value-driven quality improvement in primary care · value-driven quality improvement in primary...
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Value-DrivenQualityImprovementinPrimaryCareWilliamRollow,MD,MPH,PrimaryCareDevelopmentCorporationJanetDesGeorges,Hands&Voices,Inc.DennisKuo,MD,MHS,DepartmentofPediatrics-UAMSRichardSnow,DO,MPH,OhioHealth
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VALUE-DRIVENQUALITYIMPROVEMENTINPRIMARYCARE
WilliamRollow,MD,MPH(moderator)JanetDesGeorges
DennisKuo,MD,MHSRichardSnow,DO,MPH
November12,2015
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WhyValue?
• StudiesofPCMHtypicallyassessimpacton:– Clinicalqualitymeasures– Cost/utilization– Patientsatisfaction
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WhatDoPatientsValue?
• Health– Dimensions:physical/somatic/physical,cognitive/emotional,social/functional,spiritual
• Cure– Uni-dimensionalresolution
• Healing– Integratedimprovementacrossdimensions
• Preconditionsofhealth– Housing,employment,income,safety
• Experience– Access,relationship,amenities
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HowCanPrimaryCarePracticesCreateValueforPatients?
• Needed– Amodelthatprovidesaroadmapforpracticetransformationwitheffectivefacilitation/assistance
– Researchanddevelopmentoncomponentsofthemodel– Paymentthatcoversthecostsofprovidingcare
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WhatWillWeDiscussInThisSession?
• Whatpatientsvalue• Howcanprimarycarepracticesprovidevalue
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Value-DrivenQualityImprovementinPrimaryCareWilliamRollow,MD,MPH,PrimaryCareDevelopmentCorporationJanetDesGeorges,Hands&Voices,Inc.DennisKuo,MD,MHS,DepartmentofPediatrics-UAMSRichardSnow,DO,MPH,OhioHealth
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ParentsandPatientsasPartnersinQIWork—BeyondtheClichés
SessionJ:Value-DrivenQualityImprovementinPrimaryCare
Presentedby:JanetDesGeorges
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∗ Credentials:M.O.M.(“mom,youwouldn'thaveajobifitwasn’tforme”);ourfamilystory
∗ Systemicinvolvementforover15years(medical,educational,community)
∗ ExecutiveDirectorandCo-Founder,Hands&Voices(over50chaptersintheU.S.andabroad)
∗ Authorofpeer-reviewedarticlesinMedicalJournals∗ CertificateofCompletionattheUniversityofNorthCarolina-ChapelHillMCHPublicHealthLeadershipInstitute
MyProfessionalBackground
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ABriefhistoryofourfamily’sjourney…
•Sarawasbornin1991–priortouniversalnewbornhearingscreening;qualifiedforPartCServices–Hypotonia(at11months)•LateI.D.atagetwo–with2yearlanguagedelays(congenital,sensorineuralbilateralmoderate-profoundhearingloss);37professionalsinourlivesbyage7•Successful,youngdeafadult–bi/modalcommunicator;collegegrad;intheworkworld
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Thiswasjustour‘world’ofdeafness….imagineformorecomplexconditions?Whatwereourvalues?Ourneeds,Ourgoalsforhealth/wellbeing?...
MedicalHome
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∗ PDSACYCLE:∗ Colorado:∗ Prework:
∗ Plan:DetermineifPCPshaveresultsofhearingscreenincharts.Predicttheydo.
∗ Do:Chartreviewof10chartsfrom3PCPSthatagreedtoparticipate.∗ Study:1PCPhadall10results,2PCPShadnone.
∗ Surprisingresult∗ InpatientandOutpatientEMRsdonotcommunicate.
∗ Act:∗ DosmalltestsofchangeusingfurtherPDSAcycles:IdentifyPCPpriortohospitaldischarge;fax
resultstoPCP;provideresultstofamilyinwriting.∗ Promotestatewidedataintegrationeffortswithimmunizationregistry,developastrategic
planfordatamanagementandcasetracking.
TypicalProcessPDSA….
EXAMPLEFROMNICHQPROJECT: ImprovingFollow-UpafterNewbornHearingScreeningbyApplyingQualityImprovementStrategiestotheHealthCareSystem
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Exampleofprocess:PDSAmaytrackifaudiologistsaregivinginformationtotheMedicalHome(i.e.faxbackforms)
Ask:Howdidthatimpactparents?“DidthePhysiciandiscussyourchild’sscreeningresultswithyou?”
ThinkingaboutQIpointofviewasaparent….
