A Successful Office of Performance Review Visit at Hill Health Corporation

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• A Successful Office of Performance Review Visit
  at Hill Health Corporation
• Alexandra L. Chan, D.D.S., M.P.H., F.A.G.D.
• Director of Dental Services
• 428 Columbus Avenue
• New Haven, Connecticut
• Chief Executive Officer
• Cornell Scott, M.P.H.
• Chief Operating Officer
• Gary Spinner, M.P.H.

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• Our experience as an organization during.
• HRSAs Office of Performance (OPR) visit along
  with a visit from the Joint Commission- June
  19-22, 2007 -same time-same place!
• Hill Health Corporation- opened in 1968
• Extensive growth from 1 site to 19 sites over the
  years
• Multi specialty medical, dental and behavioral
  health care with focus on special needs
  populations
• Over 152,000 visits annually

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• What is OPR?
• -Each year HRSA conducts about 500 performance
  reviews to assure that more than 3,000
  organizations receiving grant or coopertive
  agreement funding from HRSA are successfully
  accomplishing their program goals

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• A Performance Review is a collaborative effort
  between HRSA and the grantee
• What does it involve?-
• -selection of Performance Review measures by
  Senior Leadership of the organization.
• -analysis of performance in relation to the
  selected Performance Measures.
• -creation of a Performance Report-this includes
  Performance Improvement (PI) options.
• -development of an action plan-includes PI
  actions to be completed by grantee on each
  Performance Measure

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• How did we prepare as an organization?
• -lots of pre-meetings with HRSA OPR team and
  senior leadership collaboration.
• Coordinating schedules with department heads and
  staff to prep for the visit- mock visits, team
  work, organizational preparedness and
  organizational transformation with a desire to
  learn from the collaboration-clinical,
  financial and operational lines-strengthens
  health center program overall
• -Senior Leadership-
• Review was critical in our continuous efforts in
  offering the best quality care that encompasses
  enhanced clinical quality outcomes utilizing the
  latest in reporting mechanisms- state of the art
  data capacity

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• Our Five Selected Performance Measures
• Performance Measure 1 Number of Users/Clients
  HRSA Grant Program (s)
• Health Center Cluster and Ryan White Part C
• Population Served Individuals and families from
  the Greater New Haven area.
• Clients ages cross the lifespan.
• The population reflects the community of New
  Haven. HHC currently serves 33 Black, 31
  Latino and 20 Caucasian clients. Thirty two
  percent of clients speak a primary language other
  than English.
• Services Provided Comprehensive primary care,
  behavioral health, specialty care, dental health,
  laboratory, nutrition and pharmacy services, and
  care for special populations such as the
  homeless, persons living with HIV/AIDS, and those
  with behavioral health needs.

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• Performance Measure 2 Current Ratio
• HRSA Grant Program(s) Health Center Cluster and
  Ryan White Part C
• Basis for Selection The current ratio is a
  measure of a health centers short term solvency
  (i.e., debt-paying capacity) and its ability to
  meet its current obligations.
• It measures whether an organization has enough
  assets that can be converted to cash in a years
  time (current assets) to cover its debts and
  obligations due in a years time (current
  liabilities).
• This measure gives a snapshot of the
  organizations overall financial health and
  viability.
• Important in community based organizations that
  often face challenges in balancing the provision
  of low cost care (i.e., sliding fee discounts)
  and generating revenue.

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• Performance Measure 3
• Percentage of children 5 through 18 years of age
  diagnosed with persistent asthma, who were
  prescribed appropriate medications
  (anti-inflammatory drugs)
• HRSA Grant Program(s) Health Center Population
  Served All children ages 5 through 18 with the
  diagnosis of asthma seen at any HHC sites.
• Services Provided Comprehensive primary and
  specialty care for asthma.

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• Performance Measure 4 Percentage of adults who
  were screened for depression during the
  measurement year.
• HRSA Grant Program(s) Health Center Cluster and
  Ryan White Part C.
• Population Served All adults who receive
  primary care services at HHC (N5,788)
• Services Provided Behavioral health assessment,
  psychotherapy, counseling, psycho-pharmacology
  services, psycho-educational programs and group
  therapy.
• Other services comprehensive primary care,
  specialty care, dental health, laboratory,
  nutrition and pharmacy services, and care for
  special populations such as the homeless, and
  persons living with HIV/AIDS.

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• Performance Measure 5 Percentage of clients
  with HIV infection who received an oral health
  exam during the measurement year
• HRSA Grant Program(s) Ryan White Part C
• Population Served Clients who are HIV infected
  and clients who are tested for HIV and counseled
  in New Haven County
• Services Provided Oral health exams and dental
  care for all clients who are HIVBasis for
  Selection Both the HIV/AIDS Program and the
  Dental Department are invested in assuring that
  all clients who are HIV receive the dental care
  that they need, in a timely manner.
• Data Source Dentrix in conjunction with CADR
  and Cerner
• Performance Trend There is currently only one
  data point in 2006, 60. For 2007 and 2008 it is
  expected that 10 increases will occur each year.
• This is a data development measure because data
  are not available for 3 or more years. In
  addition the CADR dataset is being cleaned and
  data entry being evaluated by a consultant.

