Michigan Improving Performance in Practice and the Patient Centered Medical Home: The Role of Asthma Education

Presented by Rose M. Steiner RN, BSN, MBAState Director-Michigan IPIP

Michigan IPIP: What is it?

Improving Performance in Practice is a grant-funded program from the ABMS (American Board of Medical Specialties) with support of the Robert Wood Johnson Foundation

Michigan Improving Performance in Practice/PCMH

• Grant project sponsored by the Michigan Primary Care Consortium

• AIAG is the fiduciary agent• Steering committee incl. physicians from

most Michigan associations and other key representatives of MI healthcare

• Goal is to improve chronic illness care, with initial focus on Diabetes and Asthma

• Currently 34 practices engaged

“Americans can have a health care system of the quality they need, want, and deserve… Higher quality cannot be achieved by further stressing current systems of care. The current systems cannot do the job. Trying harder will not work. Changing systems of care will.”

IOM 2001 – Crossing the Quality Chasm

Ready To Cross?

Chronic Care Model

IPIP’s practice change is based on the Wagner Chronic Care Model

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Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

Improved Outcomes

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health System

Resources and Policies

Community

Health Care Organization

Chronic Care Model

Health System

Health Care Organization

Health System

Health Care Organization

IPIP Asthma Measures

Asthma

Goal

Required Measures Assessment of Control

Control assessed >90% Anti-inflammatory

Persistent asthma (or equivalent level of control) on anti-inflammatory medication

>90%

Prevention

Influenza vaccination >90% Composite Measure

Receive 3 key strategies for asthma care (assessment of control, anti-inflammatory, influenza vaccination)

>75%

Optional Asthma Measures ED visit <0.3% Hospitalization <0.1% Action plan or self-management plan >90%

ADDED: Pct asthma pts/ caregivers who smoke with counseling (>90%)

Definitions of metricsA Count of asthma patients 5-40 Count of active patients >=5 and <=40yo with asthma

B Count of 'persistent' asthma patients Count of patients seen within 365 days of the last day of the current reporting periods documented as 'persistent'

C Count of asthma patients who smoke Count of active patients >=5 and <=40 yo with asthma AND who smoke

D Count of asthma pts with symptoms assessed past 12 moCount of active patients with documented evaluation during at least one office visit within 365

days of the last day of the current reporting period for the frequency (numeric) of daytime and nocturnal asthma symptoms.

E Count of asthma patients with appropriate pharma therapyPatients with persistent asthma who were seen within 365 days of the last day of the current

rerporting period who had an active prescription for either the preferred long-term control medication (inhaled corticosteroid) or an acceptable alternative

F Count of asthma patients with current flu vaccPatients with asthma who received influenza vaccination during the current or previous flu

season ( September through February inclusive). For reporting periods in March through August, this includes the immediate past flu season; for September

G Count of asthma pts with 3 care components

Patients who in the past 12 months had all of the following: 1) a documented action plan, 2) influenza vaccine, 3) symptom evaluation, and 4) who were either a) classified as persistent and had appropriate medication or b) were not classified a persistent

asthmatic

H Count of asthma patients with >=1 ED/Urgent Care visits Count of patients who had one or more asthma-related ED visit within 365 days of the last day of the current reporting period.

I Count of asthma patients with hospitalizations Count of patients who had one or more asthma-related hospitalizations within 365 days of the last day of the current reporting period.

J Count of asthma pts queried about tobacco Count of active patients >=5 and <=40 yo with asthma AND with most recent tobacco query or received cessation intervention in past 24 mo

K Count of asthma pts w/ smoking cessation counseling Count of active patients >=5 and <=40 yo with asthma AND who smoke AND with most recent cessation intervention in past 24 mo

L Count of asthma patients with action plan Count of active patients >=5 and <=40 yo with asthma AND most documented action plan in past 12 months

How to calculate metrics

Pct of asthma patients with symptoms assessed D / A

Pct of asthma pts with appropriate pharma therapy E / A

Pct asthma pts with current flu vaccine F / A

Pct of asthma patients with 3 care componentsG / A

Pct of asthma patients with >=1 ED/Urgent Care visitsH / A

Pct asthma pts with >=1 hospitalizationsI / A

Pct of asthma patients with action plan L / A

Pct of asthma pts queried about tobacco J / A

Pct asthma pts/caregivers who smoke with counseling K / C

Use of Registry

ASTHMA CHEATSHEET

BP GOAL MEDS SERVICES Flu vaccine: completed date/no result; enter “contra” as result if contraindicated Triggers: environmental triggers=dust mites, cats, dogs, molds/fungi, cockroaches, rodents, irritants Exposures: environmental tobacco exposure Ready2Chng: record result of readiness to change assessment as:

