Value-Driven Quality Improvement in Primary Care · Value-Driven Quality Improvement in Primary...

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Value-Driven Quality Improvement in Primary Care William Rollow, MD, MPH, Primary Care Development Corporation Janet DesGeorges, Hands & Voices, Inc. Dennis Kuo, MD, MHS, Department of Pediatrics-UAMS Richard Snow, DO, MPH, OhioHealth

Transcript of Value-Driven Quality Improvement in Primary Care · Value-Driven Quality Improvement in Primary...

Page 1: Value-Driven Quality Improvement in Primary Care · Value-Driven Quality Improvement in Primary Care William Rollow, MD, MPH, Primary Care Development ... (over 50 chapters in the

Value-DrivenQualityImprovementinPrimaryCareWilliamRollow,MD,MPH,PrimaryCareDevelopmentCorporationJanetDesGeorges,Hands&Voices,Inc.DennisKuo,MD,MHS,DepartmentofPediatrics-UAMSRichardSnow,DO,MPH,OhioHealth

Page 2: Value-Driven Quality Improvement in Primary Care · Value-Driven Quality Improvement in Primary Care William Rollow, MD, MPH, Primary Care Development ... (over 50 chapters in the

VALUE-DRIVENQUALITYIMPROVEMENTINPRIMARYCARE

WilliamRollow,MD,MPH(moderator)JanetDesGeorges

DennisKuo,MD,MHSRichardSnow,DO,MPH

November12,2015

Page 3: Value-Driven Quality Improvement in Primary Care · Value-Driven Quality Improvement in Primary Care William Rollow, MD, MPH, Primary Care Development ... (over 50 chapters in the

WhyValue?

• StudiesofPCMHtypicallyassessimpacton:– Clinicalqualitymeasures– Cost/utilization– Patientsatisfaction

Page 4: Value-Driven Quality Improvement in Primary Care · Value-Driven Quality Improvement in Primary Care William Rollow, MD, MPH, Primary Care Development ... (over 50 chapters in the

WhatDoPatientsValue?

• Health– Dimensions:physical/somatic/physical,cognitive/emotional,social/functional,spiritual

• Cure– Uni-dimensionalresolution

• Healing– Integratedimprovementacrossdimensions

• Preconditionsofhealth– Housing,employment,income,safety

• Experience– Access,relationship,amenities

Page 5: Value-Driven Quality Improvement in Primary Care · Value-Driven Quality Improvement in Primary Care William Rollow, MD, MPH, Primary Care Development ... (over 50 chapters in the

HowCanPrimaryCarePracticesCreateValueforPatients?

• Needed– Amodelthatprovidesaroadmapforpracticetransformationwitheffectivefacilitation/assistance

– Researchanddevelopmentoncomponentsofthemodel– Paymentthatcoversthecostsofprovidingcare

Page 6: Value-Driven Quality Improvement in Primary Care · Value-Driven Quality Improvement in Primary Care William Rollow, MD, MPH, Primary Care Development ... (over 50 chapters in the

WhatWillWeDiscussInThisSession?

• Whatpatientsvalue• Howcanprimarycarepracticesprovidevalue

Page 7: Value-Driven Quality Improvement in Primary Care · Value-Driven Quality Improvement in Primary Care William Rollow, MD, MPH, Primary Care Development ... (over 50 chapters in the

Value-DrivenQualityImprovementinPrimaryCareWilliamRollow,MD,MPH,PrimaryCareDevelopmentCorporationJanetDesGeorges,Hands&Voices,Inc.DennisKuo,MD,MHS,DepartmentofPediatrics-UAMSRichardSnow,DO,MPH,OhioHealth

Page 8: Value-Driven Quality Improvement in Primary Care · Value-Driven Quality Improvement in Primary Care William Rollow, MD, MPH, Primary Care Development ... (over 50 chapters in the

ParentsandPatientsasPartnersinQIWork—BeyondtheClichés

SessionJ:Value-DrivenQualityImprovementinPrimaryCare

Presentedby:JanetDesGeorges

Page 9: Value-Driven Quality Improvement in Primary Care · Value-Driven Quality Improvement in Primary Care William Rollow, MD, MPH, Primary Care Development ... (over 50 chapters in the

∗ Credentials:M.O.M.(“mom,youwouldn'thaveajobifitwasn’tforme”);ourfamilystory

∗ Systemicinvolvementforover15years(medical,educational,community)

