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PCMH: Learning Session Meeting #1
American Academy of Pediatrics – Arkansas ChapterOctober 17, 2014
Objectives• Introductions• SHARE Presentation: Justin Villines, MBA and Janis Bartlett• Overview of PCMH project: Dennis Z. Kuo, MD, MHS
– Primary Care Trends/General Update: Dennis Z. Kuo, MD, MHS– Upcoming Enrollment Metrics: Dennis Z. Kuo, MD, MHS
• Understanding How Data Drives Change: Dennis Z. Kuo, MD, MHS
• PCMH Milestones- Cheryl Arnold, MHSA, FACMPE • Care Plans: Jo Lynne Varner• Medical Neighborhood: Dennis Z. Kuo, MD, MHS• Information on Re-enrollment: Dennis Z. Kuo, MD, MHS• Questions?
Disclosures
• Support provided by Arkansas Medicaid
Introductions
• Arkansas AAP Leadership– Orrin Davis, MD, FAAP- President– Dennis Kuo, MD, MHS, FAAP – Vice-President– Chad Rodgers, MD, FAAP – Secretary– Chris Schluterman, MD, FAAP - Treasurer
• Arkansas AAP staff– Aimee Olinghouse, Executive Director– Kristen Pfeifer, QI specialist
CONNECTING TO SHARE
Arkansas Academy of Pediatrics
Arkansas PCMH
October 17, 2014
Jan Bartlett, Policy Director
Justin Villines, HIT Policy Integrator
Cindy Osment, SHARE Onboarding
Arkansas Office of Health Information Technology
PRESENTATION AGENDA
1. Overview of SHARE
2. How SHARE can help Clinics
3. Provider and Vendor Status
4. Getting started with SHARE
5. SHARE Demo
SHARE OVERVIEW
WHAT IS SHARE?
• Statewide health information exchange (HIE)• Established with Act 891 of 2011, governed by
HIE Council• Funded with public funds and user fees• Infrastructure for providers, labs, pharmacies,
public health, others to share clinical data• Available to any health care entity willing to
follow requirements and pay user fees
Public Health
Payers
Radiology
Centers
Hospitals
Pharmacies
Medicaid
Labs Clinics
Public Health
Payers
Radiology Centers
Hospitals
Pharmacies
Medicaid
Labs Clinics
PATHWAY TO
HEALTH DATA
1. Secure Messaging– Secure, encrypted email exchange
2. Virtual Health Record (VHR) – View patient health data in SHARE securely online– No EMR/EHR needed– Clinical In box for qualified medical professionals
3. Health Information Exchange (HIE)– Integrates with your EMR/EHR system– Send and receive patient health data– View SHARE patient health data online or in EMR/EHR
3 WAYS TO SHARE
3 WAYS TO
SHARE
WHAT DATA CAN BE SHARED?HL-7 Messages, CCDs and Unstructured Documents• Clinical Care Summaries
• Discharge Summaries
• Lab Results
• Radiology Reports
• Medication Histories
• Allergies
• CCDs
• Problem Lists / Diagnoses
• Referrals
• Transcribed Documents
BENEFITS OF USING SHARESave time • Save money •
Improve patient care • Instantly view patient health data from all points of care
• Make better-informed care decisions
• Easily coordinate care with unaffiliated providers
• Reduce administrative costs for gathering health data
• Track acute care events for your patients
• Meaningful Use (MU)
• Patient Centered Medical/Health Home (PCMH)
• Accountable Care Organizations (ACOs)
• Quality Reporting/Monitoring & Measuring Outcomes
SHARE seeks to facilitate meeting collection and data reporting goals for local and national health improvement activities
VALUE OF
SHARE
TRANSITIONS OF CARE
SHARE is a tool for facilitating transitions of care:• Care Coordination and
PCMH– Alerts transmitted through SHARE
between providers and hospitals – Transmission of ED/Inpatient
admits and discharge data
MEANINGFUL USE CRITERIA
Stage 1• Stage 1, Menu
Measure 9: Capability to submit electronic data to immunization registries or immunization information systems
Stage 2• Stage 2, Core
Objective 15: Provide a summary care record for each transition of care or referral where the recipient receives the summary of care record via exchange
• Stage 2, Core Objective 16: Capability to submit electronic data to immunization registries
WHAT’S IN IT FOR CLINICS?
