Outpatient Practice PCMH Update Jennifer Cichon Mackinnon MD MM Associate Director Ambulatory Quality Froedtert Hospital General Internal Medicine Clinic Associate Professor General Internal Medicine ID: 717437
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ACP-IL “Small Feedings of the Mind”Outpatient Practice /PCMH Update
Jennifer Cichon Mackinnon, MD, MM
Associate Director Ambulatory Quality
Froedtert Hospital, General Internal Medicine Clinic
Associate Professor, General Internal Medicine
Medical College of WisconsinSlide2
Literally
ACOs
MACRA
MIPS/PQRS
APM/AAPM
PCMH/PACT
Triple Aim or Quadruple Aim
Physician Burn-out
Coding/Billing
Team Model
Desktop Medicine
EHR
CPC+
Meaningful Use
VBPMSlide3
What we really wantSlide4
50/50 Time Ill-Spent
N= 471 community primary care practices
Clinical Time
Face to face visits 49%
Desktop medicine 51%*Goal to move to CMS Model- Comprehensive Primary Care Plus (CPC+) Initiative to pay practices for per-beneficiary-per-month care management fees combined with fee-for-service payments
Health Affairs, April 2017Slide5
Burnout and Workforce
Over half of US physicians and nearly half of nurses in primary care screen positive for burnout
Consequences- lower quality and lower satisfaction
Triple Aim by IHI now Quadruple Aim
Contributors to burnout: Excess patient volume/panel overcapacity
Turnover and insufficient team membersSlide6
Increase in Administration…
-Administrative
costs account for 25 % of total U.S. hospital
spending
-US has the
highest administrative costs of countries studied -Scotland
and Canada had the lowest at 12 % -Reducing U.S. per capita spending for hospital administration to Scottish or
Canadian levels would have saved more than $150 billion in 2011Slide7
CMS Update: MACRA 2015QPP.CMS.gov
MIPS
Calculates payment adjustments (
bonus &penalty)
based on quality data categories
Importance of registriesLikely private payers alsoSmall & large practicesAPMs
Payment models add incentives to provide high-quality and cost-efficient care for specific condition, care episode or populationCPC+ in 14 regions-5 yrs started 2011 –”PCMH on steroids”
Population based paymentsSlide8
MIPS Payment TracksQuality
- 6 measures (one must be an outcome measure)-based on PQRS
Advancing Care Information-
based on Medicare
EHR Incentive Program (Meaningful Use)Improvement Activities-
a new categoryCost -Based on Value-based payment ModifierSlide9
Performance Category
2017
2018
2019
Quality
60%
50%
30%
Cost
0%
10%
30%
Advancing Care Information
25%
25%
25%
Improvement Activities
15%
15%
15%
MIPS adjusts payment based on performance in
four performance categories
-Performance categories carry different weights that will shift as the program progresses.
-Performance in each category is weighted and used to calculate a final score (0-100).
-Payment adjustments based on performance from 2 years prior (2017-2019 for example, +/-4%
up to +/-9% in 2021)
Meigs
, et al.
American Academy of Family Physicians 2017
. Slide10
Solution?
The
Patient Centered Medical
Home
PCMH/ PACT for VA
-1967 first PCMH in Pediatrics-Joint principles- 2007 ACP, ABIM, AAFP, AAP-NCQA released standards 2008
-ACA- 2010 Primary Care central to health care delivery; “Health Homes” for MedicaidSlide11Slide12Slide13
Patient Centered Medical Home
(PCMH)- 7 Tenets
Demonstration Projects
Ultimate goal is to improve safety and quality for our patients
State- Collaborative for Healthcare Quality
Quality metrics are becoming more recognized and measured
Linked to payment models*Slide14Slide15Slide16Slide17Slide18
PCMH Data
PCMH review 2012- largely positive data though mixed studies
NDP- multicenter RCT- improved chronic care quality scores; not outcomes
Geisinger
-controlled cohort-decreased odds of DM related complications; 18% reduction in hospital admissions; 36% in readmissions; 4.3-7.1% savings
Group Health Cooperative-controlled cohort-20-30% control in HEDIS scores, increased patient satisfaction; decreased provider emotional exhaustion; 29% reduction in ER visits; 6% reduction in hospital; Estimated total savings of $10.30 per member per month (p=0.08)AHRQ Data Analysis 2012 of 498 studies from 2000-2010; data inconclusive and only 14 evaluations were adequately designedSome benefit in triple aim outcomes- quality/costs/patient experienceThought of as precursors to PCMH anyway
JGIM 2017- PCMH in 804 FQHC sites for Medicare pts- Higher cost: $111 per FQHC/Medicare pt vs $265 lower for Medicare
ptIncrease specialist visits 181 more per 1000 beneficiaries and 64 additional ER visits (no difference in inpt utilization)Slide19
Magill, Michael K, et al. Cost of Sustaining a Patient-Centered Medical Home:
Experience
from Two States.
