Better Quality,
Lower Cost,
Better Population Health
Clinical Transformation with
Focus on Performance Improvement
and Care Management
Presented at the MeHAF Integration Initiative Meeting
July 27, 2012
James A. Raczek, MD, FAAFP
Eastern Maine Medical Center
Senior Vice President of Operations and Chief Medical Officer
Overview
I.
Beacon Community Grant Program
II. Bangor Beacon Community
III. Clinical Transformation
A. Performance Improvement Intervention
B. Care Management Model Intervention
2
I. Beacon Community Grant Program
A. Competitive Grant Overview
1. Demonstration program for communities that were
ahead in Health Information Technology (HIT) and
with a history of collaboration among non-related
organizations
2. Funder: Office of National Coordinator (ONC)
3. $220 million awarded nationally. Funding for three
(3) years.
4. 17 communities selected
5. EMHS/Bangor received $12.75 million!
a. Grant funding April 2010 through March 2013
3
I. Beacon Community Grant Program
B. Beacon Community Vision
The Beacon Community Grants
Program will provide funding to
demonstrate the vision of the future
where hospitals, clinicians, and patients
are meaningful users of health
information technology and together the
community achieves measurable
improvement in health care quality,
safety and efficiency.
4
B. Beacon Community Vision
5
C. Bangor Beacon Community Vision
Performance
Improvement
To improve the
management of chronic
conditions through
health information
technology and care
coordination
Cost
To improve
compliance with
influenza and
pneumococcal
immunization
Population
Health
To reduce
preventable
healthcare
utilization through
improved
efficiency of health
care delivery
6
C. Bangor Beacon Community Vision
To reduce
preventable
healthcare
utilization through
improved
efficiency of health
care delivery
7
II. Bangor Beacon Community
A. Collaborators - Local
1. Eastern Maine Medical Center
2. St. Joseph Healthcare
3. Penobscot Community Health Care
4. City of Bangor – Health and Community Services
5. Acadia Hospital
6. Community Health & Counseling
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II. Bangor Beacon Community
A. Collaborators - Local
7. Eastern Maine HomeCare
8. Eastern Maine Community College
9. Maine Network for Health
10. Northeast Cardiology
11. Ross Manor
12. Stillwater Health Care
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II. Bangor Beacon Community
B. Collaborators - Statewide
1. HealthInfoNet – Information Exchange
2. Maine Health Management Coalition
3. Quality Counts
4. Office of the State HIT Coordinator
5. Maine Quality Forum
6. Maine Primary Care Association
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II. Bangor Beacon Community
B. Collaborators - Statewide
7. Martin’s Point Health Care
8. Maine Hospital Association
9. Maine Center for Disease Control
10. MaineCare
11. Maine Osteopathic Association
12. Leadership from MaineHealth and other health
systems
11
C. Communities of Practice
Leadership &
Governance
(Cathy Bruno)
Enables
Enables
-Statewide Advisory
Committee, Admin
Enables
Data & Performance
Measurement
Measures
(Barbara Sorondo)
Clinical Transformation
(Jim Raczek)
Performance Improvement
Care Coordination Sustains
Immunization Compliance
TelePsychiatric Services
Intervention for Long Term Care
Facilities
- Evaluation
Sustainability:
Business &
Payment Modeling
(Mike Donahue)
Enables
Health IT (Dev Culver)
Enables
Statewide Health Information
Exchange Development
Enables
12
D. Patient Demographics/Health Issues
• Bangor Hospital Service Area
o
o
Population estimated (2009):
164,099
43 cities and towns
• 2010 Community Health Need
Assessment (CHNA Report) for
this area:
o
o
o
o
o
14% uninsured
14% of residents are age 65+
7% heart disease
8% asthma
35% overweight/obesity
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E. Provider Information
• Participants in the Bangor
Beacon Community:
o
65% of the Primary Care
Physicians
o
Impacts directly or indirectly
93,000 active patients from
these practices
14
III. Clinical Transformation
A. Performance Improvement (PI) Intervention
B. Care Coordination Intervention:
1.
