Quality Improvement Program 2009 Annual Report to PIPS

Transcription

1 Quality Improvement Program 2009 Annual Report to PIPS Lisa Johnson, M.D. Medical Director for Quality Improvement Programs Community Oriented Primary Care, SFDPH

2 COPC Primary Care Clinics Medical Respite and Sobering Center (Fell St) CHPY Cole Street Clinic Ocean Park Health Center (OPHC) Castro Mission Health Center (CMHC) Special Programs for Youth (SPY) Maxine Hall Health Center (MHHC) Medical Respite and Sobering Center (Polk St) Chinatown Public Health Center (CPHC) CHPY Larkin Street Clinic Housing & Urban Health Clinic HUH Curry Senior Center Tom Waddell Health Center (TWHC) Community Oriented Primary Care Administration Potrero Hill Health Center (PHHC) Silver Avenue Family Health Center (SAFHC) Southeast Health Center (SEHC) CHPY Hip Hop to Health Clinic CHPY Balboa Teen Health Center CHPY Hawkins Clinic Last Revised: 04/14/2008

3 Slide courtesy Alice Chen, MD

4 COPC Health Centers Primary Care clinics: serve general population Castro Mission HC, Maxine Hall HC, Silver Avenue Family HC, Chinatown Public HC, Ocean Park HC, SouthEast HC, Potrero Hill HC Special Population Health Centers: Geriatric Focus: Curry Senior Center (aka NMHC) Youth: CHPY (Cole, Larkin St, Hip Hop, Balboa) Forensic: SPY (Special Programs for Youth) at YGC Homeless or Marginally Housed, w/ high prevalence psychosocial co-morbidities: Tom Waddell HC, Housing and Urban Health

5 COPC QI Program: Focus Areas Efficiency / Capacity / Access (HSF demand) Clinical Quality - Develop and Support: Centralized Quality Data reporting Data Driven QI initiatives at Health Centers Innovative Programs Population Management, Team Care (HCM) Behavioral Health / Primary Care Integration (OPHC Depression screening Program, 3 sites integrating staff this y) Chronic Disease Care PHASE, Chronic Pain Management Collaborations: SF and Regional Safety Net

6

7 COPC Utilization Active Patient Panels of COPC PCCs =35,528 FY Utilization (Visits and Undup Pts) Total Visits 200,894, made by 40,873 undup pts Medical Visits 119,695, made by 34,402 undup pts: 9,386 (27%) were new to the PCC COPC Capitated patients: enrollment 9/09 HSF: 14,878 total 28% Self-report NEW SFHP 11,181 total all lines of business Some are in Shadow Panel = enrolled but not yet seen, thus not counted in the active patient panel

8 Efficiency/Productivity Improvement Focus: increase Active Patient Panel at 8 COPC / HSF medical homes Minimum Panel size standards set: 1125 /1.0 fte Tools for measuring and tracking capacity shadow panel, panel flux reports Primary Care Redesign Project Demand moderation: return intervals, frequent flyers New Models of Care: telephone visits, group visits Team Care, health coach training, population management

9 COPC 8 PANEL SIZES (6/09): Active Patient Panel aggregate COPC 8 = 26,456 Average panel size/fte for aggregate COPC 8 clinics rose from 1040 (2/08) to 1138 (6/09) Also growing: COPC 8 Shadow Panel = 8,923 enrollees Active PCC Panel per Clinical FTE among COPC8 clinics Feb 08 Jun 08 Oct 08 Feb 09 Jun 09 Oct 09

10 COPC Efficiency Measures Measure Frequency Notes PANELS Active panel size q 3 mo Active panel size per clinical FTE q 3 mo Adjusted active panel size q 3 mo Adjusted active panel size per clinical FTE q 3 mo Avg medical visits to PCC per patient per year Yearly % of active PCC panel with PCP q 3 mo EFFICIENCY and ACCESS No show rate q 3 mo Third next available appointment q 3 mo Requires manual sampling. Panel flux (attrition from patients leaving, new pts) q 3 mo MD visits per hour (productivity) q 3 mo NP visits per hour (productivity) q 3 mo Cycle time q 3 mo Requires manual sampling.