CLINICS AND PCMH
PCMH practices are required to participate in SHARE:• Obtain patient admission/discharge data
from affiliated hospitals• EMR integration is not required until 2015• OHIT is working with AFMC, AAP, and
Qualis to ensure practices are properly connected to SHARE for PCMH compliance
SHARE FOR PCMH
Arkansas Medicaid’s PCMH initiative requires providers join SHARE to receive in patient discharge and transfer information. These “event notifications” will alert the practice of ED and hospital admissions, enhancing coordination of care for follow up visits and reducing the cost of care.*
*See Arkansas Medicaid PCMH Handbook, 240.000 – Metrics & Accountability for Incentive Payments, Measure J.
SHARE FOR PCMHWhen a Patient whose providers are connected to SHARE is admitted to or discharged from the hospital:
Participating SHARE providers receive an instant notification of the patient’s hospital status in the EMR inbox or SHARE’s VHR inbox.
This allows timely follow up and care management.
• Cloud-based
• Web-based user interface
• Functions like traditional email
• Facilitates HISP services
• Provides notifications to 3rd party
email systems
• Alerts when a message is successfully or unsuccessfully processed /sent
System with expanded features
SHARE SECURE MESSAGING
IMMUNIZATIONS REPORTING
Automate Immunizations Reporting through SHARE:• SHARE has built an interface with ADH• Send immunizations data directly to ADH through SHARE • Simplify workflow by reducing duplicate data entry• Immunizations Registry is “Live”• ELR and Syndromic Surveillance are “Live”• No additional cost to SHARE participants
PARTICIPATION UPDATE
WHO
SHARES?28
7
Health care sites participate,
including 27 hospitals with
(15) Live and 260 practices
in 99+ cities. *As October 16, 2014
CONNECTED PARTICIPANTS NOW
INCLUDEHOSPITALS PRACTICES
• Family Medicine Clinic• Family Doctors Clinic• Claude Parrish CHC• Main Street Medical• Marshall Family Practice• Ronald Reese, M.D.• Newton County Family Practice• Andrew Coble – General & Specialty Surgeon• Internal Medicine Diagnostics, Inc.• UAMS Regional Center – Pine Bluff; Fort Smith• Boston Mountain Rural Health Center (7 sites)• East Ark Health Center (5 sites)• Jefferson Comprehensive Care (6 sites)• Lee County Cooperative Clinic (4 sites)• Willow Street Health• NEA Baptist (37 sites)• Fonticiella Medical Center
• NARMC• AR Children’s Hospital• UAMS• JRMC• Ashley County• McGehee Hospital• Bradley County• White River Health System• Ark Methodist Medical Center• Stone County Medical Center• Conway Regional• Conway Regional Rehab Hospital • Howard Memorial • Magnolia Regional Med. Center• Saline Memorial Hospital
CONNECTING PARTICIPANTSHOSPIT
ALSPRACTICES• UAMS Regional Centers (4 sites)
• ARcare (23 sites)• Apache Drive Children’s Clinic• Conway / Greenbrier Children’s Clinic • Conway OB/GYN• Cornerstone Clinic for Women• Little Rock Pediatric Clinic• The Pediatric Clinic, NLR• Ozark Internal Medicine and Pediatrics• Pocahontas Medical Clinic• The Children’s Clinic of Jonesboro• Sager Creek Pediatrics• MANA• North Central Arkansas Medical Associates• Community Physical Group• The Breast Center• Paragould Pediatrics
Plus many more…
• North Metro Medical Center
• Chicot Memorial• Izard County• Pinnacle Point Hospital
CONNECTED PARTICIPANTSBehavioral Health
PRACTICES
• Families Inc. Counseling Services Corporate Office • Baptist Health Behavioral Service Community • Counseling Services Inc Cornerstone Community
Counseling • Delta Counseling Associates • Centers For Youth And Families• Life Strategies Counseling Inc (Little Rock) • Life Strategies Counseling Inc (Osceola) • Life Strategies Counseling Inc (Paragould) • Life Strategies Counseling Inc (Piggott) • Life Strategies Counseling Inc (Trumann) • Life Strategies Counseling Inc(Jonesboro) • Life Strategies Counseling Inc • Perspectives Behavioral Health Ma Corp • Counseling & Education Center Inc. • Psychiatric Associates of AR PLLC • Mid-South Health Systems
• Plus many more…
• AR Psychiatric Clinic PA• Behavior Management Systems Inc.
