Improving Asthma Care in Cincinnati: The Journey Stephen Pleatman, MD Pediatrician, Suburban...

Improving Asthma Care in Cincinnati:The Journey

Stephen Pleatman, MDPediatrician, Suburban Pediatric Associates, Inc.

Board Member, Ohio Valley Primary Care Associates, L.L.C.Cincinnati, Ohio

Keith Mandel, MDVice President of Medical Affairs, Physician-Hospital

OrganizationCincinnati Children’s Hospital Medical Center

2009 Annual Meeting & Fall Pediatric UpdateAlabama AAP Chapter

September 19, 2009

Objectives

• To describe the Physician-Hospital Organization (PHO) at Cincinnati Children’s.

• To review overall objectives and key interventions of asthma improvement initiative.

• To review impact of interventions on asthma process and outcome measures.

• To review key learnings from large-scale improvement efforts.

• To discuss improvement journey from the practice perspective.

Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved

PHO Background

• Cincinnati Children’s launched the PHO in 1996.

• Strategic objectives:

– Extend efforts to improve effectiveness and efficiency of care beyond the hospital setting.

– Strengthen improvement knowledge/capability within primary care practices, thus enhancing sustainability.

– Spread successful improvement models/interventions among primary care practices, within and beyond the PHO.

– Communicate measurable improvements to payors and employers.

– Support the business case for quality improvement.

– Focus on “triple aim”: patient, population, costs.


PHO Background (cont’d) • 3 constituents:

– Cincinnati Children’s Hospital.

– Specialists: 500 (majority employed).

– Primary care physicians: 150 (across 39 practices).

• Independent practice association; 39 primary care practices in 8 county primary service area (only 1 practice is owned by CCHMC).

• 200,000 patients age 0-21 yrs. (Cincinnati MSA: 500,000).

• Separate board with strong physician leadership.

• Practices vary in size from one to 12 physicians.

• 30% of practices contract with hospital-owned billing company.

• 20% of practices have an EMR.Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved

PHO: Background/Structure

Primary Care Practices (IPA)

Effectiveness/efficiency

Effectiveness/efficiency

PHO QI Focus PHO QI Focus

CCHMC QI Focus

Specialists Hospital

39 pediatric practices

40% of regional pediatric population

12,500 asthma patients


“Success” = PHO Network-Level Improvement of Outcome

Measures(the “Big Dots”)


Conceptual Model for Moving the “Big Dots”

Highly engaged

leadership group+

Highly scalable

interventions

Network-level incentive

Transparent, comparative data

(catalysts)

Moves the

“big dots”

Reinforces Sustainability

Enabling Factors


PHO Asthma Improvement Initiative (Launched October 2003)


PHO Asthma Initiative: Key Driver Diagram

AIM

To improve evidence-based care for 12,500 children with asthma across 39 primary care practices (40% of regional pediatric population), with at least 90% of all-payor asthma population receiving “perfect care” (composite measure), thus reducing asthma-related ED/urgent care visits, admissions, acute office visits, missed school days, missed work days, and activity limitation; and, improving parent/patient confidence and degree of asthma control

KEY DRIVERS/INTERVENTIONS(high scalability focus)

Physician leadership at Board and practice level

Network-level goal setting by Board (network-level performance defines success)

Measurable practice participation expectations/requirements (linked to ABP-MOC approval)

Multidisciplinary practice quality improvement teams

Web-based registry, with all-payor population identification/reconfirmation

Real-time patient, practice, and network-level data/reporting

Transparent, comparative practice data on process and outcome measures

Concurrent data collection/use of decision support tool, based on high reliability principles/workflow changes

Aligning P4P/incentive design with improvement objectives

Key components of evidence-based care (“perfect care”)

Population segmentation, with focus on “high-risk” cohort

Cross-practice communication/shared learning to spread successful interventions

Integration of multiple administrative/electronic data sources (hospital, practice, payor)

Network and practice-level sustainability plans

AIMTo strengthen improvement knowledge/capability within primary care practices, thus enhancing sustainability of current and future improvement efforts


Impact on PHO “Big Dots”


Results: Process Measures


Network Performance: Process Measures (as of September 8, 2009)

Population-Based Measures(Network all-payor asthma population = 12,500)

PHO Literature

% of asthma population with flu shot:2008-2009 flu season2007-2008 flu season2006-2007 flu season (delayed vaccine delivery)2005-2006 flu season 2004-2005 flu season2003-2004 flu season (baseline)

66%60%54%62%40%22%

10-40%

% of asthma population with management plan 93% 50%

% of population with “persistent” asthma on controller medication*

96% 70%

% of asthma population with severity classified 95% 50%

% of asthma population receiving “perfect care”** 92% not available

* “Persistent” asthma defined per NHLBI severity classification criteria.

