Download high scalability focus - American Academy of Pediatrics

Improving Asthma Care in Cincinnati:
The Journey
Stephen Pleatman, MD
Pediatrician, Suburban Pediatric Associates, Inc.
Board Member, Ohio Valley Primary Care Associates, L.L.C.
Cincinnati, Ohio
Keith Mandel, MD
Vice President of Medical Affairs, Physician-Hospital Organization
Cincinnati Children’s Hospital Medical Center
2009 Annual Meeting & Fall Pediatric Update
Alabama AAP Chapter
September 19, 2009
Objectives
• To describe the Physician-Hospital Organization (PHO) at
Cincinnati Children’s.
• To review overall objectives and key interventions of
asthma improvement initiative.
• To review impact of interventions on asthma process and
outcome measures.
• To review key learnings from large-scale improvement
efforts.
• To discuss improvement journey from the practice
perspective.
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved
PHO Background
• Cincinnati Children’s launched the PHO in 1996.
• Strategic objectives:
– Extend efforts to improve effectiveness and efficiency of care
beyond the hospital setting.
– Strengthen improvement knowledge/capability within primary care
practices, thus enhancing sustainability.
– Spread successful improvement models/interventions among
primary care practices, within and beyond the PHO.
– Communicate measurable improvements to payors and employers.
– Support the business case for quality improvement.
– Focus on “triple aim”: patient, population, costs.
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved
PHO Background
(cont’d)
• 3 constituents:
– Cincinnati Children’s Hospital.
– Specialists: 500 (majority employed).
– Primary care physicians: 150 (across 39 practices).
• Independent practice association; 39 primary care practices in 8
county primary service area (only 1 practice is owned by
CCHMC).
• 200,000 patients age 0-21 yrs. (Cincinnati MSA: 500,000).
• Separate board with strong physician leadership.
• Practices vary in size from one to 12 physicians.
• 30% of practices contract with hospital-owned billing company.
• 20% of practices have an EMR.
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved
PHO: Background/Structure
Primary Care Practices (IPA)
PHO QI Focus
PHO QI Focus
39 pediatric
practices
Effectiveness/
efficiency
40% of regional
pediatric population
Effectiveness/
efficiency
12,500 asthma
patients
Specialists
Hospital
CCHMC QI Focus
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved
“Success” = PHO Network-Level
Improvement of Outcome Measures
(the “Big Dots”)
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved
Conceptual Model for Moving the “Big Dots”
Reinforces Sustainability
Highly engaged
leadership group
+
Highly scalable
Moves the
interventions
“big dots”
Network-level incentive
Enabling Factors
Transparent, comparative data
(catalysts)
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved
PHO Asthma Improvement Initiative
(Launched October 2003)
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved
PHO Asthma Initiative: Key Driver Diagram
KEY DRIVERS/INTERVENTIONS
(high scalability focus)
AIM
To improve evidence-based care for
12,500 children with asthma across
39 primary care practices (40% of
regional pediatric population), with
at least 90% of all-payor asthma
population receiving “perfect care”
(composite measure), thus reducing
asthma-related ED/urgent care visits,
admissions, acute office visits,
missed school days, missed work
days, and activity limitation; and,
improving parent/patient confidence
and degree of asthma control
AIM
To strengthen improvement
knowledge/capability within
primary care practices, thus
enhancing sustainability of current
and future improvement efforts
Physician leadership at Board and practice level
Network-level goal setting by Board (network-level performance
defines success)
Measurable practice participation expectations/requirements (linked
to ABP-MOC approval)
Multidisciplinary practice quality improvement teams
Web-based registry, with all-payor population
identification/reconfirmation
Real-time patient, practice, and network-level data/reporting
Transparent, comparative practice data on process and outcome
measures
Concurrent data collection/use of decision support tool, based on
high reliability principles/workflow changes
Aligning P4P/incentive design with improvement objectives
Key components of evidence-based care (“perfect care”)
Population segmentation, with focus on “high-risk” cohort
Cross-practice communication/shared learning to spread successful
interventions
Integration of multiple administrative/electronic data sources
(hospital, practice, payor)
Network and practice-level sustainability plans
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved
Impact on PHO “Big Dots”
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved
Results: Process Measures
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved
Network Performance: Process Measures
(as of September 8, 2009)
Population-Based Measures
(Network all-payor asthma population = 12,500)
PHO
Literature
% of asthma population with flu shot:
2008-2009 flu season
2007-2008 flu season
2006-2007 flu season (delayed vaccine delivery)
2005-2006 flu season
2004-2005 flu season
2003-2004 flu season (baseline)
66%
60%
54%
62%
40%
22%
% of asthma population with management plan
93%
50%
% of population with “persistent” asthma on controller
medication*
96%
70%
% of asthma population with severity classified
95%
50%
% of asthma population receiving “perfect care”**
92%
not available
10-40%
* “Persistent” asthma defined per NHLBI severity classification criteria.