Center For Individual &Family Community Service Inc
• Cooper Clinic – Ozark• Dayspring Behavioral Health• Ascent Children's Health Services Youth
Home Inc.• Outpatient Clinic Southwest AR
Counseling Arkansas• Behavioral Healthcare Counseling
Services Of Eastern AR - Forrest City• Family Psychological Center Health
Resources of AR Hometown Behavioral Health Services Hope Behavioral
• Healthcare Jerry Blaylock MD
Behavioral Health PRACTICES
More than
893,596 patients participate
in SHARE
Help for Providers
Negotiating statewide contracts with EHR vendors THAT:1. Reduce or waive one-time
vendor interface fees to connect to SHARE
2. Shorten the implementation timeline
STATEWIDE AGREEMENTS
SHARE is helping the provider community by:
BASIC PRICING FOR PRACTICES
SHARE Fees Estimated Cost
One-Time Setup Fee Waived
Unlimited VHR and SM (for paper EMR and/or Non Interfaced System practices)
$50 per month
Interfaced System with One VHR Primary Clinical User and Clinical SM
$50 per month
Interfaced System with Unlimited VHR Primary Clinical Users and SM
$75 per month
EMR/EHR Vendor Fees Estimated Cost
One-time Fee Varies per vendor
Monthly or Annual Fees Varies per vendor
HOW TO JOIN SHARE
ONLINE OR BY PHONE
Register online at SHAREarkansas.com
OR
Call 501.410.1999
Thank you! Questions?
Now the
DEMO!
Patient-Centered Medical HomeOverview
.
Arkansas Medicaid PCMH• PCMH: “team-based care delivery model led by PCPs
who comprehensively manage patients’ health needs with an emphasis on health care value”
• Goals– Encourage population health management (all children,
regardless of whether they are coming in or not)– Align financial incentives with good preventive care– Supports primary care physicians as key partners
Terms
• Practice transformation: “adoption, implementation, and maintenance of approaches, activities, capabilities and tools” to encourage team-based care and population management– It’s all about the population management– And being proactive with patient care
• Care coordination: “ongoing work of engaging beneficiaries and organizing their care needs across providers and care settings”– This is particularly valuable for children with disabilities and special
health care needs – i.e. the high resource utilizers
Pediatric Practices
• 47 practices enrolled• Arkansas AAP is assisting 15 practices
– Monthly webinars– Weekly contacts– Listserv– Personal discussions– Review of reports
Completion of activity and timing of reporting
Commit to PCMHMonth 0-3
Start your journeyMonth 6
Evolve your proce-ssesMonth 12Activity
Month 16-18 Month 24
▪ Identify office lead(s) for both care coordination and practice transformation1
1
▪ Assess operations of practice and opportunities to improve (internal to PCMH)
2
▪ Develop strategy to implement care coordination and practice transformation improvements
3
▪ Identify top 10% of high-priority patients (including BH clients)2
4
▪ Identify and address medical neighborhood barriers to coordinated care (including BH professionals and facilities)
5
▪ Provide 24/7 access to care6▪ Document approach to expanding access
to same-day appointments7
▪ Document approach to contacting patients who have not received preventive care
9
▪ Document investment in healthcare technology or tools that support practice transformation
10
▪ Join SHARE to get inpatient discharge information from hospitals
11
▪ Incorporate e-prescribing into practice workflows312
▪ Integrate EHR into practice workflows13
Continue to innovate
Activities
▪ Complete a short survey related to patients’ ability to receive timely care, appointments, and information from specialists (including BH specialists)
8
1 - At enrollment; 2 - Three months after the start of each performance period; 3 - At 18 months
Well?
• HOW’S IT GOING????