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Performance Measure 5- HIV Clients that had an
Oral Health Exam During Measurement Year
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Dentrix exportation of Data and Cerner /AS400
Medical Practice Manager 2006 22 (using
specific ADA/CDT code for oral exams)

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• Oral Health/HIV measure selected-
• Stated Performance Measure Percentage of clients
  with HIV infection who received an oral health
  exam during the measurement year
• A. DATA OUTCOMES at HHC_-Measurement year May
  1, 2006 to April 30, 2007 (12 month period
  selected for this report)
• As discussed, in the future we will use
  Measurement year as UDS collection year (j1-d31
  calendar) or Health Center FY (July 1-June 30)
• Hill Health Center Dental Program
• There were 293 unique HIV patients (042
  diagnosis/identifier/diagnostic code used in
  Dental and Medical) from 5/1/06- 4/30/07
• There were 64 HIV/Ryan White Patients (70 visits)
  who received a dental examination for this period
• Numerator 64
• Denominator 293
• Thus there were 22 of clients with HIV infection
  who received an oral health examination during
  the measurement year. These patients also
  received HIV medical services from Hill Health.
• There were 293 unique HIV patients (042
  diagnosis/identifier/diagnostic code used in
  Dental and Medical) from 5/1/06- 4/30/07
• Numerator Number of clients with HIV infection
  who were seen for a medical visit within the
  measurement year, and had a dental exam during
  the measurement year, based on patient self
  report or other documentation1 Denominator
  Number of clients with HIV infection who were
  seen for a medical visit within the measurement
  year

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• Process for Reporting
• B. DATA Source/Methodology of data collection at
  Hill Health
• 1. In Dentrix electronic dental records a unique
  identifier code (042 code) indicates that the
  patient we serve has HIV status. (This was a
  logic method added in the early part of
  implementation of Dentrix system)
• 2. In Medical ( Cerner System/AS400 ), the 042
  code is also used/and HIV diagnostic code.
• 3. We then extract data from Dentrix using
  Procedure code (D0150 and D0120 indicting that
  patient had a Comprehensive oral exam or Recall
  exam) along with their diagnostic code 042 during
  measurement year.
• 4. Data extraction/Cross matching is then
  performed with our data warehouse system (Cerner)
  and we do a cross matching (patient
  names/DOB/diagnosis HIV/code 042 ) to see what
  patients with HIV diagnosis did indeed have HIV
  medical services during that given period.
• C.Goals/Plan for improvement- Since we are below
  IHI goal of 75 and national targets/benchmark etc

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• Our goal is to increase our 22 outcomes to 35
  by next year.
• How?
• Increase collaboration with medical services.
  Interdisciplinary care.
• Encourage and Increase number of referrals from
  Medical/HIV services to dental (via
  fax/interoffice mail/email. Walk over
  referrals/outreach)
• Hold slots have been created in Dentrix
  scheduling so our HIV patients are given
  priority appointments and care in dental once a
  referral is received
• National Goals- Comparison
• IHI Goal 75

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• Discussion Points with our Oral Health/HIV
  Performance Measure
• Community needs
• Health Care The Dental Department at HHC
  currently serves all HIV clients from HHC sites
  as well as one other Community Health Center.
• By the end of 2007 it is expected that HHCs
  client base will be accurate and reliable for
  further data collection.
• Unique identifier code is derived from the
  clients chart number, account number and name.
• HIV/AIDS providers trained about the oral health
  needs of their clients.
• To assure that the oral health needs are met in a
  timely manner a nurse will often walk the client
  from the primary care area over to the Dental
  Department to make an appointment.
• Special slots for appointments are left open each
  week for this population to assure that clients
  are seen quickly (hold slots).
• Emergency dental care within 24 hours. A dental
  triage system is in place to assess emergent
  needs.
• GOAL Show that our HIV clients are indeed
  incorporating oral health into their overall
  personal health regimen. This makes our
  Performance measure meaningful.
• Performance Improvement Options Going through
  the PI Committee, determine if HIV clients are
  getting appointments quickly while maintaining
  confidentiality. Obtain input from clients in
  how to evaluate these variables and respond to
  their feedback.

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• Innovation
• The OPR visit assisted us in identifying the
  importance of strong data collection and potent
  reporting mechanism.
• The main lessons learned is also INTENTION-
• We continue to work on improving our software and
  reporting mechanisms and data sets as a baseline
  for improvement
• BUT- we want to know how many of our patients
  are actually completing Phase 1 Therapy
  (preventive, restorative extraction, periodontics
  therapy) in a timely manner.
• Oftentimes, our special needs patients only have
  a few chances to get it done once and get it done
  right.
• My continuous vision for my program is to give
  all our patients the best possible dental care
  with robust and meaningful dental visits.
• After all, restoring and rehabilitating ones
  oral health needs greatly improves an
  individuals quality of life on many levels and
  leads to improved overall health status.

