sc pa data review
DESCRIPTION
SC PA Data Review. Robert A. Gabbay, MD, PhD Professor of Medicine, Penn State College of Medicine. PCMH-A (Patient-Centered Medical Home Assessment). Survey designed to help systems and provide practices move toward the PCMH model Utilized to help teams identify areas for improvement - PowerPoint PPT PresentationTRANSCRIPT
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SC PA Data ReviewRobert A. Gabbay, MD, PhDProfessor of Medicine, Penn State College of Medicine
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PCMH-A(Patient-Centered Medical Home Assessment)
• Survey designed to help systems and provide practices move toward the PCMH model• Utilized to help teams identify areas for
improvement• A sense of how PCMH like you are
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1 2 3 4 5 6 7 8 9 100
2
4
6
8
10
12
PCMH-A Average Change
Start End
Practice
Asse
smen
t Sca
le (1
-12)
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PCMH-A Assessment
• On average, practices reported an average increase of +2.3/12 points (20%)• The top 3 most improved categories:• Empanelment (+3.3 points)• Quality Improvement Strategy (+3.0 points)• Patient Centered Interactions (+2.6 points)
(All on a scale from 1-12)
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HEDIS Goals• HEDIS & Quality Measurement Goals• 90th Percentile of the HEDIS New England or Mid-Atlantic
Benchmarks (whichever was higher)• Standardized set of performance measures
• HEDIS goals used for PA SPREAD:• % DM pts A1C >9 – 13.63%• % DM pts A1C <8 – 74.70%• % DM pts BP <140/90 – 76.33%• %DM pts LDL <100 – 58.15%• %DM pts tobacco query – 90%• % DM pts nephrology screening – 92.46%• % DM pts eye exam – 90%• % DM pts foot exam – 90%• %DM pts with self-management goals – 90%• % DM pts with tobacco cessation interventions – 90%
*All criteria for goals based on a 12 month period EXCEPT tobacco query & tobacco cessation intervention which are based on a 24 month period
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Steady Denominators = Good!
Baselin
e
June 2012
July 2012
August
2012
Septem
ber 2012
October
2012
November
2012
December
2012
January
2013
Febru
ary 2013
March 2013
April 2013
0
200
400
600
800
1000
1200
Count of DM Patients Ages 18-75SouthCentral
Hamilton
Oyster Point
GIM
Cornerstone
Mountville
Manor
Eastbrook
Silver Creek
Carlisle
Sandrowicz
Average
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Excellent Job! Now Part of Planned Care at Every Visit
Baselin
e
June 2012
July 2012
August
2012
Septem
ber 2012
October
2012
November
2012
December
2012
January
2013
Febru
ary 2013
March 2013
April 2013
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% DM Patients Tobacco QuerySouthCentral Hamilton
Oyster Point
GIM
Cornerstone
Mountville
Manor
Eastbrook
Silver Creek
Carlisle
Sandrowicz
Average
Goal
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Mean Change in Abs %: Increased +12.0% (statistically significant)
Baselin
e
June 2012
July 2012
August
2012
Septem
ber 2012
October
2012
November
2012
December
2012
January
2013
Febru
ary 2013
March 2013
April 2013
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% DM Patients with Nephropathy Screening/TreatmentSouthCentral
Hamilton
Oyster Point
GIM
Cornerstone
Mountville
Manor
Eastbrook
Silver Creek
Carlisle
Sandrowicz
Average
Goal
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*The mean change in percentage points increased +8.1%, making it statistically significant
Baselin
e
June 2012
July 2012
August
2012
Septem
ber 2012
October
2012
November
2012
December
2012
January
2013
Febru
ary 2013
March 2013
April 2013
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% DM Patients with Dilated Eye Exam Results DocumentedSouthCentral
Hamilton
Oyster Point
GIM
Cornerstone
Mountville
Manor
Eastbrook
Silver Creek
Carlisle
Sandrowicz
Average
Goal
Mean Change in Abs %: Increased +8.1% (statistically significant)
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*The mean change in percentage points increased +19.5%, making it statistically significant
Baselin
e
June 2012
July 2012
August
2012
Septem
ber 2012
October
2012
November
2012
December
2012
January
2013
Febru
ary 2013
March 2013
April 2013
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% DM Patients with Foot ExamSouthCentral Hamilton
Oyster Point
GIM
Cornerstone
Mountville
Manor
Eastbrook
Silver Creek
Carlisle
Sandrowicz
Average
Goal
Mean Change in Abs %: Increased +19.5% (statistically significant)
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You Are Likely Doing This – How Do We Track It?
Baselin
e
June 2012
July 2012
August
2012
Septem
ber 2012
October
2012
November
2012
December
2012
January
2013
Febru
ary 2013
March 2013
April 2013
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% DM Patients with Self-Management GoalsSouthCentral Hamilton
Oyster Point
GIM
Cornerstone
Mountville
Manor
Eastbrook
Silver Creek
Carlisle
Sandrowicz
Average
Goal
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Improving As Processes of Care Get Implemented
Baselin
e
June 2012
July 2012
August
2012
Septem
ber 2012
October
2012
November
2012
December
2012
January
2013
Febru
ary 2013
March 2013
April 2013
0%
5%
10%
15%
20%
25%
30%
% DM Patients with A1C>9SouthCentral Hamilton
Oyster Point
GIM GIM
Cornerstone
Mountville
Manor
Eastbrook
Silver Creek
Carlisle
Sandrowicz
Average
Goal
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Practices Close To The HEDIS 90% Goal
Baselin
e
June 2012
July 2012
August
2012
Septem
ber 2012
October
2012
November
2012
December
2012
January
2013
Febru
ary 2013
March 2013
April 2013
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% DM Patients with A1C<8SouthCentral
Hamilton
Oyster Point
GIM
Cornerstone
Mountville
Manor
Eastbrook
Silver Creek
Carlisle
Sandrowicz
Average
Goal
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Many Practices Close To The HEDIS 90% Goal
Baselin
e
June 2012
July 2012
August
2012
Septem
ber 2012
October
2012
November
2012
December
2012
January
2013
Febru
ary 2013
March 2013
April 2013
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% DM Patients with BP <140/90SouthCentral
Hamilton
Oyster Point
GIM
Cornerstone
Mountville
Manor
Eastbrook
Silver Creek
Carlisle
Sandrowicz
Average
Goal
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Some Practices at HEDIS 90% Goal, Others – More Work To Do
Baselin
e
June 2012
July 2012
August
2012
Septem
ber 2012
October
2012
November
2012
December
2012
January
2013
Febru
ary 2013
March 2013
April 2013
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% DM Patients with LDL <100SouthCentral
Hamilton
Oyster Point
GIM
Cornerstone
Mountville
Manor
Eastbrook
Silver Creek
Carlisle
Sandrowicz
Average
Goal
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Great Work… But More To Do!
• All of this was accomplished WITHOUT extra money• Planned care at every visit• Reaching out to high risk• Self-management support• Working as a team• MEETING AS A TEAM
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Why We Have Done This• Each A1C point drop:• Eye disease risk reduced by 76%• Kidney disease risk is reduced by 50%• Nerve disease risk is reduced by 60%• Any cardiovascular disease event risk is reduced by 42%• Stroke by 57%
• Better screening nephropathy, feet and eyes reduces ESRD, amputations, and blindness.
In your population of over 11,000 diabetes patients – this is huge!