Bodenheimer, Ann Fam Med 2014
Best practices for transformation
• Culture of QI – develop formalized team process and dedicate time
• Family-centered care – recruit and utilize parent partners to motivate and visualize
• Team-based care – play to everyone’s strengths, collaborate
• Care coordination –develop care plans, dedicate time and staff, collaborate to develop patient-centered goals
McAllister et al. Ann Fam Med 2013
Successes• Looking more closely at/tracking specific information (like
24/7 access) helped to provide consistency within offices.• Tracking patients better to see when they need WCCs, PFTs,
etc.• Hired additional nursing positions/PCMH Care
Coordinators.• Monitoring PFSH components filled out by MD on first visit
with new patients.• Adding EMR software.• Better chart documentation by the physicians.• Opening of walk-in clinic model allowing immediate access
Challenges
• Lag in data• Time (webinars & care plans and audits, oh my! ;)• Inconsistencies with what qualifies as meeting metrics
(often based on subjective judgment of reporting form answers)
• Not having resources to track down patients/get them scheduled
• Some [consultants] more helpful than others• Medicaid enhanced payment set to expire at the end
of 2015 (unless reauthorized)
National trends in primary care
• Reminder: ACA – test innovative payment methods
• Projects that focus on children with medical complexity– High value proposition– Co-management
• Payments may be increasingly tied to adoption of EHR, data, and care plans
What’s ahead in 2015?
• Enroll by 11/17/14• Practices may pool with any number of PCMHs
to form a shared savings entity– Statewide pool also an option
• Beneficiary level data available– Cost data: Q4 2014– Metric data: Q1 2015
What’s ahead in 2015?
• Shared savings – likely to be determined by Q2 2015
• Possible changes in targets– Process metrics may all rise a little– Shared savings – a few will rise
• ADHD, Asthma, adolescent wellness visits
• Considering demonstration of extracting data from EHR
Also-
• Enrollment/Re-enrollment opportunity available here today and at the Pediatric Forum held at ACH tomorrow October 18th 2014
• Please see Kristen for more details.
Questions?
• .
Understanding How Data Drives Change: Dennis Z. Kuo, MD, MHS
Data
• Objective measure of performance– Patient– Physician– Practice (or care team)
• Sources– Payer– EMR– Manual review of chart– Measure patient experience
Data, continued
• Use of data for quality improvement– Set targets– Understand if variation
• Time• Between provider
• Understand performance• Communicate findings• Identify areas for improvement
Concept: Model for Improvement
• What are we trying to accomplish?• How do we know that a change is an
improvement?• What change can we make that will result in
an improvement?
Model for Improvement
• What are we trying to accomplish?– Increase the number of children who have their teeth
brushed• How do we know that a change is an improvement?
– Measurable change• What change can we make that will result in an
improvement?– Know your system– Develop SMART Objectives– Plan-Do-Study-Act cycles
Where does data come in?
• Data drives change– Establish where you are now– Establish your target– Tells you if you are making an improvement
• Data can be very complicated or very simple• You need some sort of objective measure
WHY DATA?
• Essential building block for high-performing primary care
• Measure progress• Understand successes and areas for
improvement• Communicate findings to others
What constitutes data?
• Count data – a raw number• Proportions
– Numerator – the number of children for whom the intervention was successful
– Denominator – the total number of children being measured
• Understand the numerator and denominator
Displaying results
• Run chart– Very simple– Very powerful
• Over time
4071442114
5051451914
6021461614
6301471414
7281481114
8251490814
922140%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Median; 34%
Median; 48%
Target
10 daysMedianTarget
1st UnitSecretaries Trained6/10/14
Last Unit Secretaries Trained 9/10/14
% Hospitalized patients discharged and seen within ten days
UpIs
Best
Cards printed for distribution
Hospitalists review data
What about our data reports?