11 Clinical Quality: centralized reporting on measures for all COPC Active Pt Panels Measure Frequency Notes QUALITY DM with HgA1c testing in past year q 6 mo NCQA/HEDIS DM with most recent HgA1c <7, <8<, and > 9 in past year q 6 mo 2010 NCQA/HEDIS DM with LDL testing in past year q 6 mo NCQA/HEDIS DM with most recent LDL < 100 in past year q 6 mo NCQA/HEDIS % of adults age 65 and over with pneumococcal vaccination ever q 6 mo USPSTF, ACIP % of adults age 22 and over with tetanus vaccination in past 10 Q 6 mo ACIP years Lipid screening among men 40 yrs old and women 50 yrs old Q 12 mo USPSTF Women age with breast cancer screening in past 2 years Women age with breast cancer screening in past 2 years q 3 mo USPSTF, NCQA/HEDIS Women age with cervical cancer screening in past 3 years q 3 mo USPSTF, NCQA/HEDIS Adults age with colorectal cancer screening q 3 mo USPSTF

12 Diabetes HgA1c & LDL Testing Primary Care Reporting Group, Community Oriented Primary Care, SFDPH, 07/2009

13 Adult Immunizations in Primary Care Pts age 22 and over with tetanus vax within 10 yrs Pts 65 yrs old with pneumococcal vaccine in lifetime For Pneumovax: TWHC (50% to 73%), HUH (35% to 55%) had biggest gains. Primary Care Reporting Group, Community Oriented Primary Care, SFDPH, 05/2009

14 Lipid screening among men 40 yrs old and women 50 yrs old (USPSTF A) (USPSTF Rec: screen q 5 yrs, starting at men age 35, women age 45) Primary Care Reporting Group, Community Oriented Primary Care, SFDPH, 05/2009

15 Women s Cancer Screening September 2009 Eligible Women by Age Range Age Age Age COPC Subtotal 12,645 9,879 6,795 SFGH Subtotal 10,298 5,900 3,704 CHN TOTAL 22,943 15,779 10,499 Primary Care Reporting Group, Community Oriented Primary Care, SFDPH, 09/2009

16 COPC Allergy documentation in the LCR Allergy Data for COPC Primary Care Clinics FY % 100% 80% 60% 40% 20% 0% 93% 97% 86% 88% 79% 78% 75% 77% 78% 62% 53% 31% 43% 30% 28% July-08 October-08 January-09 April-09 July-09 COPC SPY OPHC

17 COPC Fiscal Year External Audits Auditing Agency Sites Visited Results HIV Qual / CARE June 2008 Anthem Blue Cross- October 2008 Title X Family Planning December 2008 Health Care for the Homeless- July 2009 San Francisco Health Plan : FY TWHC, CHPY TWHC CMHC, MHHC, SAFHC,CPHC, CHPY CMHC, TWHC CHPY, CMHC, PHHC, MHHC,OPHC, CPHC, SEHC, TWHC Results Pending PASS Addressed all findings and recommendations. Results Pending due in November All facility Site Reviews were 96% plus All Chart Reviews were 94% plus

18 UO Categories in COPC clinics COPC- UO's by type FY Top 5 categories (225 of 273) Treatment- Diagnosis Consent Issues Medication- Drugs Safety/ Security Laboratory Medical Records Q3-4_2008 Q1-2_2009

19 2009 Health Center Data Driven QI Projects All Health Centers responsible for 2 Data Driven QI projects (2009 = YR 2) 9 Health Centers participating in HSF Strength in Numbers PCC PERF MEASURE # 1 PERF MEASURE # 2 SIN project CMHC Chronic Disease: DM Allergy documentation Chronic Pain Mgmt 02MHHC HCM: lipid screening HCM: adult IMZ Chronic Pain Mgmt 03SAFHC HCM: Ca screen (Pap) HCM: CRC screening HCM: CRC screening 04CPHC HCM: CRC screening Chronic Disease: DM Chronic Disease: Hep B 05OPHC Chronic Disease: Depression HCM: adult IMZ Chronic Disease: Depression 06PHHC HCM: CRC screening Chronic Disease: DM Chronic Pain Mgmt 07SEHC Chronic Pain Mgmt HCM: CRC screening HCM: CRC screening 08TWHC HCM: adult IMZ HCM: CRC screening Chronic Disease: HIV HUH Chronic Disease: DM Chronic Disease: CV N/A CSS Chronic Disease: DM HCM: adult IMZ N/A

