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The Role of Technology in Transitioning to a New Care Model

Session 209 // February 22, 2017Amy Mechley, MD, Former Medical Director – CPCI and Wellness

Sandra Selman, Director of Care Management

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Introductions

Amy Mechley, MDFormer Medical Director, CPCI & Wellness The Christ Hospital Health Network

Principal, PYA Consultants

Sandra Selman, RN, WWDirector of Care Management The Christ Hospital Health Network

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Conflict of Interest

Amy Mechley, MD

Has no real or apparent conflicts of interest to report

Sandra Selman

Has no real or apparent conflicts of interest to report

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Agenda

• Trigger for change: Where and why we innovated,

local, regional, national impetus

• “What is it going to take to get us from here to there?”

• Technology served as a pillar, but a bridge was required

• Lessons learned and critical success factors for care

model transformation initiatives

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Learning Objectives• Identify best practices for overcoming EHR integration challenges and

implementing technologies to meet the needs of an organization embarking on

a new care model

• Discuss learnings through a real-world case study from an advanced comprehensive primary care organization for transitioning to a Patient Centered Medical Home (PCMH) approach to healthcare delivery

• Discuss how technological solutions can better facilitate team-based care, resulting in higher clinical quality measures, fewer gaps in care, and increased revenue

• Share how data and technology solutions can be customized to accomplish specific organizational goals

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STEPS™: Satisfaction, Treatment, Electronic,

Patient & Population, Savings

• Patient experience and provider satisfaction demonstrably

improved

• Team-based care model (PCMH), significantly outperformed

peers in closing treatment gaps

• Integrated population health management IT platform with

Certified EHR technology

• Improved key quality performance measures, exceeded

advanced primary care benchmarks

• Increased Medicare revenue, decreased hospital admissions

and readmissions

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Transformation through Patient-Centered Medical Home (PCMH) & the Comprehensive Primary Care Initiative (CPCI)

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The Christ Hospital Health Network

• Integrated delivery system based in Cincinnati, OH with a 555 bed acute care hospital, 41 primary care locations, and 100+ ambulatory sites

• Recognized national leader in clinical excellence and patient experience

• Focused on improving the health of the TCH community and creating patient value by providing exceptional outcomes, affordable care, and the finest experiences

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Do you know about the Comprehensive Primary Care Initiative (CPCI)?

• 1. Yes, very familiar

• 2. Yes, aware of it but I do not know any details

• 3. No, happily not a clue…

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2013: CPCI

• 2,188 participating providers,

7 regions across the U.S.

• Approximately 2.7M patients

• 38 payers, both public and

private

What did we get ourselves into?

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The Evolution of Primary Care

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…the patient-doctor visit is no longer the primary commodity.

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CPCI Core Functions

• Identify patients with chronic conditions and more robust healthcare needs. Deliver intensive care management for patients with high needs

Risk-Stratified Care Management

• Ensure patients and providers can access patient data tools 24/7 for real-time, patient information necessary to continually provide the highest levels of coordinated careAccess & Continuity

• Proactively manage patients to determine their needs and provide timely preventative care services

Planned Care for Chronic Conditions & Preventative Care

• Actively engage patients and families in goal setting and decision making to increase patient buy-in and adherence to care plans

Patient & Caregiver Engagement

• Primary care teams will coordinate with other health providers to effectively communicate key patient information during transitions in care or referring to other providers

Care Coordination Across the Community

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CPCI: Year 1 Milestones (2013)• Budget forecast

• Care Management of high risk patients

• 24/7 access by patients

• Improve patient experience

• Use data to guide improvement*

• Care Coordination

• Shared Decision Making

• Participation in CPC learning collaborative

• Meaningful Use Stage 1

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CPCI: Year 1 Milestones (2013)• Budget forecast

• Care Management of high risk patients

• 24/7 access by patients

• Improve patient experience

• Use data to guide improvement*

• Care Coordination

• Shared Decision Making

• Participation in CPC learning collaborative

• Meaningful Use Stage 1

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Gap Analysis

• Patient registry

• Care management

• EMR interface

• Chronic disease

management modules

• Outcome measures: Quality measures and cost analytics

• Patient interface (outreach, communications, coaching platform)

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Gap Analysis (cont.)

• Global data aggregation

(EMR, claims, RX data, HRA, etc.)

• Report writing

• Coaching platform

• Capability for branding and

product development

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Team-Based Care Not Designed into EHR’s

• The EHR user experience is transactional, not actionable

• EHRs are designed for data capture, not visualization or knowledge transfer

• EHR ill-equipped to address more rigorous 2014 NCQA PCMH certification requirements, or value-based programs like CPCI and CCM

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Team-Based Care, Technology Implementation, & Key Outcomes

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Team-Based Care

Team-based healthcare is the provision of comprehensive health services to individuals, families, and/or their communities by at least two health professionals who work collaboratively along with patients, family caregivers, and community service providers on shared goals within and across settings to achieve care that is safe, effective patient-centered, timely, and efficient

Naylor MD, Coburn KD, Kurtzman ET, et al. Team-Based Primary Care for Chronically Ill

Adults: State of the Science. Advancing Team-Based Care. Philadelphia, PA: American

Board of Internal Medicine Foundation; 2010 equitable.

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Team-Based Care (cont.)

• Patients come first

• Every person in the office has responsibility for taking care of patients

• As a team, we all take care of patients, even if they never cross our threshold

• Patient care happens beyond our office walls

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First Steps

Answering essential questions

• Can we perform the new functions with the current staffing?

• How will we identify the patients in need of the new services?

• How will we document the care?

• How will we track our performance?

