johnsonjk modelinglhs handout...3/20/2019 1 modeling learning health system principles to maximize...

3/20/2019

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Modeling Learning Health System Principles to Maximize Value-based Care Delivery in Physical Therapy

Joshua Johnson PT, DPT, PhDSandra Passek PT, DPTKaren Green PT, DPTChristine Schulte PT, MBA

April 5, 2019

Disclosures

• Sandra Passek and Karen Green disclose a financial interest in the AM-PAC 6-clicks tool

• The presenters have no additional relevant disclosures

Session OutlineDefine a learning health system as it relates to value in physical therapy practiceDefine

Describe the role of standardized data collection and use to drive value-based care deliveryDescribe

Summarize clinical examples of data-driven practice change toward valueSummarize

Discuss the personnel roles contributing to learning health system successDiscuss

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Our challenge

Where do we fit in?

The patient’s

outcomes

The patient’s

experience

Porter ME. What is value in health care? NEJM. 2010.https://uofuhealth.utah.edu/value/value-equation.php

The case for a

learning health

system

• Suboptimal outcomes

• Rising costs / decreased reimbursement

• Increasing complexity in health care- Information capture – need actionable data- Patient presentation – need to do the right thing- Shifting payment reform – need to align incentives

A learning health

system

“…one in which progress in science, informatics, and care culture align to generate new knowledge as an ongoing, natural by-product of the care experience, and seamlessly refine and deliver best practices for continuous improvement in health and health care.”

Institute of Medicine

From: Institute of Medicine: Best Care Lower Cost: The Path to Continuously Learning Health Care in America 2013

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The case for a

learning health

system

Current health care context “A disturbing paradox”

• The coexistence of overtreatment and undertreatment.

• Learning and adoption that are maddeningly slow…

coexisting with overly rapid adoption of some new

techniques, devices, and drugs, with harmful results.

From: Institute of Medicine: Best Care Lower Cost: The Path to Continuously Learning Health Care in America 2013

Date of download: 10/17/2017Copyright © 2016 American Medical

Association. All rights reserved.

From: Convergence of Implementation Science, Precision Medicine, and the Learning Health Care System: A New Model for Biomedical Research

JAMA. 2016;315(18):1941-1942. doi:10.1001/jama.2016.3867

Contributions of Implementation Science, Learning Health Care System, and Precision Medicine

Figure Legend:

The objective

The synergy




JAMA. 2016;315(18):1941-1942. doi:10.1001/jama.2016.3867


Figure Legend:

Physical Therapy Practice

• Right provider• Right care• Right patient• Right time

• Standardized data collection, analysis, and feedback

• All stakeholders participate

• System-level context• Personal-level context• Organizational culture

and readiness

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Data Standardization

Sandra Passek, PT, DPT

Value = Quality/Cost

• Improve Quality of Care

• Reduce Cost of Care

QualityOutcomes

Cost Effective

Care

Safety

Standardized Clinical

Data

Journey at the Cleveland Clinic

Content only to be used with permission of authors

Uniform data collection in all

settings

Use information from large uniform data

sets to make decisions.

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Our ChallengeTo determine the role of the rehabilitation

professional in a health system striving for value

Porter ME. What is value in health care? NEJM. 2010.https://uofuhealth.utah.edu/value/value-equation.php

The Patient’s

Outcomes

The Patient’s Experience

Standardized Clinical Content

• Unified Documentation Platform- Compliance / Regulatory- Quality / Best Practice / Care Paths

• Training

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Compliance / Regulatory

• Occurrence Codes• Surgical History and Precautions

Quality and Outcomes

• Low Back Pain Subgroup Classification• Cleveland Clinic 6 Clicks• Patient Performance • Patient Reported Outcomes

Quality

Classifications

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Cleveland Clinic 6-Clicks• Short Form of the AM-PACTM

• Integrated into our EMR• Designed to be a simple, quick tool for both

providers and patients• Completed for each patient on every visit• Provides for a quick, but comprehensive “picture” of

each patient’s function• Functions as a “mini-evaluation” at each visit

What Were We Looking for in a Tool

Minimal burden on staff

Minimal burden on patients

Incorporate functional items that therapists

currently evaluated

No more than 6 questions


On evaluation and every follow up visit, each discipline completes a functional measure assessment.

