COMPASS

1. COMPASS Using Data for Improvement Establishing the Current Condition and Identifying Opportunities for Improvement Robert Ferguson Program Manager

2. Purpose and Objectives • Purpose • To describe how we collect, display, and use data (not to show you our current outcomes or results) • To elicit your feedback on how we can improve our data displays and your ideas and strategies for collecting, displaying, and responding to data • Learning Objectives • Describe COMPASS-PA’s framework for collecting and responding to data • Discuss five examples of how to collect and display data in COMPASS

3. Jewish Healthcare Foundation“A Think, Do, Train and Give Tank” A public charity with two operating arms: Pittsburgh Regional Health Initiative (PRHI) Health Careers Futures (HCF)

4. Pittsburgh Regional Health Initiative • Pittsburgh Regional Health Initiative (PRHI) • A not-for-profit, regional, multi-stakeholder collaborative formed in 1997 by Karen Feinstein and Paul O’Neill • An initiative of a business group, the Allegheny Conference on Community Development PRHI’s message Dramatic quality improvement (approaching zero deficiencies) is the best cost-containment strategy for health care

5. PRHI’s Systems Vision Data to Treat, Measure, Evaluate Informed, Activated, Discerning Consumers, particularly at End-of-Life Collaboration and Integration Perfect PatientCare Rewards for Collaboration Across Care Settings Medication Reconciliation Screening and Tx Essential Services System Requirements Hospice/Palliative Long Term Care Rehab Hospital Emergency Services Specialty Care Primary Care Care Mgt Patient Engagement Health IT QI Training Payment Incentives Clinical Pharmacy Behavioral Health

6. Implementation of Evidence-based Behavioral Healthcare in Primary Care

7. 31 COMPASS-PA • PCP Offices from 3 Groups: • Saint Vincent Healthcare Partners • Excela Health Medical Group • Premier Medical Associates

8. COMPASS Objectives • By 12/31/13, enroll 375 eligible patients per partner region • By 6/30/14, enroll 675 eligible patients per partner region • By 6/30/15: • Improve depression for 40% of patients • Improve A1c, LDL, BP control rates by 20% • Improve patient/provider satisfaction by 20% • Reduce ER visits by 20% • Reduce hospital admissions by 10%

9. PRHI’s Framework for Collecting and Responding to Data Informed by Motivational Interviewing and PRHI’s Lean-based Perfecting Patient CareSM QI Methodology

10. The Lean Perspective Problem Solving (Continuous Improvement & Learning) The 4 P’S of the Toyota Way People and Partners (Respect, Challenge, and Grow Them) People and Partners (Respect, Challenge, and Grow Them) Liker, Jeffrey K. The Toyota Way, New York: McGraw-Hill, 2004.

11. The Motivational Interviewing Perspective A way of being with people which is… • Collaborative • Evocative • Respectful of autonomy

12. Method • Obtain leadership’s support and direction • Identify the current condition and future state with those who do the work, using multiple data sources to make it meaningful and actionable: • Observations (“go and see”) • Process Mapping • EHR and AIMS CMTS data • HPIER’s Reports • Facilitated by PRHI coaches who are trained in Perfecting Patient Caresm, Motivational Interviewing, and COMPASS processes and skills • Their goal is to develop internal capacity for self-review, learning, improvement, and sustainability

14. Current Condition Observations

15. Process MappingVisualizing the Current and Future Condition Well-functioning aspect of work Improvement Opportunity

16. A3 Improvement Plan

17. Incremental Improvements Towards the Ideal Target Condition PDSA/A3 PDSA/A3 Each improvement moves the process closer to the ideal Current Condition

18. Motivational Interviewing Observation Form to Elicit Feedback on Skill Development

19. Example 1: EHR Data at One Medical Group

20. Population Health Current Condition January 2013

21. PHQ-9 Screening Current Condition, by Office October 2013 44% PHQ-9 Completion 19% PHQ-9 > 9 67% Enrollment

22. Example 2: Displaying HPIER’s Reports, by Medical Group

23. COMPASS Patient EnrollmentBy Regional Partner June 13, 2014

24. Initial Data CompletenessBy Medical Group June 13, 2014

25. PHQ-9 Documentation June 13, 2014

26. Depression Improvement:Baseline vs. Most Recent Score June 13, 2014

27. Depression Remission:Among Those in COMPASS for > 119 Days June 13, 2014

28. A1c Documentation June 13, 2014

29. A1c Control Rate:Baseline vs. Most Recent Value June 13, 2014

30. BP Documentation June 13, 2014

31. BP Control Rate:Baseline vs. Most Recent Value June 13, 2014

32. Hospital Admissions (Self-Reported) June 13, 2014

33. Example 3: CMTS Data at One Medical Group

34. COMPASS PHQ-9 May 2014 CMTS Data Last Follow-up PH-9<10 28% Initial Contact PH-9>9 Last Follow-up PH-9>9 41% 99% 32% No Follow-up PH-9 Entered in CMTS Initial Contact PH-9<10 1% 100% Last Follow-up PH-9<10

35. COMPASS A1c May 2014 CMTS Data Last Follow-up A1c<8.0 12% Initial Contact A1c > 7.9 Last Follow-up A1c>7.9 41% 49% 47% No Follow-up A1c Entered in CMTS Last Follow-up A1c<8.0 43% 30% Initial Contact A1c<8.0 Last Follow-up A1c>7.9 10% 48% No Follow-up A1c

36. COMPASS SBP May 2014 CMTS Data Last Follow-up SBP<140 23% Initial Contact SBP>139 Last Follow-up SBP>139 15% 37% 62% No Follow-up SBP Entered in CMTS Last Follow-up SBP<140 48% Initial Contact SBP<140 17% Last Follow-up SBP>139 60% 36% No Follow-up SBP

37. Example 4: CMTS Data at Another Medical Group

38. March 2014

39. Example 5: CMTS Data of Follow-up Contacts

40. Follow-up Contacts and Active Caseload by Month and Care Manager

41. COMPASS-PA’s Next Steps • Analyze internal EHR data (PHQ-9, A1c, BP) • Continue to base the Steering Groups’ discussions around the data • Use AIMS’ CMTS Caseload Statistics and Caseload Summary for real-time data and monitoring • Continue to dig into the CMTS data • Continue to utilize Lean-based quality improvement methods at the front-line • Move meaningful, actionable data to where the work is occurring

42. Care of Mental, Physical, and Substance use Syndromes The project described was supported by Grant Number 1C1CMS331048 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.