PAFP Residency Improving Performance in Practice Medical Home

PAFP Residency Improving Performance in Practice Medical Home Collaborative 44 th Annual STFM Spring Conference, session L 30 A New Orleans – April 29, 2011 PA Academy of Family Physicians Foundation (PAFP/F) Residency Program Collaborative (RPC) Presented by RPC Faculty: William Warning, MD FAAFP – Program Director Crozer-Keystone Family Medicine Residency Program Springfield, PA william. warning@crozer. org Lee Radosh, MD FAAFP – Program Director The Reading Hospital & Medical Center Family Medicine Residency Program Reading, PA radoshl@readinghospital. org

Introduction • Presentation Outline • Objectives - by the end of this presentation, attendees – Who? will be able to: – What? – List key components of – Why? one collaborative model – How? – Replicate (at least parts) in their respective communities/settings to transform “mass” practices utilizing the PCMH/CCM

Who? PAFP Residency Program Collaborative • PCMH / IPIP Collaborative of the FM residency programs in PA • 24 teams • Learning and Supportive Collaborative • Started June 2010

Who? Physician Faculty • William Warning, MD FAAFP – Director, Crozer-Keystone Family Medicine Residency Program – Roles/Expertise: Collaborative Leader and Faculty Staff Chairperson – Contact: william. warning@crozer. org • Lee Radosh, MD FAAFP – Director, Family Medicine Residency, The Reading Hospital and Medical Center – Roles/Expertise: Research/NCQA and Faculty • Jorge J. Scheirer, MD FACP – Medical Director, RPS Internal Medicine, The Reading Hospital and Medical Center – Roles/Expertise: Data integrity/Informatics and Faculty • George Valko, MD FAAFP – The Gustave and Valla Amsterdam Professor of Family and Community Medicine, Jefferson Medical College of Thomas Jefferson University – Vice-Chair for Clinical Programs and Chief Medical Information Officer, Thomas Jefferson University – Roles/Expertise: NCQA/System Design/Informatics and Faculty

Who? PAFP/F & IPIP Support Staff From the beginning. . . • Colleen M. Schwartz, RN – Quality Improvement (QI) Technical Coordinator – Pennsylvania Academy of Family Physicians Foundation (PAFP/F) • Dana Boyd – QI Program Coordinator – Pennsylvania Academy of Family Physicians Foundation (PAFP/F) • Dawn Tice BSN, MBA – QI Consultant – PAFP/F Residency Program Collaborative – Improving Performance In Practice (IPIP) Joined a few months in. . . • Molly Tally – Residency Program Collaborative Director, PAFP/F • Frendy Glasser – CME Outcomes Measurements Director, PAFP/F • Lee Ann Grajales – Vice President - Quality Initiatives, PAFP/F • Sherrie Whisler – QI Technical Support Manager, PAFP/F • Angie Halaja-Henriques – Director, PAFP/F Public Health Initiatives

What? • Largest single state collaborative of its kind in the country • IPIP (Improving Performance In Practice) Collaborative • Goals: – Transform residency program practices utilizing the CCM – Facilitate ALL of PA’s Family Medicine Residency Programs to achieve NCQA PCMH recognition • Lofty goals!

Why? Background • Previous PA Governor Rendell created the Governor’s Office of Healthcare Reform (GOHCR) • The Chronic Care Initiative (CCI) launched in May of 2008 • Goals: – Transform primary care practices into Patient-Centered Medical Homes (PCMH) – Improve quality care and reduce costs for chronic diseases using the Chronic Care Model (CCM) • Government was “convener” and insurers “persuaded” to fund practices in a pilot program • Started with 32 primary care practices in Southeast PA – Now statewide involving 154 (200 by summer) practices • No delineation: academic vs. private practices

GOHCR CCI Practices: Obligations • Practices must: • Insurers/Payers must: – Attend 1 -day learning – Pay (certain) practices sessions (about 3/year) (based on PMPM – Submit monthly data and calculations) narrative reports using • GOHCR must: diabetes/asthma as models – Monitor adherence on both sides – Attend monthly conference calls – Facilitate learning sessions – Achieve milestones: – Supply practice coaches • NCQA PCMH recognition (initially) • Hire a Care Manager by – Act as a “convener” end of year one between insurers and practices

Out Of This. . . • Staff from PAFP recognized the potential of this model for Family Medicine Residency Programs • Four faculty from “successful” practices in CCI brought on • Funding – Initial unrestricted grant from pharma – Branched into “clean” source (PA DOH, etc. ) • Physician Faculty Led – Not “practice coach” led – Faculty from academics • Know unique challenges and opportunities of academic (mostly Family Medicine Residency) clinical practice