PT evaluates the patient’s abilities in:1. Turning over in bed

2. Supine to sit

3. Bed to chair

4. Sit to stand

5. Walk in room

6. 3-5 steps with a rail

OT evaluates the patient’s abilities in:1. Feeding

2. O/F hygiene

3. Dressing Uppers

4. Dressing Lowers

5. Toilet (toilet, urinal, bedpan)

6. Bathing (wash/rinse/dry)

Scale: 1= Unable (Total Assist) 2= A Lot (Mod/Max Assist)

3= A Little (Min Assist/Supervision) 4= None (Independent)


Cleveland Clinic 6 Clicks

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PT

The Power of Data

Collect

Aggregate

Display


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Turning Data into Knowledge

Data Information Knowledge

Cleveland Clinic 6-Clicks

• Lessons learned & shared with our healthcare partners

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Outcome Measurement

• Patient Performance

• Patient Reported (generic, diagnosis specific)

Patient Reported Outcome Measurement

• Standardized - Tool driven by primary reason for visit- Collected at evaluation and progress report

• Collection- AM-PAC Short Form- Modified Oswestry- STaRT Screening Tool

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Classification of PRO’s• Use on an individual patient level:

– screen for clinical problems and identify limitations– monitor progress over time,– promote communication assist with goal setting

• Use on an aggregate level:– inform quality improvement – conduct population monitoring– drive system change


Standardized Clinical Content

• Builds trust • Display for provider decision support and

leader dashboard• Sets foundation for clinicians to ask

questions and seek answers• Define what metrics are necessary to

answer

Laying the Foundation for a Learning Health System

The Inpatient StoryKaren Green, PT, DPT

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JAMA. 2016;315(18):1941-1942. doi:10.1001/jama.2016.3867


Figure Legend:

Learning Health System

Precision:

Right Provider

Right Patient

Right Care

Right Time

Information:

Standardized Data Collection, Analysis

and Feedback

Participation from all Stakeholders

Implementation:

System Level Context

Organizational Culture/Context

Personal Level Context

Results in Improved health care and health systems

Example 1 – Transplant patients

Where we were:• All patients receiving consults for

PT, OT and Cardiac Rehab• All providers seeing all patients• Increasing length of stay for

complex patients

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Physical Therapy:

Ambulation

Surgical Precaution Education

Cardiac Rehab:

Ambulation

Surgical Team:

Requesting “More” PT

Surgical Precaution Education

Nursing:

Waiting for PT

Example 1 – Transplant patientsFrustration…

PT not working with patients that need more care

Lack of awareness…

Frustration…Over-utilized

Not able to work with patients that need more care


Physical Therapy

Cardiac Rehab

Physician / APP

Education Ambulation

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ICU• PT Consulted to evaluate and develop a mobility plan

6 Clicks

6-21

• Upon transfer to the Nursing Floor• PT to drive mobility plan with delegation to nursing

6 Clicks 22-24

• PT to Hold Treatment• Cardiac Rehab and Nursing drive mobility plan


Cardiac Rehab

Ambulation

Physical Therapy

Skilled Mobility

Physician / APP

Precaution Education


Precision:

Information:

Implementation:


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Preliminary Results:• Declining LOS• Minimal overlap of

services• Improved confidence that

PT is working with the right patient at the right time

Example 2 – Care Management

Where we were:• Less than optimal utilization of

waiver programs• Requests for updated notes for

patients who did not need them• Increasing LOS

Example 2 – Care ManagementFrustration…

Care Manager delaying discharge

by asking for information that is

not needed…

Frustration…PT delaying

discharge by not providing updated

notes…

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What is a Waiver Program?• Partnership with a payor• The payor eliminates or waives a

primary requirement• Two primary programs

Example 2 – Care Management• CM’s balancing

multiple payor, programs & initiatives

• Difficulty identifying waiver patients • Therapists

balancing large caseloads

• Difficulty managing new patients and follow-up needs

Example 2 – Care Management• EMR data mined to identify potential waiver

patients

• Clerical support labels the patients who have PT orders so initial eval can be prioritized

• If patient identified as needing SNF level of care post discharge, warm hand-off to Care Manager to leverage the waiver

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Precision:

Right Provider

Right Patient

Right Care

Right Time

Information:

Standardized Data Collection, Analysis

and Feedback

Participation from all Stakeholders

Implementation:

System Level Context

Organizational Culture/Context

Personal Level Context



Laying the Foundation for a Learning Health System

The Outpatient StoryChristine Schulte PT, MBA

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JAMA. 2016;315(18):1941-1942. doi:10.1001/jama.2016.3867


Figure Legend:

Example 1 – Low Back Pain Patients

Where we were 2010:• 55 outpatient departments with 400

outpatient therapist trained across the US• No defined workflow to get patients to

therapists with Spine Care.• Multiple phone numbers for access without

direction with how to schedule.