Annuals of Family Medicine 2015
;vol 13, no 5:429-435Slide20
The Dream Team
“The average Medicare
pt
sees 7 physicians across four different practices
+ 75% cannot identify the physician overall responsible for their care
=waste 130 billion in ineffective health service delivery.” AAFP News July 2017
“Team-based approach helps prevent physician burnout through proactive plannedCare with pre-visit planning, protocol expansion, standing orders, and panel mgmt.” Annals of Family Med 2011Slide21
Involving Learners in PCMH
Mackinnon J, Mitchell J, Muntz M. “Giving Early Medical Students a ‘Home’: Students Can Meaningfully Contribute to Care on a Year-Long Rotation. National Society of
General Internal Medicine Meeting; April 2014.Slide22
Panel Size/Staffing RatioPanel size debatable-
8
00-2400
pts:1 FTE
“Work at the top of their license”Enhanced roles of various playersTrue PCMH (Am Journal of Managed Care 2013)
1 FTE Physician: 4.25 FTE Staff Members59% higher than avg 1 FTE Physician: 2.68 FTE Physician increase productive capacity 10-20%Slide23
Communication 101Audit of processes/protocols
Co-location
“At least on same end of the court”
Huddles
Balance meaning with time managementE-huddles in EPICTeam meetings
Timing of these and who attendsHow does resultant work get achievedSlide24
Documentation/Coding: Clickety, clack
,
click
2,400 “clicks a day”
Dangerous recipe for disaster and why I miss Cook County Hospital
Major player in physician burnoutMajor player in patient dissatisfactionMajor player in payment Slide25
Scribes“For decades, physicians pinned their hopes on computers to help them manage the overwhelming demands of office visits. Instead, electronic health records have become a disease in need of a cure, as physicians do their best to diagnose and treat patients while continuously feeding the data-hungry computer.” (NYT Health,
Hafner
2017)
Documentation guidelines
Authentication guidelines
Regulations and guidance Minimum knowledge, experience, and education qualificationsDefinition of roles (i.e., scribe vs. provider)Responsibilities and clear scope of practice
Performance expectations (i.e., productivity)Continuous trainingSanctionsDocumentation auditing protocolsPrivacy and security auditing protocols
Certification and/or licensureSlide26
Mail/Test Results/Referral Management
Who does this
work and how?
Mail/faxes (!#$%>)
Test resultsTracking referrals- critical ones
How do they handle results?Normal vs abnormal vs criticalIn between visit communicationPhone Triage- ongoing battleMyChart- Email threads that are too longSlide27
Clinic Lessons LearnedEngage all staff- team concept-include learners!
Try to hold on to staff- turnover is costly and burnout is too
Standardize “some” practices- PVP and other protocols
Regular communication- colocation/huddles
Quality for our patientsUltimately…
Awareness of the continual & ongoing management of sick patients“We are all in this together” mentality- including the patient- reducing their “unrealistic expectations”Slide28
Quality Improvement Project 101:
Our Clinic’s Way to Improve Mammogram Rates
To create a visual management board for a clinical quality metric (Breast cancer screening)
Engage both physicians and staff in practice improvement
Use a visual control tool to audit a standardized process and improve it
Mackinnon J, Dreyer M,
Mitchell
J, Post S. “Bringing the Team On Board: Using Visual Management Boards as a Quality Improvement Tool.”
Wisconsin Medical Journal, June 2016;115(3):158
.Slide29
Methods
Pre-Visit Planning (PVP) protocol developed
MA review of patient chart prior to appointment
Visual Management Board
Dry-Erase board
Team Surveys- Survey Monkey or paper for “buy in”
Staff and providersSlide30
Visual Management Board
Physician Individualized Data
Visual Control Board
Pre-Visit Planning
Action Item List
MethodsSlide31
Physician Data
Baseline (%) mammogram rate
Patients (%) who completed mammogram rolling over past 12 months (goal of 80%)
Current month’s future number of appointments and completed appointments with patients needing mammogram
Patients (#) needing a mammogram in a status tracker (“tic-boxes”)
Methods
Dry-Erase/Visual Management BoardSlide32
Physician Data
3.