20 Primary Care: 2009 focus on improved prevention /screening measures As part of planning for HSF: PC QI worked with PCRG and i2i workgroup to develop Population Management tools for HCM interventions Expanded centralized reports on Health Care Maintenance measures Updated HCM field in LCR, built interface into i2i. Now can easily preview HCM prior to clinic visit, generate outreach / reminder lists, do statistical reporting. Demonstrated tools, supported pilot efforts, Result is increased focus on HCM at health centers

21 CPHC: Goal: 70% Td or Tdap Baseline: 56% (November 2008) QI strategies: Train nursing staff to conduct pre-visit chart and LCR preview to identify patients due for Td / Tdap Create standing orders to routinely administer vaccine 100% 90% 80% 70% 60% 50% 40% Tetanus: % of adults age 22 and over with documented vaccination in past 10 years Nov-08 May-09 Jun-09 Jul-09 Aug-09 Sept-09

22 Why focus on preventive care? Significant disparities in receipt of preventive care services among racial/ethnic groups and poor. Only 10% of female Medicare beneficiaries received all of 5 recommended preventive care measures (cervical, breast and colorectal cancer screening; pneumovax and influenza vaccines). General Accounting Office congressional testimony on 3/23/02, available: Barriers to screening in Safety Net Patient Financial barriers, System resource constraints Literacy, language, and cultural barriers Conflicting guidelines for PCPs 7.4 hours/day to provide all USPSTF A and B services Yarnell KS, Pollak KI, Ostbye T, Krause KM, Michener JL. Primary care:is there enough time for prevention? American Journal of Public Health 2003; Slide courtesy of Alice Chen, M.D.

23 SFDPH Primary Care Approach Agreement on evidence-based guidelines, tailored to our system s resource constraints USPSTF guidelines - posted at Treatment Guidelines Clear referral guidelines for abnormal screening tests Harness information technology EMR and Patient registry LCR HCM, i2itracks AHRQ electronic Preventive Services Selector Systems interventions Standing orders Population Management (staff training MEAs, HW s) Culturally and linguistically appropriate outreach Slide adapted from Alice Chen, M.D.

24 Example: CRC Screening Improvement Clear evidence-based guidelines, agreed upon by both GI and PC, compatible with DPH resources SF DPH recommends annual FOBT,for screening, with diagnostic colonoscopy for abnormals (USPSTF) Use of HCM field in LCR for data entry and reminders, i2itracks for reporting and outreach Systems interventions Population Management staff training (MEA s, HW s) to capture data (ouside colonoscopies) and encourage FOBT Standing orders to dispense FOBT cards if due Culturally / linguistically appropriate outreach Slide adapted from Alice Chen, M.D.

25 CRC Screening in SFDPH Primary Care Castro-Mission Health Center 38% Chinatown Public Health Center 57% Curry Senior Center 28% Maxine Hall Health Center 36% Ocean Park Health Center 67% Potrero Hill Health Center 33% Silver Avenue Family Health Center 47% Southeast Health Center 36% COPC8 Subtotal 46% Housing and Urban Health Tom Waddell Health Center (PCP panel) 13% 15% COPC Subtotal Family Health Center General Medicine Clinic Ward 1M SFGH Subtotal CHN TOTAL 41% 46% 48% 47% 43% 0% 10% 20% 30% 40% 50% 60% 70% 80% % age with colorectal cancer screening (Data capture for colonoscopies not complete at some PCCs)

