SC 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

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PCMH-A Average Change

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PCMH-A Assessment

• On average, practices reported an average increase of +2.3/12 points (20%)• The top 3 most improved categories:• Empanelment (+3.3 points)• Quality Improvement Strategy (+3.0 points)• Patient Centered Interactions (+2.6 points)

(All on a scale from 1-12)

HEDIS Goals• HEDIS & Quality Measurement Goals• 90th Percentile of the HEDIS New England or Mid-Atlantic

Benchmarks (whichever was higher)• Standardized set of performance measures

• HEDIS goals used for PA SPREAD:• % DM pts A1C >9 – 13.63%• % DM pts A1C <8 – 74.70%• % DM pts BP <140/90 – 76.33%• %DM pts LDL <100 – 58.15%• %DM pts tobacco query – 90%• % DM pts nephrology screening – 92.46%• % DM pts eye exam – 90%• % DM pts foot exam – 90%• %DM pts with self-management goals – 90%• % DM pts with tobacco cessation interventions – 90%

*All criteria for goals based on a 12 month period EXCEPT tobacco query & tobacco cessation intervention which are based on a 24 month period

Steady Denominators = Good!

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Count of DM Patients Ages 18-75SouthCentral

Hamilton

Oyster Point

GIM

Cornerstone

Mountville

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Eastbrook

Silver Creek

Carlisle

Sandrowicz

Average

Excellent Job! Now Part of Planned Care at Every Visit

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% DM Patients Tobacco QuerySouthCentral Hamilton

Oyster Point

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Cornerstone

Mountville

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Silver Creek

Carlisle

Sandrowicz

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Goal

Mean Change in Abs %: Increased +12.0% (statistically significant)

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% DM Patients with Nephropathy Screening/TreatmentSouthCentral

Hamilton

Oyster Point

GIM

Cornerstone

Mountville

Manor

Eastbrook

Silver Creek

Carlisle

Sandrowicz

Average

Goal

*The mean change in percentage points increased +8.1%, making it statistically significant

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% DM Patients with Dilated Eye Exam Results DocumentedSouthCentral

Hamilton

Oyster Point

GIM

Cornerstone

Mountville

Manor

Eastbrook

Silver Creek

Carlisle

Sandrowicz

Average

Goal

Mean Change in Abs %: Increased +8.1% (statistically significant)

*The mean change in percentage points increased +19.5%, making it statistically significant

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% DM Patients with Foot ExamSouthCentral Hamilton

Oyster Point

GIM

Cornerstone

Mountville

Manor

Eastbrook

Silver Creek

Carlisle

Sandrowicz

Average

Goal

Mean Change in Abs %: Increased +19.5% (statistically significant)

You Are Likely Doing This – How Do We Track It?

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% DM Patients with Self-Management GoalsSouthCentral Hamilton

Oyster Point

GIM

Cornerstone

Mountville

Manor

Eastbrook

Silver Creek

Carlisle

Sandrowicz

Average

Goal

Improving As Processes of Care Get Implemented

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0%

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% DM Patients with A1C>9SouthCentral Hamilton

Oyster Point

GIM GIM

Cornerstone

Mountville

Manor

Eastbrook

Silver Creek

Carlisle

Sandrowicz

Average

Goal

Practices Close To The HEDIS 90% Goal

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% DM Patients with A1C<8SouthCentral

Hamilton

Oyster Point

GIM

Cornerstone

Mountville

Manor

Eastbrook

Silver Creek

Carlisle

Sandrowicz

Average

Goal

Many Practices Close To The HEDIS 90% Goal

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% DM Patients with BP <140/90SouthCentral

Hamilton

Oyster Point

GIM

Cornerstone

Mountville

Manor

Eastbrook

Silver Creek

Carlisle

Sandrowicz

Average

Goal

Some Practices at HEDIS 90% Goal, Others – More Work To Do

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0%

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% DM Patients with LDL <100SouthCentral

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Oyster Point

GIM

Cornerstone

Mountville

Manor

Eastbrook

Silver Creek

Carlisle

Sandrowicz

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 over 11,000 diabetes patients – this is huge!