Jen Powell, MPH, MBA, National QI Consultant Ed Wise, National Data Analyst

Transcription

1 Jen Powell, MPH, MBA, National QI Consultant Ed Wise, National Data Analyst

2 Jennifer Powell, MPH, MBA I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in the CME activity. I do not intend to discuss unapproved or investigative use of a commercial product/device in my presentation.

3 Ed Wise I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in the CME activity. I do not intend to discuss unapproved or investigative use of a commercial product/device in my presentation.

4 Session Objec:ves Define key components of managing a population of patients at the practice level Describe the utility of using a registry for patients with asthma Understand how to identify patients at risk for events Develop one or more PDSA cycles with the targeted population, outlining details of implementing planned care approaches

5 Session Outline Components of Population Management Function of Registries Identifying patients at risk of an event Team Exercise: Identify target population and interventions

6 CQN3 Practice Key Driver Diagram Interventions GLOBAL CQN AIM We will build a sustainable quality improvement infrastructure within our practice to achieve measurable improvements in asthma outcomes Specific Aim From February 2013 to March 2014 we will achieve measurable improvements in asthma outcomes by implementing the NHLBI guidelines and making CQN3 key practice changes Measures/Goals Optimal asthma care 90% of patient visits with all of the following: Asthma control assessed NHLBI Stepwise approach is used to identify treatment options or adjust therapy Children with persistent asthma on a controller medication Written asthma action plan updated and reviewed, as needed Key Drivers Engaging Your QI Team and Your Practice *The QI team and practice is active and engaged in improving practice processes and patient outcomes Using a Registry to Manage Your Asthma Population *Identify each asthma patient at every visit *Identify needed services for each patient *Recall patients for follow- up * Confirm patient population in registry Using a Planned Care Approach to Ensure Reliable Asthma Care in the Office * Use of CQN3 Encounter Form * Care team is aware of patient needs and works together to ensure all needed services are completed Form a 3-5 person interdisciplinary QI Team Formally communicate to entire practice the importance and goal of this project Meet regularly (at least 1x per month) to work on improvement Collect and enter baseline data Generate performance data monthly Communicate with the state chapter and with leaders within the physician s organization Turn in all necessary data and forms Attend all necessary meetings and phone conferences Train on use of National Asthma Registry (NAR) Determine staff workflow to support registry use Populate registry with patient data Routinely maintain/review/confirm registry data Use registry to manage patient care & support population management Integrate practice billing and other administrative data sets into registry Determine workflow to support reliable use of encounter form at time of visit Use encounter form with all asthma patients Ensure registry updated each time encounter form used Monitor use of encounter form % of practice s asthma patients have at least an annual assessment using a structured encounter form >90% of patients well controlled Developing an Approach to Employing Protocols * Standardize Care Processes * Practice- wide asthma guidelines implemented Select & customize evidence- based protocols for your office Determine staff workflow to support protocol, including standing orders Use protocols with all patients, including those regarding follow- up visits Monitor use of protocols Providing Self Management Support * Realized patient / family and care team relationship Obtain patient education materials Gauge caregiver s self- assessment of comfort level in managing child s asthma Determine reliable staff workflow to support SMS Provide training to staff in providing patient self management materials Assess and set patient goals and degree of control collaboratively Document & monitor patient progress toward goals Link with community resources

7 Primary Care Trends: Popula'on- Based Care Identifying patient populations at risk by creating registries Assigning a primary care clinician to each patient Planning care proactively Stratifying patients by risk Assigning care team to manage a panel patients Using data to monitor and improve care of

8 Components of Popula:on Management Using a Registry 1. Provide real- time feedback with decision support based on evidence/guidelines 2. Generate patient- level reports and reminders, longitudinal reports, care gaps, summary lists/ plans, health status 3. Identify patients/subgroups for proactive care 4. Provide population measurement and quality outcome reports Source: AHRQ Registries User Guide

9 What s In it For Our Prac:ce? Identifies patients with asthma who are at risk Provides a snapshot at the time of visit that shows all the pertinent clinical parameters for asthma Reduce shuffling through the chart to find the date of labs, procedures and visits Assures the right timing of care based on guidelines and best evidence Ability to set up standing orders so that staff can make sure the patients have all had needed tests or the ability to monitor performance prior to the visit Source: Registries Made Simple, Bagley, B and Mitchell, J.,

10 What s In it for Pa:ents and Parents? Patients and parents will appreciate the fact that you and your care team use a system to track their children and their needs everything gets done on a timely basis important aspects of care are not delayed or forgotten Parents like to go home with all their numbers. The asthma action plan used for the patient visit can help keep patients/families engaged in their care and working to improve self- management. Source: Registries Made Simple, Bagley B. and Mitchell, J,

11 CQN3 Popula:on Management: Condi:on Specific Registry Populate all patients with asthma in your practice into a single repository Over time, stratify patients in higher and lower risk categories Design, coordinate and manage care for specific segments of practice population

12 Features of the CQN3 Asthma Registry Track asthma care quality measures (by entering encounter data and reviewing monthly reports) Maintain registry of asthma patients updated with encounter form, including patients asthma severity, follow- up, race, ethnicity and language preference Use the registry to monitor for patients who do not show up for planned asthma visits; assign staff to follow- up Generate planned visit prompting list including proactive care (e.g. influenza vaccines, review of asthma action plan, seasonal) Conduct monthly identification of poorly controlled asthma patients via billing data (hospitalizations, ED visits, and if available, medication use) Provide prompts to remind providers to effectively monitor needed services at the time of individual patient encounters

13 Report Snapshot [placeholder: can you put in an image of what that snapshot looks like?]

14 Stra:fying Your Popula:on by Risk Factors What variables should we consider when identifying patients by level of risk? Objective data (spirometry) and medication use Increased risk of an ED visit or hospitalization What about patients where we don t know their status?

15 Example: Missing Flu Shots Flu shots recommended for all children 6 months and older, but especially recommended for children with asthma Registry will flag a child that has not received the flu shot in the past 12 months Identifies child at risk for not being vaccinated this season How might that change your approach in counseling the family?

16 Example: Tracking Pa:ents Who Haven t Been Following Up NHLBI: patients should be seen 2- to 6- week intervals while initiating therapy or stepping up therapy to achieve control 1- to 6- month intervals after asthma control is achieved in order to monitor if asthma control is maintained 3- month intervals if a step- down in therapy is anticipated. What if your patient hasn t been seen in six months?

17 Team Exercise Build a site level full population report identifying patients who have not been seen in the last 6 months (15 min) Develop PDSA cycles to determine next steps around your targeted population (15 min) Discussion/report out (5 min)