PA SPREADWebinar #1

Webinar 1 of 3

• Introduction• Getting Started- Pre-work• Empanelment• Aim statement• Baseline Assessment• Webinar #2: Baseline Data Measurement• Webinar #3: Introduction to the Models

PA Spreading Primary Care Enhanced Delivery Infrastructure

• Builds on success of PA Chronic Care Initiative• Funded by AHRQ to develop infrastructure for

supporting/spreading primary care transformation• Primary Care Extension Service

• Apply lessons learned from PA initiative to 2 new collaboratives (SC and NW)

• Disseminate model, lessons learned in 3 other states (NJ, NY, VT)

Model for Primary Care Extension Service

• Based on the Agricultural Cooperative Extension Model Most successful innovation spread program in U.S. 1914 – Collaboration of federal, state, county

governments, land grant universities Helped famers adopt best practices

LAYING THE FOUNDATIONThe Medical Home and More

The Medical Home

The Chronic Care Model

Informed andActivatedPatient

ProductiveInteractions

Prepared andProactive

Practice Team

DeliverySystemDesign

DecisionSupport

ClinicalInfo

Systems

Self-Management

Support

Health SystemResources and Policies

Community Health Care Organization

Improved Outcomes

Transformation/Paradigm Shift• Population Management - shift from treating one

patient at a time to managing populations of patients

• Continuum of care - shift from defining a single medical encounter as a complete entity to viewing it as one point on a continuum of care

• Team-based care - shift from the physician providing care alone to coordinated, physician-led interprofessional team care.

NCQA PCMH 2011 Recognition

Most commonly used standards for evaluating practice-wide systems of care related to:

• Access and Continuity• Population Management• Planning and Managing Care• Self Management Support• Tracking and Coordinating Care• Measuring and Improving Performance

How This Work Will Help• We will guide you in building these systems of care

and discuss relevant NCQA standards and documentation throughout the year.

• Our focus is on diabetes, but you can apply your systems of care to other chronic and preventive care services. (Note: Both NCQA and Meaningful Use require documentation on at least 3 different preventive care services and 3 different chronic care services.)

• Lot of crossover between NCQA and Meaningful Use requirements!

Meaningful Use IncentivesMust attest this year to be eligible for maximum incentive of $44,000 per

Eligible Provider under Medicare.

CY 2011 CY 2012 CY 2013 CY2014 CY 2015 and later

CY 2011 $18,000

CY 2012 $12,000 $18,000

CY 2013 $8,000 $12,000 $15,000

CY 2014 $4,000 $8,000 $12,000 $12,000

CY 2015 $2,000 $4,000 $8,000 $8,000 $0

CY 2016 $2,000 $4,000 $4,000 $0

TOTAL $44,000 $44,000 $39,000 $24,000 $0

Medicare penalties for not achieving Meaningful Use begin in 2015!

GETTING STARTEDPre-Work

Pre-WorkGoals are to:

1. Prepare you for the first learning session2. Give you time to form your improvement team3. Collect baseline data and information on your

practice4. Allot time for you to meet your practice

facilitator

• NorthwestPatricia J. Stubber, MBAExecutive DirectorNorthwest PA AHEC8425 Peach StreetErie, PA 16509-4788814-217-6029 (phone)814-594-4740 (cell)814-864-4077 (fax)pstubber@nwpaahec.org

paspread@hmc.psu.eduPlease send any questions to

Practice Facilitators• South Central

Sharon M. Adams RN, BAExecutive DirectorSouthcentral PA AHECPO Box 509Carrolltown, PA 15722814-344-2222 (phone)814-344-2221 (fax)sadams@scpa-ahec.org

WEBSITE www.paspread.com

Role of Practice Facilitators• Support practice with QI processes, techniques• Serve as sounding board/provide feedback and

benchmarking• Assist in finding tools and resources• Help prioritize change activities• Serve as “honey bee” networker• Assess practice education, training needs• Provide “motivational coaching” (cheerleader)• Assist with problem-solving

Pre-Work Learning Objectives1.Understand the concept of empanelment and its

importance in assuring continuity of care and develop a plan to organize patients into provider panels if your practice is not already organized that way.

