize time in the waiting/exam room to answer computer-based developmental questionnaires; the data is electronically scored and automatically loaded into the patient EHR Physicians have immediate access to results and can begin discussion with families Grantees are adopting the public domain Survey of Well-being of Young Children (SWYC) screening tool 15

16 Electronic Developmental Screening Adaptation of e-screening process into grantee s institutional home Two grantees have made capital investments to implement the e-screeners across their primary care systems Grantees are creating sustainable Early Intervention referral patterns and feedback loops Two national EHR vendors are taking steps to adopt the e-screening questionnaires into their standard foundation system, which will make them available to all customers 16

17 Demonstrating the Impact of the Model Pediatric EHR Format Five grantees implemented portions of the CMS model format after performing a gap analysis of their current EHR compared to the model format Grantees determined the following requirements would have the most clinical value and greatest return on investment: Well Child/Preventive Care Children with Special Healthcare Needs Immunizations Quality Measures 17

18 Demonstrating the Impact of the Model Pediatric EHR Format Successful implementation of the model format requirements aligns health systems with Pennsylvania Medicaid s quality improvement goals through: Enabling population-level health management Supporting Pennsylvania s CMS dental strategy/action plan Increasing access to care by analyzing patient-level data Helping streamline mandatory reporting Moving from plan-level to practice-level reporting Improving immunization records by linking institutions to Pennsylvania s statewide immunization registry 18

19 Demonstrating the Impact of the Model Pediatric EHR Format Adoption of the model format requirements is generally considered a permanent change to the EHR Sustainability was determined prior to implementation through analysis of the potential for widespread positive effects Key components become institutionalized through clinical use Some changes are built at the health system level while others are offered as upgrades through the EHR vendor 19

20 Conclusion Quality demonstration projects are sustainable when: Projects are aligned with institutional priorities Institutions integrate projects into clinical processes Evidence of quality improvement endures Return on investment is realized 20

21 Contact Information David Kelley, MD, MPA Chief Medical Officer Pennsylvania Department of Human Services Office of Medical Assistance Programs 21

22 Systems Building, Reliability, and Sustainability: The North Carolina CHIPRA Quality Demonstration Grant Marian F. Earls Director of Pediatric Programs, Community Care of North Carolina

23 Community Care of North Carolina (CCNC) Infrastructure CCNC, Inc. a non-profit, central office in Raleigh 14 networks, each 501(c)(3), 100 counties, >95% primary care practices Per member, per month (PMPM) payment to networks and to practices to support care management activities Network level of support includes: Care managers, behavioral care managers, Obstetric Care Managers, network psychiatrist, PharmD, registered dietician, transitional nurses Community mental health (MCOs) participation on network boards and medical management committees 23

24 Community Care of North Carolina (CCNC) Infrastructure Clinical Director(s) at each network Regular reporting of data to networks: Quality Measures & Feedback (QMAF) Web based Care Manager System (CMIS) Informatics Center with Provider Portal Health Information Exchange (HIE) Adult and Pediatric Quality Initiatives: asthma, diabetes, congestive heart failure, emergency department utilization, mental health integration, Assuring Better Child Health and Development (ABCD), dental varnishing, pregnancy medical home 24

25 CCNC Throughout the State 25

26 CCNC Pediatrics Care Managers Assist with follow-up and disease management; link families and primary care providers (PCPs) to community resources; track emergency department usage, hospital transition Quality Improvement Specialists Practice support for quality initiatives Pregnancy Medical Home (Obstetric Care Managers) Health Check Coordinators (Early and Periodic Screening, Diagnosis, and Treatment EPSDT) Care Coordination for Children, 0-5 (CC4C) CHIPRA Quality Demonstration Grant Initiatives Developmental Screening and Surveillance (ABCD), autism screening, asthma, diabetes, dental varnishing, mental health integration, obesity, attention deficit hyperactivity disorder, EPSDT, maternal depression screening, psychosocial/social-emotional screening for schoolage and adolescents, medical home for children and youth in foster care (Fostering Health NC), sickle cell 26