• Learn from them• Shortcomings
– Delay means they do not provide immediate feedback
– Rolling 12 month averages absorb outliers but mean that recent changes will not be reflected
Know your data reports
• Medicaid Q3 data reporting up to March 31, 2014– Dependent on claims– Data cleaning
• Patient-level data– Discussion about making data available on request
• Cost in Q4 2014; Metrics in Q1 2015• Discuss with HP service desk
• Need to produce your own data
PCMH Milestones/Audit: Cheryl Arnold, MHSA, FACMPE
PCMH AuditAFMC
Central Arkansas Pediatric Clinic PA
Cheryl Arnold, MHSA, FACMPE
AAP: Learning Session & Pediatric Forum, October 17, 201467
Pilot Audit with AFMC
Friday, August 29
On-Site Visit: 2 AFMC representatives
Interview
Review of Assessment
Review of Documentation
Take-Aways
AAP: Learning Session & Pediatric Forum, October 17, 201468
Interview
Informal discussion of activities that CAPC has completed or has in process.
“What we are doing” -- daily basis, especially pertaining to HPBs
AAP: Learning Session & Pediatric Forum, October 17, 201469
Review of Documentation
Completed Assessment
Documented Strategies for Practice Transformation & processes for implementation
Timeline for Practice Transformation Implementation
AAP: Learning Session & Pediatric Forum, October 17, 201470
Review of Documentation
Documented Strategies for Care Coordination & processes for implementation
Timeline for Care Coordination Priorities Implementation
AAP: Learning Session & Pediatric Forum, October 17, 201471
Review of Documentation
Documented Barriers to Care
Documented Approaches to Coordinated Care
AAP: Learning Session & Pediatric Forum, October 17, 201472
Proof of Patient Communication for After-Hours Access
Website
Phone Message
Posted on Public Entries
AAP: Learning Session & Pediatric Forum, October 17, 201473
Same Day Appointment Access
Reviewed written process
Reviewed actual schedule – historic and future
AAP: Learning Session & Pediatric Forum, October 17, 201474
Take Aways --
They thought I was doing better than I did!!!
Document everything you are doing!
Rapid Cycle/ Small Change Process for evaluating and continuing to improve (informal).
Medical Neighborhood and Care Plans: Dennis Z. Kuo, MD, MHS
The Chronic Care Model
From Wagner EH. Figure from Antonelli R (2005). Adapted from Bodenheimer (2002)
Medical complexity
• High value proposition– Small # -> High dollars– Reduce preventable ER and inpatient visits– Increase outpatient management?
• Adult models– Identification based on frequent encounters/high
resource use– Intensive outpatient case management
Allocation of Spending Across Groups
Spending Group
Per
cen
tag
e o
f T
ota
l Sp
end
ing
in E
ach
Gro
up
Least 80% Next 15% Next 4% Top 1%0
20
40
60
80
Emergency Care
Hospital Care
Pharmacy CareOutpatient/community Care
Kuo et al. Pediatric Academic Societies abstract, 2014
Outpatient Spending Across Groups
Spending Group
Rel
ativ
e D
iffer
ence
in S
pen
din
gC
om
par
ed w
ith
th
e L
east
80%
Gro
up
Least 80% Next 15% Next 4% Top 1%0
25
50
75
100
125
PharmacySpecialty Care
Primary Care
Kuo et al. Pediatric Academic Societies abstract, 2014
Providing medical homes for children with complex/chronic care needs
• Population management– Primary care may be underutilized– How much investment in additional primary care
would result in a return on that investment?• What are the mutable (i.e. preventable) costs?
– May not get a big “signal” of excessive costs– Need to identify children at risk up front– Proactive management in outpatient setting
• What are the desirable outcomes?
But wait…there’s more
• “New morbidity”• Psychosocial needs also drive health care use
and needs• Care plan can potentially tie all of this
together
Care mapping
• A comprehensive snapshot of all of a family’s needs
• Useful to illustrate the BIG PICTURE and what families face
• Think about broad categories and then fill in the individual providers
• Start with the child and family in the middle
Case
• 1 year old, CHARGE syndrome• Thymus transplant, immunocompromised• Dysphagia, G tube dependent• Bilateral colobomas• Choanal atresia
• ….think about the number of specialists she needs to see, the services she needs and what her family is facing
Care Plans: Jo Lynne Varner
Care plan
• Documentation of Chief Complaint/Current Problems• Plan of care integrating contributions from health care team
(including behavioral health professionals) and from the beneficiary– Problem based detail of plan of care occurring twice during a 12
month time frame
• Instructions for follow-up– Documentation supporting instructions for follow-up
• Assessment of progress to date– Clear documentation identifying the course of a specific problem and
the status
BONUS VIDEO
• W. E. Deming Red Bead Experiment• http://www.youtube.com/watch?