“P” = pre-contemplative “C” = contemplative “A” = action “M” = maintenance

SM Goal: goal discussed &set=completed; specific goal entered as custom note Smke Asmt: result = “current” “past” or “never” LABS Control: 1=well controlled; 2=not well controlled; 3=poorly controlled Severity: 1=intermittent; 2=mild persistent; 3=moderate persistent; 4=severe persistent Lost Days: children # lost school or day care days; adults # lost work days in past 30 days ER Visits: # ER visits for asthma in the past 3 mos. Hospitalizations: # hospitalizations for asthma in last 3 mos.

Use of Templates

Name Chart # DOB_____/______/______ Page # History CC: Asthma management______________________________ HPI: See asthma questionnaire Long-term Intal ___________________ Tilade __________________ Control: Singulair________________ Accolate ________________ Serevent _______________ theophylline _____________ beclomethasone__________ Azmacort _______________ Flovent _________________ Aerobid ________________ Pulmicort _______________ Advair _________________ Quick Relief: albuterol __________ Maxair __________ Xopenex _________ Other Meds: _______________________________________________

Assessment Severity Mild Intermittent Moderate Persis tent Mild Persistent Severe Persistent Comorbids: Allergic Rhinitis Atopic dermatitis Sinusitis _______________ Good Fair Poor Comments Current Control _________________________ Medication Compliance _________________________ Equipment use/technique _________________________

PMH Allergies: ________________ Last flu vaccine: ___________ Sig PMH: prematurity BPO eczema formula allergy colic RSV bronchiolitis skin testing/RAST ____________________________________________ hospita lizations ____________________________________________ intubation ___________________ oral steroids ________________ anaphylaxis _________________ other ______________________ eczema pets Sig FH:______________ hay fever Sig SH: ___________smoking asthma cockroaches

Plan Asthma Continue current therapy (AAP in chart & rev iewed) Action Plan Step-up therapy (new AAP in chart) ________________________________________ ________________________________________ Step-down therapy (new AAP in chart) ________________________________________ ________________________________________ cc to nursery/school cc to second home

Education General Information Prevention vs. rescue meds Trigger reduction Smoking cessation MDI/spacer technique Peak flow monitoring Referred to asthma care manager Handouts: ________________________________ Immunization Up to date Influenza vaccine: dose 1 dose 2 Follow-up _______wks ________months 4 mos Referred to: _______________________________

Physical Abnormal ∕ Normal Not Addressed VS P_____ R_____ BP______ SaO2______ Peak flow______ Pred PF__________ GEN _______________________________________________________________ HNT Eyes___________________________________________________________ Ears ___________________________________________________________ Sinuses _________________________________________________________ Nose ___________________________________________________________ Oropharynx______________________________________________________ RESP WOB _________________________________________________________ Ausc _________________________________________ wheezing______ ________________________________________________ prolonged PF___ CV _______________________________________________________________ ABD _________________________________________________________ EXT ______________________________________ cyanosis clubbing SKIN ______________________________________ ery thema excoriation

Provider Signature

NURSE: ASTHMA VISIT

Age mos y rs

Wt kg lb

Ht in cm

PEF/FEV1 Diagnosis Date / /

Living with Asthma Please fill out this form to help us take better care of your asthma During the past month…

How often have you had coughing, wheezing, or shortness of breath?

How often have you had coughing, w heezing, or shortness of breath at night (w aking)?

How much has asthma kept you from play or other physical activ ities?

All the time Frequently Bothers me with any physical activ ity

Ev ery day More than 5 times a month

Bothers me with moderate activ ities (bike, walking)

Teaching Notes Note dic tated

3 to 6 times a week 3 to 4 times a month Only w ith a great deal of activ ity (soccer, basketball) Appropriate Long-acting Therapy based on Asthma Severity

Tw ice a week or less Tw ice a month or less Not at all unless I’m having an attack of asthma Persistent

Age Severe Moderate Mild Mild Int 6 y rs - adult

HI dose Inh Steroid +PO Steroid (wean) +Long-acting bronchodil +consider LeukMod

Med dose Inh Steroid + consider LeukMod OR Lo/Med dose Inh Steroid + Long-acting bronchodil + consider LeukMod

Lo does Inh Steroid OR Cromolyn / Nedocromil OR LeukMod

None YES NO Have you missed any school days because of asthma in the past 30 days?