** “Perfect care”: composite measure of severity classification, written management plan, and controller medications (if patient has “persistent” asthma)


Results: Outcome Measures


Asthma Admissions/10K

0

2

4

6

8

10

12

14

Baseline Post

As

thm

a A

dm

iss

ion

s/1

0K

PHO

Comparison Group

56%

36%

Baseline: 3 year average (10/1/00-9/30/03)

Post: 2 year average (10/1/06-9/30/08)

Commercial insurance only

CCHMC encounters only

Patients ≥ 2 yrs. of age

8 county primary service area

ICD-9 code of 493.xx in primary position

PHO vs. Comparison Group Asthma Admissions: Pre/Post Impact


PHO vs. Comparison Group Asthma ED/Urgent Care Visits: Pre/Post Impact

Baseline: 3 year average (10/1/00-9/30/03)

Post: 2 year average (10/1/06-9/30/08)

Commercial insurance only

CCHMC encounters only

Patients ≥ 2 yrs. of age

8 county primary service area

ICD-9 code of 493.xx in primary position

ED/urgent care visits not tied to admissions

Asthma ED/Urgent Care Visits/1K

0

0.5

1

1.5

2

2.5

3

3.5

4

Baseline Post

Asth

ma E

D/U

rgen

t C

are

Vis

its/1

K

PHO

Comparison Group

55%

9%


PHO Network: Asthma Outcome Measures

Baseline8/04 - 7/05

Current8/08 - 7/09

%∆

% parents missing ≥ 2 work days due to child's asthma over prior 6 months

18.0% 10.2% 43% ↓

% parents rating confidence in managing child's asthma < 7/10

11.1% 6.7% 40% ↓

% asthma population missing ≥ 2 school days due to asthma over prior 6 months

26.5% 17.1% 35% ↓

% activity limitation reported as “not at all” or “a little of the time” Not

captured as these

questions were

initiated in 6/06

89.7%

n/a

% receiving oral steroids within prior 12 months 19.4%

% parents rating asthma as “well” or “completely” controlled

89.6%

% physicians rating asthma as “well” or “completely” controlled

90.0%

% parent and physician agreement on rating degree of asthma control

89.9%


Asthma Decision Support/Data Collection Tool

(primary focus: degree of asthma control)

(available at www.tristatepho.org)


Web-Based Registry


Asthma Pay-for-Performance (P4P) Program


Archives of Pediatrics and Adolescent Medicine, July 2007


American Board of Pediatrics: Maintenance of Certification

ABP-MOC CriteriaPractice-level: (sign-off by IPA

Board Chair)

• 80% of asthma registry population with data collection form completed on annual basis.

• 90% of asthma registry population receiving “perfect care” (composite measure of severity classification, written management plan, and controller medication (if patient has “persistent” asthma)).

• Asthma registry population denominator re-confirmed on annual basis by reviewing hospital and practice billing data.

• Sustaining multidisciplinary quality improvement team (physician, nurse/medical assistant, office manager).

• Quality improvement team representation at network meetings.

Physician-level: (sign-off by practice leader)

• Completing data collection/decision support tool at time of patient visit.

• Reviewing patient-level data (e.g., “high-risk” report, visit planner).

• Reviewing practice-level performance on process and outcome measures, via data/erports posted on web-based registry.

• Attending at least 4 in-practice meetings on asthma initiative since project inception. (required by ABP)


Large-Scale/Population-Based Improvement:

Lessons Learned from PHO Journey• Be clear on defining “success”—unit of analysis

(practice, region, state, multi-state); process vs. outcome measures.

• Allocate significant time/energy to establishing/sustaining highly engaged leadership group.

• Bring key physician leaders to the table with quality improvement management/operations team.

• Focus on highly scalable interventions.

• Consider network-level incentive as a catalyst to accelerate engagement/improvement.

• Allocate significant resources to establishing/sustaining highly reliable data collection systems within practices, and to integrating administrative/electronic data sources.


In Summary……Population identification/registry creation

+Reliability

+“Real-time”/transparent/actionable data

+Segmenting population

+Board/practice-level leadership

+Communication/collaboration among practices

+P4P+

Highly-scalable interventions+

Intense focus on sustainability=

Builds improvement capability and accelerates improvement


Practice Perspective

Urgency for Change

• Parental perceptions of variation in care.

