Overview of Primary Care Coalition Programs and Activities

1
Overview of Primary Care CoalitionPrograms and
Activities
2
Primary Care Coalition Vision and Mission

• PCC Vision All Montgomery County residents will
  have the opportunity to live healthy lives.
  Montgomery County will be the healthiest
  community in the nation and a model for providing
  access to high quality and efficient care for
  all.
• PCC Mission The PCC will lead the development
  and coordination of a community-based health care
  system that strives for universal access and
  elimination of health disparities for all county
  residents.

3
Primary Care Coalition Organizational Structure

• The Center for Health Care Access develops and
  maintains care delivery networks for adults and
  children a pro-bono specialty care network an
  information and referral service and oral
  health, behavioral health, and health care for
  the homeless projects.
• The Center for Medicine Access assures that all
  patients have access to generic and brand
  medicine through a point-of-care distribution
  system, enrollment into the pharmaceutical
  industrys patient assistance programs, and
  through a pharmacy-benefit management program.
• The Center for Community-Based Health Informatics
  designs and supports a Web-based, shared,
  open-source electronic medical record for
  Montgomery County clinics and supports a variety
  of health information exchange (HIE) activities.
• The Center for Health Improvement seeks to
  improve quality, efficiency, equity, and outcomes
  for children and adults.
• The Center for Childrens Health is a
  public/private partnership program, The Tree
  House Child Assessment Center, for abused and
  neglected children.

4
Primary Care Coalition Governance

• The PCC was founded in 1993 as an independent,
  non-profit organization, governed by a 20-member
  volunteer Board of Directors with community
  representation and expertise in health policy and
  administration. Beyond policymaking and
  financial oversight of the organization, the
  Board of Directors is engaged in the advocacy and
  outreach, program development, and fundraising
  efforts.

Carol W. Garvey, MD, MPH Marilyn Hughes Gaston,
MD Alan S. Gregerman, PhD Arva J.
Jackson Tristram Kruger, DDS,
MS Marion Ein Lewin John G.
Luke, III Kevin J. Mell
Jorge Ribas, DVM
Jeffrey M. Rubery
Roberta Milman, Chair Richard Bohrer, Vice Chair
Wilbur Malloy, Secretary Steve Braunstein,
Treasurer Steven Galen, President Horace W.
Bernton, MD Betsy Carrier
LeCount R. Davis Charles H. Fleischer,
JD Hiawatha B. Fountain, PhD
5
What does the PCC contribute?

• The PCC builds, energizes, and maintains the
  collaborative effort to improve the health of
  low-income, uninsured, and ethnically diverse
  Montgomery County residents. The PCC aligns,
  leverages, and enhances public and private
  interests, resources, and expertise.
• The PCC functions as an
• Advocator
• Convener
• Integrator
• Innovator
• Capacity builder
• Gap filler
• Contractor
• Contract administrator

6
PCC Revenues County vs. Other
7
Center for Health Care Access
8
Center for Health Care Access Mission Statement

• The PCC Center for Health Care Access (CHCA)
  plays a strategic role in planning and
  implementing a comprehensive health care system
  for Montgomery County residents who lack health
  insurance and the resources to pay for care.
• Montgomery Cares
• Health Care for the Homeless
• Oral Health Pilot
• Behavioral Health Pilot
• Information and Referral
• Project Access/Specialty Care
• Care for Kids
• Case Management
• Specialty Care/CMS

9
Montgomery Cares

• Montgomery Cares is a public/private partnership.
  
• This unique local health care initiative supports
  the development of an integrated health care
  network that will provide high quality health
  care to 40,000 uninsured Montgomery County adult
  residents.

10
Montgomery Cares Model
11
How It Works

• Montgomery County Council is committed to the
  concept of Universal Health Care.
• DHHS establishes program policy and leads program
  planning efforts.
• Montgomery Care Advisory Board recommends policy
  and participates in planning process.
• PCC implements the program and manages operations
  and infrastructure development.
• Community-based clinics are responsible for
  providing care to uninsured patients.
• Hospitals support primary care service providers
  with community benefits and partnerships.
• Community-based partners provide support services
  and population access/expertise.

12
Participating Primary Care Clinics
13
Program Eligibility And Continuity

• Montgomery Cares
• 18 or older
• Uninsured
• 250 Federal Poverty Level

• Care For Kids
• 0-18
• Not eligible for MCHIP or other Federal or State
  program
• 250 Federal Poverty Level

eligible until 19th birthday
14
Unduplicated Clients
16,733
13,019
11,305
8,251
15
Encounters
16
FY08 Demographics Age and Gender
Does not include data for CCI.
Does not include data for CCI and Marys Center.
17
FY08 Demographics Race and Ethnicity
Does not include data for CCI.
Does not include data for CCI.
18
Rand Evaluation Report February, 2007

• Serving the Underserved An Evaluation of the
  First Year of the Montgomery Cares Program
• Challenges
• Access
• Capacity
• Quality of Care
• Cultural Competency
• Data Quality and Integrity
• Public Education and Outreach
• Organizational and Infrastructure Development