** “Perfect care”: composite measure of severity classification, written management plan, and
controller medications (if patient has “persistent” asthma)
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved
Results: Outcome Measures
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved
PHO vs. Comparison Group
Asthma Admissions: Pre/Post Impact
Asthma Admissions/10K
Asthma Admissions/10K
14
12
56%
10
8
PHO
6
Comparison Group
4
36%
2
0
Baseline
Post
Commercial insurance only
Baseline: 3 year average (10/1/00-9/30/03)
Post: 2 year average (10/1/06-9/30/08)
CCHMC encounters only
Patients ≥ 2 yrs. of age
8 county primary service area
ICD-9 code of 493.xx in primary position
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved
PHO vs. Comparison Group
Asthma ED/Urgent Care Visits: Pre/Post Impact
Asthma ED/Urgent Care Visits/1K
Asthma ED/Urgent Care Visits/1K
4
3.5
55%
3
2.5
PHO
2
Comparison Group
1.5
1
9%
0.5
0
Baseline
Post
Commercial insurance only
CCHMC encounters only
Baseline: 3 year average (10/1/00-9/30/03)
Post: 2 year average (10/1/06-9/30/08)
Patients ≥ 2 yrs. of age
8 county primary service area
ICD-9 code of 493.xx in primary position
ED/urgent care visits not tied to admissions
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved
PHO Network: Asthma Outcome Measures
Baseline
8/04 - 7/05
Current
8/08 - 7/09
% parents missing ≥ 2 work days due to child's asthma over
prior 6 months
18.0%
10.2%
43%
↓
% parents rating confidence in managing child's asthma < 7/10
11.1%
6.7%
40%
↓
% asthma population missing ≥ 2 school days due to asthma
over prior 6 months
26.5%
17.1%
35%
↓
% activity limitation reported as “not at all” or “a little of the
time”
% receiving oral steroids within prior 12 months
% parents rating asthma as “well” or “completely” controlled
% physicians rating asthma as “well” or “completely” controlled
%∆
89.7%
Not captured
as these
questions
were initiated
in 6/06
% parent and physician agreement on rating degree of asthma
control
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved
19.4%
89.6%
90.0%
89.9%
n/a
Asthma Decision Support/
Data Collection Tool
(primary focus: degree of asthma control)
(available at www.tristatepho.org)
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved
Web-Based Registry
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved
Asthma Pay-for-Performance
(P4P) Program
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved
Archives of Pediatrics and
Adolescent Medicine, July 2007
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved
American Board of Pediatrics:
Maintenance of Certification
ABP-MOC Criteria
Practice-level: (sign-off by IPA
Physician-level: (sign-off by practice
•
80% of asthma registry population
with data collection form
completed on annual basis.
•
Completing data
collection/decision support tool at
time of patient visit.
•
90% of asthma registry population
receiving “perfect care”
(composite measure of severity
classification, written management
plan, and controller medication (if
patient has “persistent” asthma)).
•
Reviewing patient-level data (e.g.,
“high-risk” report, visit planner).
•
Reviewing practice-level
performance on process and
outcome measures, via
data/erports posted on web-based
registry.
•
Attending at least 4 in-practice
meetings on asthma initiative
since project inception. (required
by ABP)
Board Chair)
•
Asthma registry population
denominator re-confirmed on
annual basis by reviewing hospital
and practice billing data.
•
Sustaining multidisciplinary quality
improvement team (physician,
nurse/medical assistant, office
manager).
•
Quality improvement team
representation at network
meetings.
leader)
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved
Large-Scale/Population-Based Improvement:
Lessons Learned from PHO Journey
• Be clear on defining “success”—unit of analysis (practice,
region, state, multi-state); process vs. outcome measures.
• Allocate significant time/energy to establishing/sustaining
highly engaged leadership group.
• Bring key physician leaders to the table with quality
improvement management/operations team.
• Focus on highly scalable interventions.
• Consider network-level incentive as a catalyst to accelerate
engagement/improvement.
• Allocate significant resources to establishing/sustaining
highly reliable data collection systems within practices, and
to integrating administrative/electronic data sources.
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved
In Summary……
Population identification/registry creation
+
Reliability
+
“Real-time”/transparent/actionable data
+
Segmenting population
+
Board/practice-level leadership
+
Communication/collaboration among practices
+
P4P
+
Highly-scalable interventions
+
Intense focus on sustainability
=
Builds improvement capability and accelerates improvement
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved
Practice Perspective
Urgency for Change
• Parental perceptions of variation in care.
