Chronic Obstructive Learning Collaborative Sponsored by AMGA and Boehringer Ingelheim Pharmaceuticals, Inc..

Transcription

1 Add your company logo here Chronic Obstructive Learning Collaborative Sponsored by AMGA and Boehringer Ingelheim Pharmaceuticals, Inc.. November Dallas, TX GEISINGER HEALTH SYSTEM INCORPORATING BEST PRACTICE FOR COPD INTO A PATIENT-CENTERED MEDICAL HOME 1

2 The Legacy Make my hospital right, make it the best. Abigail Geisinger Geisinger Quality Striving for Perfection

3 Go to view/master/slide Master and Insert your company logo here Founded in 1915, Geisinger is a physician-led fully-integrated health care system Serves 43 counties of Pennsylvania: 20,000 square miles, 2.6 million people 61 primary and specialty clinic sites (38 community practice sites) Two tertiary/quaternary care hospitals Alcohol and chemical dependency center 3

4 Go to view/master/slide Master and Insert your company logo here 26 specialty service lines 800 physicians (200 primary care physicians) 380 Advanced Practitioners 1.7 million outpatient visits/ year NCQA certified level 3 for medical home 4

5 Geisinger Population-Based Care CY % to 89% 40% to 70% 20% to 40% 10% to 20% 0% to 10% *All MRNs are defined as inpatient and outpatient for GMC, GWV, GSWB and GC Strategy & Business Development 1/10

6 Clinical Service Lines Anesthesia Cancer Cardiovascular Community Practice Dental and Oral Surgery Dermatology Emergency Medicine Endocrinology ENT Gastroenterology General, Pediatric and Trauma Surgery Laboratory Medicine Specialties Neuroscience Ophthalmology Orthopedics Pediatrics Plastic Surgery Psychiatry Pulmonary and Critical Care Medicine Radiology System Therapeutics Transplant Urology Vascular Surgery Women s Health

7 Not-for-profit Managed Care Organization 30% of patient care volume ~240,000 members (incl. ~45,000 Medicare Adv.) >20,000 contracted physicians 110 Non-Geisinger hospitals 42 PA counties 7

8 Electronic Medical Record EPIC since million unique patient records Patient portal: lab reports, appts, Best Practice tools to ensure quality 8

9 Team Composition Pulmonary and Critical Care Medicine Paul Simonelli, M.D., Ph.D. Community Practice Carolyn Houk, M.D. Frederick Bloom, M.D., MMM Thomas Graf, M.D. Clinical Innovation Jonathon Darer, MD Christopher Seiler 9

10 COPD Goals & Objectives Develop a system of care for COPD Consistent, reliable, high quality Requires a workflow redesign Incorporate needed aspects of care into a team-based approach EHR can help hard-wire change, but is not sufficient Care delegated to appropriate health care team members 10

11 COPD Goals & Objectives Focus on three steps in team-based practice redesign Workflow design & resources to allow care outside of office setting when possible Office-based care by non-providers as their education & training allows Care by providers optimized for efficiency & reliability using EHR tools 11

12 COPD Performance Measures Identification on Problem List CXR (and subsequent CT) PFTs Smoking status Influenza vaccine Pneumovax Oxygen assessment Oxygen use Appropriate medication use Sleep disordered breathing (STOP) Review of PFT data with patient if smoker All Patients At least once (I) Every 24 months (I) Non-smoking status (I) Yearly (I) Once before age 65 (I) At least yearly (I) For pts 88% at rest (I) bronchodilators At least once in absence of OSA??? FEV1 less than 35% To see Pulmonary

13 COPD Performance Measures Measure # Pts % Pts Identification on Problem List % PFTs in last 24 months % Non-smoking status % Advair order in last year (not limited to pts w/ hx of exacerbation % Pneumovax (3109 pts) % CXR (and subsequent CT)?? Influenza vaccine?? Oxygen assessment yearly?? Oxygen use (for pts 88% at rest)??