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Access and Capacity

• Expansion of Access Points
• Marys Center for Maternal Health
• Mobile Med Germantown Facility
• Proyecto Salud Olney Facility
• Expansion of Hours of Operation
• Proyecto Salud Evening and Saturday Hours
• Muslim Community Center Clinic Evening and
  Sunday Hours
• Montgomery Cares Public Education
• Montgomery Cares Brochures Available Six
  Languages
• Information and Referral Line Established
• Increased Outreach and Community Engagement
• Process Improvements
• Increasing Appointment Availability
• Decreasing Wait Times for Appointments
• Improving Telephone Systems and Customer
  Service

20
Organizational Development and Cultural Competency

• Organizational Development
• Capacity Building Grants for Strategic and
  Business Planning
• Capacity Building Grants for Volunteer
  Coordination and Human Resource Management
• TA to Develop Emergency Preparedness Plans
• On-Line OSHA and HIPPA Training
• Workforce Development and Leadership Training
• Shared Services Framework
• Cultural Competency
• Language line extended to all Montgomery Cares
  clinics and Project Access specialists
• Culturally Competent Care Workshops (Center for
  Health Disparities)
• Qualified Bilingual Staff Training
• Need system-wide strategic plan to address
  cultural competency to meet multi-lingual,
  multi-cultural needs of the population

21
Quality Improvement and Data Quality and Integrity

• Quality Improvement
• Establishing Quality Standards
• Tracking Quality Indicators in CHL Care
• Quality and Health Improvement Committee (QHIC)
  Meetings
• Participation in IHI Office Redesign Learning
  Collaboratives
• Improvements to Clinic Data Management and CHL
  Care
• Data Quality and Integrity Report
• Assessment of Data Management Workflows
• Redesign of CHL Care to Improve Use and
  Reporting
• Training to Improve CPT and ICD-9 Code Entry
• AHRQ Mini-Grants to support data management
  improvements
• Regular User Group Meetings and On-Going
  Technical Assistance

22
Specialty Care

• Project Access is the Montgomery County network
  of private physicians developed in collaboration
  with the Montgomery County Medical Society and
  hospitals who provide low-cost specialty
  services.
• FY08 Referrals Completed 1,210
• Archdiocesan Health Care Network is the Regional
  network of private physicians and hospitals
  maintained by Catholic Charities that provides
  low-cost specialty care.
• FY08 Referrals Completed 1,642
• Hospital Care is provided at low or no cost to
  patients referred through PA or AHCN. Four of
  five Montgomery County Hospitals accept the
  PA/AHCN co-pay, which does not usually excess
  25.

23
Health Care for the Homeless (HCH)

• Mobile Medical Care, Inc. and Community Clinic,
  Inc. provide services for homeless adults and
  families through a federal grant through HCH, MD.
• Montgomery Cares contracted with Mobile Medical
  Care, Inc. to conduct six shelter-based clinic
  sessions per week and serve 1,000 patients.
• Patients Served 756 Encounters 2,205
• Case Management has been linked to health service
  delivery, and service delivery is linked to
  shelter sites.
• Patients Served 470 Encounters 858
• PCC is facilitating coordination of services
  between
• shelter and housing providers
• emergency and social service providers
• hospitals and mental health care institutions
  and
• medication access programs.

24
Montgomery Cares Pilot Projects

• Oral Health Pilot links dental care to primary
  health care through direct referrals from all
  Montgomery Cares clinics to dental services
  provided by Spanish Catholic Center.
• Patients Served 625 Encounters 1,129
• Behavioral Health Pilot, a collaborative care
  model, provides on-site mental health
  assessments, medication management, short-term
  therapy and referrals at three Montgomery Cares
  clinics.
• Patients Served 490 Encounters 1,215
  
• Eligibility Pilot provided eligibility
  determination for Maryland Primary Adult Care
  (PAC) and Medicaid/MA on-site at Mercy Health
  Clinic from August 2006 through June 2008.
• Applications Processed 741 Enrolled 374
• Denied/Withdrawn 290 Applications Pending 78

25
Montgomery Cares Information Referral
Call Volume 7/1/2007 to 6/30/2008
Total Calls Processed 1,761
26
Montgomery Cares Information Referral
Caller Need 7/1/2007 to 6/30/2008
27
Care for Kids

• Care for Kids provides primary health care to
  children of low-income families who can not
  afford health insurance and are not eligible for
  other state and federal programs.

• Primary health care
• Specialty care
• Medications
• Case Management
• Dental and Eye Care Referrals

28
Care for Kids Providers
29
Program Growth
30
Race and Age
Race of Participants
Age of Participants
31
Federal Poverty Level and Geographic Region
Income of Participants Families
Region of Participants Residence
32
FY08 Program Metrics

• Care for Kids served 3,810 children during FY08.
• Average monthly enrollment is 2,599 children.
• 925 new children were enrolled in FY08.
• 98 of children who continue to be eligible for
  the program are recertified annually and retained
  in service.

