Session #206, March 8, 2018 Susan J. Kressly, MD, FAAP, Kressly Pediatrics Dr. Jacques Orces, D.O., Nicklaus Children s Hospital

Transcription

1 Improving Preventative Care in Pediatrics through Health and Technology: A Davies Story Session #206, March 8, 2018 Susan J. Kressly, MD, FAAP, Kressly Pediatrics Dr. Jacques Orces, D.O., Nicklaus Children s Hospital 1

2 Conflict of Interest Susan Kressly, MD, FAAP, Kressly Pediatrics Jacques Orces, D.O., Nicklaus Children s Hospital Has no real or apparent conflicts of interest to report. 2

3 Who We Are Founded in 2004 by Dr. Kressly with a clear vision: 3

4 Team: 3 Pediatricians, 4 RNs, 1 MA 4

5 Driven by Data.. Dedicated to the Relationship.. Always Working to Improve 5

6 Background The American Academy of Pediatrics Recommendations for Preventive Pediatric Health Care Evidence-based/evidence informed Optimum for all children to achieve a Bright Future Includes a periodicity schedule 6

7 Local Problem Not all children in our practice were receiving well visits at the periodicity outlined for optimum care Needed to change from reactive to proactive population health management Major payer P4P around well-care visits for HMO population (aligned with their HEDIS submission) 1 st 15 months of life 3 rd, 4 th,5 th and 6 th years of life Adolescents 7

8 Local Problem Had no coordinated efforts to address the problem all year long Would have reactive fire drill last quarter of the year when payer gave us preliminary data and would work hard to address gaps Often didn t have adequate available appointments to accommodate patient need In 2017 P4P expanded to PPO patients, not just HMO (doubled patients involved) 8

9 Ultimate Goal All children in the practice receive well visits at the periodicity according to Bright Futures Needed to change from reactive to proactive population health management 9

10 Design & Implementation Required a CQI format with iterative PDSA cycles, entire practice buy-in with frequent reporting back to entire practice team to collaborate and improve at monthly meetings Governance Structure: PCMH QI team Eventual Goal: 100% of patient population receiving well visits in accordance with best practice 10

11 Office Meeting Prioritize Achievable Goal Practice buy-in Set Goal Identify People, Processes, Technology Identify Owner Agree on the How Identify Technology Efficiencies Measure Report at Medical Home Meeting Adjust Process or Goal Measure, Report, Adjust 11 Implement Plan Execute Plan Identify Barriers/Gaps Monitor Buy In

12 LEVERAGING EXISTING TECHNOLOGY P h a s e 1 12

13 Step 1: Capitalizing on Existing Technology Clinical Decision Support already existed in EHR functionality to flag patients who were overdue for well visits in red Patient Chart: Taking a Message: Scheduling an Appointment: 13

14 Informed Workflow: Awareness Touch Chart: Provider or Staff Documenting Message: Provider or Staff Aware Overdue for Well Visit Schedule Well Visit at Point of Contact or Proactive Outreach Making Appointment: Provider or Staff 14

15 Step 2: Capitalizing on Existing Technology Clinical Decision Support already existed in EHR functionality to toggle easily between siblings Educated entire office on awareness of taking every opportunity to identify patients and siblings who were overdue for well visits and schedule at every point of contact 15

16 People & Processes Entire practice team (physicians and staff) educated/reminded about functionality at monthly Medical Home office meeting Ownership: everyone Agreed if family was in the office, would schedule appointments for family at the point of care Staff schedule Physicians request staff to schedule before the family leaves office 16

17 People & Processes Agreed if noticed while on the phone, staff would schedule (or physicians transfer call to be scheduled) Agreed if noticed while reviewing chart, processing transition of care, referral or other reason chart touched, staff would proactively reach out to family to schedule, or physician would send message to staff to perform outreach (leveraged messaging to by role integrated into EHR) 17

18 Challenges/Adjustments Needed to adjust schedule templates to accommodate more well visit appointments Staff suggested turning sick into well when identified in schedule at morning huddle: implemented Staff independently started looking ahead and making notations in schedule to use point of care to schedule siblings 18

19 Phase 1 Success Leveraged existing core HIT functionality in EHR CDS calculates due date for well visit according to Bright Futures periodicity Alerting (color highlighting) of user for care gap HIT functionality to easily navigate between siblings in patient chart Required increased awareness of entire team Required buy-in and ownership of entire team Limited success due to serendipitous nature of workflow 19

20 IMPLEMENTIN G POPULATION MANAGEMENT AND RECALL P h a s e 2 20

21 Population Health: Preventive Recalls Benchmark Baseline Identify Surveillance Queries Measurement Technology People Processes Recalls Prioritization Practice Implications: Positive & Negative Implementation 21

22 Health IT Leveraged Population Recalls Patient Messaging Quality Improvement Queries 22

23 Health IT Leveraged EHR functionality includes ability to identify patients overdue for well visits Can stratify by age Can stratify by payer Can stratify by other demographics 23