Format – What Participants “See” • Four, 1 day learning sessions – Different parts of the state – Usually in conjunction with other PAFP meeting • Must submit monthly, data reports (new) • Monthly conference calls/webinars • Schedule calls and/or email dialogues with physician faculty and/or staff • Must apply for NCQA PCMH recognition

Format – Behind the Scenes (What Faculty/Staff Do) • Outline curriculum/overall goals/rough timelines • Plan/lead four, one-day learning sessions • Oversee teams – Review data reports with custom feedback – Reach-out/cajole. . • • • Plan/lead monthly conference calls/webinars Answer calls and/or email dialogues with practices Update Collaborative website (add resources, links, etc. ) Occasional list-serve didactics/tips Weekly (Friday 7 AM) planning conference calls Endless faculty/staff emails – Asynchronous planning/discussions • Disseminate/share about the collaborative – Like here (STFM), Institute for Healthcare Improvement (IHI), Others

Funding - Where Does It Go? • Physician faculty – Monthly stipend; extra stipend and travel expenses for learning sessions – Minimizes conflict with current jobs/roles of faculty – Allows real-world faculty! (“To overcome that problem, in my practice we tried. . . ”) • • Some staff: salaried by PAFP (part of “core” job) Some staff: paid as consultants Occasional: outside consultant (lecturer for LS, etc. ) No “practice coaches”

Why Not Practice Coaches? • This was (and is) debated • Practice coaches (traditionally RN’s/those with clinical experience) spend time on-site at practices • Practice coach model – Probably considered the standard for these types of collaboratives & transformations – Obviously, can work VERY well but. .

Why Not Practice Coaches (con’t)? • Too busy to give true, on-site, meaningful coaching consistently, when needed – Per faculty experiences • Most of the “work” needs to be done internally at the practice level • Unique issues in residency practices vs. private practices • This model allows to save money/put costs into more practical needs • Again, this is highly debated (internally by us)

What’s in it for the Practices? • At this time, NO monetary compensation – But, we need buy-in from residencies AND their hospital administrators Educate residents for the future…Preparing the future workforce Improve quality and care in their practices Prepare for P 4 P and PCMH based incentives Recruitment! (students want to train at PCMH’s) Credibility with home institutions CME As an IPIP collaborative, faculty can get ABFM Maintenance of Certification Credit for part IV • If they don’t have a registry, one provided for free (RMD) • •

Participants • There are 30 FM residency programs in PA – 7 already involved in the GOHCR CCI • • Excluded from this collaborative 3 of the 7 are represented by a faculty physician in our collaborative – That left 23 possible programs • • Now 24 teams (some residencies w/ multiple sites, thus multiple teams) Each team—Minimum 3 members, ideal 5 members: 1. 2. 3. 4. 5. Faculty (usually the practice medical director) PGY 2 resident Clinical Supervisor—Nurse/others Practice manager IT support

Team Name Altoona Family Physicians Residency Program Altoona/Williamsburg Family Medicine Center Current Teams Chestnut Hill Hospital Family Medicine Residency Program Conemaugh Memorial Medical Center FPRP Crozer/Ches. Penn Center for Family Health at Upper Darby Forbes Family Medicine Residency Lehigh Valley Hospital Family Health Center Lehigh Valley Hospital Internal Medicine Residency Program Lehigh Valley: Neighborhood Health Centers of the Caring Place Montgomery Hospital FMRP Penn State University / ELCO Penn State University/ Good Samaritan Hospital St. Luke's Hospital FMRP St. Vincent Health Center FMRP UPENN Hospital of the University of PA FMRP UPENN Hospital/St. Leonard's Court UPMC Mc. Keesport FMRP UPMC Shadyside FMRP UPMC St. Margaret/Bloomfield Garfield UPMC St. Margaret/Lawrenceville Family Health UPMC St. Margaret/New Kensington Williamsport Hospital & Medical Center FMRP Wyoming Valley Family Medicine RP York Hospital FMRP Notes: • Several programs have more than one clinical site (each is a separate “team”) • Each consented (as part of initial collaborative agreement) for data sharing/research (all data of course de-identified)

Samples: Agendas, Timelines, etc.