2.
3.
4.
Care Managers – Primary Care Setting
Care Managers – Mental Health
Care Management Forum
Homecare Intervention
C. Immunization Compliance Intervention
D. TelePsychiatric Services Intervention for Long Term
Care Facilities
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III. Clinical Transformation
A. Performance Improvement (PI) Intervention
1. Multi-Institutional Collaboration
EMMC
• 5 Practices
• 50 providers
PCHC
SJH
• 3 Practice
• 41 providers
• 1 practices
• 14 providers
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A. PI Intervention
2. Organizational Structure
a. Clinical Leadership PI Group
• Chief Medical Officer (CMO), Medical Directors
• Practice Managers
• Lead Care Managers
• Data and Performance Measurement Personnel
b. Individual Healthcare Organization PI Groups
• CMO or Medical Directors
• Lead Physicians
• Staff Providers
• Care Managers
• Medical Assistants
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A. PI Intervention
3. Methods
a. Use of basic performance improvement techniques
i. Group consensus on indicators that would be
measured
ii. Group consensus on goals for performance on each
indicator
iii. Transparency of performance data within the groups
• Institution specific performance data
• Provider specific performance data
• Care Manager specific performance data
iv. Ninety (90) day action plans (modified Plan-Do-StudyAct cycles) to improve performance
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A. PI Intervention
3. Methods (continued)
v.
Alert systems in the EMR (Electronic Medical Record)
associated with all patient encounters
• Chronic disease management
• Preventable health
vi. Integrate Care Managers into the practice and empower
them to enhance the management of the practice’s patients
vii. Include all members of the clinic staff in the management
effort (“Team Sport”)
viii. Empower clinic staff other than just the Care Managers to
care for the patient up to their scope of practice and/or job
description (e.g. medical assistant, front desk receptionist.
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B. PI Metrics – Diabetes
Successes
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B. PI Metrics – Diabetes
Successes
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B. PI Metrics – Diabetes
Successes
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B. PI Metrics – Diabetes
Successes
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B. PI Metrics – Diabetes
Successes
1.
New definition for BP changed the bundle
•
•
Current value: 12%
Target: > 20%
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B. PI Metrics – Cardiovascular Disease
Successes
25
B. PI Metrics – Cardiovascular Disease
Successes
26
B. PI Metrics – Cardiovascular Disease
Successes
1.
Blood pressure tracking
–
–
–
2.
New definition was incorporated during Q1 2012
Current value: 78%
Target: > 80%
CVD Bundle tracking
–
–
–
New definition for BP changed the bundle
Current value: 23%
Target: > 30%
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B. PI Metrics – Chronic Obstructive Pulmonary
Disease (COPD)
Successes
28
B. PI Metrics – Chronic Obstructive Pulmonary
Disease (COPD)
Successes
29
B. PI Metrics – Asthma
Successes
30
B. PI Metrics – Asthma
Successes
31
C. Care Management Intervention
1. Primary Care Models
Role of Care Managers:
 Management of HR/HC patients using disease specific protocols
 Care Transitions/ Care Coordination
 Patient Education
 Patient Self-Management
EMMC
5 RN Care Managers
PCHC
3 RN Care Managers
3 MA Health Coaches
3 LCSW
St. Joseph
1 RN Care Manager
• Focused on DM, COPD, CHF, and Asthma
• All models have 1 RN Coordinator who manages
ED/WIC use and hospital discharges
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C. Care Management Intervention
2. Evaluation of the PCP Care Management
Model on High Risk/ High Cost Chronic
Condition Patients
Healthcare Goals
• Quality: Better
Care
Outcomes
• Clinical and Preventive
Measures
• Cost: Affordable
Care
• Healthcare Utilization
• Experience:
Improved Experience
of Care
• Patient Reported Measures
• Providers perception of care
management