If yes, how many? ____________________________________________________ Have you had any emergency room or urgent care center v isits due to asthma

since your last v isit here? If yes, describe: ___________________________ Have you had any hospitalizations due to asthma since your last v isit here? If yes, describe: ______________________________________________ Are your asthma symptoms worse during any particular time of year?

Infancy – 5 yrs

HI dose Inh Steroid +PO Steroid (pm)

Med dose Inh Steroid + Cromolyn / Nedocromil OR Med dose Inh Steroid + theophy lline

Lo does Inh Steroid OR Cromolyn / Nedocromil

None

Use of Protocols

• Evidenced-based guidelines (protocols) are built into many electronic health records or registries

• Many physicians BELIEVE they are following current protocol, but it is important to be able to measure their consistency, and use templates to assure compliance

Self-Care Management

• Asthma Action Plan• Link to community resources• Support network

Practice Transformation

• Physician practices must change their processes to meet the needs of today’s chronically ill.

• Practice Transformation means implementing all 4 elements of the Chronic Care Model in a manner that modifies your current flow to the most efficient process flow possible to give GREAT patient care.

Process improvement – it is continuous

From Paper to Electronic

• The process flow for patient care changes when you are using an electronic record.

• The changes process should be drawn out PRIOR to selecting the electronic tool if at all possible so that the tool fits with your potential process flow– For example, small practices have less

flexibility in their flow…

…add in the templates

• Templates for care must take the following form– Comply with evidenced-base guidelines– Laid out in a manner that matches the flow

of the patient visit– Either be electronic so that data is entered

directly into the electronic tool OR include organization on the template that also flows for input into the electronic system

…now the protocols

• Practices must– Use the CURRENT protocols for that

particular chronic condition • This means their electronic system must either

automatically stay current (web based often do) or be updateable with ease once new protocols are received

– Protocols should be imbedded in the templates and used for ALL patients, on chronic care visits and other incidental (acute) visits

…tie it all together with SME!

• Self-management is the key to successful control of asthma, or other chronic diseases for that matter

• All practices must have a plan that includes– Who needs to be referred– When should they be referred– Where will they refer them to, or will it be in-house– What is the expected outcome of the referral– How will they get feedback from the SME referral– How will the practice follow up on the referral to

encourage and sustain the gain for the patient

Methods of implementing SME

• Identify ALL potential sources of SME for the asthmatic patient– Hospital-based programs– Asthma educators through public health– Asthma educators that will educate within

the practice– Asthma education materials for in the

practice– Group visits within the practice

Think outside of the box…

Expectations

“The greater danger for most of us is not in setting our goals too high and falling short, but in setting our aim too low and achieving our mark”

-Michelangelo-

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Safe

Patientcentered

Equitable

Effective

Efficient

Timely

Recent Literature

• Health Affairs – Jan/Feb 2009– CCM generally improves the quality of

care and outcomes– High performing practices make changes

across multiple elements of the CCM– Only limited evidence to provide

assurance that the changes become sustained

Recent Literature

• Health Affairs – Jan/Feb 2009 (cont)– Most published experience is in large

practice organizations– Multi-stakeholder efforts have the potential

to create long term, sustainable endeavors– Must go beyond the vanguard early

adopter physician practices and reach out to the majority of providers

Recent Literature

• Annals of Family Medicine – May/June 2009– Becoming a PCMH requires transformation– Technology needed for the PCMH is not “plug

and play”– Transformation to the PCMH requires

personal transformation of physicians– Change fatigue is a serious concern even

within capable and highly motivated practices– Transformation to a PCMH is a

developmental process– Transformation is a local process

Nutting PA, Miller WL, Crabtree BF, et al. Initial Lessons From the First NationalDemonstration Progect on Practice Transformation to a Patient-Centered MedicalHome. Annals Fam Med. 2009:7(3);254-260.

Where does Asthma Education fit in?

• With the CCM, Self management education is one of the 4 key elements that must have focus from the practice

• Asthma educators play a key role in that area

Crosswalk

• To understand where the asthma educator fits with the Patient Centered Medical Home, it is important to understand the elements of the PCMH.

• Although the educator may not be a part of every element, there are many that you will have an impact on

• The PCMH crosswalk is included as an addendum to this presentation

SUMMARY: How can the Asthma Educator help the Patient Centered Medical Home?