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Center For Medicine Access
34

Significance of Medicine Access
Access to medicine is an important component of
primary health care. Nationally, approximately
20 of individuals do not fill their
prescriptions, because they cannot afford to.
Were working to eliminate that problem in
Montgomery County.
35

A Multi-strategy Approach to Medicine Access
Pharmacy Benefit Management
Community- Based Organizations

• Community Pharmacy
• Point of Service
• Over the Counter
• Diabetic Supplies
• Flu vaccine and Pneumovax

ACCESS
Medbank Program
36
Pharmacy and Therapeutic Committee Members
Staff Representatives Rosemary Botchway and
Gabriel Hidalgo
37

Pharmacy and Therapeutic Committee Guides Process

• Assists in the formulation of policies and
  procedures relating to drug and pharmacy
  management within the clinic settings
• Provides oversight and development of the various
  formularies
• Supported by evidence-based medical evaluation
• Reviews medical directors and clinic provider
  requests for drugs to be added or deleted from
  the formulary through a completed formulary
  drug-change request form
• Evaluates rationale for drug request
  additions/changes
• Conduct a review process and apprises the
  requesting provider of the committee decision
  with rational
• If requested, conducts an appeal at which time
  the provider is requested to offer further
  rational for formulary inclusion (in writing or
  in person before the committee)

38
1. Community Pharmacy Point of Service (POS)

• Unit of use pre-packaged drugs dispensed at the
  point of an encounter within the clinic setting
• Evolving formulary currently consists of 40
  generic drugsmeets 80 of medication needs
  within clinic population
• Point-of-service medications are dispensed for
• CHL network clinics
• Montgomery Cares pilot programs
• behavioral health
• dental pilot
• CHL diabetes management program
• Medication and diabetic supplies

39
Community Pharmacy Point of Service (POS)

• The dispensing system meets all state and federal
  requirements.
• The medications are
• supplied by a licensed
• drug re-packager.
• Medication comes to the
• clinics in pre-packaged
• unit doses ready to
• dispense.

RX NUMBER
EXP. DATE
PATIENTS NAME
INSTRUCTIONS
QUANTITY
DISPENSING DATE
CLINIC ADDRESS AND TELEPHONE NUMBER
MEDICATION NAME
PHYSICIANS NAME
40
Community Pharmacy Formulary

• Amlodipine
• Atenolol
• Captopril
• Clonidine
• Diltiazem SR
• Furosemide
• Gemfibrozil
• Hydrochlorothiazide
• Isosorbide Mononitrate
• Lisinorpril
• Lovastatin
• Potassium Cl ER
• Simvastatin
• Spironolactone
• Triamterene / HCTZ
• Verapamil ER
• Verapamil HCl
• Verapamil SR

• Amoxicillin
• Cephalexin
• Ciprofloxacin
• Ery-tab
• Metronidazole
• Penicillin (PVK)
• SMZ/TMP DS
• Buproprion SR
• Fluoxetine
• Phenytoin ER
• Sertraline
• Trazodone
• Venlafaxine HCl
• Tac Acetonide
• Albuterol Inhaler
• QVAR

ANTIBIOTICS
CARDIOVASCULAR
MENTAL HEALTH
DERMATOLOGICAL
RESPIRATORY
DIABETES / ENDOCRINE
GI TRACT
A generic equivalent in a custom blister pack.
41
Community Pharmacy Formulary Montgomery Cares
Pilot Programs

• Montgomery County Behavioral Health Pilot
• Buproprion HCl
• Citalopram
• Cymbalta
• Effexor XR
• Fluoxetine
• Trazadone
• Venlafaxine
• Wellbutrin XL
• Sertraline
• Seroquel
• Gabapentin

• Montgomery County Dental Health Pilot
• Penicillin
• Amoxicillin
• Ery-Tab

ANTI DEPRESSANT
ANTIPSYCHOTIC
ANTICONVULSANT
42
Community Pharmacy Diabetic Supplies

• In addition to medication, Community Pharmacy
  provides diabetic supplies to approximately 1,600
  diabetics.
• Glucometer
• Strips
• Lancets
• All diabetics receiving supplies also receive
  self- management support to help them utilize the
  supplies and manage their health.

43

• Patient Assistance Programs (PAP)
• Maryland Medbank Program

• Facilitates access to pharmaceutical companies
  free and
  reduced-cost brand name medications
• Eligibility guidelines
• lt250 FPL for 2008 (26,000/1 53,000/4)
• Citizenship status
• Residency Status (Residing in the U.S. or
  documented status)
• Programs have individual requirements/paperwork
• Programs offer access to over 2,500 brand
  medications
• Formulary of 30 brand-name medication
• Application to companies
• Drawback 1 to 8 weeks for shipment of
  medications

44
CMA PAP FormularyBrand Name Medication
45
3. Pharmacy Benefit Management (PBM)

• Current PBM relationship Catalyst RX
• Offers HMO pricing on defined formulary
• Brand/Generic medication available
• Convenience of a pharmacy card and access to
  local retail pharmacies
• Provides utilization and cost data
• Standard, custom, ad hoc report generation
• Presently utilized for Care for Kids Program and
  futuristic Project Access specialty physicians
  and disease state management programs

46
Programs Utilizing Medicine Access Strategies
Administered by the Center for Medicine Access
Montgomery Cares Safety Net Clinics Montgomery
Cares Pilot Programs (behavioral
/dental) Montgomery Cares Health Care for the
Homeless The Montgomery County Maternity
Partnership DHHS Adult Mental Health
Program Tobacco Dependence Treatment Clinic CHL
Care Diabetes Management Program Care for Kids
Program Community-based physicians
47
Value of Medication Provided to Patients FY 08

• Purchased Medicines
• Community Pharmacy
• Medicine Value 1,169,637
• 76,078 Bottles of Medicine
• 985 vials flu/pneumovax vaccine
• Diabetic Supplies 229,792
• Catalyst RxPBM 19,577
• Free Medicine
• Medbank of Maryland
• Value Free Meds Received 1,302,748
• 3,132 Prescriptions Processed