v=ckBfbvOXDvU
Information on Re-enrollment: Dennis Z. Kuo, MD, MHS
Re-Enrollment Reminder• Enrollment is September 1 through November
17th, 2014 • Current PCMH practices are REQUIRED to re-
enroll.• Please make sure all of your participating
physicians information is up-to-date, if you have new contact leads its important that you update this on the new RE-enrollment forms that will be submitted to HP
New in 2015
• Practices may pool with any number of practices to determine a shared savings entity (5,000 patients)
• Otherwise, statewide pool for shared savings– For those looking for pooling partners, several resources
are available: • List of enrolled PCMH names and locations on the APII
website: http://www.paymentinitiative.org/medicalHomes/Pages/Useful-Links.aspx
• AFMC provider reps
ARKANSAS MEDICAID PATIENT-CENTERED MEDICAL HOME PROGRAM PRACTICE RE-ENROLLMENT AGREEMENT
September 21, 2014 Dear Arkansas Medicaid Provider: Arkansas Medicaid is updating information for current PCMH Providers. Please complete, sign, and return this form to Arkansas Medicaid by email at [email protected] or fax at 501-374-0549. The form must be returned with updated contacts even if there are no changes to your information. Please return this form and any changes attached by 11/17/2014. PCMH ID: <Provider/Group Name, Provider Number>
I wish to stay enrolled as a PCMH Provider with Arkansas Medicaid and have no changes to my current information as shown on the list provided.
I wish to stay enrolled as a PCMH Provider with Arkansas Medicaid, have updates
to my enrollment information, and have completed the remainder of this form. By signing below, the practice, __________________________, hereby agrees to remain enrolled in the PCMH program and agrees to provide the necessary information to update their participation information: _______________________ ______________________ _________________ Authorized Practice Representative Medicaid Billing ID Number Date Your practice lead will be the primary contact for the PCMH program. All notifications will be sent to the information provided below.
Primary Contact Secondary Contact
Name: __________________________ Name: ____________________________
Phone: __________________________ Phone: ____________________________
Email: __________________________ Email: ____________________________
PCMH PRACTICE UPDATE/CHANGE REQUEST FORM ADD PHYSICIANS Please list the required information for the physicians you want to enroll under your practice: NOTE: Please add the date of the recently joined physicians below to be added to your PCMH. 1. Physician Name: ______________________________________
Individual Medicaid Provider ID: ______________________________________
NPI: ______________________________________
Date joined: ______________________________________
Signature: ______________________________________
2. Physician Name: ______________________________________
Individual Medicaid Provider ID: ______________________________________
NPI: ______________________________________
Date joined: ______________________________________
Signature: ______________________________________
3. Physician Name: ______________________________________
Individual Medicaid Provider ID: ______________________________________
NPI: ______________________________________
Date joined: ______________________________________
Signature: ______________________________________ 4. Physician Name: ______________________________________
Individual Medicaid Provider ID: ______________________________________
NPI: ______________________________________
Date joined: ______________________________________
Signature: ______________________________________ 5. Physician Name: ______________________________________
WITHDRAW PHYSICIANS Please list the required information for the physicians you want to withdraw from your practice: NOTE: Please remove only physicians who have recently left your practice, and include the date the
physician left.
1. Physician Name: ______________________________________
Individual Medicaid Provider ID: ______________________________________
NPI: ______________________________________
Date left: ______________________________________
2. Physician Name: ______________________________________
Individual Medicaid Provider ID: ______________________________________
NPI: ______________________________________
Date left: ______________________________________
3. Physician Name: ______________________________________
Individual Medicaid Provider ID: ______________________________________
NPI: ______________________________________
Date left: ______________________________________
4. Physician Name: ______________________________________
Individual Medicaid Provider ID: ______________________________________
NPI: ______________________________________
Date left: ______________________________________
PARTICIPATING PHYSICIANS PCMH ID: <Provider/Group Name, Provider Number> We have provided a list of the physicians currently enrolled in your practice. Please reference this when updating your status. <Insert Excel Table Here>