Timelines for Teams Learning Sessions Conference Calls Data Reporting Schedule Wednesdays 4: 00 to 5: 00 PM June 3, 2010 Lancaster, PA November 5, 2010 Pittsburgh, PA March 11, 2011 State College, PA June 10, 2011 King of Prussia, PA (Philadelphia suburb) June 23, 2010 July 28, 2010 August 25, 2010 September 22, 2010 October 27, 2010 November 17, 2010 December 15, 2010 January 26, 2011 February 23, 2011 March 23, 2011 April 27, 2011 May 25, 2011 June 22, 2011 July 5, 2010 August 5, 2010 September 7, 2010 October 5, 2010 November 5, 2010 December 6, 2010 January 5, 2011 February 7, 2011 March 7, 2011 April 5, 2011 May 5, 2011 June 6, 2011 July 5, 2011

Sample LS Agenda: November 2010 Thursday, November 4 7: 30 AM – 8: 00 AM Registration – Dana Boyd, PAFP Quality Initiatives Program Coordinator 8: 00 AM – 8: 15 AM General Announcements /Faculty and Team Introductions – Lee Ann Grajales, PAFP Vice President of Quality Initiatives 8: 15 AM – 8: 30 AM Opening Remarks – Collaborative Progress – Dr. William Warning, Residency Program Collaborative Faculty Chairman 8: 30 AM – 9: 30 AM Presentation – “NCQA – Achieving Patient Centered Medical Home Recognition” Mina Harkins, Assistant Vice President Recognition Programs 9: 30 AM – 10: 00 AM Team Sharing “Best Practices” – First Group of 10 Teams (3 Minutes Per Team) 10: 00 AM – 10: 15 AM ***** BREAK ***** - Team Time Sign-Up with Mina Harkins (NCQA) 10: 15 AM – 1: 00 PM Team Time with Mina Harkins (15 Minute Appointments/Breakout Room #1) – Dr. Lee Radosh, Facilitator 10: 15 AM – 11: 15 AM (CME Credit Pending) Presentation – “How to Use Data to Improve Performance” – Dr. Jorge Scheirer, Residency Program Collaborative 11: 15 AM – 12: 15 PM (CME Credit Pending) Presentation – “Self Management Support” – Ms. Kathy Hill, CRNP – Holistic Health Counselor 12: 15 PM – 1: 00 PM ***** LUNCH ***** – Question Submission to Mina Harkins (NCQA) 1: 00 PM – 1: 15 PM Wrap Up Session – Mina Harkins (NCQA) 1: 15 PM – 1: 45 PM Team Sharing “Best Practices” – Second Group of 10 Teams (3 Minutes Per Team) 1: 45 PM – 2: 00 PM ***** MOVE TO BREAKOUT SESSION ROOMS ***** BREAKOUT SESSION #1 2: 00 PM – 2: 30 PM Room # 1 - Presentation – “Self Management Support: Doing It, DOCUMENTING It” – Dr. Lee Radosh, Residency Program Collaborative Faculty Staff 2: 00 PM – 2: 30 PM Room # 2 - Presentation – “Referral and Test Tracking: Developing a System” – Dr. George Valko, Residency Program Collaborative Faculty Staff BREAKOUT SESSION #2 2: 30 PM – 3: 00 PM Room # 1 - Presentation – “Self Management Support: Doing It, DOCUMENTING It” – Dr. Lee Radosh, Residency Program Collaborative Faculty Staff

Sample Agenda: August Webinar

Webinars & Learning Sessions • Initially – Staff/faculty organized – Faculty-led (presentations) – NCQA application heavy • Now – Staff/faculty organized – Team-led • “Best practice” sharing • A true collaborative

Performance Improvement Tracking Tool: PITT

Outcomes of Collaborative? • Many outcomes we could track • Examples: – Educational – Clinical – Administrative/financial • Details available

Objective: What will we measure: Method of data collection: 1. increased chronic care patient satisfaction – care and process >Via practice assessment - pt section of Monitor >Via evals at LSs 3 and 4 >Pt satisfaction surveys from RPs (if available) 2. Increased chronic care patient access to services >Via practice assessment - access and care coordination section of Monitor >Via evals at LSs 3 and 4 3. Increased chronic care patient health function chronic care patient health status >Performance reports – IPIP system 4. Increased chronic care patient quality of life >Narrative reports >Solicit examples from programs (qualitative) 5. Increased primary care provider satisfaction >Via practice assessment >Via evals at LSs 3 and 4 6. Increased office staff satisfaction Office staff satisfaction >Via practice assessment >via evals at LSs 3 and 4 7. Improved care coordination health resources utilization >LS best practice report; practice assessment >>NCQA care coordination standards/certification >ER/admission statistics (if available) 8. Assisting residency practices in NCQA PCMH recognition Percentages of residency practices achieving NCQA PCMH recognition >Narrative reports >NCQA results 9. Identifying unique challenges and opportunities with regard to residency settings Challenges and opportunities (barriers/roadblocks, etc. ) with regard to practice transformation in residencies >Narrative reports >Solicit examples from programs (qualitative) 10. Instill the chronic care and PCMH models within residents, such that they lead practice transformations into the future Percentages of graduates of these programs whose future practices achieve NCQA PCMH recognition (or equivalent “objective” measure of implementation of these practice characteristics) compared with graduates of other residencies >Narrative reports >NCQA results (Note: both of these are approximately 5 year followups) 11. Develop sustainable, real-world feasibility of practice transformation Resources needed (time, funding) from practices and collaborative leadership team to achieve above goals >Narrative reports >Time logs >Financial reports

