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Domain 3: Health Systems and

Community Clinical LinkagesMarti Deacon

CDC PHAP assigned to Maryland Department of Health

Health Systems and Referrals Specialist

Center for Chronic Disease Prevention and Control

O V E R V I E W

• Meet our team

• Discuss “systems thinking”

• Review the Maryland framework of health systems work

• Review three contracts under Domain 3

• Meet our partners

• Discuss success, challenges, and lessons learned

• Discuss future direction and sustainability

1305 D O M A I N 3 T E A M

• Weekly team meetings with:

• Kathleen Graham – Health Systems Team Manager

• Marti Deacon – CDC PHAP, Health Systems and Referrals Specialist

• Marshall Washick – Graduate Research Assistant

• Colin Simms – 1422 Component 2 Lead

• Meets to coordinate across program and grants

• Engaged in program implementation and technical assistance requests

• Attends monthly monitoring calls, partnership meetings, and monthly Community of Practice calls

S Y S T E M S T H I N K I N G

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M A R Y L A N D F R A M E W O R K S Y S T E M S I N I T I A T I V E S

• Controlling hypertension and diabetes through “Quality Improvements in Health Systems” funding opportunity

• Identifying undiagnosed hypertension in health systems and dental practices

• Data warehouse and practice transformation with the Mid-Atlantic Association of Community Health Centers (MACHC)

Q U A L I T Y I M P R O V E M E N T

FY 17 - Quality Improvement in Health Systems

• Approach: to prevent and control hypertension and diabetes through the implementation of policy, systems, and environmental changes in health systems/practices to improve population level health.

• Use data to drive change

• Promote the National DPP, DSME, DSMP, and CDSMP classes to support chronic disease self-management

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Maryland Domain 3 Strategies • Increase the institutionalization and monitoring of aggregated,

standardized quality measures at the provider and systems level.• Increase electronic health records (EHR) adoption and the use of

health information technology to improve performance.• Implement decision support which assists health care providers in

gathering and using data to improve quality of care and promote strategies for maintaining good health.

• Use health information technology to facilitate bi-directional data sharing to support care coordination and to improve health outcomes.

• Increase engagement of non-physician team members (i.e., nurses, pharmacists, and patient navigators) in hypertension and diabetes management in health care systems.

A P P R O A C H T O Q I

• Focus on health systems changes• How will this impact all patients within health system?• Is there a culture change within the practice?• Are these changes sustainable?

• Strive for continued improvement • How to maintain progress already made?• How to address factors that may be inhibiting improvements in the data?• How can data be used to drive further improvements?

T E C H N I C A L A S S I S T A N C E

• Community of Practice and one-on-one calls

• Share best practices and policies

• Provide sample forms and processes

• Support linkages to community programs

• Embed changes into existing workflow

• Provide training (PDSA, process mapping)

• Provide resources

• Program evaluation support

F Y 1 6 O U T C O M E S

• 25 primary care practices• 42,003 patients with hypertension• 17,059 patients with diabetes

• 61% of practices (11 of 18) improved in NQF18 (hypertension control)• Baseline Average: 62.86%• Q4 Average: 62.28%

• 78% of practices (14 of 18) improved in NQF59 (diabetes poor control)• Baseline Average: 38.79%• Q4 Average: 30.86%

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U N D I A G N O S E D H Y P E R T E N S I O N

Identifying Undiagnosed Hypertension in Health Systems

Identifying Undiagnosed Hypertension in Oral Health Practices

Approach: to encourage LHDs to work with health systems/practices to

develop and implement policies, systems, and environmental changes to:

• Identify patients with undiagnosed hypertension;

• Refer patients to follow up care, including clinical and/or community-based services.