24 Health IT Leveraged 24

25 Health IT Leveraged Integrated Patient Message Exchange System can be utilized to proactively reach out to families according to their preference 25

26 Health IT Leveraged Quality Improvement Calculator has Internal queries, created custom report for well visit rates per percentage of active patient population 26

27 People & Processes Identified Recall Coordinator as PCMH staff role Protected Time to Work on Project (minimum 2 hours per week) 27

28 Recall Process 1 st week of month: identify Patients Overdue Send Bulk Messages Via Patient Message Exchange according to MU preference 1 week later: re-run query & print Send portal message If no response: text 1 week later: re-run query Call until get appointment scheduled Send 3 letter series if no response 28

29 Challenges Could not tackle entire population, needed to prioritize: Highest priority: Payer that rewarded P4P HMO patients first (one well visit during calendar year, did not have the 365 day rule) Age groups with school mandates: grade K, 6, 11 Already did well with children < 3 Schedule next visit at time of current visit (requires provider schedule always to be released 3 months in advance At 18 month and 24 month visits, have standing order task on well visit templates for 3 months in advance to contact family to schedule 24 and 30 month visits 29

30 Challenges Missed new patients who had not yet had well visit (recall query depends on interval since last well visit). Needed to find alternative way to capture those No shows: needed to follow up aggressively with missed well visit appointments 30

31 Task for Forward Well Visit Appt 31

32 New Patient: No Well Visit Date 32

33 PROACTIVE OUTREACH P h a s e 3 33

34 Fine Tuning the Process Expanding to Include all Payers, all age groups Proactive Recalls Altering Appointment Availability to Meet Patient Needs 34

35 Proactive Outreach: Optimizing Health IT EHR recall functionality had capability of choosing future date for running recall Release provider on the first of the month, 3 months in advance (for example: on August 1 st, release schedule for November through 11/30) Recall coordinator runs query to identify those due now or coming due through end of November and sends message through integrated messaging center: Your child has been identified as being due for a well visit between now and the end of November. We are now accepting appointments through November. Please contact our office at your earlies convenience to schedule appointment or request one through your portal account. 35

36 Proactive Outreach: Optimizing Health IT EHR recall functionality had capability of choosing future date for running recall & sent messages announcing schedule open inviting them to make an appointment 36

37 Meeting Patient Needs Outreach to patients regarding preferred time for well visits Young families requested earlier appointments: instituted 8 AM well visits (could come early and drop off at daycare a little late, rather than try to predict end of work day) Surveyed families with the intent to expand evening well visit hours, result of survey indicated preferred time frame 3-5:30 PM (avoid evening sports/activities): increased after school well visits and moved same day sick to later in day Put school holidays in appointment calendar and increase well visits for school-aged children accordingly 37

38 Value Derived Improved Patient Care: following evidence based guidelines Less last minute stress on office for required well visits (school/camp/sports) Hard ROI: P4P payer bonus Increased revenue from well visits 38

39 Value Derived: Hard ROI P4P payer bonus 2016: HMO ($36,900) and PPO ($40,560) Tier 1 Quality = $77, : 472 capitated patients Tier 1 Quality = $26, : 438 capitated patients Tier 1 Quality = $24,178 Increased revenue from additional well visits over baseline : $97, : $68, : $21,600 Total Value Derived over 3 year period: $314,892 39

40 40 95 %

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42 Asthma Home Management Plan of Care 42

43 Asthma Home Management Plan of Care 43

44 Asthma Background Asthma is the most common chronic condition of childhood and a major contributor to pediatric morbidity. One out of five children in Florida have lifetime asthma 1. In the pediatric population, asthma is one of the most frequent reasons for hospitalizations, accounting for close to 200,000 admissions, at a cost of $3 billion annually 1. Under-treatment and poor follow-up after discharge from hospitalizations, lead to poor control and increase risk of complications. 1 Forrest, J, Dudley, J. (2013, September). Burden of Asthma in Florida. Florida Health. Retrieved July 7 th, 2017 from 44

45 Asthma Background What are the Children s Asthma Core (CAC 1-3) Measures? In 2007, a set of initiatives were launched to examine children s asthma performance measures, specifically looking for quantifiable data that would help establish a baseline quality measurement of the inpatient management of asthma 1. Core Measure #1- Use of Reliever Core Measure #2- Use of Systemic Corticosteroid Core Measure #3- Home Management Plan of Care 1 Fassl, B. A., Nkoy, F. L., Stone, B. L., Srivastava, R., Simon, T. D., Uchida, D. A., Koompmeiners, K., Greene, T., Cook, L. J., Maloney, C. G. (2012, September). The Joint Commission Children s Asthma Care Quality Measures and Asthma Readmissions. Journal of the American Academy of Pediatrics. Retrieved on July 7 th, 2017 from 45

