janice bacon, md - msqii-2 leadership advisory team ... · •integrated medication therapy...
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Janice Bacon, MD - MSQII-2 Leadership Advisory Team
Central MS Health Services
Alicia Barnes, MBA, – MSQII-2 Consultant & Facilitator
BC3 Technologies, LLC
Community Health Center Association of Mississippi
Annual Conference | Biloxi, MS
August 1, 2019
History of MSQII-2
- Established in 2013, by the Mississippi State Department of Health (MSDH) Office of Preventive Health, Chronic Disease Bureau (CDB)
- Funded by Centers for Disease Control and Prevention (CDC) to prevent and control Diabetes, Heart Disease, Obesity, and associated risk factors in Mississippi.
- Leadership Advisory Team established to assist in the development of Mississippi Quality Improvement Initiative (MSQII-2) curriculum and Funding Opportunity Announcement in June 2014
- Awards given to:- 5 organizations in 2014
- 6 organizations in 2015
- 4 organizations in 2016
About MSQII-2
• A systematic approach to healthcare quality improvement in which
organizations and providers test and measure practice innovations via
PDSAs, then share their experiences in an effort to accelerate learning
and widespread implementation of successful change concepts and
ideas in a group setting.
• The Learning Collaborative uses the following Concepts and Models:
• Expanded Chronic Care Model
• Patient Centered Medical Home Concepts
• Model for Improvement
• Improve health outcomes by learning from each other’s successes and
challenges
• Changing from a provider-oriented system to a patient/family community-
oriented system of care utilizing a team-based approach
MSQII-2 Goals
• Increase implementation of quality improvement processes in
health systems
• Increase use of team-based care in health systems (nurses,
pharmacists, nutritionist, physical therapists, patient navigators,
and community health workers)
• Increase use of lifestyle intervention programs such as Diabetes
and Chronic Disease Self-Management programs
• Increase the use of health care extenders in the community in
support of self-management of high blood pressure and diabetes
Featured Components
• MSQII-2 E –Collaborative (www.msqii2.net)
• Public Website
• Learning Community Virtual Office
• Web-based reporting site and dashboard
• Pre-Learning Sessions and Learning Sessions
• Storyboards
• Pre/Post –Test Evaluation
• Quarterly Webinars /One-on-One Support
Participating Organizations
(2013 -2018)
• 2013 – 2018, 15 participating organizations:
• 3 Rural Health Centers
• 10 FQHCs
• 2 Private practices
• Aaron E. Henry Health Services Center, Inc. – Cohort 1
• Family Health Center, Inc. – Cohort 1
• Coastal Family Health Center, Inc. – Cohort 1
• North Hills Family Medical Clinic – Cohort 1
• Phillips Medical Clinic – Cohort 1
• Access Family Health Services – Cohort 2
Participating Organizations
(2013 -2018)
• Acute Care Health Services – Cohort 2
• Greater Meridian Health Clinic – Cohort
• Pioneer Health Services – Cohort 2
• Nina Jurney
• Community Health Aberdeen
• Southeast MS Rural Health Initiative, Inc. – 2
• Central MS Health Services – Cohort 3
• G.A. Carmichael Family Health Center – Cohort 3
• Mallory Community Health Center – Cohort 3
• Glover Primary Care Clinic – Cohort 3
Accomplishments –MSQII-2
Hypertension/Diabetes
• Reached over 100,000 patients with Diabetes, Coronary Artery
Disease, and Hypertension to improve health outcomes
• Over 100 healthcare professionals received SME training on
improvement efforts in Diabetes, Coronary Artery Disease, and
Hypertension
• Over $200,000 received by healthcare organizations and or
providers through Meaningful Use Incentive payments
Accomplishments –MSQII-2
Hypertension/Diabetes
• Incorporated MSQII-2 in organization QI Committee
• In-house nutrition referral for all Hypertensive and Diabetic
patients
• Implemented Standing Orders
• Implemented Morisky’s Medication Adherence Scale for
medication compliance
• Implemented Community Health Worker
• Transitioned to new Electronic Medical Records
• Meaningful Use Incentive payment receipt
• Team-based approach
• Implemented Protocols for Hypertension Management based on
Target BP, Million Hearts, and American Heart Association
• Received PCMH Recognition while participating
• Awarded supplemental grant with American Heart Association
• Clinical support guidelines embedded in EMR
• Staff training on updated guidelines
• Blood Pressure training
• Workflow Redesign to include best practices
• Self-management support classes for patients
Accomplishments –MSQII-2
Hypertension/ Diabetes
• Integrated Medication Therapy Management (MTM)
• Developed Care Plan for uncontrolled hypertension patients
• Integrated Behavioral health services
• Recalls for patient compliance with BP and A1c checks
• Established process to give BP monitors for high risk patients for
home monitoring
• Partnered with Managed Care Organizations (United Health Care and
Magnolia) Case Managers to assist in Self-management
