Practice Innovation Institute Update 2018 Health Current Summit & Trade Show December 4, 2018
Practice Innovation Institute (Pii) Pii is…. • Arizona’s Practice Transformation Network (PTN) – a collaboration among Health Current and Mercy Care – funded under the national CMS Transforming Clinical Practice Initiative (TCPI) 2
Pii Team Executive Sponsors Clinical Faculty Advisors PTN Director Directors Data/Analytics Practice Transformation Consultants HIE Account Management Finance Coordinators Policy Training 3
In one word, Pii is UNIQUE Crisis services, Specialty Corrections Integrated Practices Health Homes Statewide Health FQHC’s Information Exchange Outpatient Behavioral Mercy Care Health Pediatric Pii Equality Clinically Health Integrated Network Network 4
AIMs/Goals: Primary & Secondary Drivers 5
Progress Towards Commitments – Results as of the end of Year 3 AIM 1 – Commitment – 2,587 Enrolled Enrollment 2,500 Clinicians 100% AIM 2 – Commitment – 17,368 improved Improve Health 19,032 91% Outcomes improved AIM 3 - Commitment - 50,036 avoided Reduce Unnecessary 65,881 avoided 76% Hospital Use Hospitalizations Commitment – AIM 4 – $124,765,344 saved $81,549,090 Reduce Costs 153% saved AIM 5 – Commitment – 3,801 reduction Reduce Unnecessary 2,737 reduction 139% Tests & Procedures
Progress Towards Commitments – Results as of the end of Year 3 Enrollment 100% 80% Reduction in Test 60% Transformation & Proc 40% 20% 0% Cost Savings Clinical Outcomes Reduction in TCPI Pii Hospitalizations
5 Phases of Transformation 8
Pii Practices That Have Completed the 5 Phases of Transformation • A New Leaf • Arizona’s Children’s Association • Bayless Integrated Healthcare • Biltmore Ear Nose & Throat • ConnectionsAZ • Crazy About Kids Pulmonary Services • Crisis Preparation and Recovery • GB Family Care 9
Pii Practices That Have Completed the 5 Phases of Transformation • Horizon Health And Wellness • Jewish Family & Children’s Service • LaFrontera EMPACT • Maricopa County Correctional Health Services • Mountain Park Health Center • Native Health • Neuromuscular Clinic and Research Center • North Country Healthcare • Open Hearts Family Wellness 10
Pii Practices That Have Completed the 5 Phases of Transformation • OrthoArizona • Pendleton Pediatrics • Phoenix Children’s Medical Group • Pulmonary Consultants • Relieve Allergy Asthma & Hives 11
LESSONS LEARNED 12
The Importance of Patient & Family Engagement Inclusion of the Use of e- Measurement of patient voice in technology to patient health practice engage patients & literacy operations family Assessment to Shared decision- gauge patient Support for making among readiness to be patient clinicians & “activated” as a medication use patients partner in their care 13
The Importance of Patient & Family Engagement TCPI PFE Metrics Point of • Does the practice use an e-tool that is accessible to both patients and clinicians and that shares information? Care • Does the practice support shared decision-making? • Does the practice utilize a tool to assess and measure patient activation? Policy & • Does the practice utilize a tool to assess and measure health Procedure literacy? • Does the practice promote patient-centric medication management practices? • Does the practice have policies, procedures, and actions to support Governance patient and family participants in governance or operational decision-making? 14
The Importance of Patient & Family Engagement • Beyond the Metrics – Measure & Monitor • Capture current and emerging efforts • Enhance existing practice and expand efforts – Evaluate for Best Practice(s) • Implementation, Change Management • Most effectual evidence-based interventions/tools in practice – Scale & Replicate – Build off successful, exemplified implementation practices – Prioritize evidence-based practices with greatest impact
The Importance of Patient & Family Engagement • Connecting the Dots – Using technology to build patient registries – Linking clinic and community initiatives to data drive quality improvement projects – Using patient centered design techniques for improvement – Patient and Family Advisory councils Engagement of Patient and Family is highlighted in each transformation plan 16