2.Understand the clinical guidelines and related measures for diabetes.

3.Collect baseline data on the number of diabetes patients in your practice and the # meeting evidence-based diabetes measures.

4.Develop an aim statement for what and how much you want to improve over the next year.

Pre-Work To-Do’s Identify a provider champion Form a multi-disciplinary improvement team Write an aim statement Develop a plan to address any issues with provider

panels Complete and submit the PCMH-A assessment Collect and report baseline diabetes data on the

monthly practice status report Participate in the 3 pre-work webinars RSVP attendees for Learning Session #1

Selecting a Provider Champion• Change and improvement are not possible without

committed leadership.• Each practice should have a provider champion (not

just one for a system of practices).• Champion must want to do this work.• Champion must have standing in the practice to lead

practice-wide changes.• Champion (and entire improvement team) should be

allotted time to meet, plan, and test changes.

Forming an Improvement Team• Multi-disciplinary: provider, clinical, and

administrative champions.• Team members should be able to embrace change.• Team members should be leaders among their

peers. • Team members should be comfortable soliciting and

providing feedback to peers and providers.

Model for Improvement• Three fundamental questions

• Aim statement• Measurement plan• Selecting changes to test

• Plan-Do-Study-Act (PDSA) cycle• Scientific method used for action-oriented

learning• Cycles of testing continue until desired

outcomes, implementation, and spread

Writing an Aim Statement• Agree on what you’re trying to accomplish.• Be specific.• Set timeframes and numerical goals to clarify the

aim, create tension for change, and focus initial changes.

• Aim high: set stretch goals that cannot be met by just tweaking the system.

Aim Statement Example #1By May 2013, we will adopt components of the Patient Centered Medical Home and Chronic Care Models to improve diabetes care as follows:• Less than 15% of our patients will have an A1C

greater than 9.0.• More than 75% of our patients will have an A1C less

than 8.0.• More than 75% of our patients will have their most

recent blood pressure less than 140/90.• More than 60% of our patients will have an LDL less

than 100.

Aim Statement Example #2Within the next 12 months, we will implement components of the PCMH and Chronic Care Models to ensure that at least 90% of patients with diabetes in our practice at least annually receive:

• blood tests for A1c and LDL;• a urine test for microalbuminin;• a diabetic eye exam;• a monofilament foot exam;• smoking cessation counseling if they smoke.

ASSURING CARE CONTINUITYEmpanelment

Key to PCMH: ContinuityPCMH practices:• Assign all patients to a provider panel, confirm

assignments with providers and patients, and review and update panel assignments on a regular basis.

• Assess practice supply and demand and balance patient load accordingly.

• Use panel data and registries to proactively contact and track patients by disease status, risk status, etc.

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PCMH 1: Enhance Access and ContinuityElement D: ContinuityThe practice provides continuity of care for patients/families by:1. Expecting patients/families to select a personal clinician.2. Documenting the patient’s/family’s choice of clinician.3. Monitoring the percentage of patient visits with a selected

clinician or team.

NCQA PCMH 2011

Value of EmpanelmentEmpanelment promotes:Continuity of care with personal PCP

• Improves quality, patient safetyOrganized approach to care delivery

• Continuity increases efficiency by at least 15%.Management of provider demand to panel size

• Improves patient access to careProvider accountability for population management• Facilitates team-based care

Patients in Provider Panels

PROVIDER 1 PROVIDER 2

PROVIDER 3

PROVIDER 5

PROVIDER 4

PROVIDER 6

Each Provider Responsible For• The care of each patient in his/her panel.• Population management for his/her entire panel.• Clinical outcomes improvement for his/her panel of

patients.• The overall effectiveness and efficiency of his/her

practice.

Creating Provider PanelsNCQA Requirements:• Document and follow a process to encourage and ask

patients to choose a personal provider.• During check-in?• When patients call for an appointment?• Materials/handouts letting patients know value of choosing a

personal provider and process to do so?• What about patients who are seen infrequently?• Send a mailing?

• Document and track each patient’s choice of a personal provider.• Put in EMR and scheduling system, if not integrated.• Must be available when booking appointments, checking in

patients.• Needed for population management reports.

