Improving Quality of Care through Care Management

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Improving Quality of Care through Care Management

• Robert Moore, MD MPH FAAFP
• Medical Director, Community Health Clinic Ole
• Medical Director for Quality, Redwood Community
  Health Coalition

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I Have some Data

• Now What?

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Community Health Clinic Ole Vital Statistics

• Patients
• 22,000 patients
• 52,000 encounters/year
• 44 Monolingual Spanish-speaking
• 70 Hispanic
• 60 with no regular health insurance
• Providers
• 6 primary care physicians, 3 specialist
  physicians, 9 midlevel providers, 5 dentists
• 6 clinical sites

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Data Collection and Quality Improvement

• Necessary but not sufficient
• What else needed
• Data driven care management
• Usually clinical data
• Data driven process improvement
• Often non-clinical data
• To achieve this, clinics need
• Quality Improvement training
• Management understanding
• Leadership commitment

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Steps of Care Management

• Data collection
• Data validation
• Provider feedback
• Structured preparation for patient visits
• Managing patients with unmet care needs
• Community interventions

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Step One Data collection

• How is data collected?
• PM system, Manual, External interface
• How is data reported?
• Standard report, custom report
• By provider? By site?

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Step Two Data validation

• Validation method
• Complete chart review
• Sample chart review
• Targeted chart review
• Calculate the Error rate
• Follow over time (run chart)

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Step Three Periodic Feedback to Providers

• How often?
• What report is used for feedback? 
• Format
• Provider data alone versus clinic as whole
• run chart of data by provider
• Incentives?
• Annual review
• Bonus
• Peer pressure

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Compare Provider Data to Clinic As Whole
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How to think about differences

• Im doing something well (or bad) Im not sure
  what it is, but I feel good (bad) about this
• Look for strong areas lessons learned to spread
  to other providers
• Look for weak areas good potential for care
  management

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Step 4 Structured preparation for patient
visits

• Structured, data-populated encounter form
• Filling out lab requisitions/referrals
• Notify Providers of what to focus on
• Notify Medical Assistants of what to focus on
  (i.e. foot filament exam)
• Custom self management handout

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Step 5 Managing patients with unmet care needs

• Could be performed by provider, MA, dedicated
  case manager, volunteer, QI coordinator, or a
  team approach (Kaisers panel management)
• Requires dedicated time
• Examples No visit for gt6 months, HbA1cgt9, BP
  gt160/100
• Management options phone call, letter, home
  visit, schedule appointment

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Panel Management Process Steps
Patient status reviewed and treatment decisions
made
Identification of patients with unmet care needs
Preparation for review of patient status
Communication with patient
Medical record pull standard form placed on chart
Population Management IT tool dedicated staff
time
Dedicated practitioner time orders written
Dedicated staff time
Source The Permanente Journal, Summer 2007
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Step 6 Community interventions

• For patients for whom care management is
  insufficient to improve outcomes
• Examples
• social worker to help with housing
• a community exercise class
• training health promoters to spread basic
  messages to the community
• Media health education campaigns

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Business Case for Care Management

• Data collection
• Costs
• Population management IT system
• Training costs initial and ongoing
• Project management implementation and ongoing
• Staff time for Data entry
• Benefits
• Income from pay for performance if rewarded for
  data submission (not for improved quality)

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Business Case for Care Management II

• Data validation costs
• Staff time spent on data validation and
  improvement in quality of data

Perfect data
Quality of Data
Time spent on data validation
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Business Case for Care Management II

• Data validation
• Benefits
• Income from pay for performance if rewarded for
  improved data

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Business Case for Care Management III

• Provider feedback
• Costs
• Staff time
• 1 minute/report for simple comparison
• 5 minutes per report for run chart
• Provider time to review
• 5 minutes/report
• Benefits
• Potential improved patient outcomes
• Income for pay for performance if rewarded for
  improved outcomes

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Business Case for Care Management IV

• Structured preparation for patient visits
• Cost
• Staff time
• Set up/maintain processes 4-8 hours total
• Preparation time 10 minutes per patient visit
• Benefit
• Improved patient outcomes
• Potential pay for performance
• Improved efficiency for provider

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Business Case for Care Management V

• Managing patients with unmet care needs
• Cost
• Staff time
• Provider time

Optimum outcome
Patient Outcomes
Time spent on care management/patient/year
(minutes)
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180
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Business Case for Care Management V

• Managing patients with unmet care needs
• Benefits
• Improved patient outcomes
• Potential pay for performance

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Business Case for Care Management VI

• Community interventions
• Cost benefit analysis varies on type of
  intervention
• Examples
• Health promoter training
• Media campaign

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Summary of Business Case for Care Management

• Substantial costs
• Offsetting these costs depends on
• Pay for performance (substantial)
• Grants
• In absence of P4P and sufficient grants
• Partial implementation if can act as stepping
  stone to gain experience and build capacity to
  seek additional revenue
• Wait until more favorable business case available

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Limited--money--QI training--management
capacity--leadership commitment
Community Interventions
Managing unmet needs
Structured Preparation
Provider feedback
Data Collection and Validation
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What happens in a crisis?

• Examples
• Fiscal crisis
• Other major project being implemented
• Political crisis diverting leadership energy
• QI staff/provider/management team turnover
• Preserving Care Management in face of Crisis
• Financial reserves/attention to fiscal management
• Insulate care management team from other projects
• Instill leadership capacity into all levels of
  staff
• Cross train all jobs
• Build a culture of quality throughout organization

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How Care Management Fits in

• Portion of the Care Model
• A type of Team Care

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Summary

• There are 4 ways to use validated clinical data
  to provide care management
• Provider feedback
• Prepared patient visits
• Managing patients with unmet care needs
• Community interventions

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Summary

• Using data to improve quality requires
• Money
• QI training
• Leadership Commitment
• Management Capacity
• Favorable business case requires grants or pay
  for performance

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Report from Steering Committee

• Clinical Systems Learning Community
• Purpose of the program
• Learning Sessions
• CHC Clinical Measures
• Data definitions
• Data validation
• Data aggregation
• Measure Clearinghouse
• Transition to CPCA
• Funding needs

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UDS Clinical MeasuresCHC Clinical Measures

• Diabetes HbA1c, including ethnicity
• Childhood Immunization
• Pap Smear
• Hypertension, including ethnicity
• Childhood Lead screening
• Prenatal care trimester entering care, HIV
  status, age

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Report from Steering Committee

• Consortia Memoranda of Understanding
• Baseline Data
• Spread plans
• Training/Technical Assistance plan
• Staffing

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Timeline Clinical Systems Learning Community and
Accelerating Quality Improvement through
Collaboration
Transition CHC Clinical Measures