• Created and customized hypertension and diabetes templates in EMR
• Established and implemented protocol for high bp 2nd check prior to
leaving clinic
Accomplishments –MSQII-2
Hypertension/ Diabetes
Accomplishments –MSQII-2
Hypertension/ Diabetes
• Educate patient and staff on setting self-management goals
• PDSAs incorporated in Performance Improvement Plan
• Created alerts/reminders in EMR to inform clinical staff of labs
due or overdue
• Educated patients on “Know Your Numbers” – BP
• Provider education –CME/CEU on evidence based guidelines
• Implemented Teach Back Method with patients
• Started Data Validation for QI reports
• Implemented Team Huddle
Integration of MSQII-2 Asthma(2017- present)
• Began December 2017 by Mississippi State Department of Health Asthma Program
• Funded by Centers of Disease Control and Prevention (CDC)
• FOA was disseminated
• Three (3) FQHCs – 2017
• Three (3) FQHCs – 2018
• Learning and implementing the Chronic Care Model and Improvement Model (PDSA) to help improve health outcomes on pediatric and adult Asthma patients
Participating Organizations - Asthma
(2017 – present)
• Central MS Health Services – Cohort 1
• Family Health Center – Cohort 1
• Mallory Community Health Center – Cohort 1
• Aaron E. Henry – Cohort 2
• G.A. Carmichael – Cohort 2
• Jefferson Comprehensive – Cohort 2
• Implementation of Team Based Care
• Integration of Pharmacist and Community Health Worker on
team
• Integration of Behavioral Health
• Creation of Asthma templates in EMR
• Reassessment of Asthma diagnosis according to severity
assessment per ICD 10 codes
• Workflow redesign to capture Asthma patients ED/hospital
visits
• Trained staff on Managed Care Care Gaps
• Implementation of new EMRs
Accomplishments –MSQII-2 Asthma
• Environmental /Food Allergy Testing integration in-house
• Establishment of Asthma policies
• Received mattress covers, and pillows for high need patients
• Created protocol on dissemination of mattress covers and pillows
• Staff training on Asthma guidelines and protocols
• Sharing Best Practices Working with IT/EMR vendor
• Staff training on workflow process to capture Asthma measures
• Dedicated staff time to review Asthma measures
• Education to staff on Evidence Based Guidelines for Asthma
• New partnerships
• Thermo Fischer
• American Lung Association
• Asthma Coalition
Accomplishments –MSQII-2 Asthma
MSQII-2 ASTHMA
MEASURES PROGRESSJUNE 2019
MSQII-2 Asthma POF /POS
• Cohort 1
• Patients ages 5 -17 =388
• Patients 18 and older =185
• Total Patients = 573
• Cohort 2
• Patients ages 5 -17 = 147
• Patients 18 and older = 213
• Total Patients = 358
• MSQII-2 Asthma Total Patients
• Patients ages 5 -17 = 535
• Patients 18 and older = 396
• Total Patients = 931
Source: MSQII-2 Asthma Dashboard Report June 2019
67.87
87.33
53.87
97.03 96.2
74.77
0
20
40
60
80
100
120
PA on Anti-inflammatory Meds
Severity Assessment Asthma Action Plan
Baseline
Current
Improvements:
The number of patients
on Anti-inflammatory
Meds increased by
42.98%.
Goal =95
The number of patients
with a severity
assessment increased by
10.15%.
Goal = 90
The number of patients
receiving an Asthma
Action Plan increased by
38.80%.
Goal = 70
MSQII-2 Asthma Cohort 1
Population of Focus (POF)
29.6
21.119.7
45.2
39.3
3.6
0
5
10
15
20
25
30
35
40
45
50
ETS assessmentexposure
ETS assessmentintervention
ED/Urgent Care visits
Baseline
Current
Improvements:
The number of patients
receiving ETS assessment
exposure increased by
52.70%.
Goal =20
The number of patients
exposed to ETS receiving
an intervention assessment
increased by 86.26%.
Goal = 20
The number of patients
going to the ED/Urgent
care visits decreased by
81.73%.
Goal <5
MSQII-2 Asthma Cohort 1
Population of Focus (POF)
MSQII-2 Asthma Cohort 2
- Cohort 2 had a late start beginning data collection in January
2019. We are currently validating and processing their data
outcomes.
MSQII-2 Challenges
• EMR Reporting
• Competing organizational priorities
• Patient Transportation
• Staff retention
• $$$ - more funding to assist with solutions for social determinants of health (SDOH)
• Data capture of measures – templates vs. scan
• Workflow redesign
• Staff wearing multiple hats
• Seeing MSQII-2 as a Program/Project
• Time to put process in place
• Resources
Lessons Learned
• Quality Improvement is Continuous
• Change takes time
• Be patient
• PDSA, PDSA, PDSA
• Leadership Buy-in is a MUST
• Work together as a TEAM
• Review and discuss QI reports and create a plan (3 month, 6
month, 9 month, 12 month)
• Document process as they change
• Train staff on EMR as upgrades are performed
• Make sure a Clinical /Data Expert is on the team
MSQII-2 Highlight Video
MSQII-2 Highlight Video
• https://www.youtube.com/watch?v=H1Qw0z-yMyk
Contact
Janice Bacon, MD
Central MS Health ServicesEmail:[email protected]
Alicia Barnes, MBA
BC3 Technologies, LLC
Email: [email protected]
Website: www.bc3technologies.com
Phone: (601) 852.3894
Visit www.msqii2.net for more information!