48
Center for Community-Based Health Informatics
49
Information Technology for Better Health Care

• For PCC, Information technology is not an end in
  itself, but rather a means to support a system of
  care
• Information technology, properly deployed, can
  help address the challenges of
• Quality of care, in an increasingly complex
  medical world
• Access to care, for the low income, uninsured in
  the county
• Efficiency of care, to keep the countys costs
  low for the services provided
• Safety of care, where information available at
  the right time can mean the difference
• Disparities, to help eliminate the healthcare gap
  across societal boundaries

50
Health Care Information Data Flow and Benefits
Quality, Safety, and Efficiency benefits occur at
each level
Link Safety Net Clinics to Mainstream Healthcare
Link Safety Net Clinics Together in cohesive
system of care
Establish Safety Net IT Infrastructure in each
clinic
51
Information Technology Projects

• CHLCare
• a unique approach to a shared Electronic Health
  Record (EHR) to connect safety-net clinics in an
  integrated system of care
• Metro DC Health Information Exchange (MeDHIX)
• a regional, patient centered health information
  exchange (HIE) focused on safety net clinics
• Montgomery County Health Information Exchange
  (MCHIE)
• a PCC and Maryland State funded project to
  advance HIE statewide
• Safety net clinic information technology support

52
Health Information Technology Landscape in 2001

• There was no market for EHR systems for
  safety-net providers.
• Safety-net providers have unique characteristics
  and needs.
• Most commercial systems had high up-front and
  maintenance costs.
• Not many options for a system that could be
  shared across multiple, independent
  organizations.
• Open Source technology had become a more stable,
  sophisticated option.
• Montgomery County safety-net clinics had these
  characteristics
• Severely limited computer resources, equipment,
  expertise, and staff
• At best small, obsolete, volunteer-contributed
  data collection systems
• Few resources or time to explore the benefits of
  EHRs in their clinics.

53
CHLCare Safety-Net EHR Objectives

• CHLCare Objectives
• Basic Electronic Health Record capability
• Appointment management
• Reporting capability
• Position for regional linkage hospitals,
  specialty providers
• Position for new clinical care tools chronic
  disease management, continuity of care, decision
  support
• Referral management
• Electronic receipt of laboratory results
• Integrating Community Pharmacy point-of-service
  medication management
• Ease of use in settings with multiple volunteer
  staff
• Shared information across providers for a mobile
  patient population
• Shared medical data with mainstream providers
• Public health and community care planning
  information

54
Web-Based Shared EHR Architecture
A web-based, secure-access application
55
CHLCare (HER) Current Capabilities

• Developed collaboratively with safety-net clinics
  to meet their needs
• CHLCare in production since July 03
• Deployed by 15 clinic organizations at over 35
  clinic locations
• Montgomery and Prince Georges Counties, DC,
  Northern Virginia
• Prior electronic data converted and added to
  database
• Shared database with 250,000 visit records for
  80,000 patients
• Content includes
• Patient demographics
• Encounter data, including ICD9 and CPT codes
• Patient appointment scheduling
• Specialty referrals
• Picture ID cards
• Visit planner
• Extensive patient clinical reports and clinic
  management reports
• Clinical quality assurance data, e.g. diabetes
  quality measures
• Additional clinical data at the option of
  individual clinics, e.g. allergies, labs

56
Patient Dashboard
57
Patient Encounter
58
Encounter Objective
59
Stream-line Medical Record Decision Support
60
Lessons Learned/Positive Outcomes

• Clinics are becoming more eager to move to
  real-time data entry
• Clinics see the benefits of additional
  functionality.
• Clinics are using data for improving clinical
  outcomes and operational efficiencies, clear
  evidence of a more quantitative approach
• Clinic staff and volunteers are increasingly
  knowledgeable about EHRs.
• More and better information enhances County
  Public Health planning.
• Shared information supports a system of care for
  low-income uninsured patients.
• Clinics are better positioned in seeking grant
  and contract support for clinical quality
  improvement interventions.
• Technology supports safety-net specific features
  not in commercial systems.
• Technology facilitates innovative care models
  Chronic care model planned care Triple Aim
  care team.
• Low cost of entry allows participation for
  financially limited safety-net clinics.

61
Metro DC Health Information Exchange (MeDHIX)

• Rationale
• Secure, private, timely exchange of health
  information to improve health care quality,
  prevent medical errors, and reduce costs by
  promoting care continuity
• Initial focus
• Safety-net providers and hospitals in the Metro
  DC area (Montgomery County, P. G. County, DC, No.
  Va.)
• Current focus
• Montgomery County safety-net clinics and
  hospitals
• Demonstration project
• Exchange CHLCare data with Montgomery General
  Hospital ER Proyecto Salud collaboration
• Expand to other providers and organizations

62
Metro DC Health Information Exchange History
2004 Primary Care Coalition awarded a one-year
Regional Health Information Exchange planning
grant from the Agency for Healthcare Research and
Quality 2005 PCC awarded a-three year
implementation grant to design and build a Safety
Net Regional Health Information Exchange

63
Current MeDHIX Model
Hospital
Hospital
MeDHIX
Proxy Server
Clinic
Sub Network Organization
CHLCare
Clinic
Clinic
Clinic
Clinic
Clinic
64
MeDHIX is an Information Bridge
Health Information Exchange
Hospital Emergency Depts
Safety Net Clinics
Montgomery County, MD
Laboratory Provider
SCC Langley Park Adults
Hospital A
SCC Langley Park Peds
CHLCare
Hospital B