• Use Population –based registry for patient identification when working with practices

• You are involved in preventive services, particularly group visits, counseling, goal-setting

• The Asthma Educator is critical for self-management training

• Partner with physicians to meet their patient’s needs

Thank you for your attention…

Questions?

Special Thanks to Dr. Kevin Piggott for his input into this presentation

Joint Principle Characteristic

NCQA PPC- PCMH Standards

PGIP Domains(BCBSM)

IPIP Chronic Care Model

Personal Physician Patient- Provider Agreement 08 Secondary

Development and implementation of patient-provider agreement outlining provider and patient responsibilities and rights and establishing PC-MH partnership between provider and patient

Pt-Provider Agreement

Not specified in IPIP, but would be easy to include.

Enhanced Access to care Standard 1: Access and Communication

Extended Access 08 Access: Secondary focus

A. Has written standards for patient access and patient communication**

Planning and implementation of 24 hour patient access to clinical decision-maker by phone, after-hours urgent care access, and advanced access

Appointment availability is an essential component of implementing planned visits

A. Uses data to show it meets its standards for patient access and communication**

Access to translation services for languages common to practice

The PCMH/IPIP/CCM Crosswalk

Joint Principle Characteristic

NCQA PPC- PCMH Standards

PGIP Domains(BCBSM)

IPIP Chronic Care Model

Care is coordinated and/orintegrated

Standard 2: Patient Tracking and Registry Functions

Patient Registry 08 Registry Function: Primary Focus

Clinical Information Systems (Registry Function

A.Uses data system for basic patient information (mostly non-clinical data)

Registry should include demographics, comprehensive clinical information and evidence-based guidelines

Implementing a registry is a key improvement

Provide timely reminders for providers and patients

A.Has clinical data system with clinical data in searchable data fields

Implementing a registry is a key improvement

A.Uses the clinical data system

Implementing a registry is a key improvement

A.Uses paper or electronic-based charting tools to organize clinical information**

Implementing a registry is a key improvement

Facilitate individual patient care planning Share information with patients and providers to coordinate care

A.Uses data to identify important diagnoses and conditions in practice**

Implementing a registry is a key improvement

A.Generates lists of patients and reminds patients and clinicians of services needed (population management)

Creation of a patient list to monitor patients and plan needed care.

Implementing a registry is a key improvement

Identify relevant subpopulations forproactive care

The PCMH/IPIP/CCM Crosswalk

Joint Principle Characteristic

NCQA PPC- PCMH Standards

PGIP Domains(BCBSM)

IPIP Chronic Care Model

Care is coordinated and/or integrated

Standard 3: Care Management

Individual Care Management08

IPIP: Primary and Secondary

A.Adopts and implements evidence-based guidelines for three conditions **

Planning and implementation of systematic approach to individual patient care management, including planned visits, goal-setting, appointment tracking & follow-up, medication reviews, group visits

Registry with embedded guidelines. IPIP starts with one disease but encourages rapid spread to others.Planned care, self management support

A.Generates reminders about preventive services for clinicians

Preventive Services 09Planning and implementation of systematic approach to ensuring customized plan for preventive services (test, immunization, counseling) based on age, gender, condition and other risk factors

Rapid spread of these processes to preventive care is encouraged.

The PCMH/IPIP/CCM Crosswalk

Joint Principle Characteristic

NCQA PPC- PCMH Standards

PGIP Domains(BCBSM)

IPIP Chronic Care Model

Care is Coordinated and/or integrated

Quality and Safety: Practices advocate for their patients

Standard 4: Patient Self-Management Support

Self- Management Training 09 PrimarySetting up processes for self management support

SMS Organize internal and community resources to provide ongoing self-management support to patients

B. Actively supports patient self-management*

Planning and implementation of active training and engagement of patients and informal caregivers in self-monitoring and self-care

Setting up processes for self management support

Emphasize the patient's central role in managing their health Use effective self-management support strategies that include assessment, goal-setting, action planning, problem-solving and follow-up

A.Assesses language preference and other communication barriers

Part of self management support

Delivery System DesignHealth literacy and cultural sensitivity are two important emerging concepts in health care

The PCMH/IPIP/CCM Crosswalk

Joint Principle Characteristic

NCQA PPC- PCMH Standards

PGIP Domains(BCBSM)

IPIP Chronic Care Model

Physician Directed MedicalPractice Team

A.Uses non-physician staff to manage patient care

PrimaryEstablishing team care

A.Conducts care management, including care plans, assessing progress, addressing barriers

Secondary Not mentioned in IPIP, but compatible with overall good chronic diseasecare.

