© Pittsburgh Regional Health Initiative 2014 1 COMPASS Using Data for Improvement Establishing the Current Condition and Identifying Opportunities for

© Pittsburgh Regional Health Initiative 2014 1

COMPASSUsing Data for Improvement

Establishing the Current Condition and Identifying Opportunities for

Improvement

Robert FergusonProgram Manager


Purpose and Objectives

Purpose To describe how we collect, display, and use data (not to show you

our current outcomes or results) To elicit your feedback on how we can improve our data displays and

your ideas and strategies for collecting, displaying, and responding to data

Learning Objectives Describe COMPASS-PA’s framework for collecting and responding to

data Discuss five examples of how to collect and display data in COMPASS


Jewish Healthcare Foundation“A Think, Do, Train and Give Tank”

A public charity with two operating arms:Pittsburgh Regional Health Initiative (PRHI)

Health Careers Futures (HCF)


Pittsburgh Regional Health Initiative

• Pittsburgh Regional Health Initiative (PRHI) A not-for-profit, regional, multi-stakeholder

collaborative formed in 1997 by Karen Feinstein and Paul O’Neill

An initiative of a business group, the Allegheny Conference on Community Development

PRHI’S MESSAGEDramatic quality improvement (approaching zero deficiencies) is the best cost-containment strategy for health care


PRHI’s Systems VisionA

cro

ss C

are

Set

tin

gs

Essential Services System Requirements

Care Mgt

Clinical Pharmacy

Patient Engagement

Health IT

QI Training

Payment Incentives

Collaboration and

Integration

Medication Reconciliation

Data to Treat,

Measure, Evaluate

Perfect Patient Care

Rewardsfor

Collaboration

Hospice/Palliative

Long Term Care

Rehab

Hospital

Emergency Services

Specialty Care

Primary Care

Screening and Tx

Behavioral Health

Informed, Activated, Discerning

Consumers, particularly at

End-of-Life


Implementation of Evidence-based Behavioral Healthcare in Primary Care

2008• Analyzed

Admission Data

2009-2010• ITPC Pilot

with local funding

2010-2013• PIC

Dissemination in 4 states with AHRQ funding

2012-2015• COMPASS

Implementation as a CMMI Sub-Awardee

31 COMPASS-PA PCP Offices from 3 Groups:

• Saint Vincent Healthcare Partners

• Excela Health Medical Group

• Premier Medical Associates


COMPASS Objectives

By 12/31/13, enroll 375 eligible patients per partner region

By 6/30/14, enroll 675 eligible patients per partner region

By 6/30/15: Improve depression for 40% of patients Improve A1c, LDL, BP control rates by 20% Improve patient/provider satisfaction by 20% Reduce ER visits by 20% Reduce hospital admissions by 10%

PRHI’s Framework for Collecting and Responding to DataInformed by Motivational Interviewing and PRHI’s Lean-based Perfecting Patient CareSM QI Methodology

Process(Eliminate Waste)

Philosophy(Long-Term Thinking)

The 4 P’Sof the

Toyota WayPeople and Partners

(Respect, Challenge, and Grow Them)

People and Partners(Respect, Challenge,

and Grow Them)

Problem Solving (Continuous Improvement

& Learning)

Liker, Jeffrey K. The Toyota Way, New York: McGraw-Hill, 2004.

The Lean Perspective

The Motivational Interviewing Perspective

A way of being with people which is…•Collaborative•Evocative•Respectful of autonomy


Method

Obtain leadership’s support and direction Identify the current condition and future state with those

who do the work, using multiple data sources to make it meaningful and actionable: Observations (“go and see”) Process Mapping EHR and AIMS CMTS data HPIER’s Reports

Facilitated by PRHI coaches who are trained in Perfecting Patient Caresm, Motivational Interviewing, and COMPASS processes and skills Their goal is to develop internal capacity for self-review, learning,

improvement, and sustainability



TIME LOCATION ACTIVITY OTHER

0:00 Registration Patient arrives.

Patient checks in with registration clerk.

Told to wait until called by registration clerk. “you will be paged”

1:35 Waiting Room Takes seat in registration room.

10:42 Waiting Room Patient is paged to the registration booth.

10:52 Patient asks another patient for advice on which booth to go to before being directed to correct booth.

Patient seems confused as to where to go.

11:41 Registration Patient completes paperwork, provides insurance information

17:05 Patient is asked to take a seat and wait to be escorted to exam room.

No seat is available for patient.

27:49 MA calls patient name and escorts patient to exam room.

Exam Room 3 MA collects vitals. *MA is very attentive and seems to listen well to patient

38:03 MA is unable to find gown for patient

Travels to supply closet to retrieve gown.

