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Utilizing Data to Support Performance Improvement : Transforming into a Quality & Cost-Saving Machine Utilizing Data to Support Performance Improvement : Transforming into a Quality & Cost-Saving Machine Indiana Primary Health Care Association May 3, 2016

Affiliation Disclosure I, Heather Budd, work for Azara Healthcare, a company which sells a Affiliation Disclosure I, Heather Budd, work for Azara Healthcare, a company which sells a healthcare reporting and analytics software to community health centers. 2 © Azara Healthcare 2015

The Urgency of Improvement UDS to offer incentive bonus for UDS Performance high performers. The Urgency of Improvement UDS to offer incentive bonus for UDS Performance high performers. is now public: US Bonus not available News, web, etc. to those doing 70 Health plans will chart audit method. not be likely to Independent accept data flaw Practice In early years excuses in shared Association Shared incremental savings/risk Savings, and other improvement will evaluations. new Fix your data now. be key to $ success. reimbursement methods. 3 © Azara Healthcare 2015

Money is an Important Motivator Those of us working in FQHCs are mission-driven, but Money is an Important Motivator Those of us working in FQHCs are mission-driven, but mission alone does not pay the bills. “No Money - No Mission. ” System Organization Staff 4 © Azara Healthcare 2015

System Level Various programs across the country are looking to create financial alignment to System Level Various programs across the country are looking to create financial alignment to improve the US health care system. • Affordable Care Act and ACOs (accountable care organizations) create alignment between various stakeholders in the healthcare delivery system to create cost savings • Trend toward Value vs. Volume in patient care & PCMH 5 © Azara Healthcare 2015

Organization Level • IPAs (independent practice associations) for Value-based Purchasing, Shared Services and group Organization Level • IPAs (independent practice associations) for Value-based Purchasing, Shared Services and group negotiation of Payer contracts • Shared Savings/Risk Programs with Payers • Pay for Reporting/Performance Programs with Payers and States 6 © Azara Healthcare 2015

Provider and Staff Level • Financial bonus for providers and staff for meeting or Provider and Staff Level • Financial bonus for providers and staff for meeting or exceeding quality goals • Enabling funding for additional resources to do the work to support all of these activities • Reward or Return on Investment is not just in dollars – it can also be in funding the right person for a role that then facilitates other improvement 7 © Azara Healthcare 2015

Strategic Vision -> Action Distilling Initiatives into Manageable Measures of Focus 8 © Azara Strategic Vision -> Action Distilling Initiatives into Manageable Measures of Focus 8 © Azara Healthcare 2015

Strategic Initiatives and Measure Alignment Cancer Screening Cervical, Breast, Colon Sweet Spot O AC Strategic Initiatives and Measure Alignment Cancer Screening Cervical, Breast, Colon Sweet Spot O AC Obesity s re su ea M Child/Adolescent Weight Screening, Activity & Nutrition Advice Adult Weight Screening & Follow up l P A 1 c BP Control fu ng ni ea Use H CM Diabetes M S DI HE & Hypertension BP Control l ica s n Cli ure DS eas U M 9 © Azara Healthcare 2015

Data Foundation for “Sharing the Care” REACTIVE PROACTIVE Data and Reporting Care Manager runs Data Foundation for “Sharing the Care” REACTIVE PROACTIVE Data and Reporting Care Manager runs registries for population management, and enabling services. Outreach and Missed Opportunities Registry reports for recent patients who missed intervention. Visit Planning Care Team Powered by Data Point of Care MA uses Visit Planning report as action list standard chronic and preventative care. Admin uses report to chase missing data & prepare for team huddle. Huddle High Risk/Cost/Need Patients? Other services needed? 10 © Azara Healthcare 2015

DRVS Scorecards to reflect each CHC’s Quality Focus Make the QI Focus Measures part DRVS Scorecards to reflect each CHC’s Quality Focus Make the QI Focus Measures part of daily life… 11 © Azara Healthcare 2015

Dashboards as High Level Performance Signals © Azara Healthcare 2015 Dashboards as High Level Performance Signals © Azara Healthcare 2015