P A R T N E R S

• Identifying Undiagnosed Hypertension in Health Systems• Only St. Mary’s County• Two partner practices in the community• Will be adding measures to identify people with prediabetes in FY18

• Identifying Undiagnosed Hypertension in Oral Health Practices• Calvert, Carroll, and Charles Counties• In collaboration with 1422 and 1609 grants• Will have at least 15 partners by the end of FY18

S U C C E S S E S A N D C H A L L E N G E S

Successes• Great continuity with

partnerships

• Intensive technical assistance

• Continuous training in quality improvement

• Leveraging other funds to expand on quality improvement initiatives

Challenges• Provider engagement

• Data collection EHR capabilities

• Systems level changes take time to show improvement in NQF measures (quantitative data)

• Health systems change frequently

HEALTHLINKJACI HILLS, MPH

CHRONIC DISEASE COORDINATOR

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30 miles

9 miles

ABOUT CALVERT COUNTY

PARTNERSHIPS

Dunkirk Family Practice Private practice, 4 practitioners, 2000 patients

Calvert Internal Medicine Private practice, 15 practitioners, 16000 patients

Calvert Primary Care-Prince FrederickHospital-owned practice, 4 practitioners, 2000 patients

SYSTEM-LEVEL IMPROVEMENTS

Forging new relationships between Health Department and primary care provider offices

Needs assessment

Leverage additional resources for diabetes and hypertension

Stanford’s Diabetes Self-Management Program (Living Well with Diabetes)

American Heart Association’s Heart360

Diabetes and Hypertension Resource Guide specific to Calvert County

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PRACTICE-LEVEL IMPROVEMENTS

Dunkirk Family Practice Daily huddles include review of flagged

patients

Follow-up by MA for patients with abnormal lab results

Improvement in accuracy of coding

Participation in Chronic Care Management program

High rate of referrals

Calvert Primary Care Institute referral procedure

Flagging system for diabetes patients

A1c meter

High rate of referrals

HEALTHLINK TARGET POPULATION

Patients are referred to Healthlink using referral form OR electronic referral (EHR)

Type 2 Diabetes with an A1c > 7.0%

HTN w/uncontrolled BP

Prediabetes

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CHALLENGES

Practice engagement

Engaging at each staff level including practice manager, medical assistant AND provider

Using process-map for quality improvement

Identify one specific-quality improvement goal at each practice

Timing of data measures

SUSTAINABILITY

Reporting at practice level

Capacity building through staff trainings and providing tools for quality improvement internally

Expansion to additional offices within Calvert Physician Associates

THANK YOUJACI.HILLS@MARYLAND.GOV

Improving the health of our community…one patient at a time.

2017

Amber Starn, MPH‐Data Collection and EvaluationAngela Deal, CHES‐Program CoordinatorWanda Mahoney‐Community Health Worker and Outreach

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Charles County‐Demographics

2015 Census Population Estimate: 156,118

Diverse population: 53% Minority

Health System Partners1. Health Partners‐

Waldorf, MD‐(948) 

2. Health Partners‐Nanjemoy, MD‐(55)

3. Greater Baden‐Brandywine, MD (1363)

4. Greater Baden‐

La Plata, MD

WCFMC (182)

Western Charles Co. • The zip codes that surround this clinic;

– Have the greatest rates for heart disease and low birth weight

– Hospitalization rates are high 

– High rates of Medicaid enrollment and WIC enrollment

– Lowest life expectancy, and

– Schools in this region have the highest rates of free and reduced meal participation

• Geographically isolated

• Time study indicated that a one‐hour medical appointment would take residents 8 hours to complete on public transportation. Clinic saves residents valuable time.

Health Partners, Inc.‐Waldorf, MD• Historically a charitable clinic, offering free health services to the uninsured

• Patients did not typically seek care until things were out of control. They were not previously seeking routine care

• Health Partners has just recently been credentialed to accept medical assistance and has had a large influx of new patients in their practice

• We have a fantastic partnership with them

Waldorf, MD2010 Population‐67,752

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Process of Community Referral and Care Plan

Adapted from St. Mary’s Community Linkages Referral Form.

Each patient receives a follow up call and assistance with scheduling if needed.

Referral Data2016 and 2017 (through May)

Care Plan Data2016 and 2017 (through May)

NQF Data• Year 1 for Greater Baden. No practice level improvements in their NQF measures for diabetes or hypertension yet. 

• Year 2 for Health Partners:

• NQF measure for diabetes control: 59.69% to 55.8% with an A1C greater than 9. 

• NQF measure for hypertension control: 30.8% to 40.7% have a blood pressure less than 140/90.