Status Tracker
“
U
”: Updated Health Maintenance Section in Epic
“
R
”: Refuse mammogram despite discussion with clinician
“
O
”: Ordered mammogram as part of PVP
“
S
”: Same Day Mammogram requested; convenience, alleviate transportation issues for patient
Methods
Dry-Erase/Visual Management BoardSlide33
Visual Control Board
Pre-Visit Planning Process
% per MA provided monthly and put on board as process evolved
Used to audit processes
Green indicating
100% adherence
Red indicating
processes <100%
Absence of audit marked white
Methods
Dry-Erase/Visual Management BoardSlide34
Action Item List
Connect Meetings
Held bimonthly
Physician Leader, Clinic Administrator, Nurse Educator, and Administrative Board Updater
Physician Leader in regular contact with the data analyst
Go over monthly Visual Control Board
Methods
Dry-Erase/Visual Management BoardSlide35
Results
Mammography Data
During 11 month study interval our
mammogram rate increased 73% to 77% Slide36
Results
Pre-Visit Planning (PVP) Process
PVP process dependent on stable staff supportSlide37
Results
PVP in relation to Mammography Data
Clear dependence on PVP completion (p=0.007)
Visual board & PVP Process begin
Currently at 78.4% as of May 2017Slide38
Results
Anonymous survey between MD/MA
75% agreement that visual board important tool to address care gapsSlide39
Action Items formulated at Connect Meetings:
Shifted from
administrative processes
to
assessing root cause analysis
Results
April
May
June
July
August
September
October
November
December
Assign clinic staff member to update mammogram screening information
[ASSIGN ADMIN ROLES]
Looking at reports with Nick/IT to measure mammogram rates
[DATA MGMT]
Move round at board time to include Jen. *Jen and Sarah. 1 other provider and 1 other clinic staff. ? Monday 1245?
[PROCESS MOD – CONNECT MTG.]
PVP current status due
[PROCESS ADHERENCE – AUDIT]
Encourage MD/MA huddle (before clinic or set time to be determined by MD/MA)
[PROCESS MOD – HUDDLE]
[PROCESS ADHERENCE - HUDDLE]
Outreach (registry) subcommittee (
Jankins
, Mackinnon, Bernstein, Meyer &
Shortts
)
[EXPANSION]
Speak with providers who work in corridor F about strategy to fill in mammogram chart. What are the barriers?
[ASSESS BARRIERS W/ TEAM MEMBERS]
Sarah: Re-enforce process for MA to update board. Orient floats on process. Write up process on how re-enforcing.
Jen: discuss providers can be involved/help MAs update board
[PROCESS ADHERENCE]
Thank you-for posting metrics to board
[ADMIN]
Audit Change to done versus not done
[PROCESS MOD – AUDIT]
Divide audit cards into PVP & Huddles
[PROCESS MOD – AUDIT]
PVP audit & huddle audit 1x/
wk
with stable teams
[PROCESS AUDIT – PVP; HUDDLE]
PVP audit & huddle audit ///split cards
[PROCESS AUDIT – PVP; HUDDLE]
“PVP Huddle” w/providers and MA-time blocked, steady MA/team
[PROCESS ADHERENCE – HUDDLE]
Obtain more putty
[ADMIN]
Ask MAs about barriers to the timeframe of PVP completion
[ASSESS BARRIERS W/ TEAM MEMBERS]
New providers for July
[ADMIN]
Landscape view with PVP notes/floats
[PROCESS MOD – PVP]
Obtain updated huddle times
“Huddle times” -how long it took or time of day it is scheduled?
PVP process & time for MA to do PVP (pilot test with Dr.
