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COMPASS. Using Data for Improvement Establishing the Current Condition and Identifying Opportunities for Improvement Robert Ferguson Program Manager. Purpose and Objectives. Purpose To describe how we collect, display, and use data ( not to show you our current outcomes or results)

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Compass

COMPASS

Using Data for Improvement

Establishing the Current Condition and Identifying Opportunities for Improvement

Robert Ferguson

Program Manager


Purpose and objectives

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


Jewish healthcare foundation a think do train and give tank

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)


Pittsburgh regional health initiative

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


Prhi s systems vision

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


Implementation of evidence based behavioral healthcare in primary care

Implementation of Evidence-based Behavioral Healthcare in Primary Care


Compass

  • 31 COMPASS-PA

  • PCP Offices from 3 Groups:

  • Saint Vincent Healthcare Partners

  • Excela Health Medical Group

  • Premier Medical Associates


Compass objectives

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%


Prhi s framework for collecting and responding to data

PRHI’s Framework for Collecting and Responding to Data

Informed by Motivational Interviewing and PRHI’s Lean-based Perfecting Patient CareSM QI Methodology


The lean perspective

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.


The motivational interviewing perspective

The Motivational Interviewing Perspective

A way of being with people which is…

  • Collaborative

  • Evocative

  • Respectful of autonomy


Method

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


Current condition observations

Current Condition Observations


Process mapping visualizing the current and future condition

Process MappingVisualizing the Current and Future Condition

Well-functioning aspect of work

Improvement

Opportunity


A3 improvement plan

A3 Improvement Plan


Incremental improvements towards the ideal

Incremental Improvements Towards the Ideal

Target

Condition

PDSA/A3

PDSA/A3

Each improvement moves the process closer to the ideal

Current

Condition


Compass

Motivational Interviewing Observation Form to Elicit Feedback on Skill Development


Example 1 ehr data at one medical group

Example 1: EHR Data at One Medical Group


Population health current condition

Population Health Current Condition

January 2013


Phq 9 screening current condition by office

PHQ-9 Screening Current Condition, by Office

October 2013

44% PHQ-9 Completion

19% PHQ-9 > 9

67% Enrollment


Example 2 displaying hpier s reports by medical group

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


Compass patient enrollment by regional partner

COMPASS Patient EnrollmentBy Regional Partner

June 13, 2014


Initial data completeness by medical group

Initial Data CompletenessBy Medical Group

June 13, 2014


Phq 9 documentation

PHQ-9 Documentation

June 13, 2014


Depression improvement baseline vs most recent score

Depression Improvement:Baseline vs. Most Recent Score

June 13, 2014


Depression remission among those in compass for 119 days

Depression Remission:Among Those in COMPASS for > 119 Days

June 13, 2014


A1c documentation

A1c Documentation

June 13, 2014


A1c control rate baseline vs most recent value

A1c Control Rate:Baseline vs. Most Recent Value

June 13, 2014


Bp documentation

BP Documentation

June 13, 2014


Bp control rate baseline vs most recent value

BP Control Rate:Baseline vs. Most Recent Value

June 13, 2014


Hospital admissions self reported

Hospital Admissions (Self-Reported)

June 13, 2014


Example 3 cmts data at one medical group

Example 3: CMTS Data at One Medical Group


Compass

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


Compass

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


Compass

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


Example 4 cmts data at another medical group

Example 4: CMTS Data at Another Medical Group


Compass

March 2014


Example 5 cmts data of follow up contacts

Example 5: CMTS Data of Follow-up Contacts


Follow up contacts and active caseload by month and care manager

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


Compass pa s next steps

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


Care of mental physical and substance use syndromes

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.


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