∗ ExecutiveDirectorandCo-Founder,Hands&Voices(over50chaptersintheU.S.andabroad)

∗ Authorofpeer-reviewedarticlesinMedicalJournals∗ CertificateofCompletionattheUniversityofNorthCarolina-ChapelHillMCHPublicHealthLeadershipInstitute

MyProfessionalBackground

Page 10: Value-Driven Quality Improvement in Primary Care · Value-Driven Quality Improvement in Primary Care William Rollow, MD, MPH, Primary Care Development ... (over 50 chapters in the

ABriefhistoryofourfamily’sjourney…

•Sarawasbornin1991–priortouniversalnewbornhearingscreening;qualifiedforPartCServices–Hypotonia(at11months)•LateI.D.atagetwo–with2yearlanguagedelays(congenital,sensorineuralbilateralmoderate-profoundhearingloss);37professionalsinourlivesbyage7•Successful,youngdeafadult–bi/modalcommunicator;collegegrad;intheworkworld

Page 11: Value-Driven Quality Improvement in Primary Care · Value-Driven Quality Improvement in Primary Care William Rollow, MD, MPH, Primary Care Development ... (over 50 chapters in the

Thiswasjustour‘world’ofdeafness….imagineformorecomplexconditions?Whatwereourvalues?Ourneeds,Ourgoalsforhealth/wellbeing?...

MedicalHome

Page 12: Value-Driven Quality Improvement in Primary Care · Value-Driven Quality Improvement in Primary Care William Rollow, MD, MPH, Primary Care Development ... (over 50 chapters in the

∗ PDSACYCLE:∗ Colorado:∗ Prework:

∗ Plan:DetermineifPCPshaveresultsofhearingscreenincharts.Predicttheydo.

∗ Do:Chartreviewof10chartsfrom3PCPSthatagreedtoparticipate.∗ Study:1PCPhadall10results,2PCPShadnone.

∗ Surprisingresult∗ InpatientandOutpatientEMRsdonotcommunicate.

∗ Act:∗ DosmalltestsofchangeusingfurtherPDSAcycles:IdentifyPCPpriortohospitaldischarge;fax

resultstoPCP;provideresultstofamilyinwriting.∗ Promotestatewidedataintegrationeffortswithimmunizationregistry,developastrategic

planfordatamanagementandcasetracking.

TypicalProcessPDSA….

EXAMPLEFROMNICHQPROJECT: ImprovingFollow-UpafterNewbornHearingScreeningbyApplyingQualityImprovementStrategiestotheHealthCareSystem

Page 13: Value-Driven Quality Improvement in Primary Care · Value-Driven Quality Improvement in Primary Care William Rollow, MD, MPH, Primary Care Development ... (over 50 chapters in the

Exampleofprocess:PDSAmaytrackifaudiologistsaregivinginformationtotheMedicalHome(i.e.faxbackforms)

Ask:Howdidthatimpactparents?“DidthePhysiciandiscussyourchild’sscreeningresultswithyou?”

ThinkingaboutQIpointofviewasaparent….

HowwilltheoutcomesofQIbeutilizedtoimproveyoursystem?(Parents,askyourselftheinternal,‘sowhat?’questionwhentalkingaboutPDSA’s)

Page 14: Value-Driven Quality Improvement in Primary Care · Value-Driven Quality Improvement in Primary Care William Rollow, MD, MPH, Primary Care Development ... (over 50 chapters in the

Theconceptof‘Value-Driven’orthe‘SoWhat?’inQIwork…

HowwilltheoutcomesofQIWorkbeutilizedtoimproveyoursystem?(Parents,askyourselftheinternal,‘sowhat?’questionwhentalkingaboutPDSA’s)

BeyondPROCESSEvenbeyondIMPACTONFAMILIES/PATIENTS

GOAL:Measuring/ImprovingParent/PATIENT-CENTEREDVALUESandDesiredoutcomes -individuallyandcollectively

YESwedid!QualityImprovement

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∗ Googleit∗ About3,050,000results

∗ TheCitizenScientists(WiredMagazine,2001)∗ “Andbytheway,don'tgo

ontheInternet.”