Connecting the Data Dots Understanding Documentation Behavior and Data Results 13 © Azara Healthcare Connecting the Data Dots Understanding Documentation Behavior and Data Results 13 © Azara Healthcare 2015

Bridging the Quality Chasm Performance Data Reflects Quality of Care Delivered, Financial Reward Achieved Bridging the Quality Chasm Performance Data Reflects Quality of Care Delivered, Financial Reward Achieved CARE Document to reflect quality of care SYSTEMS Set up and maintain systems Standardize key workflows Engage staff in continuous quality improvement IT , EHR Experts, & Quality Operations & Clinical Staff Follow key standards and offer feedback Data at Point of Care for coordination and QI RESULTS Leadership Maximize credit and $ for work done Better Quality & Experience, Lower Cost Accurate Data for Reporting © Azara Healthcare 2015

Assembling the Right Team: Roles & Responsibilities A cross-functional team is critical to the Assembling the Right Team: Roles & Responsibilities A cross-functional team is critical to the success of the project to ensure quality of data capture, accuracy, extraction and measure results. Data is not just an IT project. Team Roles Team Member Responsibilities Executive Sponsor • • Leadership level sponsor for project Helps to acquire appropriate resources for program as needed Population Management Lead • • Responsible for population management at macro level Review of health home data Network Admin/DBA • • Provide access to Health Center network & EHR systems Population health management Connectivity & Performance support EHR/HIT Expert • • • Identify EHR templates for data element capture Identify EHR tables for Orders, Labs, etc. Review patient population along with QI/Clinical team members QI Specialist • • Identify all data capture workflows Complete Lookup/mapping categorization Execute Data Validation Chart Audits where needed Review values for accuracies and investigates discrepancies Provider Representative • • Identify all data capture workflows Identify PHI data capture location & criteria Support QI Specialist in Data Validation Audits where needed Provide feedback on accuracy of data Clinical Support • • Identify all data capture workflows Identify PHI data capture location & criteria Support QI Specialist in Data Validation Audits Provide feedback on accuracy of data 15

Getting to the Bottom of Data 1. Map existing workflows for key measures 2. Getting to the Bottom of Data 1. Map existing workflows for key measures 2. Standardize best practices that result in usable data 3. Train staff. Use data and analytics to see if staff is documenting in the fields that link to QI reports. 4. Rinse and Repeat. 16 © Azara Healthcare 2015

Structured vs. Unstructured Data There is tremendous value in recording data using a common Structured vs. Unstructured Data There is tremendous value in recording data using a common vocabulary and methodology. Creates data which can be recognized, ordered, analyzed, reported & shared. UNSTRUCTURED DATA Dictation, Transcription, Voice recognition typing, Free text, Memo fields STRUCTURED DATA Radio buttons, Locked down Pick-lists, Checkboxes, NDC-ID (Meds), ICD-9/10/SNOMED(Dx), LOINC (Labs), CPT (Procedures) Data not captured in structured fields is not reportable. 17 © Azara Healthcare 2015

DM A 1 c Order and Result Workflow Map Patient Arrives Front Desk Checks DM A 1 c Order and Result Workflow Map Patient Arrives Front Desk Checks in Patient MA/LPN Rooms Patient Pt. due for A 1 c? No Pre-visit planning and huddle to avoid missed opportunities Yes Run registry reports weekly for DM Patients who were in last week and sort by A 1 c result. Outreach and proactive care coordination activities Continue with visit. Prioritize most urgent patients and designate outreach staff to call and schedule a visit with PCP, diabetic educator, pharmacy educator, etc. Run registry reports weekly for DM Patients who have not been in for a visit in >90 days. MA/LPN performs vital signs MA/LPN evaluates last A 1 c date to determine need. Standing order allows MA/LPN to place an order for A 1 c every 91 days for DM patients. If sent to reference lab If being sent to Lab. Corp, Package sample. Result returned via Lab. Corp interface. If A 1 c needed MA/LPN orders and draws blood. Perform analysis in house. Enter result on the superbill, or Path Labs tab, or Path. Labs type on the Order Screen on the order. Paper A 1 c Result Arrives MA/LPN enters into the nonbillable encounter created, enter result into Path. Labs tab or Path. Labs type on the Order screen. A 1 c Complete 18 © Azara Healthcare 2015