41:28 Patient is asked to change into gown and wait for physician

1:08:36 Exam Room 3 Physician enters room and greets patient

Physician completes patient assessment and plan.

Current Condition Observations


Process MappingVisualizing the Current and Future Condition

Improvement Opportunity

Well-functioning

aspect of work


A3 Improvement Plan


Incremental Improvements Towards the Ideal

PDSA/A3 PDSA/A3

Each impro

vement m

oves

the pro

cess close

r to

the id

eal

CurrentCondition

TargetCondition

Motivational Interviewing Observation Form to Elicit Feedback on Skill Development

Example 1: EHR Data at One Medical Group


Population Health Current Condition

siteALL

DM +/or CVsuboptimum

%suboptimum

lapsed %lapsed but pending %

missing A1c %

missing LDL %

A 376 40% 40% 13% 24% 16%B 281 32% 31% 32% 28% 8%C 263 44% 33% 11% 13% 15%D 975 43% 38% 16% 22% 14%E 636 46% 33% 7% 28% 15%F 704 44% 46% 13% 23% 17%G 351 43% 43% 18% 31% 17%H 483 32% 37% 22% 18% 11%I 602 40% 39% 16% 26% 12%J 306 35% 26% 32% 29% 19%K 312 39% 32% 28% 36% 14%L 870 46% 34% 7% 32% 20%M 341 30% 28% 52% 48% 26%N 221 47% 34% 0% 38% 22%O 176 43% 41% 13% 18% 19%P 364 45% 33% 20% 27% 15%

total 7261 41% 36% 16% 27% 16%

January 2013


PHQ-9 Screening Current Condition, by Office

44% PHQ-9 Completion

19% PHQ-9 > 9

67% Enrollment

October 2013

Example 2: Displaying HPIER’s Reports, by Medical Group


COMPASS Patient EnrollmentBy Regional Partner

June 13, 2014

CHPW ICSI KPCO KPSC MACIPA MAYO MICCSI PRHI

156

514

287

515

132

463

335

546


Initial Data CompletenessBy Medical Group

July Aug Sep Oct Nov Dec Jan Feb Mar Apr May75.00%

80.00%

85.00%

90.00%

95.00%

100.00%

Average Initial Data Completeness Rate

Medical Group AMedical Group BMedical Group CGoal for Payment Rate Increase

June 13, 2014


PHQ-9 Documentation

Med

ical

Gro

up A

Med

ical

Gro

up B

Med

ical

Gro

up C

COM

PASS

-Wid

e

88% 100% 100% 97%75%

42%

77%62%

% With Documented Baseline PHQ-9 vs. A 120-Day Most Recent PHQ-9

% in care for > 119 days with baseline PHQ-9% in care for > 119 days with a PHQ-9 after 119 days

June 13, 2014


Depression Improvement:Baseline vs. Most Recent Score

Medical Group A Medical Group B Medical Group C COMPASS-Wide

10%2%

7% 6%

61%

50%

72%

59%

% With Baseline PH-9 < 10 vs. Most Recent PHQ-9 < 10 or > 4-point Improvement

% in care for > 119 days with Baseline PHQ-9 < 10% in care for > 119 days with Most Recent PHQ-9 improved by > 4 points or < 10

June 13, 2014


Depression Remission:Among Those in COMPASS for > 119 Days

18%20% 20%

27%

% with Documented PHQ-9 after 119 days in Remission

% with PHQ-9 after 119 days with Most Recent PHQ-9 < 5June 13, 2014


A1c Documentation

74%80%

64%

79%

26% 25%34%

29%

% With Documented Baseline A1c vs. 120-Day Most Recent A1c

% in care for > 119 days with baseline A1c% in care for > 119 days with an A1c after 119 days

June 13, 2014


A1c Control Rate:Baseline vs. Most Recent Value

32%25%

46%

28%

40%

30%

59%

41%

% With Baseline A1c < 8 vs. Most Recent A1c < 8

% in care for > 119 days with Baseline A1c < 8% in care for > 119 days with Most Recent A1c < 8

June 13, 2014


BP Documentation

Med

ical

Gro

up A

Med

ical

Gro

up B

Med

ical

Gro

up C

COM

PASS

-Wid

e

88% 96% 100% 96%65%

46%

80%61%

% With Documented Baseline BP vs. 120-Day Most Recent BP

% in care for > 119 days with Baseline BP% in care for > 119 days with a BP after 119 days

June 13, 2014


BP Control Rate:Baseline vs. Most Recent Value

Medical Group A Medical Group B Medical Group C COMPASS-Wide

49%

65%

80% 78%

60%69%

74%81%

% With Baseline BP < 140/90 vs. Most Recent BP < 140/90

% in care for > 119 days with Baseline BP < 140/90

% in care for > 119 days with Most Recent BP < 140/190June 13, 2014


Hospital Admissions (Self-Reported)

Med

ical

Gr..