Delivery System DesignProvide clinical case management services for complex patients

A.Coordinates care//follow-up for patients who receive care in inpatient and outpatient facilities

Coordination of Care Across Settings 09Planning and implementation of systematic approach to ensure coordination of care across settings for all patients

Not specified in IPIP. Could be in scope if practice invested in software tools.

Health SystemDevelop agreements that facilitate care coordination within and across organizationsClinical Info SystemsShare information with patients and providers to coordinate care

The PCMH/IPIP/CCM Crosswalk

Joint Principle Characteristic

NCQA PPC- PCMH Standards

PGIP Domains(BCBSM)

IPIP Chronic Care Model

Quality and safety: Information technology is utilized

Standard 5: Electronic Prescribing

Electronic Prescribing 08 IPIP: Secondary Not specifically addressed

A.Uses electronic system to write prescriptions

Implementation of electronic-prescribing capability with link to patient prescription history and efficiency decision support tools

E-prescribe is not mentioned in IPIPCould be incorporated as part of diabetes of asthma care.

A.Has electronic prescription writer with safety checks

A.Has electronic prescription writer with cost checks

Cost considerations would be relevant to planning individual care.

Quality and Safety: Information technology is utilized

Standard 6: Test Tracking Test Tracking 08 Test Tracking: Secondary

A.Tracks tests and identifies abnormal results systematically**

Planning and implementation of systematic approach to tracking and following up on test results

Not specified in IPIP, but fits with care tracking for diabetes or asthma

A.Uses electronic systems to order and retrieve tests and flag duplicate tests

Not specifiedSome registry and EMR products offer this feature

The PCMH/IPIP/CCM Crosswalk

Joint Principle Characteristic

NCQA PPC- PCMH Standards

PGIP Domains(BCBSM)

IPIP Chronic Care Model

Physician Directed MedicalPractice Team

Whole Person Orientation

Standard 7: Referral Tracking

Specialist Referral Tracking 09

Referral Tracking:Secondary

A.Tracks referrals using paper-based or electronic system**

Planning and implementation of systematic approach to tracking and follow-up on referrals to specialists

Some registry products have this capability, which could easily be incorporated in IPIP

Decision SupportIntegrate specialist expertise and primary care

Linkage to Community Services 09

Self Management Support:Primary

The Community

Planning and implementation of systematic approach for linking to community services, including referral and tracking of patients

Self management support includes linking patients with community services.Many registry products assist with tracking.

Encourage patients to participate in effective community programs Form partnerships with community organizations to support and develop interventions that fill gaps in needed services Advocate for policies to improve patient care

The PCMH/IPIP/CCM Crosswalk

Joint Principle Characteristic

NCQA PPC- PCMH Standards

PGIP Domains(BCBSM)

IPIP Chronic Care Model

Quality and Safety: Voluntary engagement in performance measurement and improvement

Standard 8: Performance Reporting and Improvement

Performance Reporting and Improvement 08

IPIP: Primary Registry Function

A.Measures clinical and/or service performance by physician or across the practice**

Incorporates Pt Satisfaction

Monitor performance of practice team and care system

A.Reports performance across the practice or by physician **

Reporting at the Provider Organization, practice unit, and individual physician level on processes and outcomes of care, service efficiency, and patient satisfaction

Reports clinical data collected in registry on Process, outcome and satisfaction measures

A.Sets goals and takes action to improve performance

Teaches quality improvement tools for improving performance

A.Produces reports using standardized measures

Produce monthly reports

A.Transmits reports with standardized measures electronically to external entities

Transmits reports electronically to external entity

The PCMH/IPIP/CCM Crosswalk

Joint Principle Characteristic

NCQA PPC- PCMH Standards

PGIP Domains(BCBSM)

IPIP Chronic Care Model

Quality and Safety; Information technology is utilized appropriately

Standard 9: Advanced Electronic Communications

Electronic Mobilization of Health Information 09

IPIP: Primary or Secondary

A.Availability of Interactive Website

Development and implementation of integrated electronic systems: electronic medical record (EMR); e-prescribing with link to clinical decision support tools and the patient’s EMR’ patient portal for appointment scheduling and e-visits

Will vary with practice.

A.Electronic Patient Identification

Will vary with practice.

A.Electronic Care Management Support

Will vary with practice.

The PCMH/IPIP/CCM Crosswalk