• Adoption of medical advances in asthma care.
• Population identification and severity classification.
• Data collection made knowledge gaps visible.
• Documenting quality.
• Earning P4P reward.
• Transparency of comparative practice data.
Challenges
• “Our practice is already busy enough.”
• “There’s no additional pay for the extra work.”
• “We’re already doing a good job.”
• “I already have my way of doing things—it’s ok if others want to go
down this path.”
• Sensitivity to measuring quality of care among physicians.
• Reluctance to “standardize” practice around evidence-based care.
• “Research project.”
• “Not sure initiative will improve care.”
• Communication within practice.
Getting Started
Pre-existing focus on asthma population.
Recruiting practice commitment—connected with inherent
desire to “do the right thing.”
Leadership.
Committed quality team.
Defining key roles.
Communication, communication, communication.
“Realistic” decision support/data collection tool.
Executing the Work
Developing the data collection tool
Mapping our process to build a foundation of highly reliable
data collection
October, 2003
Asthma Patient Data Collection Form
How severe is patient’s asthma? (circle appropriate level)
SEVERE
PERSISTENT
---------------------------------
MODERATE
PERSISTENT
---------------------------------
MILD
PERSISTENT
---------------------------------
MILD
INTERMITTENT
---------------------------------
Days
Continual (more than 1
episode/day)
Days
Daily (1 episode/day)
Days
3-6 days/week but, not
every day
Days
0-2 days/week
OR
OR
OR
OR
Nights
Frequent
Nights
5 or more nights/month
Nights
3-4 nights/month
Nights
0-2 nights/month
Typical asthma symptoms:
cough, shortness of breath, wheezing, chest tightness, waking at night, decreased ability to perform usual activities
Is patient on controller medication?
(circle yes or no; if yes, circle one or more medications listed below, as applicable)
Yes
inhaled steroid
long-acting bronchodilator
oral steroid
leukotriene modifier
cromolyn or nedocromil
theophylline
other (please specify) ____________________________________________________________________
No
Was a written asthma management plan provided to family?
(circle one)
Yes
No
Parents should answer the following two questions . . .
Has patient had a flu shot during the 2003-2004 season?
(circle one)
Yes
No
If “No”, please indicate action taken:
________________________________
If patient is 6 years of age or older, how many days of school were missed over
the last three months due to asthma? _________________ (write in number of days)
10 months later…
ASTHMA DATA COLLECTION FORM
Patient Name: _________________________________
Provider Name: _____________________________________
Date of Birth:
_________________________________
Practice Name: _____________________________________
Date of Visit:
_________________________________
Other patient identifier (OFFICE USE ONLY):_________________
Insurance Company: _____________________________
Well Visit
Asthma Sick Visit
Other Sick Visit
PARENTS - PLEASE COMPLETE THE FOLLOWING SECTION:
My child does not
attend school or daycare
1. *How many days of school or daycare has your child missed due
to asthma in the past 6 months?
2. *How many days of work have you or your spouse missed due to your child’s
asthma in the past 6 months?
3. *How many times has your child visited the Emergency Room or Urgent Care
Clinic due to asthma in the past 6 months?
4. *How many times has your child been admitted to the hospital due to asthma in
the past 6 months?
5. *How confident are you in your ability to manage your child’s asthma on a scale of 1-10? (PLEASE CIRCLE)
NOT CONFIDENT = 1
6.
2
3
4
5
6
7
8
9
10 = VERY CONFIDENT
How frequently has your child experienced episodes of cough, shortness of breath, wheezing, chest
tightness, or reduced activity due to asthma during the DAY in the past month? (PLEASE CIRCLE)
More than once per day
Once per day
3-6 days per week, but not every day
0-2 days per week
7. How frequently has your child experienced episodes of cough, shortness of breath, wheezing, chest
tightness, or waking up due to asthma at NIGHT in the past month? (PLEASE CIRCLE)
7 or more nights per month
5-6 nights per month
3-4 nights per month
0-2 nights per month
PHYSICIANS - PLEASE COMPLETE THE FOLLOWING SECTION:
8.
SEVERE
PERSISTENT
9.
Asthma diagnosis tentative
*How would you classify the patient’s asthma severity? (PLEASE CIRCLE ONE)
MODERATE
PERSISTENT
MILD
PERSISTENT
MILD
INTERMITTENT
*Is the patient on controller medication (e.g. inhaled steroid, leukotriene modifier, YES
nedocromil, cromolyn, long-acting bronchodilator)?
NO
10. *Does the family have a written asthma management plan?
