2016 Care. Quality Basic. Health

Transcription

1 Data Year Care Quality Summary Basic Health Measures

2 Santa Barbara County Public Health Department 2016 Medical Quality Improvement Summary Basic Health Measures Data Year Prepared By: Polly Baldwin, MD MPH and Melissa Gomez, RN CCM. Page 2

3 Table of Contents Comparative Table Annual Quality Comparison Summary 4 Stated Goals.5 Findings and Opportunities.5 Measure Review.6 Effectiveness of Care Results.6 Diabetes Care.6 Persistent Asthma on Controller Medication...7 Pediatric Nutrition Counseling...8 Adult Body Mass Index.9 Controlling High Blood Pressure 10 Tobacco Cessation Counseling 10 Breast Cancer Screening 11 Cervical Cancer Screening 11 Childhood Immunizations 12 Conclusions and Recommendations 15 Colorectal Cancer Screening 15 Thank you 18 References 18 Page 3

4 Comparative Table Annual Quality Comparison Summary June 2015 June 2016 The Healthcare Effectiveness Data and Information Set (HEDIS ) measures the efficacy of care provided in different health care delivery systems and sets a standard for health care across the nation. By following HEDIS and other quality measures, the Santa Barbara County Public Health Department (SBCPHD) can identify areas of success and opportunities for improvement. The SBCPHD conducted its annual audit of quality measures during the third quarter of This summary report contains a comparison of five years of data from Reporting Years 2011, , , and our current Reporting Year which included the time period from July 1, 2015 through June 30, Many of the same indicators have been measured several years in a row, but some measures are new. Comparison data may not be available for the newer measures. We continue to audit new measures every year as we identify areas where we would like to explore our care delivery. Also, we have changed our auditing method in the past few years. In the past, our audits were of a randoms sample of paper charts. We have converted to an Electronic Health Record and now our audits are electronic and we are auditing our entire patient population. PHD Quality Measures Universe Audit Result HgA1c less than 9 72% LDL <100 in DM patients Controller Medication for Persistent Asthma HTN with BP controlled(140/90 or less) Breast Cancer Screening Documented in the Chart Universe Audit Result Less Than 9= 52% Less Than 8= 45% Less Than 7=33% 34% 30% Universe Audit Result Chart Audit Chart Audit 2011 PHD Goals % 82% 61% 75% 32%(69% drawn) 42% 23% 50% 91% 87% 98% 88% 87% 70% 54% 57% 61% 65% 70% 60% 30% 30% 26% 36% 62% 59% Cervical Cancer Screening Documented in the Chart 59% 57% 58% 57% 61% 70% Page 4

5 Tobacco Cessation Counseling for Patients with Tobacco Use Weight Counseling for BMI Out of Range adult Counseling for BMI - Peds 14 Childhood IZ before 3 Yrs Colorectal Cancer Screening 66% 75% 74% 69% 47% 78% 42% 35% 7% 28% 40% 66% 43% 31% 14% 3% 31% 50% 92% 83% 93% 74% 33% 92% 29% 19% 5% N/A N/A 39% Depression Screening 22% 14% N/A N/A N/A 25% Provider wait times- Patient Satisfaction 75% N/A N/A N/A N/A 80% Stated Goals SBCPHD sets performance goals for each of the performance measures we monitor. Our goals are based on improving previous year s achievements and are guided by HEDIS percentiles for the Medicaid and Medicare populations and the goals of the National Healthy People 2020 campaign. Findings & Opportunities FINDINGS: Four of the twelve measures improved overall from measurement years 2011 to Those were for patients with Persistent Asthma on Controller Medication, Immunizations for Children under 3 years old, Tobacco Cessation Counseling provided for patients who reported using tobacco, and Depression Screening for all patients over 12 years old. The most notable improvement was for colorectal cancer screening which jumped from 5% to 29% in the past two years. Rates of HbA1c control (<9.0%) in diabetic patients dropped below our goal from 2011 to 2015, but have made steady improvement this past year. Rates of Nutritional Counseling Documented on all Pediatric patients and Adult patients with a BMI out of the normal range dropped from 2011 to 2014 with the implementation of our electronic health record, but have greatly improved in the past two years as a result of our quality improvement plan. Page 5

