Challenges Reporting Quality Measures in Small Rural Practices: Lessons Learned from the InteGREAT Project

Transcription

1 Challenges Reporting Quality Measures in Small Rural Practices: Lessons Learned from the InteGREAT Project James McCormack, PhD, Instructor, OHSU Department of Medical Informatics and Clinical Epidemiology Elizabeth Needham Waddell, PhD, Senior Study Director, ORPRN; Assistant Professor, OHSU-PSU Public Health

2 Learning Objectives What quality and performance measures are rural health providers being asked to produce? What specific challenges did the InteGREAT project identify in assessing of reporting capabilities for eight specific measures in four rural practices? How can CCOs and providers collaborate to improve their capabilities for reporting complete and accurate quality measures?

3 Presentation Overview Provide brief description of the InteGREAT project, and the importance of data reporting capacity to build a foundation for integrated care. Describe 2 phases of data capacity assessment conducted during the InteGREAT project. Present recommendations to practices and stakeholders.

4 InteGREAT: Building Capacity for Integrated Behavioral Health & Primary Care (April 2014-June 2015) 1. Build partnerships among practices that are interested in integration. 2. Collaborate with practices to create the foundation for integration (clinically, operationally, and financially). 3. Provide technical assistance as practices initiate their integrated initiatives. Funded by Transformation Grant from Pacific Source Community Solutions Columbia Gorge CCO

5 InteGREAT: Building Capacity for Integrated Behavioral Health & Primary Care Implemented in 4 primary care practices and one Community Mental Health Center Project co-lead by Department of Family Medicine, University of Colorado (Ben Miller, PsyD) and Oregon Rural Practicebased Research Network (Melinda Davis, PhD) Oversight from the Columbia Gorge Health Council and Columbia Gorge Integrated Care Work Team

6 Participating Practices and Cross- Functional Implementation Teams Four primary care practices and one behavioral health agency 24 participants on the five cross-functional implementation teams MDs, Psychiatrist, RNs, MAs, LCSWs, BH referral coordinator, Front and Back Office Leads, Practice Managers, IT Staff, Medical Directors, CEOs

7 Why integrate care? 67% 46% 66% of adults with a behavioral health disorder do not get behavioral health treatment 1 of adults will experience mental health illness or substance abuse disorder at some point in their lifetime 2 of primary care providers report not being able to access outpatient behavioral health for their patients 3 Top conditions driving overall health costs: Depression Anxiety Obesity Back/Neck Pain Arthritis When treated in harmony with mental health, chronic physical health improves significantly, along with patient satisfaction. 4,5

8 Definition: Behavioral Health and Primary Care Integration The care that results from a practice team of primary care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This care may address mental health, substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stressrelated physical symptoms, ineffective patterns of health care utilization. Peek, C. J. and the National Integration Academy Council (2013). Lexicon for behavioral health and primary care integration: Concepts and definitions developed by expert consensus. AHRQ Publication No.13-IP001-EF. Rockville, (MD), Agency for Healthcare Research and Quality.

9 Vision for Integrated Care in the Gorge All roads lead toward interdisciplinary, team based care, with substantial variation in clinical, operational and financial challenges. Setting Baseline model The Vision Independent practice Affiliated practices FQHC Community Mental Health Limited referrals and consultation with specialty mental health, MD as mental health provider Co-located mental health services (therapy) Co-located mental health services (therapy) Limited referrals and consultation with to primary care Addition of integrated BHC Addition of integrated BHC Addition of integrated BHC Behavioral Health Home, with coordinated, co-located primary and specialty mental health care

10 Practice Facilitation for InteGREAT! The Questions The Details Who? Beth Sommers Beth will work with a Practice Champion and a few key members of the clinic What? The PF and clinic team members meet in-person monthly to review data, complete assessments, and set goals. Team members work independently to accomplish goals (and receive /phone support) Sharing progress at quarterly ICWT meetings When and Where? At the practice at times agreed upon by Beth and the clinic team How? Baseline assessment (clinical, operational, financial) Relationship and team development Goal setting and re-assessment/reflection over time

11 Some tools we used to create the foundation for successful integration Practice Information Form Comprehensive Primary Care Monitor Health Home Monitor CoACH Cost Tool Minimal Data Set Capacity Assessment

12 Quality Reporting Capacity Assessment for InteGREAT Phase 1: Received self-assessment spreadsheets from each participant Phase 2: Reviewed self-assessments and identified possible reporting gaps Developed a systematic assessment process for each site Visited each site at least once with telephone and conversations as needed. Analyzed and reported the results of the assessment and site-specific recommendations

13 Background: Clinical Quality Measures (CQMs) Who is included in the initial population? Demographics (e.g., age, gender) Specific conditions (e.g., problem list or encounter diagnoses) Other patient and visit characteristics (e.g., provider, payer) What is actually counted? Vitals (BP, BMI) Results of specific tests or procedures (lab, DI, etc.) Structured data in notes, assessments, plans, follow-up, etc. Clinical orders (medications, referrals, procedures, etc.) When are the start and end dates (reporting period)? With what exclusions, exceptions, or adjustments? Reported to whom and in what form?

