Southeast Michigan Beacon Community

Transcription

1 Southeast Michigan Beacon Community GDAHC: Coffee and Controversy November 1,

2 Southeast Michigan Beacon Community (SEMBC): Part of a Health Care Quality Revolution Guiding Principles: Building and strengthening health IT infrastructure and exchange Driving measureable improvements in cost, quality, and population health Testing innovative, evidencegathering approaches to improve health care performance measurement, technology integration, and delivery 2

3 HIT-Enabled Clinical Transformation: Target Goals and Measures A 5% increase in the proportion of diabetic patients who receive standard recommended testing and examinations A 5% reduction in the proportion of nonurgent Emergency Department utilization among diabetic patients. A 5% reduction in the proportion of diabetic patients having disparity ratios for quality of care and population health measure disparities related to gender, insurer, or race. 3

4 Southeast Michigan Beacon Community (SEMBC) Vulnerable Population Detroit, Highland Park, Hamtramck, Dearborn, Dearborn Heights Population Flight Physician Flight Considerations Unemployed Uninsured Limited access to healthcare 4

5 Prevalence of Diabetes Approximately 10% of adults in Michigan have type 2 diabetes For Wayne County, as many as 12% of adult residents have type 2 diabetes In Detroit, the reported rate is as high as 16% 10% 12% 16% Source: Centers for Disease Control and Michigan Department of Community Health 5

6 Prevalence of Diabetes Medicare beneficiaries Statewide: 29.15% Beacon target zip codes: 43.5% 12% Source: Medicare Part B 6

7 SEMBC Interventions Physician data reporting and performance feedback Establish a network of physicians who are committed to process change and data exchange. Care Coordination Ambulatory Utilization of patient navigators to help patients adhere to treatment plans. Clinical Decision Support Targeted alerts, reminders, and decision support information. Care Coordination Hospital Emergency Departments Partnerships with ED that helps identify, treat, and coordinate care of diabetic patients. Patient Engagement Partnerships with community and faith-based organizations that extend the reach of SEMBC. Telehealth Use mobile and other messaging options to identify diabetes within the SEMBC. 7

8 Clinical Transformation 8

9 Clinical Transformation Objective Achieve a 5% increase in standard testing among diabetics at SEMBCaffiliated practices High impact measures include A1c testing LDL-C testing Eye Exams Foot Exams Blood pressure <140/90 9

10 Clinical Decision Support Clinical Transformation Components Reviewing Reports and Goal Setting HIT, Registry, EHR Workflow and Process Patient Health Navigators Patient Education 10

11 CT Participation and Outreach Key Participants/Activities 46 SEMBC-Affiliated Practice Sites - FQHC 22 - Private Practice SEMBC-Affiliated Physicians - FQHC 68 - Private Practice 55 4 Emergency Departments 7 Patient Health Navigators 29 Community/Faith Based Events 11

12 Emergency Department Intervention 12

13 ED Intervention Background Objective Identify and engage diabetics sooner rather than later Strategy Work with local EDs to identify previously undiagnosed diabetics and pre-diabetics and direct them to an appropriate care setting 13

14 Intervention Design Based on initiative that was started at Detroit Receiving Hospital Enhanced by Increased accessibility Linkage to primary care Community-wide expansion Multi-health system work group Detroit Medical Center Henry Ford Health System St. John Health System Oakwood Healthcare 14

15 Participating EDs Detroit Receiving Hospital Point-of-care testing Active: February 12, 2012 St. John Hospital Post ED visit data analysis and care coordination Active: March, 2012 Henry Ford Hospital Point-of-care testing Active: July 1, 2012 Sinai Grace Hospital Point-of-care testing Q

16 Participating EDs On site point of care process for non-acute patients Simple screening process to determine Hemoglobin A1c level Based on results: Patient education classes Patient Health Navigator support Access to primary care Referral to endocrinology clinic Txt4health 16

17 Emergency Department Diabetes Identification and Care Coordination Intervention Template: Detroit Receiving, Sinai-Grace, Henry Ford Hospitals Patient Arrives at DRH Triaged Checkin Non- Acute Patient Patient Referred to Ambulatory Receiving Ctr. A1C Program Assistant (PA) Approaches Patient for Testing Patient Agrees to Test: A1C Program Assistant Conducts Test (Finger Stick) Acute Patient to Main ED (STOP) Prisoner Psych (STOP) Patient Declines (STOP) Results < 5.7 No Diabetes No Action - Offered txt4health PHN Patient Follow-Up > 6.5 Pre-Diabetic - Offer DEALM Class PA can schedule - Offered txt4health Diabetic - Offer DEALM Class PA can schedule - Offered txt4health - Offered PHN Intervention > 8.0 Diabetic - Patient Referred to Endocrinology Clinic for Consult - Offered txt4health PHN Intervention Yes No (STOP) Consent Form to SEMBC Gets PHN Packet 2-3 Call Attempts No Contact (STOP) Connect with Patient Direct Patient to PCP and Help Secure Appointment < 2 Call Attempts to Patient to Confirm Appointment 17

18 Preliminary Results Non-Diagnosed Diabetics and Pre-Diabetics 2/1/12 10/15/12 7/2/12-10/21/12 3/25/12-9/30/12 (PHN referral) # Eligible Patients 16,834 6,421 n/a # Patients Tested 7,042 42% 2,342 36% n/a Pre-Diabetic (A1c ) 1,904 27% 262* 11% n/a Diabetic (A1c > 6.5) 416 6% 102* 4% n/a PHN referrals from diabetic population 294** 71% 109** 30% 374 * Lower diabetes prevalence at Henry Ford attributed to lower average age of patients tested in pilot section of ED. **DMC PHN referrals for diabetic patients only. Henry Ford PHN referrals for pre-diabetic and diabetic patients. 18

19 Preliminary Results Primary Care Coordination Detroit Receiving Hospital Total Referred 279 Engaged in Primary Care % Declined 4 1.4% Unable to Engage % In Process 67 24% 19

20 Post-ED Intervention Strategies Now What?? 20

21 Safety Net Integration Ongoing and active work with FQHCs Direct patients with no medical home to FQHCs Strategies for increased access Patient Health Navigator support 21

22 Safety Net Integration Cross-functional work group facilitated by Voices of Detroit Initiative (VODI) Evaluate frequent flyers across health systems Unique patients with 3+ ED visits in one year Survey patients for root cause of ED use i.e. lack of primary care availability, transportation, don t know other sources for care Detroit EMS data cross referenced; patient survey implemented for root cause of EMS use Recommendation to Mayor s Office for city support of intervention to include care coordination 22

23 Ambulatory Care Clinics GDAHC-Oakland Southfield Physicians (OSP)-Blue Care Network study on emergency department use Study of ED use; intervention strategy deployed; reduction in ED use in six OSP clinics SEMBC affiliated clinic training on strategies to educate patients on appropriate use of emergency services After hours messaging New patient communications Patient letters on availability of on-call physicians in practice 23

24 Conclusion Identification of diabetics in Emergency Department is a start to early identification Culture and process change required at ambulatory care practices to encourage patient clinic visits and additional access Public health campaigns such as txt4health to create awareness of risk factors and healthy habits Care coordination of diabetics identified in Emergency Department is key to moving patients into regular care 24

25 Contact Sue Hashisaka Director, Clinical Transformation