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IMPACT Quality Improvement Collaborative (QIC)
Performance Improvement in Primary Care Hypertension Blood Pressure Control
R. Anthony Minervino Jr. MPA, IHI-IA, PCMH-CCEProgram Director, Patient-Centered Medical Home (PCMH)Rochester Regional Health
Thursday, October 27th, 2016
The QIC addresses 5 of the 15 strategies related to health systems change – 4/5 are points of my emphasis:
Increase EHR adoption and the use of health information technology to improve performance.
Increase the institutionalization and monitoring of aggregated/standardized quality measures at the provider level.
Increase engagement of nurses and/or pharmacists (as non-physician team members) in hypertension management in health care settings.
Increase use of self-measured blood pressure monitoring linked to clinical supports.
Implement systems to facilitate identification of patients with undiagnosed hypertension • Using last reading from past 12 months of >= 140/90 can pose problems
• Usage of elevated reading diagnosis code
Anthony’s BackgroundHealthcare experience:
- American Red Cross hospital blood bank product coordination (3 years)
- University of Rochester clinical & pathology lab services business development (3 years)
- Clinical informatics & performance improvement/PCMH (6 years)
Education:
- Business administration major/psychology minor bachelors degree from SUNY Geneseo
- Public administration w/ non-profit & healthcare management emphases masters from SUNY Brockport
- Currently completing capstone project for masters in medical management from the University of Rochester
Professional Development/Certifications:
- Institute for Healthcare Improvement Improvement Advisor
- Patient-Centered Medical Home Certified Content Expert
- Lean Six Sigma Black Belt trained
Organizational Background
Historical focus on 16 primary care practices within Unity Medical Group, which have largely been PCMH level 3 recognized since 2010
RN care managers
Mix of urban & suburban settings
NextGen EHR implemented in 2004
Collaborative, quality-driven, “no ego” culture with strong support from administration
Dedicated clinical informatics resources for EHR modifications, report-writing, analytics in pre-merger environment
Rochester General Health (RGH) & Unity Health (UH) Systems merged in 2014, bringing the primary care practice count to 42
2016 conversions for UH from NextGen to Epic
Efforts Involving BP Control Improvement Rochester Medical Home Initiative (2010-2012, 2 practices): initial NCQA
PCMH recognition & much HEDIS 90th percentile performance achievement in clinical quality indicators
Greater Rochester Health Foundation hypertension grant (2010-2013, 2 practices): improving blood pressure control & reducing previously undiagnosed hypertension
Accountable Care Quality Arrangement (ACQA) w/ Excellus (2013-present, all practices): degree of HEDIS 90th percentile achievement determines % of savings that is shared with the organization if cost curve is bent
Monroe County Medical Society Guideline Implementation Project (2015-present, 6 practices with lowest BP control): raise awareness of local guideline’s key points for hypertension BP control management
3 Major Enablers for Better BP Control
Primary Care Provider Performance Improvement
Champions Program
“Patient-Centered Medical Home” Primary Care Dashboard &
Care Opportunities Report
National Committee for Quality Assurance Patient-Centered
Medical Home (NCQA PCMH) Recognition
Provider Performance Improvement Championship in Hypertensive Blood
Pressure ControlMinervino A(1,2), Arnone T(1,2), Bradley A(1), King S(2), Beckman H(1), Nazar M(1,2),
Spellane K(1), LoCicero A(2), & Freeman J (1)
1Finger Lakes Health Systems Agency; 2Rochester Regional Health
Background
o Finger Lakes Health Systems Agency (FLHSA) & Rochester Business Alliance (RBA) community blood pressure improvement collaborative backdrop
o In 2011, FLHSA/RBA coordinated training through the National Resource Center for Academic Detailing (NARCAD) of 8 providers & pharmacists from 2 different Rochester, NY health systems in such skills as active listening, identifying and responding to barriers to change, and respectful communication.
o The intent of the training was to develop “consultants” who would facilitate blood pressure control performance improvement (PI) efforts throughout the nine county Finger Lakes region
Evolution from Consultants to Champions
o Despite good advice and attempts at facilitating blood pressure control performance improvement (PI) efforts within the 14 primary care practice network from an DO/MD/PA consultant trio, practice PI ownership wasn’t developing for Unity Medical Group (UMG).
o In 2013, UMG kicked off a program (co-led by the clinical informatics & performance improvement manager and provider consultants) where, upon the identification of a provider “champion”, every primary care practice that cared for adult patients was encouraged to participate in a monthly committee meeting.
o While blood pressure control has remained the consistent topic, National Committee for Quality Assurance Patient-Centered Medical Home guidelines , dashboard metrics, and how to leverage an appointment with care opportunities report have also been mainstays of the performance improvement champions (PIC) program.
o In addition to committee meeting participation, champions are expected to facilitate team-based (both clinical & non-clinical) conversations with their practice about committee happenings, workflow redesign/implementation, etc.