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“One of the patients I referred in the first few weeks of using this referral form was a middle aged woman with hypertension and obesity. … She stated this referral will motivate her to start making lifestyle changes and was excited about the suggested programs. “

‐Submitted by Mary Hannah, Diabetes Case Manager CRMC

Successes Stanford’s Chronic Disease Self‐Management Program Success

• Trained 9 facilitators in the County. At least one staff (non‐physicians) from each Health System.

• Partnered with our local Hospital, University of Maryland Charles Regional to offer classes to the community.  They pay the $200 fee per class. 

• Letter

Sample Flier Resource 

Guide

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Success

• Health Partners is currently completing the referral form in their EHR and faxing copies to us.

• All providers are spending more time educating patients on hypertension and diabetes – using models we provide

• Providers are using the process maps to make changes

Challenges

• PDSAs‐Practices are making changes, just not taking the time to complete PDSAs

• Time‐Practices have limited time to complete referrals and PDSAs

Engaging Partners

• Relationship Building‐Staying in constant touch

• Outreach worker visits each office weekly

• Providing the providers the education materials they want for their patients

• Adapting Forms to the practice’s need

Sustainability

• Incorporating many of the activities from this grant into the goals and strategies of the county’s LHIC and CDPT (Chronic Disease Prevention Team). – Increase evidence based chronic disease self management by hospitals and primary care providers. 

• Increase the capacity of primary care providers to implement screening, prevention and treatment measures for hypertension and diabetes in adults through QI methods and other training approaches.  

• Link health care‐based efforts with community prevention activities.  

• Implement the Stanford Chronic Disease Self Management Program, utilizing many community agencies and partners.  Funding from this program is coming from all of the Health Systems.

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Thank you!

Angela Cochran, MS, RCEPDirector, Chronic Disease Prevention & Control

St. Mary’s County

• Population 110,000• 50.4% rural • 2570:1 (Population to PCP)• One local hospital

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Timeline

6 Participating Practices

EMR/HIT Focus

Process Mapping

Data

Pilot Program

2 Participating Practices

7 Participating Practices

CCL Referrals

Shared Team Learning Meetings

5 Participating Practices

On-site visits

Provider Training

2014 2015 2016 2017

Engaging Partners

• Request for Letters of Interest

• Established contracts with reimbursement

• Leveraged on-going partnerships

• St. Mary’s County Primary Care Collaborative Bi-monthly group meetings Shared team learning

• 1:1 meetings

• Education/Training opportunities

Work Plan in Action

Increase the institutionalization and monitoring of aggregated, standardized quality measures at the provider and systems level.

• Monthly data reports• Referrals to CCL• Aggregating data 

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Data Template

Community‐Clinical Linkages Referral Form

Work Plan in Action

Increase electronic health records (EHR) adoption and the use of health information technology to improve performance.

• Retrieving data reports from EHR• More effective utilization of EHR

EMR Strategies

• Data extraction from EMR (NQF 18 and 59)Use of rolling yearData validation

• Embedding CCL referral form

• Creation of specific reportsUndiagnosed hypertension report

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Work Plan in Action

Increase engagement of non-physician team members (i.e., nurses, pharmacists, and patient navigators) in hypertension and diabetes management in health care systems.

• 1:1 meetings and site visits• Process mapping• Provide education and training opportunities

Training and Education

Successes

• Increased number of referrals to community programs

• Embedding referral forms into EHR• Policy creation• Bidirectional data – community programs• Education/Training• Creation of EHR reports (undiagnosed HTN report)

Challenges

• Timely data collection• Data reporting from EHRs• Self‐management plans• All practices are now MedStar

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Sustainability

• Policy creation• Practice Champions• CCL Referral Systems• EHR utilization

Thank you!

Angela CochranAngela.Cochran@Maryland.gov

B R E A K

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S U S T A I N A B I L I T Y

• FY 18, Quality Improvement in Health Systems will continue in 6 of the 7 jurisdictions

• Leveraging other funding, 4 more counties will be engaged for capacity building to conduct quality improvement in health systems

• Engaging Health Quality Innovators to provide additional training in quality improvement and other relevant topics

D A T A W A R E H O U S E

• Collaborated with Mid-Atlantic Association of Community Health Centers (MACHC) to create data warehouse to aggregate EHR data across Federally Qualified Health Centers (FQHCs)

• Data warehouse provides opportunities for benchmarking to identify and share clinical best practices