• MeDHIX Exchange
• Enterprise Service Bus
• Routing and Transformation
• Data Storage (edge servers

Proyecto Salud
Mobile Med
Hospital C
Mercy

• A Health Information Exchange to link Safety Net
  clinics to mainstream healthcare
• Using CHLCare to make a single connection to
  MeDHIX, simplifying data exchange
• Linking to Quest Diagnostics for Lab Results

Peoples Comm Wellness
District of Columbia
SCC DC Medical
Virginia Counties
Arlington Free Clinic
65
MeDHIX Care Continuity Goals, Phase One

• Enhance patient safety, quality, and efficiency
  of care
• Share safety net clinic data with hospital
  emergency departments
• (ED-MC Connect)
• Continuity of care identify a patients medical
  home
• System design that protects patient privacy
• Conform to multijurisdictional privacy
  regulations
• Easy to use, web-based access
• Pertinent information to facilitate care

66
Specific Phase One MeDHIX Capabilities

• eChart
• Synopsis of patients medical record
• Web accessible
• Picture ID card
• Quest electronic laboratory result link

67
ED-MC Connect Schematic
68
ID Card Design
Identifies Safety Net Community
Issued Date
Medical Home and Contact Number
Sex and Date of Birth
Magnetic Swipe contains CHLCare ID
Patient Information
CHLCare ID and Indication of Membership in the
Health Information Exchange
Disclaimer to insure no misunderstandings' as to
the intent of the card occurs
Return to Address
69
MeDHIX eChart
70
Montgomery County Health Information Exchange
(MCHIE)

Maryland State goals Promote the adoption of
EHRs Develop a statewide health information
exchange Phase 1 Maryland Governors Task
Force to Study Electronic Medical
Records Address EHRs, HIE, school health
records 26 members appointed by the legislature
and Governor PCC asked to represent safety-net
clinic perspectives Report submitted to the
Governor and General Assembly December 31, 2007
71
Montgomery County Health Information Exchange
(MCHIE)

• Phase 2 RFA for a Citizen-Centric HIE for
  Maryland
• Issued by MHCC, funded by HSCRC
• Two awards Montgomery County HIE
  Collaborative
• CRISP Health Consortium led by Erickson
  Retirement Communities with Johns Hopkins,
  MedStar, U. of MD
• Plans and Requirements
• Recommendations to the State addressing the broad
  range of policies, principles, and practices
  necessary for the successful adoption of
  statewide health information exchange in Maryland
• Recommendations for statewide implementation
  strategies to MHCC/HSCRC, Feb. 20, 2009
• Reports submitted to be submitted to the Governor
  and General Assembly, Feb. 27, 2009
• Demonstration project to test principles and gain
  local experience

72
Montgomery County Health Information Exchange
(MCHIE)

• Project participants
• MCHIE led by Dr. Roger Leonard, VP, Medical
  Affairs, Montgomery General Hospital
• all county hospitals
• DHHS
• PCC
• Regional charitable organizations and funders
• Prince Georges County Health Department
• Demonstration project
• MGH Emergency Department
• Proyecto Salud
• CHLCare MeDHIX eChart data exchange (ED-MC
  Connect)

73
Regional Health Information Technology Activities

• DC Primary Care Association EHR Project
• National Capital Area RHIO (DC RHIO)
• Pediatric Regional Health Information Network
• DC Medicaid Transformation Grant
• INOVA EHR activities and regional implications
• Northern Virginia RHIO
• NOVA Scripts Central

74
Regional Health Information Technology Activities

• Maryland Governors HIT Advisory Committee
  Report
• Citizen-Centric Health Information Exchange for
  Maryland Grant received for Montgomery County
  HIE
• Maryland Statewide HIE plan
• PCC AHRQ-funded MeDHIX Project
• Maryland Community Health Centers EHR plans
• PCC Montgomery County EHR Assessment Activities

75
Health Information Technology Challenges and
Opportunities

• Maintaining congruency among
• Technology evolution
• Safety-net clinic needs, characteristics, and
  patient populations
• Reliance on volunteer providers pros and cons
• Links to mainstream health care resources and
  providers
• Population health
• Cost
• Importance of evolutionary curves
• Finding the proper curve and evolving
  functionally and cost effectively
• Determining when to jump to the next curve

76
Funding Sources and Collaborators

• Major development funding and sustainability
  funding
• U.S. Health Resources and Services Administration
• CAP grant ( 3 million, with 25 for health IT R
  D)
• National Library of Medicine
• Connecting Communities for Health Information
  Technology (125,000)
• Kaiser Permanente
• Multiple modest grants for safety net care
  quality improvement (100,000)
• CareFirst Blue Cross/Blue Shield
• Multiple grants to add clinically oriented
  capabilities (100,000)
• U.S. Agency for Health Care Research and Quality
• Transforming HealthCare Quality through Health
  Information Technology
• 1.5 million with 11 matching requirement)
• Maryland Health Care Commission/Health Services
  Cost Review Commission
• Montgomery County health information exchange
  collaborative
• Montgomery County DHHS
• Montgomery Cares

77
Center for Health Improvement

• MISSION
• To improve the health status of adults and
  children being served through Montgomery Cares
  and Care for Kids

78
Center for Health Improvement Goals

• Improve overall quality, safety, and
  effectiveness of care through measures of health
  outcomes and system-wide performance.
• Foster a culture of quality improvement in the
  provision of care.
• Build an environment of shared learning,
  collaboration, and best practices in areas of
  access, efficiency, and the delivery of planned
  care in the clinics and system-wide.
• Engage patients in improving their own health and
  preventing complications of diseases.
• Develop a research infrastructure to attract
  academic partners and health care leaders to
  foster innovative approaches that reduce health
  disparities.