Calculating Level of Engagement
Performance improvement champion (PIC) engagement is defined by rates of participation in monthly committee meetings and facilitating conversations at participating practices. A total score for the time period April 2014 – June 2015 was calculated. PIC practices with a total score in the lowest quartile were assigned a PIC score of 1 (n=3) and are considered to have adopted the PIC program “in name only.” All other PIC practices (n=11) were assigned a PIC score of 2. Registry practices not participating in the PIC program (n=81) were assigned a PIC score of 0.
Principal Findingso After controlling for the effect of different SES levels and racial/ethnic
compositions across PIC levels, hypertensive patients in PIC practices were 35.1% more likely to have controlled blood pressure than hypertensive patients associated with a non-PIC practice
o PIC practices demonstrate significantly lower no-read rates (5.9%) than non-PIC practices (11.0%). Moreover, within PIC practices, the no current read rate for Level 2 practices (5.9%) is nearly one-half that of Level 1 practices (10.0%).
o Unadjusted results demonstrate a small, significant difference in mean systolic blood pressure in PIC and non-PIC patients.
Conclusions & Implications
o Improved blood pressure control and a reduction in mean systolic blood pressure among PIC practices as compared to non-PIC practices
o Mean systolic blood pressure of Black non-Hispanic patients associated with a PIC practice was 4.7mmHg lower than the mean systolic blood pressure of Black non-Hispanic patients associated with a non-PIC practice. This result suggests PICs may play a pivotal role in reducing disparities in hypertension control and hypertension-related health outcomes.
o With the knowledge that for every 5mm/Hg decrease in systolic BP there is 12% decrease in CVA mortality, 9% decrease in CHD mortality and 7% all cause mortality, optimism is high that new focuses on addressing mean and stage 2 hypertension will be a natural evolution from the success realized through dedicated multi-year efforts to gain and maintain Unity Medical Group control well into the HEDIS 90th percentile.
What are we trying to promote/achieve?
Development of effective teams
Use of data to drive improvement
Standardization and proliferation of best practices: culture of quality improvement
Structured communication processes amongst 1) entire practice and 2) clinical care teams
Ability to replicate successes and learn from opportunities to do something differently
Why standardize through a proven process or best practice?
Contributes to building an infrastructure: who does what, when,
where, how and with what
Each individual can describe and execute in the same way
Removes variation in practice and data
Makes training and competency assessment easier
Feedback about defects used for learning and further redesign
Model for improvement accelerates change
Aim: what are we trying to accomplish?
Changes: what changes can we make that will result in an improvement?
Measures: how will we know that a change is an improvement?