14 CQM Specifications and Guidelines There is a growing supply of CQMs sponsored by multiple stakeholders! Detailed specifications may vary by source and stakeholder Not everyone rigorously follows the gold standard NQF measures Specifications and reporting criteria ( value sets ) change

15 Minimal Data Set (MDS) for InteGREAT MDS Measure (included age range) Type MDS Variations ~NQF # A1c not done or > 9% in diabetics PH #59 LDL < 100 mg/dl in CAD PH #74 ** BP < 140/90 in Hypertension) PH #18 Age-specific BMI screening and f/u PH #421 Depression screening and f/u BH...and improved PHQ9 #418 Substance abuse screening and f/u BH...and improved AUDIT -- Tobacco use and cessation and f/u BH #28 General anxiety screening and f/u BH...and improved GAD7 -- The InteGREAT MDS consisted of 8 measures 4 physical health and 4 behavioral health.

16 Example: Self-assessment form (Phase 1)

17 Example: On-site assessment (Phase 2)

18 Assessment Results (Phase 2) MDS Measure (included age range) Site 1: Family Med. Site 2: FQHC Site 3, 4: Affiliated Practice Site 5: BH Center A1c not done or > 9% in diabetics Yes Yes Yes No LDL < 100 mg/dl in CAD Yes Yes Partial No BP < 140/90 in Hypertension) Yes Yes Yes No Age-specific BMI screening and f/u Yes Yes Yes No Depression screening and f/u Partial Partial Partial Partial Substance abuse screening and f/u Partial Partial Partial Partial Tobacco use and cessation and f/u Yes Yes Yes Yes General anxiety screening and f/u No No No Partial The onsite assessment found much lower MDS capabilities than the selfassessment Phase 1.

19 MDS Reporting Challenges: PH CQMs Availability of structured results and vital signs in the EMR Mapping of CQM data elements (e.g., LOINC) Use of consistent workflows for data entry Useful data lost in notes or scanned reports MDS Example: A1c not done or > 9% in diabetics Percentage of 18 to 75 year olds with diabetes (all 250.xx) AND A1C NOT done within one year AND A1C value > 9% within one year

20 MDS Reporting Challenges: BH CQMs Availability of structured data for screening and follow-up Mapping of CQM data elements (e.g., PHQ, GAD, AUDIT) Use of consistent workflows for clinical documentation Useful data lost in notes or scanned reports MDS Example: Depression screening and follow-up Percentage of patients age 12 years and older: AND Screened for depression using an age-appropriate standardized screening tool AND A follow-up actions/plan is documented AND Percentage of patients with an improved PHQ-9 score

21 Data Flow Model for CQMs Data Capture Data Selection and Retrieval Analysis and Aggregation EMR (External Database) CQM = numerator / (denominator - exclusions exceptions)

22 Findings: Key Challenges in 5 Sites Key Challenges Technical Challenges Knowledge and Resource Limitations Work Practices and Local Preferences Examples from InteGREAT Access to EMR reporting capabilities Availability of structured data Vendor assumptions about workflow Data quality issues Expertise in using EMR reporting Time to learn and use EMR features Custom queries are time-intensive Access to EMR-specific guidance Data entry timing and workflows Variation in roles and responsibility Variation in clinical work practices

23 Lessons Learned CCOs Meaningful Use (MU) PQRS(I) HEDIS UDS PCMH/PCPCH P4P.

24 Recommendations for Practices Create a quality reporting committee or seek outside advice to inventory and prioritize CQM reporting requests and obligations what are YOUR quality goals? Assess your current reporting capabilities, resource limitations, and data quality for priority CQMs Seek ways to consolidate screens or forms used to capture clinical data needed for CQMs and beware of death by a thousand clicks

25 Recommendations for Stakeholders Recognize the challenges, competing priorities, and resource limitations facing small practices Develop and coordinate EMR-specific resources to assist with assessment, (re)configuration, and effective use of standard and advanced CQM reporting tools Leverage existing CQMs and value-based reporting programs (in addition to Meaningful Use and PQRS) Recognize that EMRs used in Behavioral Health are a different beast, and CEHRTs cannot be assumed

26 Suggested Resources (see handout) Topic CQM Specifications and Guidance EMR Vendor Capabilities General Health IT Resources Web Resources National Quality Forum (NQF) QPS AHRQ National Quality Measures Clearinghouse (NQMC) Oregon Health Authority Office of Health Analytics CMS.gov ecqm Library NLM Value Set Authority Center Individual CCOs and other stakeholders Certified Health IT Product List (oncchpl.force.com) Vendor website and user communities HealthIT.gov US Health Information Knowledgebase (USHIK) HIMSS, AHIMA, AMIA Independent Practice Associations Oregon Regional Extension Center for Health IT (OCHIN)

27 Acknowledgements Columbia Gorge Health Council Columbia Gorge Integrated Care Work Team Participating providers in the Gorge

28 University of Colorado Denver, Department of Family Medicine Benjamin Miller, PsyD Assistant Professor Stephanie Kirchner Practice Facilitation Program Manager Emma Gilchrist, PRA Integrated Healthcare Project Manager

29 OHSU/Oregon Rural Practice-based Research Network (ORPRN) Project Team Melinda Davis, PhD Director of Community Engaged Research; Research Assistant Professor, Department of Family Medicine Beth Sommers, MPH, CPHQ Practice Enhancement Research Coordinator (PERC) Elizabeth Needham Waddell, PhD Senior Study Director; Assistant Professor, OHSU-PSU School of Public Health

30 THANK YOU! Questions?