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First Steps (cont.)Adding new roles to address new responsibilities

• RN Care Managers

Responsible for care management of the high risk population through disease management and care transitions. This is accomplished through face to face and telephone interactions with patients to promote self management skills through education and support

• Care Coordinators

Responsible to facilitate pre-visit planning, referral management and proactive outreach for overdue appointments/labs. The care coordinators will also be trained in behavior and lifestyle coaching to help your patients reach their personal health goals

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First Steps (cont.)Population health technology

• Develop registries to identify patient cohorts for interventions

• Develop point of care tools to assist the care team in identifying care opportunities

• Utilize efficient tracking systems to manage patient cohorts

• Develop risk stratification methodology

• Develop discrete fields for documentation in the EMR

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First Steps (cont.)Reporting

• Develop reports for milestone reporting

• Develop CQM reporting at the practice level

• Develop reports for tracking staff performance

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The WorkRN Care Managers

• Care transitions: Outreach to patients discharged from the hospital or Emergency Department

• Disease management: Diabetics (poor control), COPD, high risk, CHF

• Self-management support

• Shared decision-making

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The Work (cont.)Care Coordinators

• Care Gap closure

• Pre-visit Planning

• Lifestyle Coaching

WHAT DO WE NEED?

Registries

Note templates

Discrete fields for self-management

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Risk Stratification: Crayons to Computers

•Provider and staff review attribution lists and manually assign High, Medium, or Low risk based on knowledge of the patient.Phase 1

•Apply HCC algorithm and develop cut points for High, Medium, and Low risk. Include physician feedback. Create display in patient header for HCC score and risk category. Manual entry.

Phase 2

•Identify patients with HCC score>2.5 with hospital/emergency room utilization or readmission in last 12 months.Phase 3

•Create registry to calculate HCC and identify utilization and automate High, Medium and Low risk assignment in patient header.

Phase 4

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Risk Stratification (cont.)

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Discharge Workflow

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Registries

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Point of Care Tools

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Self-Management

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Care Gap Closure

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Pre-Visit Planning

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Organizing the Work

Evolution of tracking systems

• Paper calendars

• Binder systems and paper tracking

• Outlook Calendars

• Cloud-based tracking system

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Care Team Tasking

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Reporting

• Milestone Reporting

– Track all work for submission to program portal

• eCQM Reporting

– Required at the practice level

– Epic did not have solution

– Custom report build required

• Performance Reporting

– Outcomes

– Efficiencies

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Barriers• Resources

• Validation

• Lack of documentation standardization

• Role clarity

• Resistance

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Keys to Success• Project managers are vital

• Inter-disciplinary collaboration essential

• Innovative out-of-the-box thinking critical

• Perseverance wins the day

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OutcomesQuality

Measure

%

Adherent

4 STAR Compliance

Target

5 STAR Compliance

Target

Quality

Rating

Care of Older Adults - Medication Review 95% ≥77% ≥87% 5- SUPERIOR

Care of Older Adults - Functional Status Review 89% ≥67% ≥86% 5- SUPERIOR

Care of Older Adults - Pain Assessment 95% ≥78% ≥95% 5- SUPERIOR

Diabetes Care- Kidney Disease Monitoring 97% ≥93% ≥97% 5- SUPERIOR

Diabetes Care Blood Sugar Controlled 87% ≥71% ≥84% 5- SUPERIOR

Rheumatoid Arthritis Management 100% ≥82% ≥86% 5- SUPERIOR

High Risk Medications 95% ≥92% ≥94% 5- SUPERIOR

Medication Adherence for Diabetes Medications 82% ≥75% ≥82% 5- SUPERIOR

Medication Adherence for Hypertension 81% ≥77% ≥81% 5- SUPERIOR

Breast Cancer Screening 74% ≥74% ≥80% 4- HEDIS

Colorectal Cancer Screening 71% ≥71% ≥78% 4- HEDIS

Medication Adherence for Cholesterol (Statins) 77% ≥73% ≥79% 4- HEDIS

Adult BMI 89% ≥90% ≥96% 3

Osteoporosis Management in Women w/Fracture 44% ≥51% ≥75% 3

Diabetes Care - Eye Exam 63% ≥75% ≥82% 2

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All-Payer CPC Hospital Admissions

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All-Payer CPC ACSC Admissions

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All-Payer CPC Total Cost PMPY

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Best Practices & Lessons Learned

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Value-Based Models Emerging

• New innovation models established by payers, including government (state and federal) and commercial insurers

• Difficult to give requirements document to IT, iterative model with many stakeholders

• Tenants of gap analysis still relevant in all forms of value-based care

• Political transition implies continuation of free market innovation, transparency, and focus on outcomes

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Focus on Culture

“…eats strategy for lunch”

Provider adoption & satisfaction key to ongoing success

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Learn to skate well…

Technology is required to power new risk models…keep the patient (human) always in sight

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94% | 70%

Tobacco Use Assess.

Cessation Intervention

Colorectal

Screening

60% | 42%

Breast Cancer

Screening

64% | 41%

Diabetes Hemoglobin

A1c Poor Control

11% | 12%

Diabetes LDL

Screening

80% | 62%

Diabetes LDL

Control (< 100)

46% | 42%

Blood Pressure

Control

73% | 68%

Ischemic Vascular

Disease Screening

75% | 58%

Ischemic Vascular

Disease LDL Control

50% | 42%

Influenza

Immunization

24% | 37%

STEPS: Realizing the Value of HIT - Performance vs. All-CPCI Region

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Questions?

Amy Mechley

amechley@pyapc.com

Sandra Selman

Sandra.Selman@thechristhospital.com