Plan-Do-Study-Act Cycle: Series of small tests with low risk build will and
degree of confidence that ultimate, implemented change will be worthwhile
“Pearls of Wisdom” Gained Through PIC Work in
Hypertension Blood Pressure Control
1) Act as a team: Improvement efforts don’t have to equate to more work if
designed and executed properly; involve all members of the team
2) Value of morning “huddle”: Reviewing care opportunity reports can flag
hypertensive patients and if their last BP was out of range
3) Every appointment is a BP appointment: “Heads up” from staff if last
BP was high even if patient isn’t there that day for hypertension;
encouragement of early follow-up as appropriate
“Pearls of Wisdom” Gained Through Performance Improvement Consultant Work (Continued)
4) Strive for accurate measurement: Re-check, proper cuff size, home
monitoring (which can also engage the patient in their self-management
through communication to the office of readings)
5) Treat early: Resist bargaining on allowing more time to pass before
intervention; lifestyle modifications are important but medication seems
integral for many
6) Treat aggressively: Follow up with additional meds, use combo meds
early if BP remains high, use cost-effective generics
Blood Pressure Control “Toolkit”
Why develop a toolkit?• Empowerment when provider champions construct it with care teams
• Can be used as a readiness assessment for understanding gap between what’s being done now and what could ultimately be done
• Non-traditional contributions can be achieved
Review of toolkit developed by PI champs
Non-negotiable vs. preference-based tools
Accountability for their usage• Reporting & feedback
PIC Results
Provider champions that continue to emerge as leaders in their practices
Building a common approach that can be replicated for other standards of care and operational workflows
Increase in BP control within the primary care network to a level of performance that’s well into the top 10% of the country
Springboard for other spinoff initiatives, such as addressing stage 2 (extreme) hypertension & average blood pressure
3+ years of experience to pull into a new standardized RRH program that eventually involves 65+ primary care practices
FLHSA/RBA Recognition for PIC Work
3 Major Enablers for Better BP Control
Primary Care Provider Performance Improvement
Champions Program
“Patient-Centered Medical Home” Primary Care
Dashboard & Care Opportunities Report
National Committee for Quality Assurance Patient-Centered
Medical Home (NCQA PCMH) Recognition
PCMH Dashboard & Care Opportunities Report Tracks performance in chronic (diabetes, hypertension, etc.) and
preventive (cancer screenings, etc.) care metrics
Transparency achieved through access to performance for all practices, by all practices
Patient details for proactive outreach when gaps exist to patients not coming in for appointments
Appointments w/ care opportunities report for point of care gap closure – more than what’s tracked in the dashboard
PCMH Dashboard – Group PerformancePCMH DashboardAll Primary Care Practices
Practice Compare Metric Trends PCMH Practice Detail
All Providers
------------ 2015 HEDIS Percentile ------------
Measure 9/30/2016 8/31/2016 25th 50th 75th 90th
Number Active Patients 70800 70849 ▼
1 DM HbA1C <= 9 73.3 74.1 ▼ 62.5 68.3 74.0 79.3
2 DM HbA1C < 8 61.9 62.6 ▼ 52.7 58.0 63.3 67.5
3 DM Nephropathy Assessment 82.1 81.9 ▲ 78.3 81.8 85.9 89.6
4 DM BP < 140/90 80.2 80.3 ▼ 56.5 63.2 70.7 75.2
5 DM Eye Exam 48.5 49 ▼ 42.6 50.2 59.3 70.2
6 HTN BP < 140/90 (< 150/90 no DM 60-85) 79.5 79.8 ▼ 55.2 61.1 67.3 74.4
7 CAD/IVD Aspirin / Antithrombotic 87.1 87.4 ▼ 52.0 69.0 77.0 82.0
8 CAD/IVD BP < 140/90 78.7 79.4 ▼ 56.5 63.2 70.7 75.2
