Collaborate with Physician Associations for Systems Change

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• Collaborate with Physician Associations for
  Systems Change

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What is the PAFP Foundation?

• The PA Academy of Family Physicians (501C6) is
  the professional association for family
  physicians in Pennsylvania.
• Since 1948
• 2,800 fully licensed physicians (MDs and DOs, 700
  residents and 600 medical students 80 market
  share in PA
• Largest sole specialty physician org in PA
• Unified with the American Academy of Family
  Physicians, of which the PAFP is the 3rd largest
  state chapter
• No. 1 for membership is advocacy No. 2 is CME
• The PAFP Foundation (501C3) manages CME programs
  and public health grants, partnerships and
  collaborations.

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Overview of Our Discussion

• Define systems change
• Ways to achieve long-term changes in physician
  behavior
• What is _at_HEART?
• Stakeholders
• Deliverables
• Budget
• _at_HEART progress
• Successes
• Barriers
• Adaptations
• Whats next

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What is Systems Change?

• Interventions create change
• Systematic change calls for interventions that
  consider and make change beyond individuals
  behavior systems change changes processes
• Not isolated
• Cyclical process of planning, measurement,
  feedback and revision (i.e. PDSA cycles)
• Important to monitor process change reliability
  to ensure sustainability and effectiveness
• Time intensive

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How do we change behavior in a physician
practice?

• Each practice is its own system
• Not a lot of research
• No one intervention works in all instances
• Lectures (live, teleconf, webinars, webcasts)
• Academic detailing
• Interactive case studies
• Audit/Feedback
• Increased payment
• Guidelines
• Model for Improvement

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How did we selectthe interventions for _at_HEART?

• Grant requirements
• Partner preferences
• Budget limitations
• Experience

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The Initial Meeting

• PAFP staff met with the American Heart
  Association staff of the Great Rivers Affiliate
  (PA, DE).
• NCQA Heart/Stroke Physician Recognition Program
• Audit/feedback intervention
• Benefits
• Nationally agreed upon measures
• Endorsed by the American Heart Association
• Physician NCQA is "a respected body whose
  recommendations are worth following"
• Helps to ID problems in office systems
• Challenges
• Expensive (380/physician)
• Chart review can be onerous with or without EHR
• Little/no ROI for the physicians
• Not part of most payer reward programs in PA
• Small part of a couple of payer reward programs
  in PA
• Ask will the PAFP Foundation promote the NCQA
  HSRP to members?

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The Negotiation

• PAFP suggested AHA underwrite a pilot program of
  the HSRP
• Cover the expense
• Test the interest
• Collect feedback to then help market the program
• AHA replied that they sometimes facilitate
  projects via the Department of Health and they
  would float this idea
• DOH offered a sole-source grant to cover the
  expenses of the NCQA HSRP for 100 PAFP members

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The Counter Offer

• Couple the NCQA program with the American Academy
  of Family Physicians METRIC Coronary Artery
  Disease (CAD) module
• Based on Plan, Do, Study, Act model
• Challenges
• Unknown to the American Heart Association and DOH
• Benefits
• Similar measures to NCQA HSRP
• 20 hours of CME
• Helps diplomates of the American Board of Family
  Medicine to fulfill Part IV of the ABFMs
  Maintenance of Certification
• Includes improvement component
• Inexpensive (25 total/physician)
• Known to PAFP members (because theyre also AAFP
  members)

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The Final Product

• When PAFP members register for _at_HEART, the PAFP
  Foundation pays the registration fees for the
  NCQA Heart/Stroke Recognition Program and the
  AAFP METRIC CAD module a 405 value.
• Our goal was to register 75 PAFP members into the
  _at_HEART program.

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Additional Collaborations

• PMSLIC Insurance Co. agreed to include _at_HEART in
  its Loss Prevention Program.
• _at_HEART enrollees who were PMSLIC insureds were
  eligible for a 5 premium discount
• Feature _at_HEART on the PMSLIC website and created
  a flier about the program to explain the discount
• Engaged Highmark to enroll _at_HEART members in its
  pilot program that also covered NCQA physician
  recognition program fees but also paid an
  incentive bonus
• 5 _at_HEART enrollees (3 practices) were accepted
  into the program
• Small project so those practices represented 50
  of family medicine practices enrolled in the
  pilot
• Want to partner again if theres opportunity

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Logistics

• Physicians register at www.pafp.com/Heart.
• The PAFP Foundation sends the registration form
  to NCQA and METRIC, who keep track of _at_HEART
  registrants in their programs.
• NCQA bills a PAFP corporate credit card.
• METRIC sends an invoice.
• The PAFP Foundation invoices the DOH for those
  fees monthly.

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Communicating _at_HEART to Physicians

• Message development was critical
• Detailed promotional plan
• Created a project-specific area on our website
• www.pafp.com/Heart
• Kick-off at popular CME event
• Support cardiac and quality improvement CME at
  those events
• Articles and ads in member physician magazine
• Direct mail
• Project-specific emails and faxes
• Blurbs in email/fax newsletter
• Displays for METRIC and NCQA at major CME events
• Materials and endorsement at regional member
  meetings

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_at_HEART Year 1 (06-07) Results

• 54 physicians had registered by Dec. 31 and we
  registered the target number of 75 physicians by
  April 16
• Conservatively, those 75 physicians treat more
  than 40,000 patients with CVD. More than half of
  those patients reside in high-risk counties.
• Greater challenge was in helping registrants
  participate fully in each program
• Physicians werent non-compliant
• NCQA process full of landmines
• All feedback was provided to NCQA and they were
  appreciative
• Unexpected physician support severely taxed the
  budget
• Applied for and received supplemental funding
• Based on registration data provided by
  physicians.