HowwilltheoutcomesofQIbeutilizedtoimproveyoursystem?(Parents,askyourselftheinternal,‘sowhat?’questionwhentalkingaboutPDSA’s)
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Theconceptof‘Value-Driven’orthe‘SoWhat?’inQIwork…
HowwilltheoutcomesofQIWorkbeutilizedtoimproveyoursystem?(Parents,askyourselftheinternal,‘sowhat?’questionwhentalkingaboutPDSA’s)
BeyondPROCESSEvenbeyondIMPACTONFAMILIES/PATIENTS
GOAL:Measuring/ImprovingParent/PATIENT-CENTEREDVALUESandDesiredoutcomes -individuallyandcollectively
YESwedid!QualityImprovement
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∗ Googleit∗ About3,050,000results
∗ TheCitizenScientists(WiredMagazine,2001)∗ “Andbytheway,don'tgo
ontheInternet.”
GettingThere:Clinician–ParentPartnership
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ExampleofParentInvolvement
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NICHQhasworkedwithHRSA-MCHBon5collaborativestoimproveoutcomesforchildrenwithhearinglossandtheirfamilies,across52statesandterritories:∗ ImprovingFollow-uptoNewbornHearingScreeningbyWorkingthrough
theMedicalHomeLearningCollaborative∗ AZ,CA,FL,KS,MI,NE,PA,WI(2006-2007)
∗ ImprovingSystemsofCare(ISC)forChildrenandYouthwithSpecialHealthcareNeedsLearningCollaborativesA&B∗ LC-A:NHS:CO,MA,MN,NV,NY,UT,WA(2007-2009)∗ LC-B:NHS:HI,IL,IN,IA,ME,NC,VA(2009-2010)
∗ ImprovingHearingScreeningandInterventionSystems(IHSIS)LearningCollaborativesA&B∗ LC-A:AL,AK,GA,ID,KY,LA,MS,MO,NH,NM,OH,RI,SC,DC(2011-2012)∗ LC-B:AR,CT,DE,MD,MT,NV,NJ,ND,OK,OR,PR,TN,TX,USVI,VT,WV,WY(2012-2013)
NICHQNewbornHearingCollaboratives
IHSISfundedbytheUSDeptofHealth&HumanServices,HealthResources&ServicesAdministration,MaternalandChildHealthBureau,ContractNo.HHSH250201000021C
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∗ Planning∗ Involvementatthebeginningofeachproject∗ Guidingthedevelopmentofcollaborativecontentfromthefamilyperspective∗ Mandatedparentparticipationonteams
∗ Facultylevel∗ Roleequaltothatofotherfaculty∗ Askedtocontributebeyond‘parentstuff’
∗ Teams∗ T.A.inensuringtheirparentsareinvolved∗ Presentatlearningcollaboratives∗ Supportparent-driveninitiatives
∗ Parentinvolvementsupport∗ Spendtimewithparentsasagroupatlearningsessions∗ Createandsharetoolsformeaningfulinvolvement
NICHQParentFacultyRole
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∗ PowerfulPartnerships:AHandbookforFamiliesandProvidersWorkingTogethertoImproveCare
Downloadfrom:www.nichq.org
http://www.nichq.org/how-we-improve/resources/powerful-partnerships
Resources:
The“HOWTO”!
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Disturb the Peace
Sustain Tension
Contain Anxiety
Provide Leadership
Janet DesGeorges
You can reach Janet at [email protected]
303-492-6283
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Value-DrivenQualityImprovementinPrimaryCareWilliamRollow,MD,MPH,PrimaryCareDevelopmentCorporationJanetDesGeorges,Hands&Voices,Inc.DennisKuo,MD,MHS,DepartmentofPediatrics-UAMSRichardSnow,DO,MPH,OhioHealth
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archildrens.org uams.eduarpediatrics.orgarchildrens.org uams.eduarpediatrics.org
VALUE-DRIVENQUALITYIMPROVEMENTINPRIMARYCARE:Thepediatricsperspective
DennisZ.Kuo,MD,MHSAssociateProfessorofPediatrics,UAMS
November12,2015
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archildrens.org uams.eduarpediatrics.orgarchildrens.org uams.eduarpediatrics.org
Pediatrics
• Children– 48%ofMedicaidenrollees– 21%ofspend(KaiserFamilyFoundation)
• Mostchildrenaccessingprimarycare– Preventivecarevisits– Immunizations
• ~1%=25-33%ofcosts(Neff,2004;Cohen,2012)
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archildrens.org uams.eduarpediatrics.orgarchildrens.org uams.eduarpediatrics.org
ChildrenareNOTlittleadults!
The5D’s Implicationforchildren
Development • Enhancedevelopmentandgrowth
Dependency • Dependentonadults–notautonomous
DifferentialEpidemiology • Largenumberofrelativelyrarechronicconditions• Subspecialistsbasedinacademicmedicalcenters
DemographicPatterns • Highpoverty• Moreracialandethnicdiversity
Dollars • ROIoverlongtermlifecourse
Stilleeta.TheFamily-CenteredMedicalHome:SpecificConsiderationsforChildHealthResearchandPolicy.AcademicPediatrics2010;10:211-7.