27 CCNC Pediatrics Pediatric Pillars Data Practice Support Risk Stratification Quality Improvement (Primary Care Clinician training & Maintenance of Certification Part 4) Population Management Network Pediatric Teams Pediatric Electronic Health Record (EHR) Format Medical Homes Prevention Early, Periodic, Screening, Diagnosis & Treatment (EPSDT) Well Visits Vision and Hearing Body Mass Index Percentile Coding Lead Screening Immunization Oral Health Routine Screening (all ages) Attention Deficit Hyperactivity Disorder Maternal Depression Screening Adolescent Depression Screening Children and Youth with Special Health Care Needs Mental Health Integration Social/Emotional/Developmental Foster Care Asthma Obesity Sickle Cell Language & Communication Delays 27

28 Strategies to Hard Wire Pediatric Quality Priorities Quality Improvement (QI) and Practice Support Pediatric QI Specialist in each network Model of QI coaching and academic detailing CHIPRA experience has led to CCNC adopting this model for entire population (both children and adults) Pediatric team at each network part of fundamental expectations Pediatric team at the Central Office Data and informatics for quality activity Crosswalk of Child Core Quality Measures (CQMs) and CCNC QMAF (Quality Measures and Feedback) Establishment of the EPSDT Profile Informatics Center to include: Pediatric Preventive Registry Foster Care Passport Shared Care plans for patients with sickle cell disease 28

29 Strategies to Hard Wire Pediatric Quality Priorities (continued) Practice Support/Training Maintenance of Certification (MOC) 4 Modules approved by American Boards of Pediatrics and Family Medicine: Comprehensive Adolescent Health Screening Maternal Depression and Infant Toxic Stress Screening Oral Health: Promoting Dental Homes for Young Children Through Screenings, Varnishings, and Referral Creating a Medical Home for Children/Youth in Foster Care Early Childhood Prevention of Obesity (Healthy Weight and Nutrition) Enduring materials: Engaging Adolescents videos One-Pagers Patient visit materials Obesity (motivational interviewing based) and asthma (shared decision-making) 29

30 Strategies to Hard Wire Pediatric Quality Priorities (continued) Pediatric EHR E-measures and vendor guidance based on quality priorities Shaping state HIE standards for pediatric data Partners to carry projects forward MOC 4: NC Pediatric Society and NC Academy of Family Physicians Fostering Health NC Project: NC Pediatric Society Integration of Activities into broader CCNC planning: Logic Models with short term and long term outcomes Return on investment 30

31 Logic Models (Refer to Handouts) Project Logic Model: Developmental, Behavioral, Social, and Emotional Health Goal: Universal age-appropriate developmental and behavioral screening, referral, feedback, co-management, and community linkages (ages 0-21) Project Logic Model: Oral Health Systems Change Goal: Universal dental home and pediatric dental varnishing by age 3.5 Project Logic Model: CHIPRA D Goal: Evaluate the effectiveness of a Model Children s EHR Format to improve quality of care and reduce health care cost by: Increasing awareness of role of EHR systems in children s health care Improving content and functionality of current EHR systems 31

32 Pearls Primary care clinicians and local network care managers involved in development of quality projects from the beginning Time-limited work groups to develop trainings, practice materials, care manager materials adolescent, obesity, asthma, sickle cell Ongoing forums for reality checks and addressing barriers ABCD QI and State Advisory Groups, Pediatric Work Group (Network Care Managers and Physician Champions), Oral Health Standardized processes for communication among primary care clinicians, specialists (including mental health professionals), and care managers 32

33 Contact Information Marian F. Earls, MD, MTS, FAAP Director, Pediatric Programs Community Care of North Carolina Prevention It is easier to build strong children than repair broken men and women. Fredrick Douglas 33

34 Discussion Question and Answer 34