Importance of HIT Tools HIT Platform Services & Applications Data Sources Used by Used by clinicians other staff • • Population Health & Claims from CareQuotient Analytics health plan • Predictive Analytics • Benchmarking • Risk Stratification • • Care Unify Care Management Claims from • Care Pathways health plan • • Risk Stratification HIE ADTs • Patient Panels • Alerts & Notifications • • Alerts Providers, via Health Current • Clinical data aggregation direct Health • Clinical data repository connection Information • Direct secure e-mail Exchange (HIE) • Provider Portal (query & response) • Newly implemented High 17 Risk Member Report
Importance of HIT Tools • Health Current (HIE) - Over 55 Pii organizations are connected with the HIE either receiving alerts, accessing provider portal and/or sharing data – Alerts have notified clinicians of ED visits and discharges in order to coordinate appropriate follow-up care – Connectivity has provided clinicians with patient history information to help reduce unnecessary testing and admissions Access to real time information and alerts in order to facilitate care and care coordination 18
Importance of HIT Tools • Population Health Management – CareQuotient – Implemented at 14 Pii Organizations • Utilizes Mercy Care claims data • Provides data on key measures for health plan paneled patients – HIE High Risk Report • Utilizes HIE data Identification of • Scores patients on factors high risk patients is (ED utilization, IP stays, A1c, critical to patient and radiology) care management 19
Importance of Targeted Approaches • Practices are deploying targeted approaches – Opioid Management – Diabetes Control – Joy in the Workplace – Breaking down barriers • Optimizing use of PDSA lifecycle • Education on management protocols 20
Tackling the Opioid Epidemic • Education – Arizona Opioid Epidemic Act signed the into law by Governor Ducey on January 26, 2018 – Provision of one-on-one technical assistance – Collaborative educational sessions ongoing • Care Coordination – Intensive care coordination – Development and implementation of Medical Neighborhoods – Leadership Engagement – Adoption of data-driven quality improvement methodology for practice transformation • Use of HIT Tools – Use of CareQuotient • 2 HEDIS measures for tracking/monitoring created in CareQuotient – PDMP 21
Success Story – Opioid Management St. Elizabeth’s Health Center • Medical Director (Dr. Mark Schildt) took on role of champion to address opioid epidemic within the organization • Revised policies & procedures • Identified at-risk population – Relationships developed – Proper referrals to behavioral health and/or MAT provider utilized – Utilization of PMP for monitoring Evaluation of 2 HEDIS opioid measures indicates consistent decrease of dosage and length of use since inception of above 22
Success Story – Diabetes Control Diabetes Commitment – 693 patient that 667 patients improved by end of Q11 A1c > 9 will improve by 96% of Commitment (NQF 59) Year 4 Native Health, Horizon Health & Wellness, St. Elizabeth's Health Center, and Mountain Park Health Center • 7,977 members with A1c values greater than 9 • Management of these diabetic members showed an 11% (862 members) improvement rate in A1c values • An 11% improvement in this complex population demonstrates the effectiveness of focused management of chronic disease members with abnormal lab values • Of note, this analysis does not include improvement in A1c values for members whose last value was less than 9 23
Success Story – Joy in the Workplace The MomDoc LEARN! Program was designed to promote opportunities for the personal development of participating employees. Ten different learning modules were offered: ✓ Leadership ✓ MomDoc Culture ✓ Español ✓ Personal Finance ✓ Food & Fitness ✓ The MomDoc Difference ✓ Workplace Skills ✓ Creating Happiness ✓ CPR Certification ✓ MomDoc 2018 Roadmap to Greatness 24
Success Story – Breaking down barriers GB Family Care • Implementing a Medical Home partnership through co-location of the practice with Valle del Sol • Eliminating the barrier – literally – to behavioral health care for their patients by remodeling their office to include a connecting door between the two practices • Integrating leadership meetings and patient co-management into work flows • Closing the communication and care coordination loop by sharing access to their EHR system with their BH partner 25
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