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archildrens.org uams.eduarpediatrics.orgarchildrens.org uams.eduarpediatrics.org
Healthcarespendingbychildren
Kuoetal(2015)Pediatrics.Inpress
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archildrens.org uams.eduarpediatrics.orgarchildrens.org uams.eduarpediatrics.org
Highresourceutilizers:childrenwithmedicalcomplexity
• Multiplechronicconditions• Highincidenceofneurodevelopmentaldisability• Technologyneeds• Socialcomplexity• Muchofcareintertiarycaresetting
Cohenetal.Pediatrics(2011)
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archildrens.org uams.eduarpediatrics.orgarchildrens.org uams.eduarpediatrics.org
The Chronic Care Model
Wagner EH. Figure from Antonelli R (2005). Adapted from Bodenheimer (2002)
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archildrens.org uams.eduarpediatrics.orgarchildrens.org uams.eduarpediatrics.org
Drivingvalueinprimarycare
• PCMH/practicetransformation– Primarycareisinexpensiveandhighvolume– Savingsconcernasmallnumberofpatients
• Challenges– Commonmetricsarenotpediatric-based– Mosthighresourceutilizerspendisintertiarycarecenter– WhatistheROIonmore$$inprimarycare?– Whatistheclinicalmechanismtogeneratevalue?
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archildrens.org uams.eduarpediatrics.orgarchildrens.org uams.eduarpediatrics.org
Deepthoughts
• Understandthehighresourceutilizer• Emphasizetheroleoftheprimarycarephysician
– BuildcapacitywithQI,careteams,registry– Community-basedtherapies,familyengagement
• Alignprimarycarewithaco-managementarrangementwithtertiarycareservices
• Supportivepaymentstrategies
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Value-DrivenQualityImprovementinPrimaryCareWilliamRollow,MD,MPH,PrimaryCareDevelopmentCorporationJanetDesGeorges,Hands&Voices,Inc.DennisKuo,MD,MHS,DepartmentofPediatrics-UAMSRichardSnow,DO,MPH,OhioHealth
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Value Driven Quality Improvement in Primary Care
Richard Snow, DO, MPH System Vice President, Clinical Transformation, OhioHealth
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Model of Patient Centered Care Moving Towards Value Following Donnabedian Model of Health Care Measurement
• Structural orientation – Accreditation
• Process oriented – HEDIS measures
• Outcomes focused – Value oriented
• Clinical and financial quality • Payers increasingly moving towards
– Comprehensive Primary Care – Commercial
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Approach of OhioHealth• Large hospital system in Central Ohio with
– 28,000 associates and family members in self insured – Clinically integrated network with Medical Group of Ohio
with ~ 160,000 covered lives • Developing Pathways to Value
– Series of value oriented projects focused on improved clinical and financial quality – all projects link the 2 outcomes
• Deploying at a system level – Describe what we want for our primary care practices
• Aligning force – Per Member Per Month
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•DiabetesPreventionProgram •ChronicKidneyDisease •PreventionofMusculoskeletalSurgery
•ObstructiveSleepApnea •AmbulatoryEDUtilization •HospitalObservation •PreventableHospitalization •EDCTUtilization •TotalKneeReplacement
•EndStageRenalDisease •ChronicObstructive PulmonaryDisease •CongestiveHeartFailure •PathwaystoWellness
Pathways to Value Initiative in OhioHealthy
Physician Leadership and Engagement
Prevention
Matching Medical
Necessity with Intensity of
Service
Managing Chronic Disease
Demonstrated Value Differential
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How Does This Translate to a Primary Care Office and Patient Centered Care
• Diabetes Prevention Program – Cost of care doubles as patients progress from pre-DM to DM – DPP reduces progression to DM by 58% – Managing to value – percent enrollment
• Reduction of progression of high risk patient CKD-3 – Hypertension management, nephrotoxic drug avoidance, guideline
adherence • Conservative management of low back and joint problems
– Identification of patients – Referral and co-management
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Implications for Primary Care Office
• Providing primary care with direction to provide value – Who is at risk? – What is the modifiable portion of risk? – What can my office do to reduce the risk?
• Reengineering Payment – How do we incentivize and support the office to be successful?
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Value-DrivenQualityImprovementinPrimaryCareWilliamRollow,MD,MPH,PrimaryCareDevelopmentCorporationJanetDesGeorges,Hands&Voices,Inc.DennisKuo,MD,MHS,DepartmentofPediatrics-UAMSRichardSnow,DO,MPH,OhioHealth