.

Med

ical

Gr..

.

Med

ical

Gr..

.

COM

PASS

-...

0.06

0.30.22 0.24

0.47

0.22

0.74

0.41

Hospital Admission Rates, Pre and Post

Baseline Hospital Admit Rate Per Patient-Year (For those Enrolled > 119 Days)

June 13, 2014

Example 3: CMTS Data at One Medical Group

Entered in CMTS

Initial Contact PH-9>9

Last Follow-up PH-9<10

No Follow-up PH-9

Initial Contact PH-9<10

Last Follow-up PH-9>9

Last Follow-up PH-9<10

99%

1%

28%

32%

41%

100%

COMPASS PHQ-9May 2014 CMTS Data

Median Contacts Per Patient with Initial PHQ-9>9 3

Median Treatment Weeks Per Patient with Initial PHQ-9>9 38

Entered in CMTS

Initial Contact A1c > 7.9

Last Follow-up A1c<8.0

No Follow-up A1c

Initial Contact A1c<8.0

Last Follow-up A1c>7.9

Last Follow-up A1c<8.0

No Follow-up A1c

Last Follow-up A1c>7.9

49%

30%

12%

47%

41%

43%

10%

48%

COMPASS A1cMay 2014 CMTS Data

Median Contacts Per Patient with Initial A1c > 7.9 3

Median Treatment Weeks Per Patient with Initial A1c > 7.9 29

Entered in CMTS

Initial Contact SBP>139

Last Follow-up SBP<140

No Follow-up SBP

Initial Contact SBP<140

Last Follow-up SBP>139

Last Follow-up SBP<140

No Follow-up SBP

Last Follow-up SBP>139

COMPASS SBPMay 2014 CMTS Data

60%

37%

23%

15%

62%

48%

17%

36%

Median Contacts Per Patient with Initial SBP>139 3

Median Treatment Weeks Per Patient with Initial SBP>139 42.5

Example 4: CMTS Data at Another Medical Group

-505

10152025

PHQ-9 Initial vs. Most Recent Value Change

for Individual Patients

Patients

PHQ

-9 C

hang

e

-3

-1

1

3

5

A1c Initial vs. Most Recent Value Change for Individual Patients

Patients

A1c C

hang

e

020406080

100120140160

LDL Initial vs. Most Recent Value Change for Individual Patients

Patients

LDL C

hang

e

-40

-20

0

20

40

60

80

SBP Initial vs. Most Recent Value Change for Individual Patients

Patients

SBP

Chan

ge

March 2014

Example 5: CMTS Data of Follow-up Contacts


Follow-up Contacts and Active Caseload by Month and Care Manager

Care Manager’s Current % Time on COMPASS

# Follow-up Contacts

# Pts. Active End of….

Nov Dec Jan Feb Mar Apr May Feb Mar Apr May

100% 11 42 43 35 49 54 57 83 88 82 89100% 24 37 22 28 52 36 41 76 68 74 77100% 58 88 59 58 64 49 49 73 81 82 8220% NA NA NA NA NA NA 0 NA NA NA 090% NA NA NA NA 1 16 15 NA NA 16 185% 3 1 2 0 0 3 0 9 9 9 92% 1 1 0 1 1 0 1 1 2 2 25% 10 5 5 4 3 4 5 7 7 7 85% 0 1 3 4 0 1 2 5 4 4 45% 0 1 1 1 3 1 2 4 5 4 45% 3 5 9 9 7 8 10 8 8 9 82% 0 0 0 0 0 1 1 4 5 5 55% 6 4 8 1 0 0 0 7 8 9 9100% 131 121 135 105 103 122 111 86 NA 99 101


COMPASS-PA’s Next Steps

Analyze internal EHR data (PHQ-9, A1c, BP) Continue to base the Steering Groups’ discussions

around the data Use AIMS’ CMTS Caseload Statistics and Caseload

Summary for real-time data and monitoring Continue to dig into the CMTS data Continue to utilize Lean-based quality improvement

methods at the front-line Move meaningful, actionable data to where the work

is occurring


Care of Mental, Physical, and Substance use Syndromes

The project described was supported by Grant Number 1C1CMS331048 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

Documents

© Pittsburgh Regional Health Initiative 2014 1 COMPASS Using Data for Improvement Establishing the Current Condition and Identifying Opportunities for