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NW PA Data ReviewRobert A. Gabbay, MD, PhDProfessor of Medicine, Penn State College of Medicine
PCMH-A(Patient-Centered Medical Home Assessment)
• Survey designed to help systems and provide practices move toward the PCMH model• Utilized to help teams identify areas for
improvement• A sense of how PCMH like you are
PCMH-A Assessment
• On average, practices reported an increase of +1.8/12 points (15%)• The top 3 most improved categories:• Continuous Team-Based Healing Relationships
(+2.7 points)• Quality Improvement Strategy (+2.6 points)• Organized Embedded Care (+2.4 points)
(All on a scale from 1-12)
HEDIS Goals
90th Percentile of the HEDIS New England or Mid-Atlantic Benchmarks
(whichever was higher)
Steady Denominators = Good!
Baselin
e
June 2012
July 2012
August
2012
Septem
ber 2012
October
2012
November
2012
December
2012
January
2013
Febru
ary 2013
March 2013
April 2013
0
200
400
600
800
1000
1200
Count of DM Patients Ages 18-75NorthWest
Seneca
Warren
Oil Valley
MGC
Semeyn - Brookville
Semeyn - Fair Mount
Average
Excellent Job! Now Part of Planned Care at Every Visit
Baselin
e
June 2012
July 2012
August
2012
Septem
ber 2012
October
2012
November
2012
December
2012
January
2013
Febru
ary 2013
March 2013
April 2013
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% DM Patients Tobacco QueryNorthWest
Seneca
Warren
Oil Valley
MGC
Semeyn - Brookville
Semeyn - Fair Mount
Average
Goal
Mean Change in Abs %: Increased +12.0% (statistically significant)
Baselin
e
June 2012
July 2012
August
2012
Septem
ber 2012
October
2012
November
2012
December
2012
January
2013
Febru
ary 2013
March 2013
April 2013
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% DM Patients with Nephropathy Screening/TreatmentNorthWest
Seneca
Warren
Oil Valley
MGC
Semeyn - Brookville
Semeyn - Fair Mount
Average
Goal
Mean Change in Abs %: Increased +8.1% (statistically significant)
Baselin
e
June 2012
July 2012
August
2012
Septem
ber 2012
October
2012
November
2012
December
2012
January
2013
Febru
ary 2013
March 2013
April 2013
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% DM Patients with Dilated Eye Exam Results DocumentedNorthWest
Seneca
Warren
Oil Valley
MGC
Semeyn - Brookville
Semeyn - Fair Mount
Average
Goal
Mean Change in Abs %: Increased +19.5% (statistically significant)
Baselin
e
June 2012
July 2012
August
2012
Septem
ber 2012
October
2012
November
2012
December
2012
January
2013
Febru
ary 2013
March 2013
April 2013
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% DM Patients with Foot ExamNorthWest
Seneca
Warren
Oil Valley
MGC
Semeyn - Brookville
Semeyn - Fair Mount
Average
Goal
You Are Likely Doing This – How Do We Track It?
Baselin
e
June 2012
July 2012
August
2012
Septem
ber 2012
October
2012
November
2012
December
2012
January
2013
Febru
ary 2013
March 2013
April 2013
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% DM Patients with Self-Management GoalsNorthWest
Seneca
Warren
Oil Valley
MGC
Semeyn - Brookville
Semeyn - Fair Mount
Average
Goal
Improving As Processes of Care Get Implemented
Baselin
e
June 2012
July 2012
August
2012
Septem
ber 2012
October
2012
November
2012
December
2012
January
2013
Febru
ary 2013
March 2013
April 2013
0%
5%
10%
15%
20%
25%
% DM Patients with A1C>9NorthWest
Seneca
Warren
Oil Valley
MGC
Semeyn - Brookville
Semeyn - Fair Mount
Average
Goal
Practices Getting Closer To The HEDIS 90% Goal
Baselin
e
June 2012
July 2012
August
2012
Septem
ber 2012
October
2012
November
2012
December
2012
January
2013
Febru
ary 2013
March 2013
April 2013
0%
10%
20%
30%
40%
50%
60%
70%
80%
% DM Patients with A1C <8NorthWest
Seneca
Warren
Oil Valley
MGC
Semeyn - Brookville
Semeyn - Fair Mount
Average
Goal
Many Practices Close To The HEDIS 90% Goal
Baselin
e
June 2012
July 2012
August
2012
Septem
ber 2012
October
2012
November
2012
December
2012
January
2013
Febru
ary 2013
March 2013
April 2013
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% DM Patients with BP <140/90NorthWest
Seneca
Warren
Oil Valley
MGC
Semeyn - Brookville
Semeyn - Fair Mount
Average
Goal
Getting Closer to Goal – More Work To Do
Baselin
e
June 2012
July 2012
August
2012
Septem
ber 2012
October
2012
November
2012
December
2012
January
2013
Febru
ary 2013
March 2013
April 2013
0%
10%
20%
30%
40%
50%
60%
70%
% DM Patients with LDL <100NorthWest
Seneca
Warren
Oil Valley
MGC
Semeyn - Brookville
Semeyn - Fair Mount
Average
Goal
Great Work… But More To Do!
• All of this was accomplished WITHOUT extra money• Planned care at every visit• Reaching out to high risk• Self-management support• Working as a team• MEETING AS A TEAM
Why We Have Done This• Each A1C point drop:• Eye disease risk reduced by 76%• Kidney disease risk is reduced by 50%• Nerve disease risk is reduced by 60%• Any cardiovascular disease event risk is reduced by 42%• Stroke by 57%
• Better screening nephropathy, feet and eyes reduces ESRD, amputations, and blindness.
In your population of 4,000 diabetes patients – this is huge!