GettingThere:Clinician–ParentPartnership

Page 16: Value-Driven Quality Improvement in Primary Care · Value-Driven Quality Improvement in Primary Care William Rollow, MD, MPH, Primary Care Development ... (over 50 chapters in the

ExampleofParentInvolvement

Page 17: Value-Driven Quality Improvement in Primary Care · Value-Driven Quality Improvement in Primary Care William Rollow, MD, MPH, Primary Care Development ... (over 50 chapters in the

NICHQhasworkedwithHRSA-MCHBon5collaborativestoimproveoutcomesforchildrenwithhearinglossandtheirfamilies,across52statesandterritories:∗ ImprovingFollow-uptoNewbornHearingScreeningbyWorkingthrough

theMedicalHomeLearningCollaborative∗ AZ,CA,FL,KS,MI,NE,PA,WI(2006-2007)

∗ ImprovingSystemsofCare(ISC)forChildrenandYouthwithSpecialHealthcareNeedsLearningCollaborativesA&B∗ LC-A:NHS:CO,MA,MN,NV,NY,UT,WA(2007-2009)∗ LC-B:NHS:HI,IL,IN,IA,ME,NC,VA(2009-2010)

∗ ImprovingHearingScreeningandInterventionSystems(IHSIS)LearningCollaborativesA&B∗ LC-A:AL,AK,GA,ID,KY,LA,MS,MO,NH,NM,OH,RI,SC,DC(2011-2012)∗ LC-B:AR,CT,DE,MD,MT,NV,NJ,ND,OK,OR,PR,TN,TX,USVI,VT,WV,WY(2012-2013)

NICHQNewbornHearingCollaboratives

IHSISfundedbytheUSDeptofHealth&HumanServices,HealthResources&ServicesAdministration,MaternalandChildHealthBureau,ContractNo.HHSH250201000021C

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∗ Planning∗ Involvementatthebeginningofeachproject∗ Guidingthedevelopmentofcollaborativecontentfromthefamilyperspective∗ Mandatedparentparticipationonteams

∗ Facultylevel∗ Roleequaltothatofotherfaculty∗ Askedtocontributebeyond‘parentstuff’

∗ Teams∗ T.A.inensuringtheirparentsareinvolved∗ Presentatlearningcollaboratives∗ Supportparent-driveninitiatives

∗ Parentinvolvementsupport∗ Spendtimewithparentsasagroupatlearningsessions∗ Createandsharetoolsformeaningfulinvolvement

NICHQParentFacultyRole

Page 19: Value-Driven Quality Improvement in Primary Care · Value-Driven Quality Improvement in Primary Care William Rollow, MD, MPH, Primary Care Development ... (over 50 chapters in the

∗ PowerfulPartnerships:AHandbookforFamiliesandProvidersWorkingTogethertoImproveCare

Downloadfrom:www.nichq.org

http://www.nichq.org/how-we-improve/resources/powerful-partnerships

Resources:

The“HOWTO”!

http://www.nichq.org/
http://www.nichq.org/how-we-improve/resources/powerful-partnerships
http://www.nichq.org/how-we-improve/resources/powerful-partnerships
Page 20: Value-Driven Quality Improvement in Primary Care · Value-Driven Quality Improvement in Primary Care William Rollow, MD, MPH, Primary Care Development ... (over 50 chapters in the

Disturb the Peace

Sustain Tension

Contain Anxiety

Provide Leadership

Janet DesGeorges

You can reach Janet at [email protected]

303-492-6283

Page 21: Value-Driven Quality Improvement in Primary Care · Value-Driven Quality Improvement in Primary Care William Rollow, MD, MPH, Primary Care Development ... (over 50 chapters in the

Value-DrivenQualityImprovementinPrimaryCareWilliamRollow,MD,MPH,PrimaryCareDevelopmentCorporationJanetDesGeorges,Hands&Voices,Inc.DennisKuo,MD,MHS,DepartmentofPediatrics-UAMSRichardSnow,DO,MPH,OhioHealth

Page 22: Value-Driven Quality Improvement in Primary Care · Value-Driven Quality Improvement in Primary Care William Rollow, MD, MPH, Primary Care Development ... (over 50 chapters in the

archildrens.org uams.eduarpediatrics.orgarchildrens.org uams.eduarpediatrics.org

VALUE-DRIVENQUALITYIMPROVEMENTINPRIMARYCARE:Thepediatricsperspective

DennisZ.Kuo,MD,MHSAssociateProfessorofPediatrics,UAMS

November12,2015

Page 23: Value-Driven Quality Improvement in Primary Care · Value-Driven Quality Improvement in Primary Care William Rollow, MD, MPH, Primary Care Development ... (over 50 chapters in the

archildrens.org uams.eduarpediatrics.orgarchildrens.org uams.eduarpediatrics.org

Pediatrics

• Children– 48%ofMedicaidenrollees– 21%ofspend(KaiserFamilyFoundation)