• Adoption of medical advances in asthma care.

• Population identification and severity classification.

• Data collection made knowledge gaps visible.

• Documenting quality.

• Earning P4P reward.

• Transparency of comparative practice data.

Challenges• “Our practice is already busy enough.”

• “There’s no additional pay for the extra work.”

• “We’re already doing a good job.”

• “I already have my way of doing things—it’s ok if others want to go down this path.”

• Sensitivity to measuring quality of care among physicians.

• Reluctance to “standardize” practice around evidence-based care.

• “Research project.”

• “Not sure initiative will improve care.”

• Communication within practice.

Getting Started

Pre-existing focus on asthma population.

Recruiting practice commitment—connected with inherent desire to “do the right thing.”

Leadership.

Committed quality team.

Defining key roles.

Communication, communication, communication.

“Realistic” decision support/data collection tool.

Executing the Work

Developing the data collection tool

Mapping our process to build a foundation of highly reliable data collection

October, 2003

Asthma Patient Data Collection Form How severe is patient’s asthma? (circle appropriate level)

SEVERE

PERSISTENT ---------------------------------

Days Continual (more than 1 episode/day) OR Nights Frequent

MODERATE PERSISTENT

--------------------------------- Days Daily (1 episode/day)

OR Nights 5 or more nights/month

MILD

PERSISTENT ---------------------------------

Days 3-6 days/week but, not every day OR

Nights 3-4 nights/month

MILD

INTERMITTENT ---------------------------------

Days 0-2 days/week OR Nights 0-2 nights/month

Typical asthma symptoms: cough, shortness of breath, wheezing, chest tightness, waking at night, decreased ability to perform usual activities

Is patient on controller medication? (circle yes or no; if yes, circle one or more medications listed below, as applicable) Yes inhaled steroid long-acting bronchodilator oral steroid leukotriene modifier cromolyn or nedocromil theophylline other (please specify) ____________________________________________________________________ No

Was a written asthma management plan provided to family?

(circle one) Yes No Parents should answer the following two questions . . .

Has patient had a flu shot during the 2003-2004 season? (circle one) Yes No If “No”, please indicate action taken: ________________________________

If patient is 6 years of age or older, how many days of school were missed over the last three months due to asthma? _________________ (write in number of days)

10 months later… ASTHMA DATA COLLECTION FORM

Patient Name: _________________________________ Provider Name: _____________________________________

Date of Birth: _________________________________ Practice Name: _____________________________________

Date of Visit: _________________________________ Other patient identifier (OFFICE USE ONLY):_________________

Insurance Company: _____________________________ Well Visit Asthma Sick Visit Other Sick Visit PARENTS - PLEASE COMPLETE THE FOLLOWING SECTION:

1. *How many days of school or daycare has your child missed due to asthma in the past 6 months?

My child does not attend school or daycare

2. *How many days of work have you or your spouse missed due to your child’s

asthma in the past 6 months?

3. *How many times has your child visited the Emergency Room or Urgent Care

Clinic due to asthma in the past 6 months?

4. *How many times has your child been admitted to the hospital due to asthma in

the past 6 months?

5. *How confident are you in your ability to manage your child’s asthma on a scale of 1-10? (PLEASE CIRCLE)

NOT CONFIDENT = 1 2 3 4 5 6 7 8 9 10 = VERY CONFIDENT

6. How frequently has your child experienced episodes of cough, shortness of breath, wheezing, chest

tightness, or reduced activity due to asthma during the DAY in the past month? (PLEASE CIRCLE) More than once per day Once per day 3-6 days per week, but not every day 0-2 days per week

7. How frequently has your child experienced episodes of cough, shortness of breath, wheezing, chest

tightness, or waking up due to asthma at NIGHT in the past month? (PLEASE CIRCLE)

7 or more nights per month 5-6 nights per month 3-4 nights per month 0-2 nights per month

PHYSICIANS - PLEASE COMPLETE THE FOLLOWING SECTION: Asthma diagnosis tentative

8. *How would you classify the patient’s asthma severity? (PLEASE CIRCLE ONE) SEVERE

PERSISTENT MODERATE

PERSISTENT MILD

PERSISTENT MILD

INTERMITTENT

9. *Is the patient on controller medication (e.g. inhaled steroid, leukotriene modifier,

nedocromil, cromolyn, long-acting bronchodilator)? YES NO

10. *Does the family have a written asthma management plan? YES NO UNKNOWN

11. *Is the patient currently followed by a specialist?