79
Programs/Activities

• Transforming health care deliveryBuilding the
  foundation and infrastructure for quality
  improvement
• Infusing planned care into Montgomery Cares
  clinics
• Develop measurement system for quality,
  access, efficiency
• IHI Collaboratives Office Practice Redesign
  Triple Aim
• Patient activation and community partnership
  initiatives   7331 Healthy Families Having Fun 
  Diabetes self-management education
• Community-based cancer prevention projects
• Research
• Community-Based Participatory Research NIH
• Health literacy NIH
• IP-RISP NIH/Georgetown University
• Emergency Department utilization HSCRC
• Komen Community-Academic Partnership Research
  Grant

80
The Model of Planned Care

• A design for delivery of primary care for all
  patientsmust support quality, effective,
  patient-centered care
• PCC adopts Institute for HealthCare Improvement
  (IHI) model of Planned Care, the notion that
  every patient should have a plan of care.
• Planned Care model is used across the nation to
  improve care by creating a reliable and lean
  system for all patients.
• Model calls to support four elements of service
  delivery.
• Care Team Clinical Information System
• Patient Activation Leadership

81

IHIs Planned Care Model


82

Building the Foundation for Quality Improvement
Infrastructure building Began with IT
Streamline Enhance EHR Planned
Care Metrics/ Performance Dashboard
Fostering Learning Environment Knowledge
Transfer Learning sessions Newsletters Quality
Visits QHIC/MD Mtgs
Practice Redesign Office Practice IHI
Collaborative FY08 2 Clinics FYO9 3 Clinics

Transforming System Culture Triple Aim
83
Building IT infrastructure The Process

• Created CHLCare (EHR) and Diabetes Registry
• Embedded functionality into CHLCare to support
• Planned Care
• Diabetes Registry
• Developed metrics for Quality
• Medical Directors approved nationally recognized
  diabetes, hypertension and chronic disease
  preventive measures
• Developed Performance Dashboard
• Hired a Data Manager
• Established annual and quarterly reports to
  assess performance

84
Streamline Medical Record/Decision Support
All-in-one
85
Foster a Learning Environment Activities to
promote knowledge transfer and spread

• Periodic Learning Sessions
• Quality Health Improvement Committee
• Medical Directors meet quarterly
• Review and approve metrics
• Share knowledge and best practices
• Quality Subcommittee Working group
• Quarterly and Annual Reports
• Performance Dashboard
• Planned Care Tipsmonthly e-bulletin
• Online Continuing Medical Education (CME)
• The Role of Culture in Breast Health Care (funded
  through Komen)
• www.primarycarecoalition.org/cme/welcome

86
QI Tool used to Accelerate Change Model for
Improvement
What are we trying to accomplish?
AIM Statement Demings PDSA
87
Performance Dashboard

• Promote Quality Improvement by sharing best
  practices to improve
• Access
• Efficiency
• Patient Experience
• Compare performance over time and with other
  industry benchmarks. Reported quarterly and
  annually
• Diabetes
• Hypertension
• Cancer Prevention
• Adult Vaccination

88
Diabetes patients with controlled blood pressure
lt 140/90
89
Diabetes Process Measures for Clinic E over time
90
Patient Activation and Community Partnership
Initiatives

• Child Health Improvement Initiative (Kaiser
  submitted)
• Promote assessment and treatment of childhood
  obesity consistent with evidence-based guidelines
• Facilitate referral to 7331 Healthy Families
  Having Fun and other appropriate support
• 7331 Healthy Families Having Fun
  Family-centered, culturally relevant healthy
  lifestyle program for overweight and obese
  children
• To date 105 pediatric provider-referred children
  with families
• Documented improvements in nutrition and physical
  activity behaviors
• Diabetes Self-Management Education
• Standardized support to low-income diabetic
  patients to engage self-management of this
  chronic disease

91
Community-Based Cancer Prevention Projects
92
Komen I Patient Navigation Project

• 3 Montgomery Cares clinics selected to
  participate in Breast Health Patient Navigation
  Project.
• 2 Clinics began project 9/07
• 1 Clinic began project 1/08
• All 3 participating clinics provide culturally
  competent patient
• navigation at clinic site
• Measures include
• Mammogram Referral Rate
• Mammogram Screening Rate

93
Komen 2 Process Improvement Three Phases

• PHASE I Setting Priorities and Kick-Off
• PCC and WCCP use PDSA tests of change
• to improve efficiencies and reduce waste.
• PHASE II Measure Impact of PDSA
• Reduction in cycle time from clinic referral to
  WCCP receipt of patient application.
• Reduction in cycle time from WCCP receipt of
  patient application to voucher sent to patient.
• PHASE III Scaling Up and Sustainability
• The final phase of the project will focus on
• developing QI initiatives in other breast
• cancer screening programs including
• Holy Cross Hospital MAPS 2
• Adventist Healthcare
• (Washington Adventist and Shady Grove Adventist)

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Prevent Cancer Foundation Goals

• Goal 1
• To increase the scope of cancer screening patient
  navigation at the
• participating CHL clinics to include colorectal
  cancer screening.
• Colorectal chart abstraction of all women gt 50
  years of age
• Build on current patient navigation model to
  expand clinic cancer prevention services
• Utilization of CHLCare to track colorectal cancer
  screening and coordinate patient care.
• Goal 2
• To test direct-referral pilot designed to address
  barriers to access and
• improve efficiency from referral to completion in
  mammography screening.
• i.e. Holy Cross Hospital MAPS 2 and Adventist
  Healthcare.

