The Medical Home: A Continuing Renovation Job. Paul Kaye, MD Executive VP, Practice Transformation February 22, 2012

Transcription

1 The Medical Home: A Continuing Renovation Job Paul Kaye, MD Executive VP, Practice Transformation February 22, 2012 DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.

2 Conflict of Interest Disclosure Paul Kaye, MD Has no real or apparent conflicts of interest to report HIMSS

3 Learning Objectives Describe how senior leadership can use quality as an organizational management strategy Explain the role of team based care in achieving better patient experience and outcomes Detail how the judicious use of structured data and reporting within a clinical information system can improve performance

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6 Demographics HRHCare Patients by Race/Ethnicity Asian 1.10% Others 7% White 31.50% Hispanic/ Latino/a 44.50% African American 16%

7 Demographics Level of Poverty Level of Insurance % 6% Over 200% 11% Other Public Insuranc e 8% Medicare 7% No Insurance 38% % 17% 100% Below 66% Private 14% Medicaid 33%

8 Growth of users Patients 71,000 80, ,139 Patients ,807 6, projected

9 Recognition JCAHO Accreditation since 1998 U.S. Department of Health and Human Services 2006 Innovation in Prevention Award New York State Patient Safety Award 2006 NCQA Physician Practice Connection 2006 NCQA PCMH Level

10 Quality as Strategy: Becoming a Data-Driven Organization

11 HRHCare Quality Timeline Clinical Staff Training Institute-each year Together for Tots HRSA Prevention Collaborative IHI Innovation Community Strategic Aims & Measures Adopted 2007 & 2010 HRSA Diabetes Collaborative Implementation of Dentrix IHI Collaboratives: Access & Redesign Dental Adoption of Cliniflow-EHR in 4 sites by 2006 Harvesting Meeting Care Team Model Training Site Visits-SAMQIT Adoption of ECW Formation of the Quality Council 2011

12 Common Themes of QI Projects Integrated Teams Everyone does the highest level of work possible Consistent support staff with defined roles Work centered around the patient: on site testing Planning of visits Daily huddles Standing orders Rooms and equipment stocked and ready Use information systems to track patients and analyze performance

13 Quality Lessons Learned System change should precede technology introduction Relentless Board and Senior Leadership essential Quality management IS management-not a separate function National expertise in change and leadership (IHI,HRSA) adds value

14 Board of Directors Role in the Quality Strategy Understand and review Health Center quality data-statutory responsibility! Understand the financial impact of the EHR and PCMH on the Health Center Help to communicate the benefits of EHR and PCMH to other patients and the larger community

15 CEO: Chief Quality Champion Provide consistent visible leadership on Quality Strategy Ensure that key staff are all communicating with the same message Lead collaboration with other entities Provide adequate staffing for the implementation of change, including EHR implementation Develop an understanding of the cost of implementation Establish a team of key staff to help the organization navigate the electronic world and give them the time they need to meet, plan and execute activities Make decisions when it may be needed to go outside of the organization to get help Ensure that communication to staff, patients and BOD is on-going Celebrate milestones with Staff and BOD

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19 Team-based Care: HRHC s Care Team Model

20 The Effectiveness of QI Strategies: Findings from a Recent Review of Diabetes Care Shojania, K. G. et al. JAMA 2006;296:

21 Ideal Team Composition 2 Providers 1-2 Nurses 2 Medical Assistants 1 Patient Care Partner 0.5 FTE Social Worker 2 Patient Representatives (front desk) 1 Health Information Worker 0.5 FTE Care Solutions/Financial Access Specialist

22 New Team Members Medical Assistants Patient Care Partners Access Coordinators/Financial Coordinators Community Health Workers

23 New Roles for Staff EHR/Registry Management Care Coordination Health Coaching Medical Translation Access Assistants

24 EHR/Registry Management Registry Technical Tasks Data entry Generation of reports First level troubleshooting Panel Management Identify patients who have not been seen Identify patients with chronic illness for specific interventions that are due Produce and disseminate quality and access reports

25 2011 NCQA PCMH Standards 1 Enhance Access and Continuity 2 Identify and Manage Patient Populations 3 Plan and Manage Care 4 Provide Self Care Support and Community Resources 5 Track and Coordinate Care 6 Measure and Improve Performance

26 Enhanced Access 10 year project started with IHI Do today s work today Adjust supply to meet demand when possible Always try to schedule with PCP/PCG Monitor backlog of appointments and time to 3 rd open slot Provide extended hours and easy after hours access Culture change-admit you have no control!