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_at_HEART Year 2 (07-08)

• Started off with a waiting list
• Continued aggressive promotional campaign
• mailed brochures
• e-mail
• newsletters
• magazine ads and articles
• live CME
• METRIC and NCQA displays at meetings
• lead physicians to www.pafp.com/heart to enroll

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Closing Out _at_HEART

• Hesitant to continue _at_HEART in its original form
• Budgetary and programming barriers
• Time-intensive for staff
• NCQA
• Expensive (biggest line item in budget)
• Email process of document distribution was
  unchanged
• Unclear instructions
• Chart pulls (35 charts vs. 10 for METRIC)
• Once the (NCQA) requirements were made known
  (the workbook, chart review and reporting) I
  found them too cumbersome to complete.
• Only 25 registrants as of April 21
• Submitted a request to alter the program for the
  remaining months
• Remove NCQA requirement
• Offer live webinar which could be taped and
  archived online to extend the life of the program
• _at_HEART will sunset June 30, 2008

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IPIP

• _at_HEART grant funds re-channeled to IPIP
• Improving Performance In Practice
• A national program of the American Board of
  Medical Specialties funded by the Robert Wood
  Johnson Foundation.
• Managed in PA by the PAFP Foundation, PA Chapter
  of the American College of Physicians (general
  internists), the PA Chapter of the American
  Academy of Pediatrics (primary care
  pediatricians)
• PA is one of four pilot IPIP states
• Tied to the PA governors Chronic Care Commission
  and implementation of the Chronic Care Model in
  Pennsylvania.

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IPIP Basics

• Redesign care delivery by giving primary care
  physician-led practices the tools and support
  they need to provide high quality care to all
  patients all the time.
• Continuously tracking, sharing and improving
• 3-year commitment
• Learning collaboratives
• Regional
• Regular learning sessions
• Supported by quality improvement coaches

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Elements of IPIP

• National Quality Measures and Goals
• diabetes or asthma and then other conditions and
  prevention
• Include specifications (details on how patients
  are classified i.e. denominators, numerators)
• Reporting
• Analysis of monthly data reports provides
  practices with feedback on how they perform
  compared to national goals and other IPIP
  practices (statewide and nationally)
• Change Package
• Registry, which leads to population management
• Protocols
• Self-management support (patient education)

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Other Features Part of Rollout

• Governors Office of Health Care Reform
• Patient-centered medical home
• Use NCQA patient-centered medical home program as
  the assessment tool
• Enhanced payment incentives
• Patient Education
• Collaborating with organizations like the
  American Lung Assoc., American Cancer Society,
  American Heart Assoc. to connect practices with
  community services

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QI Coaches

• Free support for the practices
• Vital when every practice is its own system
• Dedicated to helping the practices implement all
  IPIP elements
• Building and using a registry system for visit
  planning and patient outreach
• Understanding and reporting the performance
  measures
• Analyzing and using the monthly performance
  reports to direct their improvement efforts

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IPIP and Reform in PA

• Simultaneous events
• IPIP grant awarded to Pennsylvania
• Continuous quality improvement within primary
  care physician-led practices
• Formation of the Chronic Care Commission within
  the Governors Office of Health Care Reform
• Dissemination of the Chronic Care Model Plan
  through learning collaboratives, practice
  coaches, patient registries, data collection on
  key measures, alignment with health plans and
  patient self-management
• Health plans in southeast PA
• Independence Blue Cross and Aetna began primary
  care-based medical home pilot project
• As a result - under the auspices of the GOHCR -
  IPIP, the GOHCR and health plans are working
  together to roll out primary-care-based reform
  across Pennsylvania
• For 08-10, funds previously used for _at_HEART will
  be used to support the CVD component of the
  overall effort.

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Review of Our Discussion

• Systems change
• Has to impact the process in practices
• Cyclical with reliability monitoring
• Can take a long time to implement
• Achieve long-term change in physician behavior
• Use a mix of interventions
• Work with physician organizations to find out
  what works best for the physician population
  youre targeting
• _at_HEART IPIP
• Successful first-time collaboration among
  American Heart Association, PAFP Foundation and
  the PA Dept. of Health
• Evolving statewide CVD system change from a
  program based on individual physician review and
  intervention (_at_HEART) to one of regionally based
  quality improvement with many primary care
  practices working together to implement
  evidence-based interventions for sustainable
  change.
• What physician organizations can contribute
• Third-party endorsement to your program/project
• Existing, trusted channels of communication
• Credibility

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Contact Information

• Angie Halaja-HenriquesDirector of Public Health
  InitiativesPA Academy of Family PhysiciansSuite
  A 2704 Commerce DriveHarrisburg, PA17110
  ahalaja_at_pafp.com1-800-648-5623717-635-7577
  (direct)FAX [phone] www.pafp.com