• Dashboard reports include 29 measures, which align with national standards such as UDS, Meaningful Use, HEDIS, and NQF

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MACHC, Health Centers, and The Role of Data in Population 

Health Improvement

July 18, 2017

CDC Site Visit

Mid‐Atlantic Association of Community Health Centers (MACHC)

98

34‐year old non‐profit Federally designated Primary Care Association providing support, training, technical assistance and advocacy to Federally 

Qualified Health Center

MACHC serves:

• community health centers

• migrant health centers

• homeless health centers

• other community‐owned healthcare programs

Maryland 

and 

Delaware

Small but mighty

staff of six

MACHC

FQHCs

99

Federally Qualified Health Centers (FQHC) Nationally

Provide high quality preventive and primary health care to patients regardless of their ability to pay.

Approximately 1 in 14 people in the U.S. relies on a health center for medical care. 

Nearly 1,400 health centers operate 9,800 service delivery sites in every U.S. state, D.C., Puerto Rico, the Virgin Islands and the Pacific Basin

Health centers employ more than 188,000 staff who provide care for over  24 million patients.

FQHCs

100

Federally Qualified Health Centers (FQHC) MD and DE

MarylandMaryland• 17 Health Centers

• 303,352 patients served

• 30.4% children; 7.4% over 65 years of age

• 67% racial or ethnic minority

• 91% at or below 200% poverty

• 19% uninsured; 50% Medicaid

DelawareDelaware• 3 Health Centers

• 45,487 patients served

• 27.5% children; 5.4% over 65 years of age

• 81% racial or ethnic minority

• 97% at or below 200% of poverty

• 29% uninsured; 42% Medicaid

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CCIC Mission Statement

101

The mission of the CCIC is to support operational, clinicaland quality excellence within its participating healthcareorganizations while enabling strategic imperatives related to:

population health management,  quality improvement and  value‐based purchasing  

through a comprehensive data analytics and managementstrategy.

CCIC Goals

102

Goal 1: Implementation of flexible & scalable technologies that support the generation of aggregate data across the participating organizations and allow expansion beyond data traditionally captured by  EHRs

CCIC Goals

103

Goal 2: Establishment of an advisory structure that guides the data management strategy of the CCIC by developing standardized benchmarks to be utilized 

internally by participating organizations and externally by stakeholders while leveraging evidence‐based standards of care for addressing targeted diseases. 

CCIC Goals

104

Goal 3: Support participating organizations in the incorporation of aggregate and individual data into their ongoing activities associated with quality improvement, chronic disease management and  

PCMH in addition to readying them for  alternative payment methodologies.

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General Project Structure

105

Phase

Phase I Phase II Phase III

Strategic Engagement Initial Cohort Spread

Objectives

Obtain a better understanding of 

participating member needs and obtain 'buy‐in' for the sharing of data and participation in the project

Set up technical and organizational 

infrastructure to support the ongoing sharing of data as well as the 

improvement of care

Spread the support and infrastructure to all 

members

Phase I: Data AnalyticsInitial Data Set

Preventive Care MH NQF UDS HEDIS

Lead Screening ‐ 29 ‐ LSCCervical cancer screening ‐ 32 Table 6b‐3 CCSChlamydia Screening ‐ 33 ‐ CHLColorectal cancer screening ‐ 34 Table 6b‐10 COLBreast Cancer Screening ‐ 2372 ‐ BCS

Immunization MH NQF UDS HEDIS

Childhood Immunizations Combo 3 ‐ ‐ Table 6b‐2 ‐Childhood Immunizations Combo 10 ‐ ‐ ‐ CISImmunizations for Adolescents ‐ 1407 ‐ IMA

Cardiovascular risk assessment MH NQF UDS HEDIS

Weight Assessment & Counseling for Nutrition & Physical Activity for Children/Adolescents (WCC)