Krippendorf
)
[PROCESS MOD – PVP]
[PROCESS AUDIT – PVP]
Add “order pended” to factors
[PROCESS MOD – AUDIT]
Take picture of April board and whites for May
[ADMIN]
Write prioritization list where PVP comes after pt care
[PROCESS MOD – PROTOCOL]
Rolling baseline % include u/o s
[PROCESS MOD – DATA]
[DATA MGMT]
?1 hour blocked for PVP Primary MAs
[PROCESS MOD – ADHERENCE]
Alphabetize providers/train next board updater
[ADMIN]Slide40
Brings “the team” on board
Survey was useful tool for the key players:
MD/MA
Reliance on single person to bring up metric is unsustainable
Increase in the quality metric of mammogram in our clinic
Using a visual board for transparency
and emphasis of
WCHQ
PQRS measures/ report cards
Audit process is helpful to stay on target
Leadership needs to be part of this
Importance of being open to ongoing feedback from providers and all team players
Visual
Boards:Take
Home PointsSlide41
MIPS (PQRS): Depression
Screening
“…if you’re not depressed yet….”Slide42
Have a seat at the table-
ACP/AMA/SGIM
support
Evolving PCMH transformation nationally
We need reimbursement for “in-between” care
Social
Determinants of health are
key to this working
Inpatient to outpatient transitions- cannot stay in silos
Future shift in payment
models- we need to be at table
Reliance on quality metrics- “one size does not fit all”Cost- and Task- sharing necessary across healthcare system
FutureSlide43
Questions?Slide44
ReferencesD. U.
Himmelstein
, M. Jun, R.
Busse
et al., "A Comparison of Hospital Administrative Costs in Eight Nations: U.S. Costs Exceed All Others by Far," Health Affairs, Sept. 2014 33(9):1586–94.
Mackinnon J, Mitchell J, Dreyer, M. “Bringing the Team On Board: Using Visual Management Boards as a Quality Improvement Tool.” Wisconsin Medical Journal, June 2016; 115(3): 158.Singh P, Gandhi N. “Listening is a Lost Art in Medicine: Here’s How to Rediscover It.” Harvard Business Review; Nov. 2017.Bujold EJ. An Opinion Piece: PCMH. JAMA Internal Medicine; Sept 2017.Reynolds P, et al. The Patient-Centered Medical Home: Preparation of the Workforce, More Questions than Answers. JGIM, Feb. 2015; 1013-1017.
Helfrich CD, et al. The Association of Team-Specific Workload and Staffing with Odds of Burnout Among VA Primary Care Team Members. JGIM, Feb. 2017:760-766.
Magill, Michael K, et al. Cost of Sustaining a Patient-Centered Medical Home: Experience from Two States.
Annuals of Family Medicine 2015
;vol 13, no 5:429-435.Mackinnon J, Muntz M, Mitchell J. Giving early medical students a “home”: students can meaningfully contribute to care on a year-long continuity rotation in a PCMH. MCW Faculty Development, 2015.
Sinsky
C, et al. Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties. Annals of Internal Medicine 2016;165:753-760.
Peikes
D et al. Early Evidence on the Patient-Centered Medical Home. AHRQ Report ; Feb. 2012
Berk-Clark C, et al. Do Patient-Centered Medical Homes Improve Health Behaviors, Outcomes and Exerperiences of Low-Income Patients? A Systematic Review and Meta-Analysis. Health Services Research; Educational Trust DOI: 10.1111/1475-6773.12737
Wong E, et al. Patient-Centered Medical Home Implementation in the Veterans Health Administration and Primary Care Use: Differences by Patient Comorbidity Burden; JGIM 2016;31(12):1467-74.
Arend
J, et al. The Patient-Centered Medical Home: History, Components, and Review of the Evidence. Mount Sinai Journal Of Medicine 2012;79:433-450.
Timble
JW, et al. Association Between Patient-Centered Medical Home Capabilities and Outcomes for Medicare Beneficiaries Seeking Care from Federally Qualified Health Centers. JGIM, May 2017; 32(9);997-1004.
Mackinnon J, Mitchell J, Muntz M. “Giving Early Medical Students a ‘Home’: Students Can Meaningfully Contribute to Care on a Year-Long Rotation. National Society of General Internal Medicine Meeting; April 2014.
Williams M. “The Pros and Cons of Using Scribes.” ACP Internist; October 2016.\
Proctor L. “diagnostics Errors: Medical Scribes Improve Physician Satisfaction. Can They Improve Diagnosis, Too? “
www.pshq.com
Banks A, et al. Impact of scribes on patient
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Hafner
K. A busy doctor’s right hand, ever ready to type. The New York Times, Jan. 2014
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Barrett T. NCQA PCMH Recognition: 2017 Standards Preview. Jan 2017.