Population Health/Clinical Quality Department

1. Population Health/Clinical Quality Department

2. Austin Regional Clinic (ARC) brought managed care to Central Texas in 1980. ARC spent it’s first two decades focused on delivering high quality, capitated care. Then the healthcare marketplace changed…. 2000-2010, was a decade of pure Fee for Service. Then in 2011 it changed again and we turned again to value based care

3. Profile of Austin Regional Clinic Physician owned and governed 294 ambulatory care physicians and providers Multi-specialty group built on 75% primary care platform Approximately $250M in annual revenue 16 of 50 payer contracts have value based component (9 commercial, 5 Medicare, 2 Medicaid) 200,000 of 450,000 lives in quality and efficiency contracts 65 employees work in Population Health and Clinical Quality Use EPIC with MyChartpatient portal $16+ Million in cost-of-care savings returned to ARC in first 6 years

4. More about ARC… Specialties: Primary care and Allergy, Derm, ENT, General Surgery, Podiatry, Ortho Same Day appointments at every location, every day, every doctor After Hours availability – 6 locations Extended hours (7-7) – one pilot, plan to expand to other locations in 2018 Adding more locations (6 in the next year)

5. What Worked Combination of: • Meeting quality metrics • Cancer screenings, chronic care management, closing gaps in care and medical records • Cost effectiveness • ER visits/1000, readmissions, total cost of care • Being better than rest of “market” • Compared to ourselves, other PCMH/ACO practices in Austin or Texas, or some other health plan region

6. Results – Quality • Colon cancer screening rate improved from 52% to 58% • Breast cancer screening rate – from 69% to 74% • HTN control rate from 64% in 2014 to 73% in 2016 • 97% of pedi patients received appropriate tx for pharyngitis and URIs • Fall risk screening and depression screening at 32% for ARC

7. Results – Performance

9. Care Gap Management Focus on Visits! • Don’t chase care gaps but encourage regular PCP visits • Proactively reach out to schedule • Well Child Checks • Physicals • Medicare Wellness Visits • Well Woman Exams • Routine chronic care visits for hypertension, diabetes, COPD • Send reminders for tests ordered at visits and bulk ordering for colon cancer screening

11. Reporting and Analytics • Understand and report on quality measures • Receive and process membership and claims files for use in day-to-day operations • Provides analysis of risk, cost, and Medical Home initiatives • Support ARC Clinical Quality Council • Provide clinical reports to health plan partners • Collaborate across ARC departments

13. Financial & Contract Compliance • Monthly Dashboards – reviewing Part A, B, and D across all plans • Monthly budget variance review • Monthly review of health plan data for RAF and HEDIS • Contract review and summary - compliance

15. Medicare Wellness • Wellness Assessments provided by Advanced Practice Nurses on behalf of PCPs • Visits conducted at patient’s home clinic • Goals are screenings, vaccines, advance care planning, referrals to PCPs for treatment & evaluation

16. Medicare Wellness Process

17. Medicare Wellness Code Gap Report

18. Medicare Wellness Preview Form

19. Problem List-Before Preview

20. Problem List-After Preveiw

21. Medicare Wellness Process • Daily work queues by clinic staff – billing and diagnoses links • Monthly chart review with supervising MD – knowledge and education • Monthly chart review at Medicare Wellness meetings – education and improvement in documentation and risk adjusting • Quarterly chart review by Coding Quality Department – accuracy of documentation and coding

23. Nurse Navigator Training • Foundational: Patient Engagement, Motivation Interviewing, Care Transitions, and Decision Support • GundersenPalliative Care - “Respecting Choices-Advanced Care Planning” (Detering, 2010) • Diabetes Education at Seton Medical Centers • Diabetes Management Reviews • Oral Medications • Insulin Therapy • Nutrition management • Home Health and Medicare • Resource/Caregiver Support https://www.auntbertha.com/

24. Clinical Inventions Chronic Care Navigation • Ensure necessary preventative care • Co-location with providers (Ghorob & Bodenheimer, 2015) • Teach patients about their specific conditions • Simplify medication regimens • Goal setting for weight loss, quitting tobacco , getting exercise, & taking medication consistently • Offer resources for transportation, therapy, medical equipment & in-home care • Guide and help patients record their end of life decisions and share their decision with family

25. Clinical Inventions-General Assessment

26. Clinical Inventions Hospital and ER Navigation • Make follow up appointments for patients discharged from the hospital and ER • Educate patient about their medications and disease processes • Ensure patients have necessary support, equipment, medications (Dreyer, 2010) • Inform patients about their options for receiving quality care in the most affordable setting

27. Clinical Inventions-Outreach Encounter

28. Clinical Inventions-CRM

29. Clinical Inventions

31. Clinical Quality - Scope • Works with clinical leadership to improve patient health and clinical workflows – screening rates, vaccine rates, correct vital sign collection • Tracks and communicates performance on clinical quality measures • Reviews and disseminates information on “current events”: disease alerts/outbreaks, medication recalls, clinical practice guideline updates • Facilitates our participation in ad hoc and ongoing quality improvement initiatives

32. Clinical Quality – Best Practices • Combine top-down and bottom-up approaches • Top-down: Leadership sets priorities • Bottom-up: Frontline staff and clinicians (and patients?) co-design solutions • Consistent communication & project management • Standing and project-based committees/workgroups • “Connect the dots” between clinical, technical, and operational teams • Clear presentation of data • Quality improvement methodologies

33. Clinical Quality – Challenges • Combine top-down and bottom-up approaches • Who decides what’s important? • Consistent communication & project management • Competing priorities and production-based payment • Clear presentation of data • No stories without data, no data without stories • Quality improvement methodologies • Discipline, patience, scale, stamina

34. Hypertension Campaign

35. Colon Cancer Screening Program

36. What Did NOT Work Advanced Care Coordination Clinic Patients left PCP for “Team Care” MD/personal nurse access around the clock Located at regionalized clinics (North and South) Social Work/Psychologist Medical Resource and Behavior Modification Located at regionalized clinics (North and South) Telephonic Navigation Diabetes patients only Focus on patients still in workforce, not retired/elderly

37. Reference List Casalino, Lawrence P., Gans, David, Weber, Rachel, Cea, Meagan, Tuchovsky, Amber, Bishop, Tara F. , Miranda, Yesenia, Frankel, Brittany A., Ziehler, Kristina B., Wong, Meghan M. and B. Evenson, Todd (2016) US physician practices spend more than $15.4 billion annually to report quality measures Health Affairs 35, no.3 (2016):401-406 http://content.healthaffairs.org/content/35/3/401 Detering, K. M., Hancock, A. D., Reade, M. C., & Silvester, W. (2010). The impact of advance care planning on end of life care in elderly patients: randomized controlled trial. BMJ, 340:c1345. http://www.bmj.com/content/340/bmj.c1345.https://respectingchoices.org/ Dreyer, T. (Jan 2014) Care Transitions: Best Practices and Evidence-based Programs, Center for Healthcare Research & Transformationhttp://www.chrt.org/publication/care-transitions-best-practices-evidence-based-programs/ Ghorob, A., & Bodenheimer, T. (2015). Building teams in primary care: A practical guide. Families, Systems, & Health, 33(3), 182-192. http://dx.doi.org/10.1037/fsh0000120