Practice Monitor: One Instrument • Standardized instrument (utilized in the Colorado Collaborative) – 14 sections, each having several questions • 1 st Practice Monitor – June 3, 2010 – 3 -4 members from each practice (as a team) at learning session – 13 practices • 2 nd Practice Monitor (new practices had joined) – December 2010 – Survey Monkey – 20 practices • Initial discrepancy in practice numbers - we couldn’t do paired analysis – Mann Whitney U test (non-parametric test for independent samples) • Now, paired analysis

Summary: Paired Mean Ratings (out of 10) for Each Section of the Practice PCMH Monitor Form Paired data only shown

Summary: Paired Mean Ratings (out of 10) for Each Section of the Practice PCMH Monitor Form Statistically significantly different based on The Wilcoxon signed ranks test (a nonparametric test for paired data); Alpha was set at. 05 and P values of less than or equal to. 05 were considered to demonstrate a statistically significant difference Paired data only shown

Preliminary Data • NCQA PCMH recognition – Litmus test for transformation – As of March, 7 achieved level 3 recognition! • Clinical data – Most recent (compiled) as of October 2010 – 5, 909 patients represented – Reporting at all is an accomplishment • Practices hadn’t done this previously • Common: takes 6+ months for data integrity to mature

Foot Exams

March LS#3 – Sample Feedback

Selected Collaborative Highlights • Physician Led and supported – • Experienced faculty who each oversaw NCQA Level 3 teams NCQA guidelines (“litmus test” – got program/practice buy-in) Then evolved into CCM implementation Our collaborative - similar to a “Community of Practices” Sustainable - lean faculty structure – STRONG, talented, experienced administrative support Large organization (PAFP) at the core – Can leverage resources (ex: tack on our LS’s to PAFP CME, to reduce overhead/costs) – Attract donors/funders, bridge to other organizations – Instant “credibility” We began with developing the infrastructure and goals – • • • IPIP recognized Streamlined reporting and communicating by the web (PAFP Quality Improvement site) Performance Improvement Tracking Tool – Allows teams to be self reflective – Organizes specific faculty suggestions

Selected Collaborative Challenges • Participant AND faculty distractions – Clinical (other responsibilities, flu season, etc. ) – Residency (resident orientation, recruitment season, holiday season, etc. ) • Lack of administrator buy-in – Must be able to show clear benefits to hospital system • Lack of financial incentive for practices – Sustainability (beyond practices’ interests in PCMH recognition)? • Evolving / expanding goals by dynamic faculty and staff (exciting opportunities, but too many directions? ) • Inconsistent (even absent) data reporting by some practices – Takes 6 months to get good, consistent reporting – Data integrity an issue early on • Curriculum is fluid. . driven by participants’ needs – A positive. . but a challenge! • Changing healthcare world – CCM/PCMH should be king. . or we all bought into a failed experiment

The Next Steps • More formalized feedback process – Faculty assigned to oversee certain practices: roles expanded • Develop “formal” educational curriculum for the residencies • Expand to Internal Medicine, Pediatric residencies? – Conference calls with PA AAP, ACP already happened • • Solidify outcomes after year one Develop long-term tracking/outcomes systems Financial incentives for practices? Years 2, 3 goals – Debated/recently decided – IVD (Ischemic vascular disease) added • Expanding funding sources • Shift from NCQA focus to CCI focus – Needs identified: SMS, for example

Summary • A large collaborative like this can be developed and sustained • Identify the goals (PCMH recognition, CCM transformation, etc. ) and infrastructure, then the format/details • Utilize experienced peers (such as physicians) with similar challenges/understanding as participants • Leverage technology (webinars, etc. ) and asynchronous communication • Hire outstanding support staff to oversee/develop the day to day operations and logistics – Faculty provide leadership/vision and practice assistance • Be flexible in curriculum and format Questions/Comments? Please contact us - we’d love your feedback!