26 How did CRC rates improve at 2 clinics? FLU-FOBT program at Chinatown PHC. Led by Mike Potter, Albert Yu) with CDC funds 2008: results: Flu shot only: 52.9% 57.3% eligible completed FOBT Flu shot+ FOBT: (education and pre-paid mailer) 54.5% 84.3% eligible completed FOBT Difference of 25.4 points, p<0.001 Potter MB, Phengrasamy L, Hudes ES, McPhee SJ, Walsh J. Offering annual fecal occult blood tests at annual flu shot clinics increases colorectal cancer screening rates. Annals of Family Medicine 2009; 7: Overall CPHC rate Sept-09 = 57% 7 COPC clinics to participate in similar program 2009 flu season Ocean Park HC gains all achieved with population management by MEAs and HWs sustained effort over 18 months Baseline Jan-08 = 40%, Sept -09 = 67% Slide courtesy of Albert Yu and Mike Potter

27

28

29 Depression Program at OPHC Why? 5 th OPHC dx, co-morbidity w/ chronic disease, need to treat in Primary Care AIM: By July 2009, screen 80% of DM patients (PHQ tool) How? Adapt IMPACT Model: 4 elements Screen in Primary Care with PHQ-2/9 tool: 494 DM pts Develop New Role: Depression Care Manager Internationally trained behavioral health workers working as a team with Social Worker education, SMGs, monitors depression sx closely, f/u on meds, consults with providers, social worker/ psychiatrist Psych back-up consultation q week - CBHS collaboration Tracking process and outcome measures To date at 5 mos: 80% of diabetics screened. Of those screened, PHQ score for 25% = mild (9%) or moderate (16%) depression. Slide courtesy of Lisa Golden, MD

30 PC Chronic Pain Management Initiative Feb 08: SFDPH-Wide Pain Taskforce Report SFGH focus April 09: Primary Care Pain Workgroup (SFCCC, SFGH PC, COPC) -- commitment to uniform minimum standard of care August 09: COPC Chronic Pain Management Policy and Procedure approved by PC QI links to tools / templates Informed Consent for Long-Term Controlled Substances Therapy for Chronic Pain Patient-Provider Agreement for Long-Term Controlled Substances Therapy for Chronic Pain Chronic Pain Assessment and Treatment Plan Documentation Form in draft: Special Circumstances in Use of Controlled Substances in the Treatment of Chronic Pain: Inappropriate Use and Diversion". Registry Use at 6 clinics (5 COPC and GMC): 1594 patients identified on chronic opiate pain management (7% of the combined active pt panel of those 6 clinics) Measures selected (example: % with pain contract in chart)

31 Chronic Disease: PHASE Program Preventing Heart Attacks and Strokes Everyday Kaiser funding to replicate in safety net settings Goal: embed evidence-based CV risk reduction guidelines in day-to-day practice. Emphasis: med adherence (ASA, Statin, b-blocker, ACE-Inh) Lifestyle change: smoking cessation, diet, exercise Implemented in 4 SFDPH clinics Jan OPHC, CPHC, GMC, FHC - $400K over 2 years Funds used for staff training in TEAM CARE skills (panel managers, health coaches, registry use) partnered with Dr. Tom Bodenheimer and his training team Applied for PHASE 2 ( ) $300,000 over 2 yrs to expand program to total of 7 PHASE sites

32 SFDPH PHASE Results /1/2008 7/1/2008 8/1/2008 Population Size in Registry: All Patients at All Sites 100 Percent of Total DM Patients with HbA1c < 7, < (N = 993) 7/1/2008 8/1/2008 9/1/ /1/ /1/ /1/2008 1/1/2009 2/1/2009 3/1/2009 4/1/2009 5/1/2009 6/1/2009 7/1/2009 8/1/2009 9/1/ /1/ /1/ /1/2009 1/1/2010 % of Patients with HbA1c < 7 % of Patients with HbA1c < 8 Goal for % of Patients with HbA1c < 7 Goal for % of Patients with HbA1c < Percent of Patients with LDL < 100 (N = 1122) Percent of Patients with BP< 130/80 (N = 1122) /1/2008 8/1/2008 9/1/ /1/ /1/ /1/2008 1/1/2009 2/1/2009 3/1/2009 4/1/2009 5/1/2009 6/1/2009 7/1/2009 8/1/2009 9/1/ /1/ /1/ /1/2009 1/1/2010 7/1/2008 8/1/2008 9/1/ /1/ /1/ /1/2008 1/1/2009 2/1/2009 3/1/2009 4/1/2009 5/1/2009 9/1/ /1/2008 6/1/2009 7/1/2009 8/1/ /1/ /1/2008 9/1/ /1/ /1/ /1/2009 1/1/2010 1/1/2009 2/1/2009 3/1/2009 4/1/2009 5/1/2009 6/1/2009 7/1/2009 8/1/2009 9/1/ /1/ /1/ /1/2009 1/1/2010 Population Size in Registry N = 1193 Subpopulation DM patients (N = 1051)