6 Rates of Blood Pressure control in patients with a diagnosis of Hypertension (HTN) dropped from 2011 to 2016, but remains close to goal. Breast and Cervical Cancer screening rates have seen a declining trend since The decline in Pap smear rates may be due to provider confusion as the recommendations for the onset and frequency of Pap smear screening have recently changed. The vaccination rate, which in previous years has been 80-90%, dropped to 33% in has recovered to 92% this year. This reflects our efforts to complete all the recommended vaccinations on schedule. Depression Screening is our newest measure. We have worked hard on meeting our goal, and actually exceeded our expectations. OPPORTUNITIES: SBCPHD will continue to devote time and resources to improve the care we provide. In 2016, efforts will be made to provide more collaborative care and case management to patients we see for their primary care needs. The following are some of the changes we are planning: Dedicated staff at each healthcare center will case manage patients with HIV infection, Asthma and Diabetes. As part of the Patient Centered Medical Home model, patients with other conditions which would benefit from more support will be identified for intensive case management. SBCPHD will present regular reports at healthcare center meetings to remind staff of our goals and the importance of quality care. SBCPHD will assist providers and care teams to gather and review their own quality data regularly. SBCPHD will report their quality data to providers, patients and the public. SBCPHD will develop policies and procedures for improving care in areas with opportunities for improvement. SBCPHD will enhance the accessibility of Medical Quality Improvement reports to staff and providers to increase their participation in the Quality Improvement process. SBCPHD will remind providers of the current guidelines for breast and cervical cancer screening. SBCPHD will be purchasing new software for population management and clinical, financial, and workflow quality improvement tracking. Measure In-depth Review Page 6

7 The following offers a review of SBCPHD quality measures from , and where possible include data from previous years including 2010, 2011, 2012, 2013, and The last three measurement periods have included a separate measurement of patients identified as experiencing homelessness. Our goals are the same for the entire population we serve; however, we have identified those experiencing homelessness as our most vulnerable patients, and as such want to ensure that we are doing everything possible to provide for their health care needs. Diabetes Care Chronic Disease Care Results Diabetes Care is measured by two metrics: level of hemoglobin A1c control and LDL cholesterol control. Specifically, we measured the percentage of patients years of age with diabetes (Type 1 & 2) who during the year had: Hemoglobin A1c levels < 9.0% LDL levels < 100 The percentage of patients with diabetes with good blood glucose control, those with a HbA1c <9%, had been declining in our system. Two years ago, it dropped into the 50% range, falling well short of our goal of 80%. During this past measurement year we adjusted our goal to 75%, and with outreach, care management, and a collaborative diabetes clinic at several of our care centers we have increased our diabetic control figure to 72%. The following chart shows how these numbers have fluctuated over the past several years. Page 7

8 According to American Diabetic Association the reductionn of HbA1c below 9% has a substantially greater impact on complications than reductions at lower levels. Less than 8% is the safest control level across the population for nearly all patients with diabetes and thee most net benefit can be gained by HbA1c levels reduced less than 8%. The number of diabetic patients with a Low Density Lipoprotein (LDL) under 100 mg/dl showed a slight increase to 34% this year. In this measure, we have struggled to reach our goal of 50% and there has been a lot of fluctuation over the years.. In 2011, the percentage was 23% %, in 2010 it was 36% and in 2009 it was 16%. Results forr this measure are based upon the patient s most recent LDL test, and it is important to note that if the LDL level was missing from the chart, or if an LDL test was not performed during the measurement year, the patient was consideredd out of range for this measurement. Healthy People 2020 set a national goal of 58.3% for LDL <100 mg/ /dl in patients with Diabetes. The chart below shows how our LDLL control has fluctuated over the years. Page 8

9 Cardiovascular disease is the leading cause of death for patients with diabetes. LDL can deposit in the walls of blood vessels, contributing to atherosclerosis (hardening off the arteries) and heart disease. People with Diabetes and high LDL cholesterol have a higherr risk for cardiovascular disease than people who do not have Diabetes. Persistent Asthma Patients on Controller Medications This measure quantifies the percentage of patients with the diagnosis of persistent asthma during the measurement period who were given a controller medication such as an inhaled corticosteroid or Singulair. This measure was added too our audits in 2011, so comparison data prior to then is not available. Page 9