YES
NO
UNKNOWN
11. *Is the patient currently followed by a specialist?
YES
NO
UNKNOWN
YES
NO
Name of specialist:__________________________________
12. *If NO, do you plan to refer the patient to a specialist?
Name of specialist:
Please fax to Tri State Child Health Services at (513)636-7540
2 ½ years later…
Reliability
System designed to reduce “missed opportunities” to capture data
from parents/providers and address key issues at point of care
Prior to visit:
– Asthma sticker
placed on chart and
data collection form
inserted.
On arrival:
– Registration staff
asks parent if child
has asthma at
check-in.
– Parent/patient
completes data
collection form while
in waiting area.
Exam room:
– Nurse/medical
assistant reviews
medication list (to
identify asthma
patients) and collects
data when patient
taken to exam room.
– Parent/patient
completes form while
in exam room.
– Physician completes
form while in exam
room.
– “Reminder” built into
EMR.
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved
Before departure:
- Nurse/medical
assistant assures data
collected and issues
addressed; collects
missing data prior to
patient departure.
Beyond typical office
visits:
- Data captured at time of
parent phone call to refill
asthma medications.
- Data captured at
flu shot-only visits.
- Data captured via regular
mailings.
inical Assessment Process Map – Suburban Pediatrics
Office Visit
Patient signs in
Medical Assistant
gives parent
responses on
paper form to
Physician
Medical Assistant
views patient
record in EMR
Physician decision to fill
out form during the visit
EMR alerts
Medical Assistant
if child has a
diagnosis of
asthma
Medical Assistant
gives assessment
form to parent
Parent completes
top half of
assessment form
If time permits,
Medical Assistant
will enter parent
responses into
EMR
Physician entry – preferred method
Physician enters
physician
responses into
EMR during visit
Medical Assistant
reviews
assessment form
and enters parent
responses into
EMR, if needed
Medical Assistant/Asthma Nurse entry – alternate method
Medical Assistant
collects paper
form, forwards to
proper physician
for entry into EMR
Medical Assistant/
Asthma Nurse
assists with form
completion in EMR
Paper forms are
collected and
entered into the
EMR by the
Asthma Nurse
Practice Improvement Capability:
Areas of Focus
• Commitment.
• Leadership.
• Communication.
• Reliability of data collection.
• Data entry.
• Interventions to improve clinical asthma care.
The “Ideal”…..
• Physician, nurse, and practice manager (quality leadership team)
meets regularly to review project status/data/reports, and discuss
improvement opportunities.
• Physician administrative leader visibly supports project and
encourages improvement work.
• Project information/updates discussed with physicians and staff at
regular practice meetings, data/information shared, and
input/feedback recruited.
• Quality leadership team discusses data collection process at regular
intervals and identifies/pursues opportunities to improve reliability.
• Accuracy and timeliness of data entry monitored and addressed.
• Improvement interventions pursued using test of change
methodology.
Using Registry/Data to Drive
Improvement
Dashboard
Process Dashboard (Year End 2008 Results)
Outcomes Dashboard (Year End 2008 Results)
State of Asthma Care
Key Outcome Statistics
Visit
Planner
High Risk Patient List
Utilization Report
Improving Influenza Immunization Rates
Key Learnings
Leadership
Develop quality improvement team
Effective communication
Build consensus within practice
Use disconfirming data to drive improvements and sustain
engagement
Recruit parent involvement/feedback to accelerate
improvement.
Improve “reliability”—build improvement into daily work.
Learn from others—don’t reinvent the wheel.
Impact on Our Practice
• Parents more confident and knowledgeable.
• Nurses report reduced volume of phone calls.
• Positive feedback from families has energized practice and helped
sustain improvement work.
• Clinicians proactively engaging patients and parents in more
meaningful dialogue to improve care vs. more “passive” approach of
the past.
• Data has uncovered issues/gaps not previously identified.
• Discussing how to spread improvement work to other conditions.
• Positioned to win on current/future P4P programs.
• Appreciate value of registry.
• Staff roles/responsibilities revised to sustain improvement efforts.
Copyright © 2006 Cincinnati Children’s Hospital Medical Center; all rights reserved
Patient/Parent and Staff
Perspectives
This is Hard Stuff
This takes lots of work to initiate and sustain.
1
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Thank You!!
Questions?
Contact Information
Stephen Pleatman, MD
Pediatrician, Suburban Pediatric Associates, Inc.
Board Member, Ohio Valley Primary Care Associates, L.L.C.
513-336-6700
[email protected]
Keith Mandel, MD
Vice President of Medical Affairs,
Physician-Hospital Organization
Cincinnati Children’s Hospital Medical Center
513-636-4957
[email protected]