33 SFDPH PHASE Results Percent of Patients on ASA (N = 1122) Percent of Patients on Statin (N = 1122) /1/2008 8/1/2008 9/1/ /1/ /1/ /1/2008 1/1/2009 2/1/2009 3/1/2009 4/1/2009 5/1/2009 6/1/2009 7/1/2009 8/1/2009 9/1/ /1/ /1/ /1/2009 1/1/2010 7/1/2008 8/1/2008 9/1/ /1/ /1/ /1/2008 1/1/2009 2/1/2009 3/1/2009 4/1/2009 5/1/2009 6/1/2009 7/1/2009 8/1/2009 9/1/ /1/ /1/ /1/2009 1/1/ Percent of Patients on ACE/ARB (N = 1122) Percent of Patients on all 3 medications (Statin, ASA, ACE/ARB) (N=1122) /1/2008 8/1/2008 9/1/ /1/ /1/ /1/2008 1/1/2009 2/1/2009 3/1/2009 4/1/2009 5/1/2009 6/1/2009 7/1/2009 8/1/2009 9/1/ /1/ /1/ /1/2009 1/1/2010 7/1/2008 8/1/2008 9/1/ /1/ /1/ /1/2008 1/1/2009 2/1/2009 3/1/2009 4/1/2009 5/1/2009 6/1/2009 7/1/2009 8/1/2009 9/1/ /1/ /1/ /1/2009 1/1/2010

34 SFDPH PHASE Results Percent of Patients with Documented Self-Management Goal EVER (N = 1122) 100 Percent of Patients with Foot Exam DM patients (N = 993) /1/2008 8/1/2008 9/1/ /1/ /1/ /1/ /1/ /1/2009 3/1/2009 4/1/2009 5/1/2009 6/1/2009 7/1/2009 8/1/2009 9/1/ /1/ /1/ /1/2009 1/1/ /1/ /1/ /1/ /1/ /1/ /1/ /1/2009 2/1/2009 3/1/2009 4/1/2009 5/1/2009 6/1/2009 7/1/2009 8/1/2009 9/1/ /1/ /1/ /1/2009 1/1/ Percent of Patients with Retinal Exam DM patients (N = 993) Percent of Patients with Smoking Status Documented (N = 1122) /1/2008 8/1/2008 9/1/ /1/ /1/ /1/2008 1/1/2009 2/1/2009 3/1/2009 4/1/2009 5/1/2009 6/1/2009 7/1/2009 8/1/2009 9/1/ /1/ /1/ /1/2009 1/1/2010 7/1/2008 8/1/2008 9/1/ /1/ /1/ /1/2008 1/1/2009 2/1/2009 3/1/2009 4/1/2009 5/1/2009 6/1/2009 7/1/2009 8/1/2009 9/1/ /1/ /1/ /1/2009 1/1/2010

35 Future directions Collaborations to coordinate care in SF SF DPH Primary Care Clinics + SFCCC Clinics Primary Care (COPC) + Behavioral Health (CBHS) Integration Kaiser Specialty Care Initiative (Specialty + Primary Care Co- Management of Chronic Conditions) SFHP / HSF QI Committees Move to Standard Quality Measures in Safety Net Clinical Quality / Efficiency / Patient + Staff experience Measures CPCA Standard Measures Group membership CAPH Safety Net institute : Seamless Care Initiative (QI Leaders Group membership) SFDPH Primary Care Dashboard development