‐ 24 Table 6b‐4 WCC

Adult BMI Assessment ‐ 421 Table 6b‐5 ABASmoking Assessment and Treatment Yes 28 Table 6b‐6 ‐Hypertensive Patients with Blood Pressure < 140/90  Yes  18 Table 7a‐2 115Blood Pressure Screening Yes ‐ ‐ ‐Diabetic Eye Exam ‐ 55 ‐ CDCDiabetes Foot ExamDiabetes RiskDiabetic HbA1c Testing ‐ 57 ‐ CDCDiabetes Patients with HbA1c <= 9% by racial and ethnic group  ‐ 59 Table 7a‐3Diabetic Nephropathy Monitoring ‐ 62 ‐ CDCCholesterol Management – Population Yes n/a ‐ ‐Cholesterol Management – Diabetes Yes NQF‐ 64 ‐ ‐Cholesterol Management – IVD Yes NQF ‐75 ‐ ‐

106

Phase I: Data AnalyticsInitial Data Set

Chronic conditions MH NQF UDS HEDIS

Coronary artery disease (CAD) and lipid lowering therapy ‐ 74 Table 6b‐8 ‐Ischemic Vascular Disease (IVD) and antithrombotic therapy Yes 68 Table 6b‐9 IVDHIV linkage to care ‐ ‐ Table 6b‐11 ‐Appropriate pharmacologic asthma therapy ‐ ‐ Table 6b‐7 ASMMedication Management for People with Asthma ‐asthma controller medication for at least 50% of their treatment period.

‐ ‐ ‐ MMA

Medication Management for People with Asthma ‐asthma controller medication for at least 75% of their treatment period.

‐ ‐ ‐ MMA

Depression screening ‐ 518 Table 6b‐12 ‐

Prenatal care MH NQF UDS HEDIS

Early entry into prenatal care.  ‐ 1517 Table 6b‐1 PPCLow Weight Births by racial and ethnic group ‐ 1382 Table 7a‐1a ‐Very Low Weight Births by racial and ethnic group ‐ ‐ Table 7a‐1b ‐Post‐partum visit ‐ 1517 PPC

Primary Care Utilization MH NQF UDS HEDIS

Adolescent Well Care Visit ‐ ‐ ‐ ‐Disabled (SSI) Children ‐ ‐ ‐ ‐Well Child Visit ‐ ‐ ‐ W347‐Day Follow‐up After Hospitalization ‐ ‐ ‐ ‐Disabled (SSI) Adults: Members age 21–64 years and older who have been enrolled for 320 days or more that have had at least one ambulatory care visit in an office or other outpatient visit.

‐ ‐ ‐ ‐107

Current reporting

8

12

2 3 2

12

0%10%20%30%40%50%60%70%80%90%

100%

YES NO

Current data distribution

108

Results of Phase I: Data Analytics

10

0

12

0Share outsidestakeholders

Share withstaff

Share withboard

Share withpatients

YES NO

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Phase 1 – Challenges and Successes

• Contracting

• Telling our story/ Building relationships

• Buy‐in from health centers

• Development of Advisory Council

• Health center challenges

• Two platforms (i2i Tracks and Azara DRVS)

• Staffing limitations

• Financial limitations

• EHR challenges

109

Phase 2 – Challenges and Successes

• Developing and building dashboard

• Data mapping and validation

• Developing a process for ensured continued data integrity

• Committee structures changed

• Temporary lull in momentum

• Customer service issues with one vendor

• Solidified the understanding of a need to go further to patient level data in next phase

• Findings from initial colorectal data analysis

110

Complexity Scale Project

• Considers chronic disease, social determinants of health, payer risk scores

• Allows health centers to evaluate patient mix and costs associated with points on the complexity scale

• Allows health centers to apply scarce resources more appropriately leading to improved efficiencies and patient health outcomes

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Partners

• Maryland Department of Health• Center for Chronic Disease Prevention and Control

• Maryland Colorectal Cancer Control Program, Center for Cancer Prevention and Control

• Health Centers and Vendors

• Garden State Practice Transformation Network

• University of Maryland Learning Collaborative

• Maryland Healthcare Commission

• Technology Partners

• Partners in Progress

• Payers – Commercial and MCOs

• Maryland Community Health Resource Commission

• MDH, Office of Oral Health

• CRISP112

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Sustainability

• Partners in Progress

• Health Center User Fees

• HRSA HCCN Grant

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CCIC: Where We’re Going

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Continued Engagement of CHCs 

Evaluating our Tools – current and available

Continued Work  to meet the Triple Aim

Considering IPA/ACO formation 

Complexity Scale Project

Community Health Centers are an integral part of improving the health of populations and reducing overall healthcare costs

Questions

115