• Mostchildrenaccessingprimarycare– Preventivecarevisits– Immunizations

• ~1%=25-33%ofcosts(Neff,2004;Cohen,2012)

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archildrens.org uams.eduarpediatrics.orgarchildrens.org uams.eduarpediatrics.org

ChildrenareNOTlittleadults!

The5D’s Implicationforchildren

Development • Enhancedevelopmentandgrowth

Dependency • Dependentonadults–notautonomous

DifferentialEpidemiology • Largenumberofrelativelyrarechronicconditions• Subspecialistsbasedinacademicmedicalcenters

DemographicPatterns • Highpoverty• Moreracialandethnicdiversity

Dollars • ROIoverlongtermlifecourse

Stilleeta.TheFamily-CenteredMedicalHome:SpecificConsiderationsforChildHealthResearchandPolicy.AcademicPediatrics2010;10:211-7.

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archildrens.org uams.eduarpediatrics.orgarchildrens.org uams.eduarpediatrics.org

Healthcarespendingbychildren

Kuoetal(2015)Pediatrics.Inpress

Page 26: Value-Driven Quality Improvement in Primary Care · Value-Driven Quality Improvement in Primary Care William Rollow, MD, MPH, Primary Care Development ... (over 50 chapters in the

archildrens.org uams.eduarpediatrics.orgarchildrens.org uams.eduarpediatrics.org

Highresourceutilizers:childrenwithmedicalcomplexity

• Multiplechronicconditions• Highincidenceofneurodevelopmentaldisability• Technologyneeds• Socialcomplexity• Muchofcareintertiarycaresetting

Cohenetal.Pediatrics(2011)

Page 27: Value-Driven Quality Improvement in Primary Care · Value-Driven Quality Improvement in Primary Care William Rollow, MD, MPH, Primary Care Development ... (over 50 chapters in the

archildrens.org uams.eduarpediatrics.orgarchildrens.org uams.eduarpediatrics.org

The Chronic Care Model

Wagner EH. Figure from Antonelli R (2005). Adapted from Bodenheimer (2002)

Page 28: Value-Driven Quality Improvement in Primary Care · Value-Driven Quality Improvement in Primary Care William Rollow, MD, MPH, Primary Care Development ... (over 50 chapters in the

archildrens.org uams.eduarpediatrics.orgarchildrens.org uams.eduarpediatrics.org

Drivingvalueinprimarycare

• PCMH/practicetransformation– Primarycareisinexpensiveandhighvolume– Savingsconcernasmallnumberofpatients

• Challenges– Commonmetricsarenotpediatric-based– Mosthighresourceutilizerspendisintertiarycarecenter– WhatistheROIonmore$$inprimarycare?– Whatistheclinicalmechanismtogeneratevalue?

Page 29: Value-Driven Quality Improvement in Primary Care · Value-Driven Quality Improvement in Primary Care William Rollow, MD, MPH, Primary Care Development ... (over 50 chapters in the

archildrens.org uams.eduarpediatrics.orgarchildrens.org uams.eduarpediatrics.org

Deepthoughts

• Understandthehighresourceutilizer• Emphasizetheroleoftheprimarycarephysician

– BuildcapacitywithQI,careteams,registry– Community-basedtherapies,familyengagement

• Alignprimarycarewithaco-managementarrangementwithtertiarycareservices

• Supportivepaymentstrategies

Page 30: Value-Driven Quality Improvement in Primary Care · Value-Driven Quality Improvement in Primary Care William Rollow, MD, MPH, Primary Care Development ... (over 50 chapters in the

Value-DrivenQualityImprovementinPrimaryCareWilliamRollow,MD,MPH,PrimaryCareDevelopmentCorporationJanetDesGeorges,Hands&Voices,Inc.DennisKuo,MD,MHS,DepartmentofPediatrics-UAMSRichardSnow,DO,MPH,OhioHealth

Page 31: Value-Driven Quality Improvement in Primary Care · Value-Driven Quality Improvement in Primary Care William Rollow, MD, MPH, Primary Care Development ... (over 50 chapters in the

