Community Care Physicians Quality of Care Initiatives 2006 Bridges to Excellence Bridges to Excellence Performance Improvement Projects Performance Improvement

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  • Community Care Physicians Quality of Care Initiatives 2006

    Bridges to ExcellencePerformance Improvement ProjectsEMR Implementation

  • Bridges to Excellence Status Report

    17 Practices representing 84 Physicians achieved recognitionImproved patient outcome and responseQuality brandingSignificant monetary reward: >$470,000 and counting from the collaborativeAn additional $188,000 anticipated by years end~ $500,000 received in related incentives (Healthplans)Corporate Application in progress with EMR implementation

  • BTE Related ActivitiesDiabetes Care Initiative

    Diabetes Case Management Program

    Diabetes Self Management Education Program

    ProCare

    EMR

  • DCIDiabetes Care Initiative

    Diabetes Performance Measurement and Improvement

    - Develop Diabetic registry - Conduct process audit - Provide benchmarking data- Develop interventions and implement- Re-measure

    Phase 1 conducted at 5 Practices involving 40 Practitioners and 3000 patientsPhase 2 expanded to total of 10 Practices, 60 Practitioners4500 patients

  • Areas of Opportunity and Interventions

    Tobacco screening- Staff education on Diabetic patient prep and Tobacco screeningScheduling of follow-up visits- Process changes in the way we schedule patients Comprehensive foot care- Diabetes Tool Kits filled with tools for the provider and the patient to facilitate foot examsAnnual dilated retinal exam- Documentation Tools: flow sheets, standing order sets etc. Nephropathy testing- Educational information on nephropathy testing Self Management EducationADA Certified Diabetes Self Management Education Program

  • Chart1

    2

    1.9

    1.8

    2.4

    3.9

    Visits

    Chart2

    6.79

    6.8

    6.84

    6.68

    6.33

    Practice 1

    Practice 2

    Practice 3

    Practice 4

    Practice 5

    Note: Demographics of each practice - including age, sex, geographic location and insurance all very similar.

    Practice Experience

    Number of Visits/Year

    A1C Levels

    Relationship of # of Visits per Year to A1C LevelsSelected CCP Practices (2004)

    Sheet1

    A1CVisits

    DFG6.792

    LIM6.81.9

    KS6.841.8

    LMG6.682.4

    CHA6.333.9

    VisitsA1C

    26.79

    1.96.8

    1.86.84

    2.46.68

    3.96.33

    Sheet2

    Sheet3

  • Diabetes Case Management Project

    CDPHP Health Plan and Community Care Physicians Diabetes Case Management2004 - 2005

  • The Collaborative ProjectPatients were included in the project if their HbA1c was >9.0% (Case Management Trigger)CDPHP Case Managers worked with patients on lifestyle modifications, medication and diabetes management and provided general diabetes disease education.The Case Manager sent a follow-up report to the patients physician documenting the intervention.The Provider incorporated the intervention into the plan of care thereby reinforcing the message.

  • A1c Average With CM

    10.1388.676

    Last Draw

    First Draw

    # of Lab Draws

    A1c Value

    Average A1c - Case Management

    A1c Average without CM

    Average A1c for the First DrawAverage A1c for the First DrawAverage A1c for the First Draw9.96

    Average A1c for the Second DrawAverage A1c for the Second DrawAverage A1c for the Second Draw9.45

    Average A1c Without Case Management - 2005

    Summary

    Case Management Summary For 2005

    Total Number of Patients Referred for Case Management with an A1c > 9.0189

    Total Number of Patients Disengaged from Case Management for 2005( - )99

    86 Refused/Were Terminated/Deceased/Other

    13 Were Successful in Case Management

    Total Number of Active Patients( = )90

    Plus Number of Successful Patients( + )13

    Total Number of Patients Either Active or Disengaged But Successful( = )103

    Number of Patients with only 1 Lab Draw( - )27

    Total Number of Patients Evaluated for Improvement( = )76

    Number of Patients with Increase in A1c or Stayed the Same( - )21

    Number of Patients with Improvement in A1c( = )55

    ACTIVE/SUCCESSFUL PATIENTS (76 Patients)

    Average A1c for the First Draw10.138

    Average A1c for the Second Draw8.676

    PERCENT IMPROVEMENT =1.462%

    Of the 55 Patients that Improved:16Improved 0 - 1%29%

    13Improved 1.1 - 2%24%

    11Improved 2.1 - 3%20%

    15Improved .> 3%27%

    DISENGAGED PATIENTS (43 Patients)

    Total Number of Disengaged/Terminated/Deceased/Other Patients86

    Total Number Deceased, Terminated by PHP, or Changed PCP( - )18

    Total Number of Patients Eligible to be Evaluated( = )68

    Minus the Number of Patients who only had One Lab Draw( - )2537%

    Total Number of Disengaged Patients Evaluated( = )43

    Average A1c for the First Draw9.96

    Average A1c for the Second Draw9.45

    PERCENT IMPROVEMENT =0.510%

    Conclusion: Patients that received Case Management had a .952% difference in reduction of A1c. Case Management patients realized a reduction in A1c of

    1.462%, while patients without Case Management only had a .51% reduction in A1c.