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Current Dental treatment plan completion rates
ALL clients 53
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Current Dental Treatment Plan Completion rate for
our HIV Patients for measurement year July 1,
2006- October 31, 2007 48
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• Collaboration/Integration
• The Dental Director and the HIV/AIDs Director
  meet to address quality of care, data issues,
  operational issues, QI projects and outcomes.
• The HIV/AIDS Director actively meets with other
  Community Health Centers with Part C programs to
  learn of other programmatic opportunities that
  might be successful-best practices
• The HIV Director continues to provide clinical
  updates for the Dental Department and the
  HIV/AIDS providers and staff.

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• More Collaboration
• The HIV/AIDS Director also collaborates with the
  MIS Director and the Operations Director and
  Performance Improvement (PI) Committee
• Determine how continuous training should be
  accomplished
• What reports should be generated and shared on a
  regular basis to test the system and inform
  Senior Leadership.
• When all is completed, this measure should be
  evaluated again using HHCs PI process.

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• Outcomes
• Goal- Continuous Quality Improvement and
  surpassing previous levels of compliance.
• Demonstrating that our HIV and all patients are
  incorporating oral health into their overall
  health practices

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• Data capacity
• OPR findings
• Goal, quality care.
• Measuring outcomes of care requires utilizing
  many internal operations i.e. MIS, PI, staff time
  etc.
• Work needed to identify methodology, conduct data
  collection, perform analysis and generate reports
  is very labor intensive.
• May be exaggerated possibly because much of the
  work is done within a department with little
  cross-departmental sharing from the very
  beginning of each project. Not unusual within
  health care environments.
• Addressing quality communication mechanisms,
  staff training and coordination of activities
  will improve data outputs, staff efficiency and
  satisfaction.
• Goal-more reliable reports on outcomes will be
  generated.
• Quality information helps to document
  organization wide outcomes which can then be
  utilized as part of marketing.
• Data quality improvement improved data capacity
  more client outcomes and operational processes
  can be measured.
• HHC considering hiring a PI coordinator. This
  coordinator could share the responsibility for
  implementation of the chart manager and
  eventually the EMR.

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• Replication/Sustainability
• Quality enhances our focus on continuous quality
  improvement.
• With designated performance measures through
  reliable data collection this allows us to
  constantly identify opportunities for healthcare
  improvement and delivery
• Results-better care and improved clinical
  outcomes for our patients.

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• Challenges being resolved/barriers
• Some of the quality of data for the HIV/AIDS
  program has been compromised due to data
  corruption from Careware (HIV software).
• Corrective actionNew dedicated server was just
  installed in August 2007 at Hill Health.
• Careware generated the CADR report - we all know,
  not everything captured by UDS or CADR is
  precise.
• Once this problem is fixed, it was identified
  that data entry needs to be re-visited since
  client data are entered into multiple HHC
  databases.
• Based on some data that have been graphed during
  our OPR visit it appeared that data collection
  may also be a problem.
• Findings from visits indicated that in the past,
  demographic information is very inconsistent from
  year to year.

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• Administrative Effectiveness
• Future investment in Electronic Medical Record
  with HL 7 interface w/ Dentrix and have best
  practice alerts to indicate to medical providers
  if their HIV client or any client is due for an
  oral health exam.
• A focus on interdisciplinary care approach is our
  goal. Oral health is integral to overall health.

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• Facts
• Numerous achievements have been made at HHC in
  the past few years
• Extensive building expansions and new site
  purchases
• Profitable ventures such as innovative practices
  with Dental, pharmacy and behavioral health
• EMR in the dental department with an eye towards
  future implementation throughout the organization
• Business upgrades with the telephone system,
• Partnerships with Yale, and greater financial
  stability etc.
• Currently undergoing a multi million dollar
  expansion of our dental programs 3 sites with
  continuous dental residency training
  partnerships.

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• Our Main site
• 428 Columbus Avenue New Haven
• Expansion, increase access
• 7 to 10 rooms
• Cost over 2.2 million
• Spring/Summer 2008 opening

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• Our Derby, CT site now. Too small
• Moving to new building
• Major access issues
• Very few dentists take Medicaid in area
• From 2-6 chairs
• Cost over 1.2 million
• Spring 2008 opening

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• Our School Based Site
• Katherine Brennan School-New Haven, CT
• Fully equipped dental suites, underutilized
• Expanding to new population of users
• Cost over 65,000
• Expansion Winter 2008

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• Lastly, success of a program stems from
• Continuous passion, support, leadership
  encouragement.
• I could not have asked for a better CEO and COO.
  A great place to BE. Thank you Gary and Mr. Scott
  for being you!

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• Thank You!
• Questions
• achan_at_hillhealthcenter.com
• Visit us on the web
• www.hillhealthcenter.com