PUBLIC-PRIVATE PARTNERSHIPS Ohio Medicaid s Experience in Improving Children s Quality of Care & Reducing Costs through Collaboration and Improvement Science Mary Applegate, MD, FAAP. FACP Ohio Medicaid Medical Director May 24. 2011
Ohio s Partnership: Starting with Children The mission of BEACON is to improve the quality and outcomes of health for children in Ohio, with a special emphasis on Medicaid eligible children, youth and their families. To do so requires: initiatives targeted to important health issues; the establishment of sustainability, quality improvement infrastructure, and public private collaboration.
BEACON: Best Evidence for Advancing Child Health in Ohio NOW Statewide collaboration Encourage & support initiatives that achieve rapid cycle / measurable improvements in children s health & outcomes through improvement science Partners Ohio Children s Hospital Association Business Roundtable Cardinal Health Voices for OH Children OH Chapter American Academy of Pediatrics Children s Hospitals/University Partnerships, Cincinnati Child Health Policy Research Center Case Western Reserve University Center for Child Health & Policy Ohio Dept. of Health, ODJFS (Medicaid) & Ohio Dept. of Mental Health Ohio State University Resource Center, National Alliance on Mental Illness & many others 23 organizations total & 100s of interested people, including patients and families
History of BEACON Several years of building a work in process/progress National Academy for State Health Policy (NASHP) Developmental Screening & Ohio Child Health Improvement Partnership 07 Developmental & social emotional screening Medicaid federal support, autism advocacy & legislative funding 07 Perinatal Quality Improvement CMS Neonatal Transformation Grant Ohio Dept. of Health Regional Perinatal Centers 08 Expanding partnership/collaborations Ohio Health Care Coverage & Quality Council 08 Impact of health care reform on children s quality care 09 CHIPRA Grant-Children s Health Quality application 09 BEACON Council born out of collaborative experience, Co-Chaired by Dr. Mary Applegate/State Medicaid Medical Director; Dr. Ted Wymyslo, Director, Ohio Dept. of Health & now (2011); Tracy Plouck, Director, Ohio Dept. of Mental Health BEACON as the way to access MEDTAPP funds 10 BEACON as the pediatric advisory group to Ohio s Health Transformation Office
OPQC: Ohio s Perinatal Quality Collaborative - Mission: Reducing the proportion of all Ohio pregnancies with prematurity-related poor outcomes - Accelerated by Medicaid Transformation Grant (CMS) - All 24 Ohio NICUs (44 teams) - Neonatologist, Obstetricians, nurses, administrators - March of Dimes, Medicaid, Families, Professional organizations - Cincinnati s QI shop with IHI expertise - Data center: VON + Hospital Site Specific (web-based reporting) + Vital stats - Monthly feedback to sites with aggregates, calls, Learning Sessions
ODJFS OPQC OH Dept of Health CMS U of C NICHQ RPCs Others Families Providers Data System and feedback Loop/Improvement Science/Empowerment/Education
4/06 6/06 8/06 10/06 12/06 2/07 4/07 6/07 8/07 10/07 12/07 2/08 4/08 6/08 8/08 10/08 12/08 2/09 4/09 6/09 8/09 10/09 12/09 The OPQC NICU Project Proportion of infants 22-29 weeks gestation discharged with at least one nosocomial infection 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 18.2% 14.3% Month 20% decrease in the overall NICU infection rate 60 fewer Ohio infants 22-29 weeks with infection per year, 16 fewer deaths due to infection and $1.8M cost savings
Percent OPQC Results Infants 22-29 Weeks discharged with at least one Nosocomial Infection data from Jan, 2006 through Dec, 2007 used to compute mean and control limits 40% 35% 30% 25% 11 sites began reporting VON data Jan-May, 2006 2 sites began reporting VON data Feb, 2007 9 sites began reporting VON data Jan-Mar, 2008 LS 1 09-08 LS 2 01-09 LS 3 10-09 20% 15% 10% 5% 0% Monthly Percent Mean Control Limits Special Cause
07-08 08-08 09-08 10-08 11-08 12-08 01-09 02-09 03-09 04-09 05-09 06-09 07-09 08-09 09-09 10-09 11-09 12-09 01-10 02-10 03-10 04-10 Number 07-08 (33 /127 ) 08-08 (35 /240 ) 09-08 (49 /422 ) 10-08 (69 /522 ) 11-08 (55 /481 ) 12-08 (53 /565 ) 01-09 (45 /518 ) 02-09 (38 /542 ) 03-09 (44 /515 ) 04-09 (22 /552 ) 05-09 (22 /496 ) 06-09 (27 /469 ) 07-09 (15 /469 ) 08-09 (12 /442 ) 09-09 (23 /524 ) 10-09 (10 /450 ) 11-09 (8 /406 ) 12-09 (6 /413 ) 01-10 (3 /370 ) 02-10 (5 /269 ) 03-10 (3 /318 ) Percent The OPQC OB Initiative Percent of Scheduled Deliveries 36 0/7th to 38 6/7th Weeks Without Medical or Obstetrical Indication Documented 30% 25% 20% 15% Clarification of Scheduled Delivery Form 3-09 10% 5% 0% 80 70 60 50 40 30 20 10 0 Number of Scheduled Deliveries 36 0/7th to 38 6/7th Weeks Without Medical or Obstetrical Indication Documented a statewide improvement collaborative
