Improving Performance in Practice National Conference Day 2

1. Improving Performance in Practice National Conference Day 2 May 29, 2009 Asheville, NC

2. Table of ContentsIn “slide show” view, click titles to jump directly to individual presentations

3. Aligning Forces for Quality Bruce Siegel MD MPH Director Center for Health Care Quality George Washington University School of Public Health and Health Services

4. What is Aligning Forces for Quality? • AF4Q is the Robert Wood Johnson Foundation’s signature effort to improve the quality of health care Americans receive. • Quality is a national problem, but health care is delivered locally. • The aim is to improve the quality of health care in up to 20 targeted communities, reduce racial and ethnic disparities and provide models for reform. Targeted Regions will Improve and Sustain High-Quality, Patient-Centered, Equitable Care by 2015

5. Consumer Engagement Performance Measurement & Public Reporting Quality Improvement Nursing Equity

6. 2009 AF4Q Communities

7. AF4Q Alliances Represent More than 10% of the U.S. population • Over 12% of all MDs • Nearly 11% of all RNs • 11% of hospitals AF4Q Alliances

8. Sample Expectations • Performance Measurement/Public Reporting • By October 2009, 11 of the communities will have produced reports of physician performance for the physicians in those communities to review. • By February 2010, 11 of the communities will have produced public reports of physician performance on 50% of the primary care physicians. • Equity • By December 2011, 11 of the communities will have a region-wide approach to collecting and using race, ethnicity and language data. • Long-Term • By 2015, 80% of all funded regions will meet the standard that 70% of the patients in the region are receiving the right care. * Version dated 2/26/08

9. © MN Community Measurement. All rights reserved. .

10. 2008 Health Care Quality Report • Reports on 12 quality measures • Reports results on 143 medical systems/350 sites • Results from health plan and medical group data • Improved results for most measures

11. Minnesota AF4Q • Leadership team includes MNCM, Stratis, ICSI, providers, plans, employers, consumers • Key strategies • Expand performance measures • Patient experience • Race/ethnicity/language data • Hospital care measures • Consumer use of information – TheD5.org • Patient Activation Project

12. Opportunities with Minnesota IPIP • Participation in Leadership Team – state wide health reform • Use of Standardized Performance Measures • Expand data collection to additional practices • Align the improvement process with ICSI

13. Questions or Comments Jim Chase President, MN Community Measurement 612-455-2911 chase@mncm.org www.mnhealthscores.org www.thed5.org © MN Community Measurement. All rights reserved.

14. AF4Q in South Central PA-York and Adams Counties Quality Improvement Improved Health and Healthcare in South Central PA (York/Adams Counties) Engaged Consumers Publicly-Reported Quality Measures AF4Q Key Driver Diagram 9.3.08

15. AF4Q in South Central PA-York and Adams Counties • Governor’s Office of Healthcare Reform • AF4Q/IPIP/American Society for Quality (ASQ) • Nurses Council- TCAB • Social Marketing Campaign- I Can! • consumer tested (Consumer Research Panel) • Motivational Interviewing- Choose to Change • Public Reporting on website- June 2009

16. Western Michigan Alliance for Health Paul Ponstein, D.O.

17. Areas of Focus • Center for Health Improvement • Clinical Data for Performance Measurement • Public Reporting Dilemma • Consumer Self Management • Race, Language and Ethnicity

18. Greater Detroit Area Health Council Jan Whitehouse

19. Save Lives Save Dollars • Multi-year initiative of coordinated immediate and long-term actions to drive quality improvement (save lives) • Derive cost reductions (save dollars) • Lead improvement in the quality, cost-effectiveness and accessibility of health care

20. Wisconsin Collaborative for Healthcare Quality Cindy Schlough

21. Potential for Alignment • Quality Improvement initiatives • Public reporting • Assembly meetings to review comparative results • Partnership with Wisconsin Hospital Association • IPIP has a proven model for engaging health care organizations in QI

22. IPIP May 2009

23. Agenda • Brief Review of Patient Centered Medical Home • Aligning IPIP with: • ARRA • PCMH • Current state-regional projects • Medicare Demo • “truly” patient centered care • Beyond the PCMH to the patient centered health care system

24. Align with ARRA “Meaningful Use”orDon’t ignore billions and billions

25. Basics of ARRA related to Health • Billions and billions • 2B Office of the National Coordinator 2 B • 17B Adoption of EHR’s (via CMS but ?? With rules from ONC) • 2B Dept of Agriculture distance learning and telemedicine • 1B HRSA for Community Health Center HIT • 1B AHRQ, DHHS, NIH for Comparative Effectiveness Research • And a few million here and there

