Aligning for Ambulatory Clinical Excellence at Providence St. Joseph Health

Transcription

1 Aligning for Ambulatory Clinical Excellence at Providence St. Joseph Health Trista Johnson, PhD Chris Dale, MD MPH Andrea Ramirez VP, Ambulatory Quality and Clinical Services-Providence St Joseph Chief Quality Officer Swedish Health Services Pathways Program Supervisor Swedish Health Services 1

2 Objectives Objective 1: Share our process to develop aligned clinical performance measures for medical groups across a large health system and to implement proactive population health management. Objective 2: Share our progress to date in developing a framework to focus and prioritize organization attention on creating the reliable delivery of personcentered, high-value health at scale. Objective 3: Provide a strategic process for the sharing of best practices and driving improvement activities across a large health system. Objective 4: Share how a large health system has partnered to align clinical quality metrics in various ACO and at risk contracts to optimize clinical quality outcomes and use resources effectively. 2

3 Disclosures The speakers do not have any conflict of interest to declare. 3

4 Providence St. Joseph Health Providence St. Joseph Health 4

5 Clinical Governance Aligning Ambulatory Clinical Performance Metrics 5

6 IMPROVEMENT AT SCALE: Rapid system learning to narrow variation TIGHT LOOSE TIGHT Why, What by When System goals and Bundle Elements: Evidence-based practice Who & How Regional/ Local Tactics: putting theory into practice How we know Metrics reflecting bundle adherence and outcome improvement Facilitating Factors (Epic, Supplies, Communication, etc.)

7 Ambulatory Clinical Governance Structure Medical Group Executive Council Clinical Council Top Clinical Governance Group- CMOs and CNOs across system Sets System Clinical Strategy Operations Council Ambulatory Quality Council (AQC) Top Clinical Medical Group Governance Group- CMOs and Quality Leaders in medical groups Sets Ambulatory Quality Strategy Ambulatory Clinical Decision Team (CDT) Quality Leaders Meeting Focus on Sharing Best Practices to Improve Quality Outcomes Clinical Metric sub-group Specific Epic usability sub-groups Detailed groups working on Metric definitions and Epic design 7

8 Governance Structures Overall Governance Structures with representation from all regions- provides opportunity for input and engagement in decisions that should be done consistently across the organization Ambulatory Quality Council has over 70 members from all regions that come together to set the ambulatory strategy- clinical focus areas, metrics, etc. Challenges: - Multiple organizations with different historical cultures - Some new on the EMR Epic or planning to transition soon. - Different historical governance structures and work to integrate with these. 8

9 Healthy Planet Real-time Decision Support Proactive Gaps in Care Outreach Real-time Reporting for Providers to see Performance 9

10 1) Select metrics to investigat e 2) Review of national and existing definitions 3) Convene groups of clinicians to make recommendations 4) Design of metric details- Inclusions/ Exclusions 5) Approval of metric and definitions- AQC, CC, PEPN LC 6) Build metric and review initial data 7) Set baseline and move to performance metric 8) Performance Improvement and/or Management of Metric 1) Depression screening and monitoring metrics 2) BMI screening and follow-up metric 3) Advance Care Planning metric 4) Hepatitis C screening and follow-up metric 5) Opioid Management Metric 6) Pediatric Wellness Metrics (split these up for 2017) 10

11 Metric Prioritization Process

12 Metric Prioritization Process

13 Background: 2017 Advance Care Planning 2017 Ambulatory Quality Council Advance Care Planning Learning Metric The Percentage adult patients 65+ assigned to PCP with Advance Directive: Numerator: Healthy Planet patients with Advance Care Planning Documentation Advance Directive (AD) Living Will (LW) Power of Attorney (POA) 2017 AQC ACP Learning Metric Denominator: Healthy Planet: Active PCP/Care Team assigned patients 65 years and older in the Healthy Planet Adult Wellness Registry Data Source: Epic electronic medical record data in flow sheet and others from Doc Types in Scanned Documents Note: * AQC 8/3/17 Meeting: August 3, 2017 AQC Members Approved to Remove POLST From ACP Learning Metric

14 Quality Metrics Alignment Created a cross walk of the numerous (>400) clinical quality measures we report on for Medicare, Medicaid, Commercial, CMS and State oversight of clinical quality performance For our eligible clinicians participating in regular MIPS, these are the 26 clinical quality metrics that we are focusing on for the 2017 performance year. We will select 6 metrics for reporting Clinical Quality Measures listed by category: Metrics in Green: Core measures reported to the Board Metrics in Yellow: Included in MSSP and CPC+ programs Metrics in Grey: Selected areas not part of MSSP/CPC+ 14

15 Framework for Prioritization- Clinical and Financial Value 15

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17 2018 PSJH System Quality Goals Clinical Excellence Index--Acute Care CAUTI CLABSI SSI Colon SSI Hysterectomy C diff Sepsis mortality Patient experience (Inpatient, ambulatory, ED and home health) Readmission (AMI, CHF, PNA, COPD, CABG, Hip/Knee) PRO Collection Average direct cost per case (Top 20 conditions) Clinical Excellence Index--Population Health Breast cancer screening Cervical cancer screening Colon cancer screening Pediatric immunization Statins in ASCVD Diabetes bundle Depression Screening Advanced care planning 17