Percent The OPQC OB Initiative Percent distribution of Ohio births, full term and near term by month, January 2006 to March 2010 70 60 50 40 30 20 10 0 Jan-06 Mar-06 May-06 Jul-06 Sep-06 Nov-06 Jan-07 Mar-07 May-07 Jul-07 Sep-07 Nov-07 Jan-08 Mar-08 May-08 Jul-08 Sep-08 Nov-08 Jan-09 Mar-09 May-09 Jul-09 Sep-09 Nov-09 Jan-10 Mar-10 Near term (36-38 wks) Full term (39-41 wks) Mean, near term Mean, full term From August 2008 to March 2010, the number of Ohio births 36-38 weeks was 8,256 fewer compared to the number expected based on the preceding 2 years experience; 150-250 fewer near-term infants admitted to the NICU per year at an average cost of $50k each, a 10 Million $ savings
4 Keys to Collaboration Focus Areas Clinical partners, Data/systems and feedback, Medicaid structure to support work, Change Improvement Science Process Relationship building, transparency, IHI /rapid cycle PDSA Results!! 16 babies saved, 64 fewer infections 8,300 deliveries moved to full term, 3,300 fewer C sections, eliminating 200 NICU admissions Sustainability: Impossible without public-private partnerships
National Quality Strategy CMS CMMI IHI AHRQ NCQA Program Requirements State Priorities OHT Medicaid Data OHP QUALITY STRATEGY MCP Strategy BEACON Adult Initiatives EQRO MCAC QUALITY IMPROVEMENT IMPROVED POPULATION HEALTH
Ohio Medicaid s Quality Strategy Based on hotspotter ( Cost/quality) analysis of data: PRIORITIES for OH children 2011 Prematurity Mental health Acute Care Condition: Infections Chronic Condition: Asthma
Percent Percent 4 Active Prematurity -related initiatives (OPQC): 1 2 Percent distribution of Ohio full-term and near-term births, by month January 2006 to September 2010 Infants 22-29 Weeks discharged with at least one Nosocomial Infection data from Jan, 2006 through Dec, 2007 used to compute mean and control limits 70 60 50 40 30 20 10 0 Jan-06 Mar-06 May-06 Jul-06 Sep-06 Nov-06 Jan-07 Mar-07 May-07 Jul-07 Sep-07 Nov-07 Jan-08 Mar-08 May-08 Jul-08 Sep-08 Nov-08 Jan-09 Mar-09 May-09 Jul-09 OPQC inception Since OPQC inception, 12,000 expected near-term births statew ide w ere delayed to full-term. Baseline averages w ere calculated from the initial 24 months, January 2006 to December 2007. Sep-09 Nov-09 Jan-10 Mar-10 May-10 Jul-10 Sep-10 Near-term (36-38 weeks) Full-term (39-41 weeks) Baseline, near-term Baseline, full-term 3 4 PILOT Obstetrics project Antenatal corticosteroids Aligns with JCAHO and Ohio Hospital Compare 40% 35% 30% 25% 20% 15% 10% 5% 0% 11 sites began reporting 2 sites began reporting 9 sites began reporting VON data Jan-May, 2006 VON data Feb, 2007 VON data Jan-Mar, 2008 04-06 n=52 07-06 n=53 10-06 n=63 01-07 n=65 04-07 n=63 07-07 n=84 10-07 n=68 01-08 n=73 04-08 n=109 07-08 n=105 PILOT NICU project Reduce skin injury LS 1 09-08 LS 2 01-09 Aligns with active HAI project (#2 above) LS 3 10-09 10-08 n=84 01-09 n=109 04-09 n=123 07-09 n=118 10-09 n=134 01-10 n=106 04-10 n=111 07-10 n=131 10-10 n=69 Monthly Percent Mean Control Limits Special Cause
Aspiration and Initial Goals for Children s Hospitals Aspiration Shared vision of making Ohio the safest place in the nation for children s health care Initial goals by June 2010 Reduce overall Adverse Drug Events (ADE s) by 33% Reduce events of Opiate Over Sedations by 50% Reduce Surgical Site Infections (SSI s) in designated Cardio, Neurosurgery and Ortho Procedures by 50% Increase Collaborative Participants Self-Assessment of Quality Improvement Capability by 33%
Medication Safety Accomplishments Utilization of a Standardized ADE Trigger Tool Estimated 850 ADE s/month with monthly costs of $650,000 Improvement Focus: Highly reliable use of Narcotic & Laxative Order Sets. Cost avoidance of $4.5MM per year Estimated 3552 fewer children harmed per year
Surgical Site Infection Accomplishments Adopted a State SSI Basic Care Bundle Baseline rate: 4 SSI s/100 Procedures Improvement Focus: Highly Reliable use of SSI Basic Care Bundle Cost avoidance of $680,000 per year 24 fewer children harmed per year
Lessons Learned from Public-Private Partnerships They work better than either funding source alone: A high value proposition They glue together the individual experience cumulatively with data to achieve population health outcomes, innovation and savings Public reporting is helpful Consistent Leadership is a requirement, especially for initial relationship and trust Structure and Governance is important for ownership, empowerment & sustainability Shared decision-making is key to transparency and shared resources
Ohio s Public-Private Partnership Next Steps Continue BEACON input to Medicaid HIT incentive program, state HIT plan & meaningful use/metrics. Continue BEACON collaborative work with Medicaid to examine health care reform, quality of care implications for children. Continue work to take BEACON pilot initiatives to statewide spread and start new initiatives (e.g. asthma) based on data and best medical evidence Develop analogous Adult Partnership http://www.odh.ohio.gov/landing/beacon/beacon.aspx Mary Applegate, MD: mary.applegate@jfs.ohio.gov Special Thanks to all BEACON partners and Harvey Doremus, ODJFS