9 Colorectal Cancer Screen 63.4 63.6 ▼ 54.3 59.8 66.6 71.6
10 Breast Cancer Screen 59.2 59.8 ▼ 68.0 71.3 76.0 80.3
11 Lead Screen 76.4 77.2 ▼ 58.4 70.8 80.8 85.8
12 Child BMI Percentile 87.2 88.6 ▼ 32.4 49.5 64.7 80.8
13 Immunization Set of 7 75.7 79.2 ▼ 68.6 75.4 81.0 84.9
14 Falls Assessment 43.9 43.9 = 50.0 55.0 59.0 73.0
PCMH Dashboard – Practice Performance
PCMH DashboardUnity Family Med @
Practice Compare Metric Trends PCMH Practice Detail
All Providers
------------ 2015 HEDIS Percentile ------------
Measure 9/30/2016 8/31/2016 25th 50th 75th 90th
Number Active Patients 8144 8191 ▼
1 DM HbA1C <= 9 80.3 81.1 ▼ 62.5 68.3 74.0 79.3
2 DM HbA1C < 8 67.3 68.1 ▼ 52.7 58.0 63.3 67.5
3 DM Nephropathy Assessment 80.7 80.4 ▲ 78.3 81.8 85.9 89.6
4 DM BP < 140/90 83.6 85.2 ▼ 56.5 63.2 70.7 75.2
5 DM Eye Exam 50.8 51 ▼ 42.6 50.2 59.3 70.2
6 HTN BP < 140/90 (< 150/90 no DM 60-85) 85 85.9 ▼ 55.2 61.1 67.3 74.4
7 CAD/IVD Aspirin / Antithrombotic 85.9 86.2 ▼ 52.0 69.0 77.0 82.0
8 CAD/IVD BP < 140/90 86.2 86.2 = 56.5 63.2 70.7 75.2
9 Colorectal Cancer Screen 68 68.9 ▼ 54.3 59.8 66.6 71.6
10 Breast Cancer Screen 64 65 ▼ 68.0 71.3 76.0 80.3
11 Lead Screen 84.6 78.6 ▲ 58.4 70.8 80.8 85.8
12 Child BMI Percentile 88.7 93.3 ▼ 32.4 49.5 64.7 80.8
13 Immunization Set of 7 84.6 85.7 ▼ 68.6 75.4 81.0 84.9
14 Falls Assessment 29 26.2 ▲ 50.0 55.0 59.0 73.0
PCMH Dashboard – PCP Panel PerformancePCMH Dashboard
Unity Family Med @Practice Compare Metric Trends PCMH Practice Detail
Last Name MD, First Name
------------ 2015 HEDIS Percentile ------------
Measure 9/30/2016 8/31/2016 25th 50th 75th 90th
Number Active Patients 1937 1969 ▼
1 DM HbA1C <= 9 78.9 79.5 ▼ 62.5 68.3 74.0 79.3
2 DM HbA1C < 8 65.5 65.5 = 52.7 58.0 63.3 67.5
3 DM Nephropathy Assessment 85.4 84.8 ▲ 78.3 81.8 85.9 89.6
4 DM BP < 140/90 84.8 83.6 ▲ 56.5 63.2 70.7 75.2
5 DM Eye Exam 74.9 76 ▼ 42.6 50.2 59.3 70.2
6 HTN BP < 140/90 (< 150/90 no DM 60-85) 84.2 85 ▼ 55.2 61.1 67.3 74.4
7 CAD/IVD Aspirin / Antithrombotic 85.1 85.1 = 52.0 69.0 77.0 82.0
8 CAD/IVD BP < 140/90 81.1 81.1 = 56.5 63.2 70.7 75.2
9 Colorectal Cancer Screen 67.6 68.2 ▼ 54.3 59.8 66.6 71.6
10 Breast Cancer Screen 70.5 72 ▼ 68.0 71.3 76.0 80.3
11 Lead Screen 100 100 = 58.4 70.8 80.8 85.8
12 Child BMI Percentile 90.7 92 ▼ 32.4 49.5 64.7 80.8
13 Immunization Set of 7 100 100 = 68.6 75.4 81.0 84.9
14 Falls Assessment 39.5 39.5 = 50.0 55.0 59.0 73.0
Low-tech approaches can be just as effective and fundamental…
Lessons Learned About Performance Dashboards/Care Opportunity Triggers
Allow care teams managing the populations to validate the data – develops trust in accuracy
Develop an accompanying guide that outlines exactly what’s measured (qualifying diagnosis codes, exclusions, where to document, etc.) to clearly demonstrate how to “get credit”
Display comparative, trending, etc. performance data in a way that care teams & practice management prefer & understand
Be direct and honest about any caveats
Respond to issues timely and with empathy
Dashboard Metrics as a Subset of Care Opportunities
Manual vs. Automated Outreach for Patients Not Presenting Manually generating lists of patients that need something is time
consuming, prone to error, and reports may be difficult to modify
Phytel Outreach is an example of a product that mines for gaps in care and calls patients that qualify for an intervention
RRH is currently switching from Phytel to a similar approach using Televox, but need to be mindful of considerations such as how many patient response calls can the practice handle per day, how quickly can patients be scheduled, every outreach type doesn’t require a visit, etc…BP measurement & management certainly does!