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Institute for Healthcare Improvement

• The Institute for Healthcare Improvement (IHI) is
  an independent not-for-profit organization
  helping to lead the improvement of health care
  throughout the world. 
• IHI works to accelerate improvement by building
  the will for change, cultivating promising
  concepts for improving patient care, and helping
  health care systems put those ideas into action  

IHI homepage www.ihi.org/ 9-24-08
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Sustainable Changes Rely on Linking Clinical
Quality Improvement and Business Improvements

• Improving Efficiency
• Improving Team Productivity
• Efficient Facility Design and Standardization
• Availability of Key Resources
• Team-based care
• Optimizing utilization of staff
• Cross-training staff in a team-based model
• Generating Revenue
• Reducing Expenses

Roger Chaufournier, CSI Solutions
97
Institute for Healthcare Improvement
Collaboratives

• IMPACT Community Office Practice Redesign
• PCC Sponsored Clinics
• The Peoples Community Wellness Clinic 9/07-9/08
• Spanish Catholic Charities 9/07-9/09
• Proyecto Salud 9/08-9/09
• Muslim Community Center Medical Clinic 9/08-9/09
• 15 - 60 organizations working together to achieve
  significant improvements within learning
  collaborative model
• Community brings together known improvements in
  the areas of access efficiency and delivery of
  planned care
• Triple Aim Learning Collaborative
• PCC invited to join 15 other organizations
  globally to work together to test models and
  methods to transform health care delivery systems
• Completed Phase I April 2008
• One of nearly 40 organizations participating in
  Phase II
• Project ED-MC Connect

98
The Spanish Catholic Charities Experience
Small PDSAs, Big Improvements
Langley Park Shows a Decrease in Cycle Time
Patients Safety Report
QI Opportunities Reports
Better Design Forms at DC Medical
Huddles and Meeting
Better No Show Rate with an Innovative Scheduling
System at Montgomery Dental
Phone System Coordination
Data Collection Improvement
Office Redesign
Less Time to Have an Appointment at DC Clinic
Our Clinics Score High in Patient Satisfaction
99
IMPACT Office Practice Redesign results

• Quality and Process Improvement Mind-shift
• Utilizing QI Tools Ideas into Action/Results
• Collecting and utilizing data
• Overcoming resistance
• Empowerment of staff to make quality changes
• Improved workflow and efficiency
• Improved communication
• Exam room standardization
• Spread of knowledge to all CHL Clinics

100
The Triple Aim
Population Health

• Optimizing health care by balancing three
  health care delivery dimensions
• Improve the health of the population
• Enhance the patient experience (quality, access,
  reliability)
• Reduce, or at least control costs of care

Experience of Care
Per Capita Cost
101
Organizations in Triple Aim Phase II
Hospital-Based Systems Bellin Health
(WI) Cincinnati Childrens Hospital Medical
Center (OH) Genesys Health (MI)
(Ascension) ThedaCare (WI) Health Plans Blue
Cross Blue Shield of Michigan (MI) CareOregon
(OR) New York-Presbyterian System SelectHealth
(NY) UPMC Health Plan (PA) Independent Health
(NY) Integrated Health Systems Group Health
(WA) HealthPartners (MN) Kaiser Permanente (CO,
MD) Alaska Native Medical Center (AK) Veterans
Health System (OH, OR, NE) Health Department
King County (WA)
State Initiative Vermont Blueprint for Health
(VT) Safety Net Colorado Access (CO) Contra
Costa Health Services (CA) North Colorado Health
Alliance (CO) Primary Care Coalition Montgomery
County (MD) Queens Health Network
(NY) Employers/Businesses General Mills
(MN) QuadGraphics/QuadMed (WI) International Blac
kburn With Darwen Primary Care Trust (UK) Bolton
Primary Care Trust (UK) Central East Local
Health Integration Network (Canada) East
Lancashire Teaching Primary Care Trust
(UK) Eastern and Coastal Kent Primary Care Trust
(UK) Forth Valley (Scotland) IMPACT BC
(Canada) Jönköping (Sweden) Saskatchewan
Ministry of Health (Canada) Tayside
(Scotland) Social Services Common Ground (NY)
102
Triple Aim System Components

• Redesign primary care services and structures
• System integration and execution
• Focus on individuals and families
• Population health management
• Cost control platform

103
Strategy Segment the population, plan the
intervention

• Domains
• 1. Income deprivation
• 2. Employment deprivation
• 3. Health deprivation, disability
• 4. Education, skills, training deprivation
• 5. Barriers to Housing and Services
• 6. Living environment deprivation
• 7. Crime