Name of specialist:__________________________________

YES NO UNKNOWN

12. *If NO, do you plan to refer the patient to a specialist?

Name of specialist:

YES NO

Please fax to Tri State Child Health Services at (513)636-7540

2 ½ years later…

Reliability

Prior to visit:– Asthma sticker

placed on chart and data collection form inserted.

On arrival:– Registration staff

asks parent if child has asthma at check-in.

– Parent/patient completes data collection form while in waiting area.

Exam room:– Nurse/medical

assistant reviews medication list (to identify asthma patients) and collects data when patient taken to exam room.

– Parent/patient completes form while in exam room.

– Physician completes form while in exam room.

– “Reminder” built into EMR.

System designed to reduce “missed opportunities” to capture data from parents/providers and address key issues at point of care

Before departure:- Nurse/medical assistant assures data collected and issues addressed; collects missing data prior to patient departure.

Beyond typical office visits:- Data captured at time of parent phone call to refill asthma medications. - Data captured at flu shot-only visits. - Data captured via regular mailings.


Clinical Assessment Process Map – Suburban PediatricsO

ffice

Vis

it

Patient signs inMedical Assistant

views patient record in EMR

EMR alerts Medical Assistant

if child has a diagnosis of

asthma

Medical Assistant gives assessment

form to parent

Parent completes top half of

assessment form

If time permits, Medical Assistant will enter parent responses into

EMR

Medical Assistant gives parent responses on paper form to

Physician

Medical Assistant/Asthma Nurse

assists with form completion in EMR

Physician enters physician

responses into EMR during visit

Medical Assistant collects paper

form, forwards to proper physician

for entry into EMR

Paper forms are collected and

entered into the EMR by the

Asthma Nurse

Medical Assistant reviews

assessment form and enters parent

responses into EMR, if needed

Physician decision to fill out form during the visit

Physician entry – preferred method

Medical Assistant/Asthma Nurse entry – alternate method

Practice Improvement Capability: Areas of Focus

• Commitment.

• Leadership.

• Communication.

• Reliability of data collection.

• Data entry.

• Interventions to improve clinical asthma care.

The “Ideal”…..

• Physician, nurse, and practice manager (quality leadership team) meets regularly to review project status/data/reports, and discuss improvement opportunities.

• Physician administrative leader visibly supports project and encourages improvement work.

• Project information/updates discussed with physicians and staff at regular practice meetings, data/information shared, and input/feedback recruited.

• Quality leadership team discusses data collection process at regular intervals and identifies/pursues opportunities to improve reliability.

• Accuracy and timeliness of data entry monitored and addressed.

• Improvement interventions pursued using test of change methodology.

Using Registry/Data to Drive Improvement

DashboardProcess Dashboard (Year End 2008 Results) Outcomes Dashboard (Year End 2008

Results)

State of Asthma Care

Key Outcome Statistics

Visit Planner

High Risk Patient List

Utilization Report

Improving Influenza Immunization Rates

Key Learnings

Leadership

Develop quality improvement team

Effective communication

Build consensus within practice

Use disconfirming data to drive improvements and sustain engagement

Recruit parent involvement/feedback to accelerate improvement.

Improve “reliability”—build improvement into daily work.

Learn from others—don’t reinvent the wheel.

Impact on Our Practice• Parents more confident and knowledgeable.

• Nurses report reduced volume of phone calls.

• Positive feedback from families has energized practice and helped sustain improvement work.

• Clinicians proactively engaging patients and parents in more meaningful dialogue to improve care vs. more “passive” approach of the past.

• Data has uncovered issues/gaps not previously identified.

• Discussing how to spread improvement work to other conditions.

• Positioned to win on current/future P4P programs.

• Appreciate value of registry.

• Staff roles/responsibilities revised to sustain improvement efforts.


Patient/Parent and Staff Perspectives

This is Hard Stuff

This takes lots of work to initiate and sustain.

ikikik Tc

GRgR

4

8

2

1

Thank You!!

Questions?

Contact Information

Stephen Pleatman, MDPediatrician, Suburban Pediatric Associates, Inc.

Board Member, Ohio Valley Primary Care Associates, L.L.C.

[email protected]

Keith Mandel, MDVice President of Medical Affairs, Physician-Hospital Organization

Cincinnati Children’s Hospital Medical Center513-636-4957

[email protected]

mailto:[email protected]

mailto:[email protected]

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