Whether outreach is manual or automated, using protocols (check-in at no visit in 2 years, 3 month follow-up for controlled & 6 month follow-up for uncontrolled) can help tightly manage
Care Opportunities Report
Home Blood Pressure Monitoring via RN Care ManagementDetermine Patient Eligibility (RN Care Manager)
BP outside of parameters (JNC8) for 2 most recent BP readings from the past 12 months:
(> 140/90 for 18-85 year old patients with diabetes or > 150/90 for non-diabetic patients 60-85)
OR
Last BP qualifies as stage 2 hypertension (>160/100) from the past 12 months
OR
Patient is hypertensive but doesn’t have uncontrolled readings as specified above (least compelling reason and first two take priority)
Home Blood Pressure Monitoring via RN Care Management (continued)AND If the patient has diagnosed hypertension, appears to have a history of consistently taking anti-hypertensive medication (as evidenced by refills); if non-compliance may be due to financial burden, consider patient as meeting criteria and CM will work with patient on medication assistance
Patient is in good standing with the practice: < 2 no shows over the past 12 months or per CM discretion
RPCN grant, no or insufficient insurance coverage, or financial hardship(CM discretion)
Patient has a method (portal, phone, etc.) to report home BP readings *PCP approval required on all patient enrollments (see below)*
Home Blood Pressure Monitoring via RN Care Management (continued)Enroll Patient in Program (RN Care Manager, Patient, Provider)
CM will reference the home BP monitoring eligibility report and bring recommendations to the PCP about program enrollment based on upcoming appointments and who is likely to benefit most (no more than 2 per week or 8 per month during the initial rollout)
Upon agreement of which patients to target, the CM will reach out to the identified patients either by phone or letter to communicate that they may benefit from the program and to mention that it’d be ideal for them to meet with the CM after their next provider visit if they’re interested
On the day of the patient’s next provider visit, the patient will be flagged for Home Blood Pressure Monitoring (HBPM) on the appointments with care opportunities report, which will alert the provider
Provider will mention the program and communicate that they’d like the patient to meet with the CM afterwards
Home Blood Pressure Monitoring via RN Care Management (continued)If agreeable, patient will meet with the CM to complete the following:
• Receive an overview of the program, including a welcome/FYI packet
• Learn about patient responsibilities:» Taking, recording, & reporting accurate home measurement, supported by a CM demo and issuing of tracking log
» Reporting daily per week via chosen method: Morning, afternoon, and evening readings
» Call the practice if the patient is experiencing prolonged elevated readings (per BP readings reference guide “When to Call” section)
Patient will decide if they want to enroll in the program and, if so, sign off on patient “contract” to solidify buy-in (agreeing to responsibilities, including choosing a reporting method) and demonstrate the proper technique for taking a BP reading and documenting findings
Care manager will track via Excel:• Which patients have been issued cuffs
• Whether patients issued cuffs have completed the program or become un-enrolled prior to completion
• Monthly BP control trending of active cohort
At one month post home BP monitoring enrollment, CM & provider discuss:• Whether the patient should continue to report home BP readings
• Whether a follow-up appointment should be sought with a provider or nurse (BP re-check)
• Whether CM patient re-education on any topic seems prudent if ongoing participation is the aim
3 Major Enablers for Better BP Control
Primary Care Provider Performance Improvement
Champions Program
“Patient-Centered Medical Home” Primary Care Dashboard &
Care Opportunities Report
National Committee for Quality Assurance Patient-
Centered Medical Home (NCQA PCMH) Recognition
NCQA PCMH Tie-Ins for BP Control Efforts PCMH 1A3 (alternative encounters): prescheduled calls with patients monitoring blood
pressure from home
PCMH 2D3 (patient care team meetings): huddling around care opportunities/pre-visit planning for BP control
PCMH 2D7 (care team training for patient populations): standardized hypertension training for every member of the practice
PCMH 2D 8-9 (scheduled team meetings that involve all roles in QI/PI activities): PI champion-facilitated conversations
PCMH 2D10 (involving patients in quality improvement efforts through teams or advisory councils and to share performance results): can be difficult, but can also be very insightful
NCQA PCMH Tie-Ins for BP Control Efforts (continued) PCMH 3D3 (proactive outreach on chronic care services): Phytel/Televox outreach or
manual method
PCMH 3D4 (patients not recently seen by the practice): outreach after 2 years or no visits
PCMH 3E2 (evidence-based clinical decision support for chronic care): care opportunity reminders, patient data reports, documentation templates and flowsheets
PCMH 4A3 (care management eligibility criteria): uncontrolled hypertension
PCMH 4B (care planning and self-care support): lifestyle goals, treatment goals, barrier identification & intervention, self-management (home monitoring)
NCQA PCMH Tie-Ins for BP Control Efforts (continued) PCMH 4C (medication management)
PCMH 4E 1-5 (support self-care & shared decision making)
PCMH 6A3 (measure chronic care clinical measures): dashboards
PCMH 6A4 (identify disparity in 6A3): stratify Medicaid vs. general population
dashboard performance, for example
PCMH 6D 1-2, & 7 (practices must set goals and take action to improve: 3 clinical
measures, & 1 identified disparity in care): PDSAs or QI worksheets