10 Our audit found that 91% of the time our patients with persistentt asthma were given a prescription for a controller medication. Our goal for this measure was 70%. Given thatt we a performing over our goal on this measure, we are considering replacing this measure in upcoming years. Nutrition and Activity Counseling for Pediatric Patients This HEDIS measure quantifies the percentage of patients between 2 and 17 years of age who have their Body Mass Index (BMI) measured at least once during the reporting year and who were given counseling on nutrition and activity. This measure was added in 2011, so comparison data prior to then is not available. The last few yearss our audit was conducted using the reporting functions in our Electronic Health Record (EHR). In previous years, our audits were done manually. Using the EHR has allowed us to audit our entire universe of patients, rather than just a small percentage for each provider. This also means that if the counseling components were not entered in a way thatt our program can detect it, the results may not have been captured in our audit. Page 10

11 In 2011, when we audited manually, we met this measure 31% of the time. When we started auditing with the electronic health record, we droppedd to 3% and this year we rose up to 43%. Our prior audits found that the counseling was not documented in a way that was recognized by our reporting system electronically. Ourr EHR training team has worked with providers in documenting this measure in a manner that can be captured electronically, and we have seen tremendous improvement in our results. Adult BMI Measurement and Counseling for those with a BMI Out of Normal Range This HEDIS measure quantifies the percentage of patients over 18 years of age who have their BMI measured at least once during the reporting year and who were offered counseling if their BMI was out of the normal range. This measure was added in 2011, so comparison data prior to then is not available. Our audit showed that for patients with a BMI out of the normal range counseling was offered 42% of the time. Our goal for this measure was 60% %. SBCPHD has defined a BMI out of the normal range using World Health Organization (WHO) guidelines as a BMI lesss than 18.5 or greater than or equal to 25 for patients under the age of 65. For patients 65 and older, out of the normal range is defined as a BMI lesss than 22 and greater than or equal to 27. Page 11

12 Reporting Years Centers for Disease Control currently reports that over 34% of Americans are obese. Obesity-related conditions include heart disease, stroke, type 2 diabetes and certain types of cancer, some of the leading causes of death. Controlling High Blood Pressure (HTN) This HEDIS measure quantifies the percentage of patients years of age who have a diagnosiss of hypertension (HTN) and whose blood pressure was adequately controlled (<140/90). SBCPHD dropped from our goal of 60% too 54% this year. This may be in part because we audited electronically and therefore were able to auditt every chart, rather than just a random sample of charts. As a Patient Centered Medical Home, patients with HTN are being case managed by our medical support staff at the Health Care Centers. By focusing extra support on patients with HTN, we hope to help them achieve and maintain healthy blood pressure levels. Page 12

13 Reporting Years Untreated or inadequately treated high blood pressure can lead to stroke, heart disease, renal failure, and other medical problems. About 1 in 3 adults in the United States have high blood pressure. The condition itself usually has no symptoms. Tobaccoo Cessation Counseling This was a new HEDIS measure starting in Our 2011 audit found that we offered tobacco cessation counseling to our smoking patients 47% of the time. In the audits we increased this to 69%, and this year our result dipped to 66%. We have a goal to offer cessation counseling 78% of the time. We have been striving to reach our goal by working with our health care team to document their counseling efforts in the EHR and working with our tobacco cessation outreach coordinator to develop a program for patients who need this service. Also, as part of a Patient Centered Medicall Home, our patients who are identified as tobacco users are being case managed by our medical team and receive a care plan at least once a year. Page 13

14 Tobacco use is responsible for about one in every five deaths in the United States each year. Overall mortality among smokers is about three times higher than that among people who never smoked. Diseases that are related to smoking include cancer, heart disease, vascular disease and lung disease. Breast Cancer Screening Mammography This measure quantifies the percentage of female patients years of age who received a mammogram exam in the past year. The percentage of women who completed mammograms declined to 30% in 2015, from 36% in , as compared to 63% in It was 67% in The SBCPHD has set a goal of 59% completion of mammograms. In part the decline we have seen is due to our electronic health record which requires mammogram resultss be entered manually on to the flow sheet in the e-chart. We have been training staff on the workflow and are developing a preventive care form for each chart to help providers record, recall and track preventive services like mammograms. Page 14