46 Asthma Background Call to Action The Burden of Asthma written by Florida Department of Health in 2013 was a Call to Action for health care providers and hospitals. Two of those actions called for: Assessment of readmission rates at different time intervals. Ensure patients have an Asthma Action Plan Dudley, J. & Forrest, J. (2013). Burden of Asthma. Retrieved on July 7th, 2017 from 46

47 Local Problem Goal Elevated asthma readmission rates. Children s Asthma Core measure 3 compliance 75%. Higher costs Average cost for an inpatient asthma readmission - $ Increase Children s Asthma Core measure 3 compliance from 75% to 100%. Reduce asthma readmission rates and costs. 1 Hyer, R. (2011, August). Inpatient Treatment of Asthma Is Costly. Engage Healthcare Communications, LLC. Retrieved on July 7 th, 2017 from 47 Asthma Local Problem

48 Asthma Design & Implementation Project Team Respiratory Unit RN Respiratory Unit Clinical Specialist PICU RN Pulmonologist Hospitalist Chief Resident Parent Advisory* Information Technology Pharmacy Informatics Respiratory Therapist Director of Quality Risk Manager Education 48

49 Asthma Design & Implementation Overview: Year-long design and implementation process Monthly project team meetings LightHouse assisted in meeting the first 2 CAC measures What is LightHouse? Cerner Quality & Process Improvement Application Measure 1 Use of a Reliever Measure 2 Use of a Systemic Corticosteroid CAC Measure 3 Asthma Home Management plan of care form optimized to an electronic form 49

50 Asthma How Health IT was Utilized ❶ ❷ Provider places Asthma order set containing the Children s Asthma Quality Measure Dashboard 50

51 Asthma How Health IT was Utilized ❸ Asthma order set contains a link to Zynx Health Evidence Based Information (guidelines for diagnosis and management of Asthma). 51

52 Asthma How Health IT was Utilized ❺ ❹ ❻ 52 Clinical Specialist reviews Asthma Quality Measure dashboard daily to ensure compliance.

53 Asthma How Health IT was Utilized ❼ When the provider places the Asthma Discharge Diagnosis, the system will trigger an Asthma Action Plan Alert to remind the provider to complete the Asthma Action Plan form. 53

54 Asthma How Health IT was Utilized ❼ The alert allows the provider to view the reference information and/or complete the Asthma Action Plan. 54

55 Asthma How Health IT was Utilized ❽ Asthma Action Plan form is completed. 55

56 Asthma How Health IT was Utilized ❾ In order to ensure that all medications ordered match those in the Asthma Action Plan, the system will trigger an alert if medications are ordered after the plan is completed. 56

57 Asthma How Health IT was Utilized Pre Asthma Home Management Plan of Care Form Difficult to read. Not patient/family friendly. 57

58 Asthma How Health IT was Utilized ❿ Patient/Parent/Guardian Asthma Home Care Plan 58

59 75% 87% 100% 100% Asthma Value Derived: Compliance CHILDREN S ASTHMA CORE-3 COMPLIANCE CAC-3 Compliance Expon. (CAC-3 Compliance) Q1 59

60 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Asthma Value Derived: Patient Safety Asthma Implementation Asthma Admissions Total Asthma Admissions 60 Total Asthma Readmissions

61 Asthma Value Derived: Patient Safety Asthma Implementation 178 % of Asthma Readmissions % 2.25% 2.27% % 0.87% 1.14% % % 20% 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% Total Asthma Admission Log. (% of Asthma Readmissions) 61 % of Asthma Readmissions

62 Asthma Value Derived: Patient Safety Total Asthma Readmissions Asthma Implementation Total Asthma Readmissions Expon. (Total Asthma Readmissions) Reduction in Asthma Readmission Rates 62

63 Asthma Value Derived: Finance $35,468 Asthma Implementation $23,645 $23,645 Asthma Readmission Costs $5,911 $11,823 $11,823 $23,645 $17, Q Q Q Q Q Q Q Q $40,000 $35,000 $30,000 $25,000 $20,000 $15,000 $10,000 $5,000 $0 Total Asthma Readmissions Log. (Total Asthma Readmission Costs) 63 Total Asthma Readmission Costs

64 Asthma Value Derived: Finance Asthma Readmission Costs $88, $65, Total Asthma Readmission Asthma Readmission Costs Cost Savings 64

65 Asthma Surveillance The Asthma Quality Measure dashboard is used on a daily basis to monitor compliance by the providers and clinical specialist of each intensive care and medical-surgical unit. The Asthma Measure compliance is also reported and available in the organization s web portal for all staff to view. 65

66 Asthma Summary Providing an asthma home management plan of care, which provides the information needed to manage symptoms and triggers at home, helped decrease asthma readmissions. The less frequent a family has loved one hospitalized, the less work days/school days are missed and the more satisfied they are with their care. Providing patients and families with the knowledge to manage their own care the more empowered they are as healthcare consumers. 66

67 Thank you! 67

68 Questions? 68