Example 1 – Low Back Pain Patients

Physical Therapist

Patient Satisfaction

CCRST Leadership

Education Function

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Low Back Pain Patients

Where we moved in 2014:• Defined systematic scheduling workflow in

Epic with Specific Visit Type and Template for documenting for Cleveland Clinic Rehab & Sports Therapy (CCRST)

• Defined Low Back Care path for CCRST• Communicated to outpatient PT’s via 4 hour

training with ongoing training for new hires.


Epic Data

Spine visit types

Discrete data fields in

documentation

Compliance with Outcome

data toolsLow Back Pain Care

path adherence; use of Classification

guidelines;

follow through of Plan of Care

Reviewed Standard Elements

1. Modified Oswestry2. STaRT Screening tool3. LBP Template used4. Patient Classification which determined average

visits per classification range5. Number of visits seen6. Variance between the 2

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Where we were in 2017:• Data pull of Epic Spine visit types• Determine key audit edits• Data pull of Epic Documentation of discrete data• Reviewed for follow through of Care path workflow

across 55 Outpatient sites• Performance improvement plan

- Re-educated the Outpatient therapists

Low Back Pain PatientsPhysical Therapist

Patient Satisfaction

CCRST Leadership

Physician / APP

Education

Fun tion


Precision:

Information:

Implementation:


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Regulatory Audit Compliance

Where we were:• Less than optimal compliance review

- Totally Manual

• Requests for notes and Medical review was real.

• Seeking ways to instill importance to all caregivers in daily routine

• Improving efficiency with locating required data elements

Regulatory Audit ComplianceFrustration…

Medical records reviewer is not

familiar with outpatient

documentation and keep asking for

information that is in my flow sheet

rows…

Frustration…PT delaying timely

billing by not providing

occurrence codes or delays with

requested Medical Record information such as Certified Plans of Care in Encounters…


Where we began 2010:• 400 outpatient therapist • No defined workflow to audit therapists

adherence to regulatory components in daily documentation.

• Individual managers were doing their best to review and supply information as requested

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Where we moved in 2013:• Defined systematic Outpatient Audit to be

performed on 30 encounters for each therapist. • Average audit looked at 5-7 patient charts• Developed a training mechanism to teach

auditors to review and record in Excel workbook• Shortfalls not standard workflows.

- Paper and Electronic billing

Regulatory Audit ComplianceWhere we are in 2018:• Data pull of Epic CCRST visit types including insurer to target

Medicare/Medicaid plans.

• Using 30 patients to review

• Determine key audit edits and established an excel workbook with formulas to calculate scored points including appropriate billing practice

• Individual, Site, Region, Departmental compliance graphs available

• Performance improvement plan- 97% target - Re-educated the Outpatient therapists

Value of the work

CCRST choose 97% as our teams goal

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Audit Data Summary

Challenged Department versus Compliant Department

Outpatient Waiver Program

What is a Waiver Program?• Partnership with a payor• The payor eliminates or waives a

primary requirement- Removed the Preauthorization

requirement for Medicare Advantage plans

- Trial as they monitor utilization.

Outpatient Waiver Program • Payer removing

preauthorization requirements

• Trusting the clinician to do the right thing

• Therapists balancing large caseloads

• Allowing them to establish a Plan of Care based on skilled needs

• Avoids delays for patients

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Build Now for the Future

Developing an LHS takes collaboration

Clinicians

“Do the doing”

Identify gaps

Administrators

Drive culture

Align goals

Health services researchers

Science-based thought

Other system stakeholders

Other providers

Data scientists

The patient &

caregivers

Role of Clinicians

• Be mindful of value-based care principles• Identify where care delivery does not match

value-based principles• Formulate clinical questions – ASK THEM!

Clinicians

“Do the doing”

Identify gaps

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Role of Administrators

• Culture- Value role of all stakeholders

- Facilitate/encourage standardized data collection

- Feed pertinent data back to stakeholders

• Align goals- Interaction/advocacy with organizational leaders

- Department goals to organization goals

Administrators

Drive culture

Align goals

Role of Others in the System

• Other providers- Overlapping services

- Collaboration where we fit in

• Data scientists- Facilitate extraction/visualization of data

• “External” collaborators (payers, etc.)