Value Driven Quality Improvement in Primary Care

Richard Snow, DO, MPH System Vice President, Clinical Transformation, OhioHealth

Page 32: Value-Driven Quality Improvement in Primary Care · Value-Driven Quality Improvement in Primary Care William Rollow, MD, MPH, Primary Care Development ... (over 50 chapters in the

Model of Patient Centered Care Moving Towards Value Following Donnabedian Model of Health Care Measurement

• Structural orientation – Accreditation

• Process oriented – HEDIS measures

• Outcomes focused – Value oriented

• Clinical and financial quality • Payers increasingly moving towards

– Comprehensive Primary Care – Commercial

Page 33: Value-Driven Quality Improvement in Primary Care · Value-Driven Quality Improvement in Primary Care William Rollow, MD, MPH, Primary Care Development ... (over 50 chapters in the

Approach of OhioHealth• Large hospital system in Central Ohio with

– 28,000 associates and family members in self insured – Clinically integrated network with Medical Group of Ohio

with ~ 160,000 covered lives • Developing Pathways to Value

– Series of value oriented projects focused on improved clinical and financial quality – all projects link the 2 outcomes

• Deploying at a system level – Describe what we want for our primary care practices

• Aligning force – Per Member Per Month

Page 34: Value-Driven Quality Improvement in Primary Care · Value-Driven Quality Improvement in Primary Care William Rollow, MD, MPH, Primary Care Development ... (over 50 chapters in the

•DiabetesPreventionProgram •ChronicKidneyDisease •PreventionofMusculoskeletalSurgery

•ObstructiveSleepApnea •AmbulatoryEDUtilization •HospitalObservation •PreventableHospitalization •EDCTUtilization •TotalKneeReplacement

•EndStageRenalDisease •ChronicObstructive PulmonaryDisease •CongestiveHeartFailure •PathwaystoWellness

Pathways to Value Initiative in OhioHealthy

Physician Leadership and Engagement

Prevention

Matching Medical

Necessity with Intensity of

Service

Managing Chronic Disease

Demonstrated Value Differential

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Page 35: Value-Driven Quality Improvement in Primary Care · Value-Driven Quality Improvement in Primary Care William Rollow, MD, MPH, Primary Care Development ... (over 50 chapters in the

How Does This Translate to a Primary Care Office and Patient Centered Care

• Diabetes Prevention Program – Cost of care doubles as patients progress from pre-DM to DM – DPP reduces progression to DM by 58% – Managing to value – percent enrollment

• Reduction of progression of high risk patient CKD-3 – Hypertension management, nephrotoxic drug avoidance, guideline

adherence • Conservative management of low back and joint problems

– Identification of patients – Referral and co-management

Page 36: Value-Driven Quality Improvement in Primary Care · Value-Driven Quality Improvement in Primary Care William Rollow, MD, MPH, Primary Care Development ... (over 50 chapters in the

Implications for Primary Care Office

• Providing primary care with direction to provide value – Who is at risk? – What is the modifiable portion of risk? – What can my office do to reduce the risk?

• Reengineering Payment – How do we incentivize and support the office to be successful?

Page 37: Value-Driven Quality Improvement in Primary Care · Value-Driven Quality Improvement in Primary Care William Rollow, MD, MPH, Primary Care Development ... (over 50 chapters in the

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Page 38: Value-Driven Quality Improvement in Primary Care · Value-Driven Quality Improvement in Primary Care William Rollow, MD, MPH, Primary Care Development ... (over 50 chapters in the

Value-DrivenQualityImprovementinPrimaryCareWilliamRollow,MD,MPH,PrimaryCareDevelopmentCorporationJanetDesGeorges,Hands&Voices,Inc.DennisKuo,MD,MHS,DepartmentofPediatrics-UAMSRichardSnow,DO,MPH,OhioHealth


Primary Care Office Manual - Welcome to ASTHO Primary Care... · PRIMARY CARE OFFICE MANUAL 4 PCOs need to know about many facets of primary and preventive care in their state’s

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STEM: 2015 - Hartford HealthCare Library/Publications...New Primary Care Patients: 32,652 Primary Care Visits: 319,799 Provider of primary care, surgical care, urgent care and specialty

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Missouri Primary Care Association March 2011 Missouri Primary Care Association1.

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