14 Improvement Interventions Primary Care redesign incorporating systems of care for COPD Medical home nurse integrated into primary care office Primary care partnering with specialty focused on value Quality measurement Reimbursement redesign 14

15 Improving Systems of Care for COPD Influenza and Pneumococcal immunization Outreach to patients with chronic disease Smoking Cessation Improved diagnosis through increased use of spirometry Improved identification of COPD through the EMR using improved taxonomy

16 Improved Taxonomy for COPD Current EHR Display Name New EHR Display Name CHRONIC AIRWAY OBSTRUCTION NEC CHRONIC AIRWAY OBSTRUCTION NEC CHRONIC AIRWAY OBSTRUCTION NEC CHRONIC AIRWAY OBSTRUCTION NEC CHRONIC AIRWAY OBSTRUCTION NEC OBSTRUC CHRON BRONCHITIS W/ACUTE BRONCHITIS COPD, mild COPD, mod COPD, severe COPD, Chronic Resp Fail, O2 below 89% at rest COPD, Chronic Resp Fail, pco2 over 44 at rest Acute Bronchitis w/ COPD

17 Medical Home Nurse Integration into Primary Care Identify patients at risk and actively follow patients Patients have enhanced access to care Provide comprehensive education Protocols for COPD exacerbations Closely monitored transitions of care Advanced directive and EOL discussions incorporated into their treatment plan

18 COPD Self-management Action Plan COPD Self Management Action Plan Date: March 26,2010 Patient s Name: MRN #: COPD Monitoring: Monitor the following symptoms for worsening of COPD: Increased shortness of breath Wheezing Increased cough Chest tightness Fever or Chills Increased sputum with change in color and consistency Increased fatigue Decrease in appetite COPD Action Plan: Contact your health care provider as soon as possible Start the following medication: Drink 6-8 glasses of water per day to help loosen sputum. Continue to take all your regular COPD medicines. May benefit from using your nebulizer (if available). Comments: Case Manager: Phone #:

19 Quality Measurement all or none bundle metric Participant in the CMS Physician Group Practice (PGP) demonstration project

20 Spirometry Orders Spirometry Orders Approximately 25% increase in spirometry orders since last year Spirometry Orders Spirometry Orders - PCP Sep '08 Oct '08 Nov '08 Dec '08 Jan '09 Feb '09 Mar '09 Apr '09 May '09 Jun '09 Jul '09 Aug '09 Sep '09 Oct '09 Nov '09 Dec '09

21 Influenza Immunization Rate in High Risk Patients over Age 65

22 Pneumococcal Immunization Rate in High Risk Patients over Age 65

23 Challenges or Obstacles Physician acceptance of system interventions Patient acceptance and understanding of COPD Training staff in spirometry and COPD patient education Financing a medical home care manager Data Acquisition and Measurement Reimbursement 23

24 Outcomes and Successes Improved identification of patients with COPD Improved immunization rates Decreased hospitalizations for COPD Decreased risk-adjusted expenditures for COPD 24

25 Decreased Hospitalizations 11,500 Discharges Per 10,000 COPD Beneficiaries Discharges per 10,000 Beneficiaries 11,000 10,500 10,000 9,500 Geisinger Discharges per 10,000 COPD Benificiaries was rising in This trend has now reversed in 2006 and ,000 8,

26 Decreased risk-adjusted expenditures 300 Risk Adjusted Total Expenditures: Comparison Group Minus Geisinger Risk Adjusted Total Expenditures: Comparison Group Minus Geisnger Geisinger expenditures were initially greater than the comparison group. The trend line is upward showing improvement in expenditures The Geisinger expenditures are now less than the comparison group

27 Future Steps Use spirometry to diagnose COPD in at risk patients and obtain baseline spirometry on patients labeled with COPD to determine accuracy/severity of diagnosis Improve rates and programs for smoking cessation counseling Measure % of COPD patients on appropriate med regimen Reduce admissions for COPD patients Direct appropriate referrals to advanced pulmonary care clinic (KeyHIE, Keystone Beacon Community grant) 27

28 Lessons Learned Need to redesign care - more than just developing EHR tools Team-Based Model - too much for one person Measures are necessary - initially lots of mistakes but data gets better every month Care management is important for reducing ER/Admissions/Readmissions. Identification, Education, Close Follow up, Tight integration with the physician Compensation helps - but it is not about paying a great deal of money for everyone to work longer and harder - it is about incenting to try the right thing - working smarter not harder. 28

29 Questions 29