    &C&"Arial,Bold"CDPHP CASE MANAGEMENTEVALUATION 4-26-05

    Improvement with CM

    VariableAverage HbA1c95% Confidence

    (%)Interval

    Baseline HbA1c10.1389.0 - 15.9

    Post Case Management8.6765.6 - 15.2

    HbA1c

    76 Patients with 2 or More Lab Draws were evaluated for this project

    &C&"Arial,Bold"&20Case Management Referral Results

    Percent Improv.

    % ImprovementNumber of Patients with Improvement% of Total

    from the 55 Patients Evaluated that

    Had Improvement

    0 - 1 %1629.0

    1.1 - 2 %1324.0

    2.1 - 3 %1120.0

    > 3 %1527.0

    &C&"Arial,Bold"&14% ImprovementApril 2005

  • A1c Average With CM

    10.1388.676

    Last Draw

    First Draw

    # of Lab Draws

    A1c Value

    Average A1c - Case Management

    A1c Average without CM

    Average A1c for the First DrawAverage A1c for the First DrawAverage A1c for the First Draw9.96

    Average A1c for the Second DrawAverage A1c for the Second DrawAverage A1c for the Second Draw9.45

    Average A1c Without Case Management - 2005

    Summary

    Case Management Summary For 2005

    Total Number of Patients Referred for Case Management with an A1c > 9.0189

    Total Number of Patients Disengaged from Case Management for 2005( - )99

    86 Refused/Were Terminated/Deceased/Other

    13 Were Successful in Case Management

    Total Number of Active Patients( = )90

    Plus Number of Successful Patients( + )13

    Total Number of Patients Either Active or Disengaged But Successful( = )103

    Number of Patients with only 1 Lab Draw( - )27

    Total Number of Patients Evaluated for Improvement( = )76

    Number of Patients with Increase in A1c or Stayed the Same( - )21

    Number of Patients with Improvement in A1c( = )55

    ACTIVE/SUCCESSFUL PATIENTS (76 Patients)

    Average A1c for the First Draw10.138

    Average A1c for the Second Draw8.676

    PERCENT IMPROVEMENT =1.462%

    Of the 55 Patients that Improved:16Improved 0 - 1%29%

    13Improved 1.1 - 2%24%

    11Improved 2.1 - 3%20%

    15Improved .> 3%27%

    DISENGAGED PATIENTS (43 Patients)

    Total Number of Disengaged/Terminated/Deceased/Other Patients86

    Total Number Deceased, Terminated by PHP, or Changed PCP( - )18

    Total Number of Patients Eligible to be Evaluated( = )68

    Minus the Number of Patients who only had One Lab Draw( - )2537%

    Total Number of Disengaged Patients Evaluated( = )43

    Average A1c for the First Draw9.96

    Average A1c for the Second Draw9.45

    PERCENT IMPROVEMENT =0.510%

    Conclusion: Patients that received Case Management had a .952% difference in reduction of A1c. Case Management patients realized a reduction in A1c of

    1.462%, while patients without Case Management only had a .51% reduction in A1c.

    &C&"Arial,Bold"CDPHP CASE MANAGEMENTEVALUATION 4-26-05

    Improvement with CM

    VariableAverage HbA1c95% Confidence

    (%)Interval

    Baseline HbA1c10.1389.0 - 15.9

    Post Case Management8.6765.6 - 15.2

    HbA1c

    76 Patients with 2 or More Lab Draws were evaluated for this project

    &C&"Arial,Bold"&20Case Management Referral Results

    Percent Improv.

    % ImprovementNumber of Patients with Improvement% of Total

    from the 55 Patients Evaluated that

    Had Improvement

    0 - 1 %1629.0

    1.1 - 2 %1324.0

    2.1 - 3 %1120.0

    > 3 %1527.0

    &C&"Arial,Bold"&14% ImprovementApril 2005

  • Case Management Results

  • Diabetes Self Management Education Program

    ADA certified Multiple sites, times, group and individual classes - access

    Improve patient outcome by providing a previously un-reimbursable form of patient intervention.

    Promote continuum of care

  • DSME Outcomes*Mean difference between HbA1c pre and post DSME Program was -2.8% (95% CI -2.09 to -3.55)* p.001

  • Post DMSE HbA1c Distribution

    *68.18% of patients who participated in the DMSE Program achieved a HbA1c7.0%

  • Disease Management Pro-Care

    Systematic method of identifying patients in need of care and contacting them for follow up

    Evidenced based management of chronic illness

    Utilizes data mining of internal and external information sources

    Improves Provider payor profiles by cleaning claims data

  • ProCare ROI - 5 PracticesPilot Project 2nd half 2005Using 3 Most Prevalent Conditions# of Pts Identified ------------- 2351# of Visits scheduled ---------- 677Success rate --------------------- 28%Total charges ---

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