18 Index of Clinical Concern (Frequent) (Important) (Modifiable) Richard Wernick, MD, Medical Education Faculty at Providence Portland Medical Center 18

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20 Swedish Five Bests

21 Mission & Five Bests Externalities 21

22 Effect Size: Number Needed to Screen/Treat Example Data Colon Cancer Screening (colonoscopy) Number needed to screen to detect one cancer 154 Number needed to screen prevent one cancerrelated death 252 Cervical Cancer Screening (pap smear) Number needed to screen to detect one case of invasive cancer Number needed to screen prevent one cancerrelated death?? 6000 Breast Cancer Screening (mammography) Number needed to screen to detect one cancer 625 Number needed to screen prevent one cancerrelated death 2500 Rembold CM, BMJ 1998;317:

23 Swedish Health Services (Example Data) Measure Projected Incentive based on current performance (Thousands) Top Incentive Possible with Top Tier Performance (Thousands) CAUTI $900 $1,100 CLABSI $200 $1,100 MRSA $900 $1,100 C.Diff $1000 $1,800 Surgical Site Infection - Abd $(200) $1,000 Surgical Site Infection - Colon Surgery $0 $1,100 HCAHPS $600 $4, Day Readmissions (AMI/COPD/PN/HF/TKA/THA) $150 $2,400 Mortality (AMI/HF/PN) $900 $1,200 PSI-90 Modified Composite $200 $200 MSPB-1 $0 $1,500 23

24 Health System Prioritization (ΔHealth) (ΔRevenue) (ΔEffort) Sutton s Law: Rob banks because that s where the money is. 24

25 Prioritization and Project Size High Priority and Low Priority 25

26 Sharing Best Practices and Driving Improvement Activities 26

27 Large health system in greater Puget Sound area Affiliated with Providence in Hospital Campuses 75+ specialties and subspecialties 30 Primary Care Practices About 800,000 total patients About 300,000 primary care patients Swedish Medical Group

28 Pathways at SMG An intent to treat a population of patients in an agreed upon way Serves as a foundation for improvement

29 Pathway Production Team Quality and Value Clinical Stakeholders Practice Coaches Best Practice Team

30 Pathway Production Process What is our approach? How do we make it easy? How do we make it real? Pre-Pathway Research Stakeholder engagement Epic and Workflow optimization Implementation

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32 Implementation Clinic Process Improvement Teams Centralized Outreach Weekly Performance Data Aligned Incentives

33 Results More than 11,000 additional patients up to date on screening

34 Key Learnings Missional focus drives engagement Implementation builds on local structures Successful pathways are: Focused Aligned Integrated Sustained improvement takes time and focus

35 Swedish Pathways: The Future Bring more patient voice into pathway development Alignment of pathways across the continuum Balance between system (PSJH) and local pathways

36 Aligning Quality Performance Metrics in ACO and At Risk Contracts 36

37 OVER 600,000 PATIENTS IN VALUE BASED CONTRACTS Added PREMERA GOC MSSP to CPC+ PHP products drop

38 CHALLENGES Aligning organizational metrics with multiple contracts Large insurers have their own national metrics Coordinating quality contract requirements within a large organization Claims based results from insurers are delayed, not actionable Focus on total population vs. payer group VALUE BASED CARE - POPULATION HEALTH

39 COORDINATING WITH CONTRACTING Contracting sends new proposal for quality metric review Quality review makes alignment recommendations, may negotiate Contracting finalizes contract VALUE BASED CARE - POPULATION HEALTH

40 CONTRACT MANAGEMENT Accountable care services meets regularly with payers and key regional leaders Regions and Accountable care services respond to quality reports as appropriate. VALUE BASED CARE - POPULATION HEALTH

41 MACRA Quality Metrics Alignment Created a cross walk of the numerous (>400) clinical quality measures we report on for Medicare, Medicaid, Commercial, CMS and State oversight of clinical quality performance For our eligible clinicians participating in regular MIPS, these are the 26 clinical quality metrics that we are focusing on for the 2017 performance year. We will select 6 metrics for reporting Clinical Quality Measures listed by category: Metrics in Green: Core measures reported to the Board Metrics in Yellow: Included in MSSP and CPC+ programs Metrics in Grey: Selected areas not part of MSSP/CPC+

42 How are we reporting for Quality in MACRA? 1. MSSP TINS 2. CPC+ Practices Quality reporting will remain exactly the same, under the oversight of the Health Intelligence Team through the CMS Web Interface. We have successfully reported three years of MSSP data. The quality reporting requirements of the program will also satisfy this category. 3. MIPS - Non MSSP TINs/ CPC+ Practices The performance of the 2017 quality metrics will be monitored by the Ambulatory Quality Council, who will share performance and gap improvement with regions and select the 6 top performing metrics for all TINs that need to report in advance of the reporting period. Generally, reporting will occur much as it does today in that it will be delivered through the standard Epic and HI tools and will be accessed and used for internal reporting by other analytics groups within Providence (i.e. Physician Services, Clinical Analytics, GPS) The Ambulatory Quality Council with The Government Programs team will be responsible to ensure the submission of data to CMS through Epic, using the infrastructure in place for PQRS and Value Modifier reporting.

43 Quality Improvement Process and Timeline The Physician Services MACRA Quality Metrics Improvement Timeline shows the work that will be done through the end of 2017 in preparation for the 2018 reporting period.

44 Questions? 44