104
Next steps for PCC in the health improvement arena

• Dissemination of quality improvement activities,
  knowledge among clinics and partners
• Population-Based EMR that supports the care team
  to provide the right care at the right time for
  every patient, assist with implementation of
  MedHIX to exchange patient information with
  hospitals
• Change culture of the MontgomeryCares to focus on
  quality and efficiency within a caring
  environment apply Triple Aim principles to move
  toward family centered care
• Community-based Wellness Collaborative
• Community Engagement
• Continue learning from Triple Aim model and
  promoting systems redesign
• Data analysis (including GIS) to examine links
  between clinic utilization and reductions in
  emergency department visits, patterns of clinic
  utilization, and areas of need
• Development of coordinated, patient centered
  cancer control plan

105
Funders/Grant
Funding resources for two years 2.4M

• Consumer Health Foundation 7331, IT
  Mini-technology grant, Geo-mapping
• Trawick Foundation 7331
• Morris Gwendolyn Cafritz Foundation 7331
• CareFirst I CareFirst II Planned Care/
  Diabetes
• Susan G. Komen Foundation I II Community-based
  Cancer Prevention Projects Breast Cancer
• Prevent Cancer Foundation Colorectal Navigation
• Healthcare Initiative Foundation Triple Aim,
  Community Wellness Collaborative
• DHHS Diabetes Education/IHI Practice Redesign
• Eagle Bank Breast Cancer Initiatives
• BBT 7331

106
CBPR Research Project Goals

• To determine major barriers to health care
  access among uninsured persons in Montgomery
  County
• To implement and test community-suggested
  strategiesvia a CBPR processto increase access
  to care
• _________________________________________________
  _______
• Overall To use Community-based Participatory
  Research to build health care infrastructure

107
What is community-based participatory research)?
CBPR is a collaborative research approach
that is designed to ensure and establish
structures for participation by communities
affected by the issue being studied,
representatives of organizations, and researchers
in all aspects of the research process to
improve health and well-being through taking
action, including social change. Viswanathan
et al., 2004 CBPR Assessing the Evidence AHRQ
2004
108
Relevance of community engagement

• Essential to the understanding of barriers and
  deterrents
• (use of preventive measures, primary care, and
  to improve health)
• Critical to identifying community perceptions and
  attitudes as well as identifying cultural issues
  and opportunities.
• Secures the use of appropriate related
  terminology and language to reach, particularly
  those community members who need services the
  most.
• Includes active community-wide opportunities for
  discussion, dissemination, advocacy and idea
  generation (local forums and trainings regarding
  lessons learned and needs identified).
• Promotes documentation of needs and baseline
  information based on evidence-based practices.
• Encourages community exchange that leads to
  development and implementation of best practices
  that are culturally appropriate to our community
  (ownership and promotion) .

109
Working with different communities
Chinese Community Health Fair
African-American Heart Health Symposium
Latino Health Fair (2006)
Cambodian Community Health Fair
110
Community Recommendations for Increasing Access
to Care

• Support and increase patient navigation and
  health promotion efforts targeted toand tailored
  forparticular communities.
• Increase and support efforts to improve
  staff/provider sensitivity, professionalism, and
  cultural competence.
• Assure mechanisms for lay involvement and input
  in county health programs and initiatives.
• Increase community outreach initiatives through
  media regarding services available for the
  uninsured, as well as health promotion
  opportunities.
• Increase flexibility in documentation
  requirements for service eligibility.
• Support preventive health efforts like community
  health fairs that provide health screenings and
  education as a means to increase access.
• Increase language-appropriateness of available
  services.

111
Partnerships and Acknowledgments

• County Partnerships African American Health
  Program, Asian American Health Initiative,
  Latino Health Initiative, Office of Health
  Promotion Substance Abuse Prevention
  (G.O.S.P.E.L. Program), MC Cancer and
  Tobacco Initiatives, Up-County Multicultural
  Health Promoter Program
• Montgomery Cares Clinics Proyecto Salud,
  Spanish Catholic Center, Pan Asian Volunteer
  Health Clinic, Mobile Med, Community Clinic Inc.,
  Holy Cross, Mercy Health Clinic, The Peoples
  Community Wellness Center
• Hospitals Holy Cross, Suburban, Montgomery
  General, Adventist H.C.
• Academic Partners Georgetown University,
  George Washington University, Uniformed
  Services University Ctr. for Health Disparities,
  University of Maryland -- Anthropology
  Public Health
• Community-Based African Immigrant and Refugee
  Found., African Womens partners Cancer
  Awareness Assoc., Chinese Culture and Community
  Svs. Center (CCACC), Cambodian Buddhist
  Society Inc., Community Ministries of
  Rockville, CASA Maryland, Inc., Maryland
  Vietnamese Mutual Association (MVMA)
• More partners Capital Technology
  Information Services Inc. (CTIS), National
  Kidney Foundation of the National Capital
  Area, ENACCT, Summit Health Institute for
  Research and Education, Inc.

112
Thank you for your for being part of our
community!
113
Primary Care Coalition Senior Staff

• Steve Galen, President and CEO
• Bill Bletzinger, Chief Operating Officer
• Sharon Zalewski, Director, Center for Health Care
  Access
• Rosemary Botchway, Director, Center for Medicine
  Access
• Tom Lewis, Chief Information Officer
• Maria Triantis, Director, Center for Health
  Improvement
• Maria Rosa Watson, Research Director
• Diane Briggs, Director, External Affairs