26. Areas of ARRA related to IPIP • David Blumenthal –Head of the Office of the National Coordinator for HIT (ONC) • Establishes two key committees that have already met • Policy • Standards • For 17 Billion jackpot “What is “meaningful use” • Legislative language • Certified EHR technology which shall include the use of electronic prescribing • Connects in such a manner that provides…exchange of information … to improve the quality of care, such are promoting care coordination • Submits information…on clinical quality measures and such other measures as selected by the Secretary • Some thoughts as to what may evolve (2010 to 2013) • Registries (reminders, care management) • Computerized order entry • Quality measurement and feedback-quality improvement-starting with small set of existing measures (diabetes, CAD, hypertension) PCMH level 2 and 3 will likely be far beyond any meaningful use criteria

27. Some things to watch for • Will ARRA HIT focus practice attention more on HIT and less on transformation? • Work with practices to help them understand what is required by ARRA-and what is needed to make this really “work” in their practices (PCMH)

28. Aligning with the future of the PCMH

29. Align with PCMH Demonstrations • State-local (you should know them well) • National • Medicare Demonstration • Tax Relief and Health Care Act (TRHCA) of 2006 (Sec. 204) • Medicare Improvements for Patients and Providers Act (MIPPA) of 2008 (Sec. 133)

30. Overview • Goal: to redesign the health care delivery system to provide targeted, accessible, continuous and coordinated, family-centered care to high-need populations” • 3 years, up to 8 states (including urban, rural, underserved areas)-400 practices

31. Technical Assistance • John A. Hartford Foundation grant • Awarded to the Lipitz Center for Integrated Health Care at Johns Hopkins University • PI: Charles E. Boult, MD, MPH, MBA

32. Care Management Fee • Monthly fee for each medical home Medicare patient • Adjusted for complexity of patient • Valuation set by AMA’s Relative Value Scale Update Committee (RUC) • Designed to cover inter-visit activities • “Work” = staffing mix, level of effort • Practice expenses

33. Payment • Fee-for-service for covered services • Care management fee to personal physicians • Incentive payment for medical home practice • Share of savings attributable to medical home • Savings calculated net of care management fees

34. What Is the Care Management Fee?

35. Evaluation • Measure against comparison population • Value added • Clinical quality • Physician perspective • Beneficiary/family/caregiver perspective • Savings to Medicare • Lessons learned

36. Expansion Expansion may occur if the project • Improves the quality of patient care without increasing spending, or • Reduces spending without reducing the quality of patient care

37. Be where the puck is going, not where it isThe future of the PCMH beyond HIT

38. What is Patient-Centered Care? Davis et al, 2006 • Access to care, including alternatives for in-person visits • Patient engagement in care-- provider as advisor, information for patients, clear delineation of patient responsibility, help with self-care, behavior change, education • Integrated, comprehensive care and smooth information transfer across provider teams • Coordination and communication among care providers across location & time • Publicly available information on practices

39. Domains of Patient-Centered Care

40. Principles of PCC Measurement • Two types of metrics needed • Systems to support patient-centered interactions • Patient experiences ratings to show whether patients perceive interaction as patient-centered • Build on existing tools • Identify which items best evaluated by systems vs patients (and don’t duplicate)

41. Metrics for Patient-Centered Care Systems

42. Metrics for Patient-Centered Care Experiences

43. Addressing Patient Needs • Customizing care • “Patient-centered care is focusing on the individual needs of that patient and looking at things for that patient in a very broad scope, looking at how certain conditions, problems really tie into each other and how one thing may be affecting another.” • Promoting evidence-based care • “Treating all patients the same, using consistent protocols (including follow-up frequency) so all staff and clinicians can provide consistent message.”

44. Tensions in Patient-Centered Care • Competing demands of different aspects of patient-centered care • Improving access may make it challenging to provide education • Accommodating patient wants versus patient needs • Patients want refills over the phone when the clinician believes that face-to-face visit would be more beneficial

45. Appendix Details of Medicare PCMH demo

46. Personal Physician • Board certified • First point of contact • Continuous care • Ongoing support, oversight, guidance to implement plan of care • Staff & resources to manage comprehensive & coordinated care

47. Practice Responsibilities • Target beneficiaries for participation • Provide safe, secure technology to promote access to personal health information • Develop health assessment tool • Provide training for personnel involved in coordination of care • Provide medical home services

48. Medical Home Services • Oversee development & implementation of plan of care • Use evidence-based medicine & decision-support tools • Use health information technology to monitor & track health status of patients, provide patient access to services • Encourage patient self-management • Non-visit-based access & care

49. Design Issues • Medical home definition • Practice eligibility • Beneficiary eligibility • Care management fee • Technical assistance

50. Definition of Medical Home • What are the minimum requirements to ensure practices have capacity to act as “quarterback” for health care team caring for participating beneficiaries? • Should we recognize multiple levels of medical home practices? What should differentiate them?