GERI-METRICSRUHS Guide to

Quality Goals with Geriatric Patients

Shunling Tsang, MD MPHAssociate Medical Director – Quality

June 5, 2018

PRIME Project 1.1 Integration of Behavioral Health

DISCLOSURES

None of the faculty, planners, speakers, providers nor CME committee has any relevant financial relationships with

commercial interest

There is no commercial support for this CME activity

Objectives

• Describe RUHS specific quality metrics in relations to geriatric care

• Define national and state quality metrics that impact geriatric care

• Discuss diabetes quality metrics as an example framework for

interdisciplinary geriatric care

Disclosures

• None financially

• I do love quality and performance improvement

• I have 2 beautiful children and a wonderful husband

RUHS Quality Reporting

Medi-Cal 2020 Programs – 5 year Medicaid Waiver that provides new federal funding that shift the focus away from hospital-based inpatient care towards outpatient primary and preventive care (from Volume to Value)

• PRIME – Public Hospital Redesign and Incentives in Medi-Cal• GPP - Global Payment Program • WPC - Whole Person Care

RUHS Quality Reporting

PRIME:

Public Hospital Redesign and Incentives in Medi-Cal metrics (28 of 57 Total Metrics include patients >=65yo)

RUHS Quality Reporting

PRIME:

Public Hospital Redesign and Incentives in Medi-Cal metrics (28 of 57 Total Metrics include patients >=65yo)

IEHP Pay 4 Performance • Through the health plan (IEHP) based on NCQA HEDIS

• 2 types: Traditional and Global P4P

• Traditional P4P for Geriatric Metrics include:

• Dual Choice Annual Visit

• Global P4P for Geriatrics include:

• Initial Health Assessments

• Comprehensive Diabetes Care A1C<8 (18-75yo)

• Concurrent use of opioids and benzodiazepines (new)

• Screening for clinic depression in primary care

• Positive depression screening with follow-up plan

• Breast cancer screening (50-74yo)

RUHS Quality Reporting

RUHS Quality ReportingMeaningful Use

CMS provided incentives to encourage eligible clinicians to use health IT --> certfiied EHR (e.g. EPIC) technology to allow for electronic information sharing and submission data to CMS

This will become one of the 4 components of the new Merit Based Incentive Payment System (MIPS)

which is part of MACRA

MACRA

• Medicare Access and CHIP reauthorization Act (MACRA) of 2015

• Repeals the Medicare sustainable growth rate (SGR) formula which would have resulted in payment cuts for physicians

• Rewards physicians for providing higher quality care through:

MIPS: Merit-Based Incentive Payment Systems, and

AAPMS: Advanced Alternative Payment Models, and

• Consolidates 3 existing quality reporting programs: PRMS –physician quality reporting system, BVPM - Value-based payment modifier, MU - Meaningful Use, plus adds a new performance category called IA – improvement activities, into a single system through MIPS

QIP – Quality Incentive Program **new**

• CAPH and SNI working with the California Department of Health Care Services (DHCS), Medi-Cal to finalize a proposal that comply with MACRA

• 20 of the 25 metrics may involve geriatric patients

NCQA Patient Centered Medical Home Recognition

• Clinical quality measures as in the previous slides

• Practice develops supportive partners with social service organizations in the community - demonstrates practice activities in which community entities are engaged to support better health (KM25*)

• Case conferences – practice has regular “case conference” involving parties outside of the practice -- multidisciplinary with community organizations and specialists for complex patients (KM28*)

• Care management and support with availability of resources to meet daily needs, safety, social support, crime, socioeconomic conditions (CM01-3*)

• Written care plans for patients identified for care management (CM05*)

• Patient preferences and functional/lifestyle goals in individual care plans (CM06*) and care plan integration across settings of care including cross-organizations (CM09*)

*PCMH 2017 Standards

Geriatrics Diabetes Data Review

253/2138 patients January-March 2018 were identified as >=65yo and diabetic

• 104/253 had an A1C >=8 (not including no A1C)

• 58/253 had an A1C >9 (not including no A1C)

• 6/253 had no A1C

• 143 had A1C<8

Our quality goals:

PRIME uncontrolled A1C (>9) = 36.09 or lower (RUHS 1st qtr 2018 = 25.3%)

P4P(HEDIS) Controlled A1C (<8) = 58% or higher (RUHS 1st qtr 2018 = 56.5%)

*PCMH 2017 Standards

Data to Drive Change253/2138 patients January-March 2018 were identified as >=65yo and diabetic

• 104/253 had an A1C >=8 AND 58/253 had an A1C >9 AND 6/253 had no A1C

How do we break this down to improve patient outcomes?