27 Changes for Improved Access Get your patient panels accurate! Always offer appointment with PCP first Empower multiple staff to add on or double book Limited triage Regular monitoring of practice data Control of vacation time (partial success!)

28 Days to third appointment Agency - Timeliness: Access to Appointments (Time to 3rd Appt. - Goal=1 day) Nov-05 Nov-06 Nov-07 Nov-08 Nov-09

29 It s Only a Medical Home If the Patient Says So

30 CAHPS Clinician-Group Survey Developed by AHRQ Adopted by AQA and submitted for endorsement by NQF Core composites: Access: Getting appointments and care when needed Doctor communication Office staff courtesy and helpfulness NCQA and AHRQ developing Medical Home CAHPS Still needs improvement but what doesn t?

31 Days Time to 3rd Appointment Yonkers- Valentine Lane

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33 Lessons Learned Patient experience data yielded much more than traditional patient satisfaction scores Patient experience data revealed flaws in our QI data Despite CHC Board-majority governance, accurate picture of patient experience requires systematic approach

34 Using the EHR for Quality

35 Structured Data Uses Numerical values Standardized processes Graphs and Flowsheets CPT and ICD Coding Medication and Allergy information Immunization Self Management Support Reporting

36 Structured data entry: what is lost? Nuances of patient variability Temporal relationships of symptoms Clinician thought processes Richness of individual patient stories

37 Data Strategy: Structure Only What You Must Meaningful Use Chronic Disease Management Coding HIV Care Grant and Government Reporting

38 Reporting Strategy Recognized limitations of vendor solution for FQHC needs Purchased COGNOS with vendor in agreement Mapped metadata tables Developed internal report creation capacity Multidisciplinary input into report content and format

39 Used by permission of eclinicalworks

40 Used by permission of eclinicalworks

41 Used by permission of eclinicalworks

42 Used by permission of eclinicalworks

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44 HIV Screening and Treatment HIV screening Hiv CD4 and viral load

45 Two Years of EHR Progress Apr-09 Apr-10 Apr

46 UDS Process Data

47 UDS Outcome Data

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49 Quality Improvement in Billing and Finance Increased efficiencies in billing department Increased electronic claims Increased electronic payments Automated CPT code capture ecw made claims more accessible to quickly work and resolve issues Reduced resources required for chart audits Increased efficiencies at front desk Ease of windows environment Opportunity to retrain all staff on registration requirements Integrated eligibility from appointment schedule

50 Enhanced Reporting= Faster Payment by Empowering Billing Staff Batch eligibility on self pay receivables to identify missed opportunities Batch eligibility on top payers receivables to validate coverage and PCP Quick receivables audit for trending and problem escalation Scheduled reporting automates what was once manual to produce (ie-30 month end reports that took multiple days to finish each month now are auto ed at the designated interval)

51 2008 Payor Mix % 13% 12% 34% 13% 11% 13% 38% 12% 30% 40% % 10% Medicaid Medicare Self-pay 13% 25% Private Insurance Medicaid Managed Care

52 Financial Performance Improvement Net Patient Revenue per Visit Current Ratio $ $ $ $ $ $ $ $ Net Patient Revenue per Visit $ $ $ Current Ratio

53 Where to Start? Use quality as organizational strategy Empanel your patients Improve your access Achieve Meaningful Use Build and train robust clinical teams Measure patient experience

54 Resources Safety Net Medical Home Initiative / American College of Physicians /pcmh/ Primary Care Development Corporation TransforMed-AAFP project

55 We are honored to be here!