Other Things to Consider• Historical information on patient visits:

• Which provider seen most often• Which provider did last physical exam• Which provider seen last

• Maximum panel size for each provider based on:• # of hours/provider/year• # of provider appointments available/hour• Type of patient population and related visits/year

(risk stratification)• Goal is to balance supply and demand and

balance provider panels.

Maximum Panel Size Formula

• A part-time provider working 1,000 hours per year (20 hr/wk x 50 wks) and having 4 appointments/hour has 4,000 appointment slots per year.

• If the patient population requires 10 visits/year, the panel size for the provider could not exceed 400 patients.

• If the population requires 4 visits/year, the panel size could be 1,000 patients.

Example

(# of hours worked/year) x (# of appointments/hour) (average # visits/year for panel of patients) = maximum provider panel size

Ongoing Support, Monitoring• Need scheduling policies to support patient visit

continuity with selected provider.• Likely need some form of open access scheduling to

facilitate sick visit continuity.• Same-day appointments (NCQA PCMH Standard 1, Element

A: Access During Office Hours—MUST PASS and CRITICAL FACTOR).

• Evaluate weekly schedules to see which days more open appointment slots are needed to accommodate patient demand.

• NCQA: Practice should monitor the percentage of visits that occur with the selected clinician and team.

NCQA DocumentationDocumentation Needed for NCQA:Documented process for patient/family selection of

a personal clinician.Screen shot from electronic system showing

documentation of patient/family choice of clinician.One week of data showing proportion of patient

visits that occurred with chosen clinician.

Empanelment Resources• Safety Net Medical Home Initiative

Offers Implementation Guides and Webinars on Empanelmenthttp://www.safetynetmedicalhome.org/change-concepts/empanelment

BASELINE ASSESSMENTSPCMH-A and Clinical Measures

Assessing Where You Are Now• Two types of baselines

• PCMH Assessment (PCMH-A)• Clinical measures baselines: Topic of Webinar #2

• Practice Facilitators also will be collecting some baseline assessment information when they visit with you.

The PCMH-A• Self-assessment tool developed by Qualis and the

MacColl Institute for the Safety Net Medical Home Initiative.

• Assesses current level of “medical homeness.”• Identifies areas for improvement.• Should be completed at the practice level by the

team leader or provider champion in consultation with improvement team.

Completing the PCMH-A• Available online at: http://

www.safetynetmedicalhome.org/sites/default/files/PCMH-A.pdf.

• Will also be emailed to key contacts (person who completed your application).

• When you’re done, save a copy for your files and print a copy to share with us.

• Please email a copy of your completed PCMH-A by May 11 to paspread@hmc.psu.edu or fax it to 717-531-0182.

UPCOMING DATESWebinar #2, #3; Learning Session #1

Dates for Upcoming Sessions• Webinar #2: Baseline Data Measurement

• May 2: 7-8am• May 8: 5-6pm

• Webinar #3: Introduction to the Models• May 16: 7:30-8:30am• May 21: 4-5pm

• NW Learning Session #1: May 23, 5-9pm• SC Learning Session #1: June 7, 5-9pm

Please RSVP the team members who will be attending Learning Session #1 to paspread@hmc.psu.edu by May 11.

Pre-Work To-Do’s Identify a provider champion Form a multi-disciplinary improvement team Write an aim statement Develop a plan to address any issues with

provider panels Complete and submit the PCMH-A assessment Collect and report baseline diabetes data on the

monthly practice status report Participate in the 3 pre-work webinars RSVP attendees for Learning Session #1

Practice Facilitators• Northwest

Patricia J. Stubber, MBAExecutive DirectorNorthwest PA AHEC8425 Peach StreetErie, PA 16509-4788814-217-6029 (phone)814-594-4740 (cell)814-864-4077 (fax)pstubber@nwpaahec.org

• South CentralSharon M. Adams RN, BAExecutive DirectorSouthcentral PA AHECPO Box 509Carrolltown, PA 15722814-344-2222 (phone)814-344-2221 (fax)sadams@scpa-ahec.org

paspread@hmc.psu.eduAny Questions CENTRAL EMAIL

WEBSITE www.paspread.com