15 Breast cancer is the second leading cause of cancer death among women in the United States. Widespread uses of screening, along with treatment advances in recent years, have been credited with significant reductions in breast cancer mortality. The US Preventive Services Task Force recommends screening mammography every two years for women aged 500 to 74 years.. Cervical Cancer Screening This HEDIS measure quantifies the percentage of female patients years of age who received a pap smear at least once in the past 3 years. The percentage of women who have received pap smearss was 59% this measurement period. The SBCPHD has set a goal of 70%. As demonstrated in the graph below, our cervical cancer screening rates have been relatively consistent over the past several years. As part of our Patient Centered Medical Home tasks, we are case managing preventive care and giving our patients annual reminders when they are due for preventive services. We hope to see improvement in our cervical cancer screening rates next year. We have also identified this measure as part of our yearly quality improvement plan, focusing on those women experiencing homelessness. Page 15

16 Women Receiving Cervical Cancer Screening 90% 80% 70% 60% 50% 40% 61% 57% 58% 57% 59% Cervical Cancer Screening Cervical Cancer Screening- Homeless 30% 20% 37% 32% 37% Goal (70%) 10% 0% Reporting Years Childhood Immunizations This HEDIS measure quantifies the percentage of patients at 3 years of age who have completed their recommended immunizatio ons (IZ). These immunizations are Polio (3), TDAP (4), Hepatitis B (3), HIB (3), MMR (1), Varicella (1), and Prevnar (4). After the SBCPHD compliance rates dipped in the lastt measurement period, one of our pediatricains organized a quality improvement team at one of the health care centers to work on improving this measure. The team was able too create a workflow(that was shared with the other centers) to address a childs immunization needs at every visit. Page 16

17 Reporting Yearss Colorectal Cancer Screening This HEDIS measure quantifies the percentage of patients over the age of 50 who have had colorectal cancer screening either with annual fecal occult blood tests, flexiblee sigmoidoscopy every five years, or a colonoscopy every 10 years. Thiss is a fairly new measure for us and we only have four years of comparison data. In the first measurement year, we were screening and documenting on 3% of our patients. Then we rose to 5% in This year we rose to 29%. The SBCPHD had set our goal at 22% for this measure, we will increase this goal to 39% for the next measurement period. Page 17

18 Reporting Year We feel we have significant room for improvement on this measure, and therefore formed a corrective action plan around this service over the lastt two years. We have made tremendous progress, and anticipate even better resultss on our next audit. Similar to mammography, results of the colorectal cancer screening must be entered manually into the flow sheet in the patient s e-chart. The EHR team has worked with staff on capturing the results in a measurable way.this year we have seen much higher numbers of patients being screened and having the screening documented correctly. Through ongoing training in documenting in the electronic record, and improved indexing of colonoscopy results, we anticipate continued improvement on this measure. Page 18

19 Conclusions and Recommendations Effective and successful interventions to reduce the onset and support the management of illnesses and chronic disease are crucial for the SBCPHD s patient population. Monitoring of HEDIS measures demonstrates the efficacy of the care we provide and is useful for identifying areas of success and opportunities for improvement. As we move forward with respect to the findings in this summary, we have great hopes to improve future care by collaborating with our providers and patients. We are dedicated to our mutual goals of promoting wellness and providing the highest quality of care for Santa Barbara County residents. Future goals include: Develop a Patient Centered Medical Home care approach at all of our Health Care Centers. Expand the use of provider teams to address the management of chronic disease. Facilitate patient access to care by fully integrating our electronic health record system into our medical practice and by offering patients access to the health centers via a patient portal. Utilize our electronic health record for case management of preventive and chronic disease care. Focus care management at the Health Care Centers to address the care needs of patients with Chronic Diseases like Diabetes and Asthma as well as to coordinate preventive health services such as cervical and breast cancer screening and annual preventive health assessments. Continue to support our Medical Practices Committee and its participation in program development, improvement and evaluation. Page 19

20 Thank You The, Quality Improvement Division, would like to thank all the staff that participated in the chart review and data gathering process required to complete our reporting. We would like to offer a very special thank you to our Information Technology, Systems Analyst Sr., Kim Loyst, for her assistance generating the reports from our EHR and Lorena Ocampo for her help with the graphics in this report. References American Diabetes Association Complications Accessed 6/2012. World Health Organization BMI Classification. Updated 6/2012. Accessed 6/2012 United States Preventive Task Force Website Updated 12/2009. Accessed 6/2012. Centers for Disease Control and Prevention Tobacco Related Mortality Accessed 8/2013. Page 20