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C. Care Management Intervention
3. Results - High Risk/High Cost Chronic
Condition Patients
Enrollment Update
Organization
Enrolled
Completed 6
months
Completed 12
months
Completed 18
months
EMMC
470
372 (79.1%)
245 (52.1%)
67 (14.3%)
St. Joseph
167
66 (39.5%)
4 (2.4%)
0 (0%)
PCHC
493
406 (82.4%)
235 (47.7%)
3 (.6%)
Control
TOTALS
308
1438
168 (54.5%)
1012 (70.4%)
44 (14.3%)
528 (36.7%)
4 (1.3%)
74 (5.1%)
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C. Care Management Intervention
3. Results - High Risk/High Cost Chronic
Condition Patients
Successes
• Clinical Measures
Within the first 6 months of receiving care
management
– The percentage patients with HbA1C >9
were reduced from 40% to 16%
– The percentage of patients with HbA1C
<8 increased from 32% to 61%
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C. Care Management Intervention
3. Results - High Risk/High Cost Chronic
Condition Patients
Successes
• Healthcare Utilization
– Hospital admissions were reduced by
43.7%
– ED visits were reduced by 38.4%
– Walk-in-care visits were reduced by 48.7%
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C. Care Management Intervention
3. Results - High Risk/High Cost Chronic
Condition Patients
Successes - Patient Reported Measures
N
Prior to Care
Management
6 months after
Care Management
Significance
p<0.05 (CI)
1 QUALITY OF LIFE - GLOBAL
Overall perception of the current health
status using a visual analog scale from
0-100 (EQ5D Health Status-VAS)
665
63.2
68.8
P=0.000
2 QUALITY OF LIFE - SPECIFIC
718
Measure
(-7.06to -4.12)
0.761
0.787
PARAMETERS
(-0.039 to -0.012)
Index calculated from 5 questions
addressing: mobility, self care, usual
activities, pain/discomfort and
anxiety/depression (EQ5D State Score)
3 Adherence to Medication -
724
2.05
2.38
P=0.000
(-0.333 to 0.992)
723
2.59
2.62
P=0.249
(-0.037 to 0.871)
723
6.78
7.21
P=0.000
Motivation (Modified Morisky Scale)
4 Adherence to Medication -
Knowledge (Modified Morisky Scale)
5 Chronic Disease Self Efficacy Survey
Score of 6 questions related to
confidence in managing their
condition (scale 1-10)
P=0.000
(-0.421 to 1.90)
C. Care Management Intervention
3. Results - High Risk/High Cost Chronic Condition
Patients
Provider Perception about the Care Management Model
Benefits of the Care Management (CM) model:
• Helped to reach those patients who had not effectively
managed their health before without a care manager
because we did not have the time.
• Increased communication about patients reduces my
workload and clearing things off of my desktop.
• Patients feel like there is a group of people taking care
of them instead of only one person.
• They are able to reach patients on a more personal
level and help them.
C. Care Management Intervention
3. Results - High Risk/High Cost Chronic Condition
Patients
Provider Perception about the Care Management Model
Limitations of the Care Management (CM) model:
• Financial sustainability of having additional team
members to help care for patients.
• Being interrupted in order to go meet with a patient who is
being CM in order to complete the visit and to be
reimbursed.
• Initially explaining to patients the benefits of a care
management model
• Lacking clinical protocols to identify what the different
responsibilities are by role (PCP, CM, health coach, etc.)
C. Care Management Intervention
4. Care Management Forum
• Total number of CM: 26
• Total number of patients who had received
CM services: 1,217
Care Coordination
Interventions:
Primary Care
Care
Management
Mental Health
Care
Management
Inpatient Care
Management
• Medication reconciliation
• Discharge summary flow
• Care Manager performance dashboard
• Disease-specific education opportunities
Homecare and
• Patient text messaging reminders
Home Health
• Patient assistance program
Services
Cardiology
Care
Management
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Dale Hamilton, Executive Director for
Community Health and Counseling
Services
Care Management within Mental Health
Centers and the Important Contributions
Beacon has Made to Develop a System
the Supports Improved Health for
Individuals with Mental Illness
41
Panel Discussion
42