MA PCMHI: Impact on Clinical Quality atMidpoint

1. Massachuse(s
Pa+ent-­‐Centered
Medical
Home
Ini+a+ve:
Impact
on
Clinical
Quality
at
Midpoint
Judith
Steinberg,
MD,
MPH;
Sai
Cherala,
MD,
MPH;
Chris+ne
Johnson,
PhD;
Ann
Lawthers,
SM,
ScD
Center
for
Health
Policy
and
Research,
Commonwealth
Medicine,
University
of
Massachuse;s
Medical
School
§ Massachuse;s
Pa=ent
Centered
Medical
Home
Ini=a=ve
(MA
PCMHI):
§ Mul=-­‐payer,
statewide
ini=a=ve,
sponsored
by
MA
Health
&
Human
Services
§ 45
par=cipa=ng
prac=ces:
35
adult
prac=ces,
7
pediatric
prac=ces
and
3
adult
and
pediatric
prac=ces
§ 3-­‐year
demonstra=on;
Start:
March
29,
2011
§ Includes
payment
reform
and
technical
assistance
VISION:
All
MA
primary
care
prac3ces
will
be
PCMHs
by
2015
Aim
§ Assess
data
trends
of
12
clinical
quality
measures
from
par=cipa=ng
prac=ces
for
first
21
months
of
the
ini=a=ve
Design
§ Quality
improvement
study
using
self-­‐reported
monthly
clinical
quality
measures
data
from
all
PCMHI
prac=ces
from
June
2011
through
February
2013
§ Clinical
quality
measures
covered
the
domains
of
adult
diabetes,
pediatric
asthma,
care
coordina=on
and
care
management,
and
adult
preven=on.
Interven+on
§ Technical
Assistance:
Three-­‐year
Learning
Collabora=ve:
• Learning
sessions,
conference
calls,
webinars,
online
courses,
support
for
obtaining
NCQA
PCMH
recogni=on
and
prac=ce
facilita=on
§ Financial
Incen+ves:
32/45
prac=ces
receive
payment
reform
Methods
§ Linear
Mixed
Model
Analysis
§ Data
were
divided
into
three-­‐month
periods:
Time
1
(2011-­‐June,
July
and
August)…..
to
Time
7(2012-­‐
December,
2013-­‐
January
and
February)
§ Analysis
of
Change
over
Time:
Time
1
or
Time
2
(Care
Coordina=on
and
Care
Management
measures
collec=on
started
at
later
=me)
vs.
Time
7
TABLE
1:
PRACTICE
CHARACTERISTICS
FIGURE
1.
CLINICAL
QUALITY
MEASURES
CHANGE
OVER
TIME
Prac+ce
Characteris+cs
Percentage
Geography
Rural
(<10,000
popula=on)
9%
Suburban
(10,000
to
50,000)
20%
Urban
(>=
50,000)
71%
Prac+ce
Size
(Based
on
No.
of
Full
Time
Prac++oners)
Small
(<
6
FTE)
31%
Medium
(Between
6
and
11
FTE)
29%
Large
(>
11
FTE)
40%
Type
of
Prac+ce
Community
Health
Center
56%
Residency
or
Academic
Prac=ce
11%
Group
Prac=ce
29%
Solo
Prac=ce
4%
Payer
Mix
(Prac+ces
with
Financial
Incen+ves
N=31)
Commercial
12%
Health
Safety
Net
15%
Medicaid
72%
Medicare
1%
3
measures
showed
sta+s+cally
significant
improvement
from
Baseline
to
Time
7:
§ Diabe=c
pa=ents
screened
for
depression
(25.8%
to
42.4%,
p=0.0009)
§ Ac=on
plan
for
children
diagnosed
with
persistent
asthma
(19.6%
to
50.7%,
p=0.0076)
§ Highest
risk
pa=ents
with
care
plan
(36.5%
to
54.2%,
p=0.0147)
All
other
measures
showed
a
non-­‐significant
trend
towards
improvement
or
no
change
FIGURE
2.
CLINICAL
QUALITY
MEASURES:
SIGNIFICANT
CHANGE
OVER
TIME
71.3
16.2
61.7
47.7
25.8
35.1
80.9
45.1
76.1
19.6
66.9
36.5
68.7
15.2
61.6
45.8
42.4*
39.2
86.3
50.1
77.6
50.7*
70.6
54.2*
0
10
20
30
40
50
60
70
80
90
100
BP
<
140/90
mmHg
HbA1c
>
9%
HbA1c
<
8%
LDL
Control
<
100mg/dL
Screened
for
Depression
Adult
Weight
Screening
and
Follow-­‐Up
Tobacco
Use
Assessment
Tobacco
Cessa+on
Interven+on
Use
of
Appropriate
Medica+ons
for
Asthma
Persistent
Asthma
Pa+ents
With
Ac+on
Plan
Hospital
Discharge
Follow-­‐Up
Management
of
Highest-­‐Risk
Pa+ent:
Developing
Care
Plan
Percent
Measures
Baseline
Time
7
Adult
Diabetes
Adult
Preven+on
Pediatric
Asthma
Care
Coordina+on
and
Care
Management
*
Values
met
the
study’s
defini+on
of
sta+s+cal
significance
p<.05.
0
10
20
30
40
50
60
Time
1
Time
2
Time
3
Time
4
Time
5
Time
6
Time
7
Percent
Time
Screened for Depression
Persistent Asthma Patients With Action Plan
Management of Highest-Risk Patient:
Developing Care Plan
INTRODUCTION
METHODS
§ In
the
first
21
months
of
the
MA
PCMHI,
par=cipa=ng
prac=ces
have
significantly
improved:
• Diabetes
care
delivery
by
more
consistently
screening
pa=ents
for
depression
• Pediatric
asthma
care
by
more
consistently
developing
ac=on
plans
for
pa=ents
with
persistent
asthma
• Care
management
by
more
consistently
developing
care
plans
for
highest
risk
pa=ents
§ Sta=s=cally
significant
change
seen
in:
• Process
measures,
new
processes
and/or
newly
documented
processes
• Measures
for
specific
pa=ent
popula=ons
RESULTS
DISCUSSION
CONCLUSION
AND
POLICY
IMPLICATIONS
§ Primary
care
prac=ce
transforma=on
takes
=me
§ Processes
of
care
are
more
likely
to
improve
before
outcomes
are
impacted
§ Use
of
a
clinical
quality
measures
set
is
important
for:
• Developing
prac=ces’
skill
set
in
QI,
a
PCMH
component
• Evalua=ng
the
impact
of
implemen=ng
PCMH
processes
on
pa=ent
care
and
outcomes