american public health association- annual meeting 2014 presentation
TRANSCRIPT
Using Quantitative Data for Medical Home Facilitation in the Massachusetts
Patient Centered Medical Home Initiative (MA PCMHI)
Sai Cherala, M.D., M.P.H.
Joan Johnston, R.N., C.I.H., C.P.E.
Jaime Vallejos, M.D., M.P.H.
Judith Steinberg, M.D., M.P.H.
Christine Johnson, Ph.D.
Commonwealth Medicine
UMass Medical School
Presenter Disclosures
(1) The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months:
Sai Cherala
“No relationships to disclose”
Introduction
The Patient‐Centered Medical Home (PCMH) offers an innovative model of care: comprehensive primary care, quality improvement, care management, and enhanced access in a patient centered environment
Objective:
To evaluate how targeted practice facilitation has improved clinical performance in a PCMH demonstration
Background: Massachusetts Patient Centered Medical Home Initiative
Multi-payer, statewide initiative
Sponsored by Massachusetts Health & Human Services; legislatively mandated
46 participating practices
3-year demonstration: March, 2011 − March, 2014
Includes payment reform and technical assistance
Technical Assistance: Massachusetts Patient Centered Medical Home Initiative
Three‐year Learning Collaborative
• Periodic Learning Sessions
• Monthly conference calls or webinars
• Online courses
• Monthly submission and review of practice‐level performance data
• Support for obtaining NCQA PCMH recognition
Practice Facilitation
Clinical Quality MeasuresAdult Diabetes
HbgA1c Control (<8%) HbgA1c Control (>9%) BP < 140/90 mmHg LDL Control < 100mg/dL Screened for Depression Self-Management Goal
Adult Prevention Adult Weight Screening and
Follow-up Tobacco Use Assessment Tobacco Cessation Intervention
Other Adult Target Blood Pressure Control Hypertension with Documented
Self-Management Goal Depression with Documented
PHQ-9 Score Depression with Documented Self-
Management Goal
Childhood Prevention Immunization Status Multiple
vaccines Weight Assessment and Counseling
for Children and Adolescents
Pediatric Asthma Use of Appropriate Medications for
Asthma Persistent Asthma Patients with
Action Plan
Other Pediatric Target Follow-up Care for Children
Prescribed ADHD Medication Management Plan for Children
Prescribed ADHD Medication
Care Coordination/ Care Management Follow-up after Hospital Discharge Highest Risk Patients with Care Plan
Operations Continuity of Care
Clinical Quality Measures that Showed Significant Improvement in Change over Time
25.2 23.8
37.1
82.4
46.5
16.7 17.3
11.5
18.6
46.4
22.3
36.1
48.7
32.0
47.6
90.5
51.3
25.321.4
19.3
62.7 63.161.2
64.7
0
10
20
30
40
50
60
70
80
90
100
Screened forDepression
Self-Management
Goal
Adult WeightScreening &Follow-Up
Tobacco UseAssessment
TobaccoCessation
Intervention
HypertensionSelf-
ManagementGoal
DepressionPHQ-9 Score
DepressionSelf-
ManagementGoal
Patients WithAction Plan
ImmunizationStatus
MultipleVaccines 1
ImmunizationStatus
MultipleVaccines 2
Care Plans forHighest Risk
Patients
Pe
rce
nt
Baseline Time 11
11 of 22 measures showed statistically significant improvement
Adult Diabetes Adult Prevention Other Adult Measures Pediatric
Asthma
Childhood
Prevention
Care
Management
Targeted Medical Home Facilitation: Approach
Underperforming practices were targeted for facilitation follow-up
Intervention focused on the performance on certain measures and which also included the implementation of key components of the PCMH
Started in the year 3 of the intervention
Customized interventions were developed and delivered by three practice facilitators over a six-month period
Following the targeted facilitation, practices were assessed for the impact of the targeted facilitation on the performance of measure
Targeted Medical Home Facilitation: Focus
On aggregate analysis, we identified five measures with a trend toward improvement from baseline.
• Screening for depression for adults
• Tobacco cessation counseling for adults who have been identified as smokers;
• Self-management goals for adult diabetics,
• Use of appropriate medications for pediatric patients with persistent asthma; and
• Follow-up after hospital discharge.
Targeted Medical Home Facilitation: Methods
Analysis: Using ANOVA, we analyzed the individual practice contribution to the aggregate for each of these measures.
Interventions: Facilitators used a wide array of tools including: practice-wide assessments, PCMH team based care workflows, Lean trainings and online courses.
Variables included: Change in clinical performance over the demonstration
Data sources: Clinical data submission, practice-wide assessments, facilitators interviews
Targeted Medical Home Facilitation: Results
For measures marked * Baseline is Time 6
23.8 25.7 26.029.4 31.1 32.0
46.5
41.2
47.744.5 44.1
46.849.9 48.9 49.7 50.1 51.3
17.3 16.719.7
22.7 22.8 21.4
0
10
20
30
40
50
60
Time 1 Time 2 Time 3 Time 4 Time 5 Time 6 Time 7 Time 8 Time 9 Time 10 Time 11
Rat
e
Self-Management Goal for Adult Diabetics*
Tobacco Cessation Counseling for Adult with History of Smoking
Screening for Depression for Adults*
Intervention Started
3 out of 5 measures of focus showed significant improvement
Targeted Medical Home Facilitation: Results II
Targeted Medical Home Facilitation: Lessons Learned
Develop infrastructure and procedures that support effective use of data monitoring through training, introduction of dashboards, and other resources
Assessing the practice and providing regular performance feedback and using this data to inform QI
Building the internal capacity of a practice to engage in data-driven change
Provide training to the practice staff and providers on QI methods and strategies
Adapting EMR functionality for QI
Provide technical assistance in specific areas, such as registry development for implementing team-based care and other foundational elements of PCMH
Quality Improvement Study
Multiple Interventions
Length of time
Limitations
At the close of the MA PCMHI initiative (3 years), 11 of 22 clinical measures showed statistically significant improvement
Measures that showed significant improvement:
Process measures
New or newly documented processes
Targeted practice facilitation, informed by analysis of practice level and aggregate clinical quality data, may be effective in promoting achievement of practice and initiative goals in PCMH implementation
Summary
Conclusions
Quality of care in the management of chronic diseases, prevention and screening, and high risk care management was significantly improved in this PCMH demonstration
Supporting practices in developing a QI infrastructure and skillset is a foundational element of the building of the medical home that facilitates overall change
Practice transformation takes time
Acknowledgments
We would like to acknowledge the Massachusetts Executive Office of Health and Human Services (EOHHS), the MA PCMHI Leadership and Medical Home Facilitator Teams, as well as MA PCMHI participating practices without whom this work would not be possible.
Contact Information:
Sai Cherala, M.D., M.P.H.Assistant Professor
Senior Clinical AnalystCommonwealth Medicine
UMass Medical [email protected]