Other providers

Data scientists

Role of Researchers

• Health Services Researchers1

- Desire and skills to engage in transformational research at some level of a “system”



Defining the “system”• The national health system• Your health system• Your clinic• You

• Learning Health System Researchers2

• Somehow embedded within the health system• Questions and study designs in real-world settings• Leverage clinical data sources to drive improvement

1Adapted from: Burgess JF, Menachemi N, Maciejewski ML. Update on the Health Services Research Doctoral Core Competencies. Health Services Research. 2018;53(5):3985-4003.2Adapted from: Forrest CV, Chesley FD, Regear ML, Mistry KB. Development of the Learning Health System Researcher Core Competencies. Health Services Research. 2018;53(4):2615-2632.

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Attributes of LHS researchers

“Researchers who merely use data collected within health systems, without clear links to the priorities and operations of the system, would not be considered LHS researchers.”

Forrest CV, Chesley FD, Regear ML, Mistry KB. Development of the Learning Health System Researcher Core Competencies. Health Services Research. 2018;53(4):2615-2632.

Attributes of health services researchers

1. Understand the context of health care delivery2. Can transform clinical problems and opportunities into

relevant and important scientific questions3. Can understand and apply appropriate study designs and

data collection/analysis methods4. Conducts research that is responsible, reproducible, and

ethical5. Able to successfully collaborate with all stakeholders6. Able to effectively disseminate a study’s process, findings,

and implications and contribute to policy and/or practice change

Adapted from: Burgess JF, Menachemi N, Maciejewski ML. Update on the Health Services Research Doctoral Core Competencies. Health Services Research. 2018;53(5):3985-4003.

Additional attributes of LHS researchers

1. Somehow embedded within a health system2. Applies systems theory to research and

implementation3. Can apply appropriate study designs and analytic

methods within the context of real-world health systems

4. Can leverage clinical data sources5. Able to successfully collaborate with health

system stakeholders to address important questions and drive clinical improvement.

Adapted from: Forrest CV, Chesley FD, Regear ML, Mistry KB. Development of the Learning Health System Researcher Core Competencies. Health Services Research. 2018;53(4):2615-2632.

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So… Monday…

Clinicians

“Do the doing”

Identify gaps

Administrators

Drive culture

Align goals




Other providers

Data scientists

The patient &

caregivers

Identify your clinical

gap/question

Organizational alignment and

scale

Get the right people to the

table

Inquire using appropriate

methods

Citations1. Porter ME. What is value in health care? N Engl J Med. 2010;363(26):2477-2481.

doi:10.1056/NEJMp1011024

2. Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Wasington, DC: The National Academies Press; 2013. doi:10.17226/13444

3. Chambers DA, Feero WG, Khoury MJ. Convergence of Implementation Science, Precision Medicine, and the Learning Health Care System. JAMA. 2016;315(18):1941. doi:10.1001/jama.2016.3867

4. Forrest CB, Chesley FD, Tregear ML, Mistry KB. Development of the Learning Health System Researcher Core Competencies. Health Serv Res. 2018;53(4):2615-2632. doi:10.1111/1475-6773.12751

5. Burgess JF, Menachemi N, Maciejewski ML. Update on the Health Services Research Doctoral Core Competencies. Health Serv Res. 2018;53:3985-4003. doi:10.1111/1475-6773.12851

Additional References1. Jette AM. 43rd Mary McMillan Lecture. Face into the storm. Phys Ther.

2012;92(9):1221-1229. doi:10.2522/ptj.2012.mcmillan.lecture

2. Jette AM. Moving From Volume-based to Value-based Rehabilitation Care. Phys Ther. 2018;98(1):1-2. doi:10.1093/ptj/pzx112

3. Jewell D V, Moore JD, Goldstein MS. Delivering the physical therapy value proposition: a call to action. Phys Ther. 2013;93(1):104-114. doi:10.2522/ptj.20120175

4. Krumholz HM. Big data and new knowledge in medicine: the thinking, training, and tools needed for a learning health system. Heal Aff. 2014;33(7):1163-1170. doi:10.1377/hlthaff.2014.0053

5. Krumholz HM, Terry SF, Waldstreicher J. Data Acquisition, Curation, and Use for a Continuously Learning Health System. JAMA. 2016;316(16):1669-1670. doi:10.1001/jama.2016.12537

6. Porter ME, Larsson S, Lee TH. Standardizing Patient Outcomes Measurement. N EnglJ Med. 2016;374(6):504-506. doi:10.1056/NEJMp1511701

7. Smoyer WE, Embi PJ, Moffatt-Bruce S. Creating Local Learning Health Systems: Think Globally, Act Locally. JAMA. 2016;316(23):2481-2482. doi:10.1001/jama.2016.16459

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Thank you!

Questions?

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