Montefiore Medical Center Road to Excellence
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1 Montefiore Medical Center Road to Excellence Noel C. Brown MD, MBA Director of Performance Improvement and Quality
2 Agenda Overview Early beginnings Transition Recognition Next steps 2
3 Montefiore Medical Group MMG 1 MMG 2 MMG 3 MMG 4 Original Medical Group (1947) Ambulatory Care Network (1965) New York Medical Group (2000) Moses OPD (2002) Sites: MDs: Teaching: (181 residents) (105 residents) FQHC Sites: Visits: 169, , ,000 89,000 3
4 MMC NETWORK in the Bronx and Southern Westchester County MMG - Eastchester MMG - CROSS COUNTY MMG - Greene Medical Arts Pavilion CHILDREN'S HOSPITAL AT MONTEFIORE (CHAM) MONTEFIORE MEDICAL CENTER - MOSES DIVISION MONTEFIORE MEDICAL CENTER - NORTH DIVISION Montefiore North Mental Health Clinic Montefiore North Alcoholism Clinic MMG - Riverdale Mercy Community Care (DTC) MMG - WILLIAMSBRIDGE MMG - MARBLE HILL MMG - FAMILY HEALTH CENTER MMG - UNIVERSITY AVENUE MMG - GRAND CONCOURSE MMG - FORDHAM FAMILY PRACTICE Montefiore North Family Health Center MMG - CO-OP CITY AT DREISER LOOP MMG - Co-op City Office MMG - Burke Avenue MMG - Astor Avenue Pediatrics MMG - White Plains Road MONTEFIORE MEDICAL CENTER - WEILER DIVISION MMG1 Locations MMG2 LOCATIONS MMG3 LOCATIONS Montefiore North Clinics Hospitals MMG - WEST FARMS MMG - CFCC MMG - CHCC SOUTH BRONX HEALTH CENTER FOR CHILDREN & FAMILIES MMG - CASTLE HILL MMG - BRONX EAST
5 Creating A Culture of Excellence Multiple efforts across MMC Clinical Diabetes Center at Einstein Medical Center Three Ambulatory FQHC participated in Health Disparities Collaborative. Academic Chronic Care Collaborative Montefiore Medical Group Physician incentive program. Achieving Clinical Excellence Montefiore Care Management Organization On site RN works with patients as they come to see MD education, case management, MD reminders Telephonic case management Tiered education program mail, 4 hour, 10 hour - based on stage of disease and CV risk Registry
6 MMC CARE MANAGEMENT ORGANIZATION DIABETES MANAGEMENT PROGRAM Diabetes DM Program: Glycemic Control Measures For the 2736 members that were enrolled and actively case managed between Jan 2004 Mar 2009, their first 2-yr experience in the program demonstrates: On enrollment: 34% with A1c >9 24% with A1c <7 Most current: 18% with A1c >9 42% with A1c <7 Diabetes Quality Metrics (Comparison between 1Q-2008 to 1Q-2009) 8% admissions PMPY 25% in 1 o Diabetes admissions PMPY 22% in 30-day readmits PMPY 9% in ED Visits PMPY
7 MMG2 Health Disparities Collaborative FHC Diabeaters 2001 HRSA-IHI Breakthrough Series Collaborative Lowered A1c 9.2 to 7.8 Improved foot exams 30% to 80% Pneumovax 50% to 83% Improvement in LDL 18% to 54% <100 Bronx Defeats Diabetes Program $2.5 million HRSA grant to BCHN to provide outreach, community education, and peer education at CHCC, FHC, CFCC and Promesa Integrated with Collaborative work
8 Creating a Culture for Diabetes Excellence Pre-EMR Tool Integrate clinical guidelines in progress notes. DM guidelines available at every visits
9 MMC Diabetes Improvements ACE audit MMG Looks at glucose, BP, lipid control, foot exam, flu vaccine, Pneumovax in 20 chart audit Low performer chart review, intervention Clinical Looking Glass to replace chart review? FCC Diabetes program Sweethearts Internal Medicine resident referral clinic with APRN, nutritionist, SW, medical supplier A1c report cards for residents from CLG
10 Supporting a Culture of Excellence New York State P4P Demonstration Project Bronx CHAMPION Bronx Community Health and Acute Medical Performance Improvement Organizational Network. 2 year project Adult Providers Financial incentives for quality performance.
11 Diabetes Measures: External Comparison 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% BP BP < < 130/80 130/90 Eye exam HbA1c > 9.0% HbA1c done LDL < 100 LDL done Urine protein screen Bronx CHAMPION, 2009 NCQA, Medicaid 2008 NCQA Commercial, 2008 Benchmark Data Source: NCQA 2009 State of Healthcare Quality Report (2008 Data)
12 MMC/MMG Diabetes Recognition 3500 patient medical records collected over 2 years. Independent organization scored the records. 14% MMG P4P DM with A1C >9 (Medicaid 45%; Commercial plans 28%. 63% MMC LDL <100 (Medicaid 34%; Commercial 46%). 118 Physicians recognized from a combined 20 ambulatory sites 3 Year Recognition. Physician listed at the website. NCQA Recognition. Certificate of Recognition.
13 Next Steps MMC/MMG endorsed incentive program. Peer review Target low performers. Site QI activities. Chronic Disease QI/PI Electronic Medical Records Physician Report Cards PCMH ACO
14 Supporting a Culture of Excellence Electronic Medical Record
15 Acknowledgement Jonathan Swartz MD, MBA, FAAP Regional Medical Director Zach Rosen MD Family Health Center Sheila Felleman Director CMO Disease Management Sandra Barnaby RN, MPH, CDE CMO Disease Management Rohit Bhalla MD, MPH Chief Quality Officer
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