58 patient can be quickly identified by a care manager

Interdisciplinary approach

Case conferencing

Referrals to community based interventions

Community-Based Adult Services (CBAS) centers where nutritional counseling and healthy lunches are provided with transportation

IEHP Community Centers

Data to Drive Change253/2138 patients January-March 2018 were identified as >=65yo and diabetic

• 104/253 A1C >=8 AND 58/253 A1C >9 AND 6/253 no A1C

How do we break this down to improve patient outcomes and achieve better A1C control?

• 58 patient can be quickly identified by a care manager

• Interdisciplinary approach

• Case conferencing

• Referrals to community based services

• IEHP Community-Based Adult Services (CBAS) centers where nutritional counseling and healthy lunches are provided with transportation

• IEHP Community Centers (see next slide)

• Cognition and Mobility Program Referral

• Behavioral Eval for co-morbid depression

• Office of Aging for additional support for patient and caregivers

Data to Drive Change

58 geriatric patients in 3 months connected to care and care coordination

DOCUMENTATION IS KEY Patient Care Plan, care managers and other interdisciplinary members noted in patient record

Primary Goal patient outcomes improve

2ndary goal improved organizational outcomes (less patients with uncontrolled A1Cs mean increased reimbursement to continue to expand services for care coordination)

Case ReviewBJ is an 80yo F presented to the ED with feeling unsteady and having intermittent chest pain and headache.

PMHx includes: A Fib not on anticoagulation, CAD with stent on plavix, CVA with minimal residual deficits (uses walker at baseline, has caretaker), hx of small brain aneurysm, HTN, HLD, osteoarthritis, possible dementia

Vitals on admission:

Temp: [98 °F (36.7 °C)-98.3 °F (36.8 °C)] 98 °F (36.7 °C)Heart Rate: [51-66] 64Respirations: [16-22] 22Blood Pressure: (131-228)/(70-142) – initial SpO2: [94 %-100 %] 98 %75.8 kg (167 lb)

Patient was admitted for Bradycardia and Hypertensive Urgency versus emergency.

Case ReviewBJ is an 80yo F presented to the ED with feeling unsteady and having intermittent chest pain and headache. Patient was admitted for bradycardia and hypertensive urgency versus emergency.

Of note, patient was recently in a car accident and had lost of her medications.

Social hx: homeless, was staying in a hotel but willing to go to her daughters.

Chart review revealed that she is a patient in our geriatric clinic and there is an APS case open for her.

Admission Course:

BP controlled. Chronic medications restarted. Bradycardia resolved. Geriatrics was consulted to provide input on patient care.

SW called to assist with referral to Office on Aging. Daughter expressed appreciation for the support provided and expressed feeling overwhelmed in taking care of the patient.

Patient was discharged to Daughter.

Case ReviewBJ is an 80yo F presented to the ED with feeling unsteady and having intermittent chest pain and headache. Patient was admitted for bradycardia and hypertensive urgency versus emergency.

SW called to assist with referral to Office on Aging. Daughter expressed appreciation for the support provided and expressed feeling overwhelmed in taking care of the patient.

Inpatient team discussed case with Geriatric Care Manager to provide short interval follow up for the patient.

Patient was discharged to Daughter.

Thank You!

References• https://www.aafp.org/content/dam/AAFP/documents/practice_manag

ement/restricted/2018-mips-playbook.pdf

• http://caph.org/wp-content/uploads/2018/02/managed-care-rule-fact-

sheet-jan2018.pdf)

• http://www.ncqa.org/programs/recognition/practices/patient-centered-

medical-home-pcmh

• https://caph.org/priorities/medi-cal-2020-waiver/prime/

• https://ww3.iehp.org/en/providers/p4p-program/

PRIME Project 1.1 Integration of Behavioral Health

Please feel free to contact Alicia with an questions you may have.

Alicia (Ali) Platt

Program Coordinator

Geriatric Medicine Division

a.platt@ruhealth

(951) 486-5623