Low Hanging Fruit for QI- Diabetes Registry Sort by A 1 c ascending to Low Hanging Fruit for QI- Diabetes Registry Sort by A 1 c ascending to find patients who have not been tested. mo De ta Da © Azara Healthcare 2015

Low Hanging Fruit for QI- Diabetes Registry Sort by A 1 c descending to Low Hanging Fruit for QI- Diabetes Registry Sort by A 1 c descending to find : - Data quality issues such as Glucose results mis-entered in A 1 c field - Out of control patients at risk for stroke, hospitalization, etc. mo De ta Da © Azara Healthcare 2015

Maintain the Integrity of the Bridge Structure • Make data hygiene part of your Maintain the Integrity of the Bridge Structure • Make data hygiene part of your daily, weekly, monthly, and annual routines. – Daily: Visit Planning Tools – Weekly: Registry and Care Management Reports – Monthly: QI and Performance Improvement, Data Validation of a subset of measures – Annual: UDS Reports (check stubborn data points like birth weight and trimester of entry quarterly) • Assign responsibility and accountability for these activities. © Azara Healthcare 2015

Team Based Care and Visit Planning Embedding Quality Improvement in Daily Care Delivery for Team Based Care and Visit Planning Embedding Quality Improvement in Daily Care Delivery for PCMH and Improved Outcomes to Transform into a Quality Machine 22 © Azara Healthcare 2015

Care Team Members Patient Resource Managers Discharge FU RNs Provider Care Managers Health Educators Care Team Members Patient Resource Managers Discharge FU RNs Provider Care Managers Health Educators Patient CDE Nutrition BH MA/LPN Referral Clerks Team Office Manager Front Desk © Azara Healthcare 2015

Comprehensive Standing Orders for MAs • Usually standing orders are fragmented; leads to a Comprehensive Standing Orders for MAs • Usually standing orders are fragmented; leads to a lack of clarity. Need one comprehensive set which is part of the Policy and Procedures. • Empower MAs to do support their provider by giving them the freedom and trust to follow the protocol. • Standing orders create the basis for use of the visit planning report as a foundation for trust to delegate in team-based care. Team. Based Care Visit Planning Report Standing Orders 24 © Azara Healthcare 2015

MA/LPN Comprehensive Standing Orders All Adults LDL Population All >17 Frequency every 5 years MA/LPN Comprehensive Standing Orders All Adults LDL Population All >17 Frequency every 5 years Dx Code V 77. 91 Action Remind Provider FIT >49, w/o colonoscopy past 10 yrs yearly V 76. 51 Give Kit and Instructions to patient Tobacco Usage/ Advice to Quit >12 yearly Perform Flu Pneumovax Depression Screening yearly repeat once yearly NA Remind Provider Adult Females All patients > 65, if last was > 5 years ago All patients >12 All patients, f/u plan for BMI >24 or <18. 5 Population NA V 04. 81 V 03. 82 NA Frequency Dx Code Action Mammogram F >39, no bilateral mastectomy every 2 years V 76. 12 Referral or Order F >21 -64, no hysterectomy Dx Code(s) Colon Cancer Screen Standing Orders for MAs Weight Screening &Follow-Up Perform Pedi/Adolescent Population every 3 years every 5 years if HPV test with Pap Frequency BMI Nutrition & Activity Advice All patients <18 yearly NA Remind Provider Diabetes Type 1: 250. 01 Type 2: 250. 00 Frequency Dx Code Hb. A 1 c All patients with Diabetes every 3 months 250. 01 or. 02 Foot Exam Nephropathy Screen LDL Eye Exam Flu Pneumovax Asthma Flu Pneumovax All patients with Diabetes All patients with Diabetes Population All patients with Asthma yearly yearly once in lifetime Frequency yearly once in lifetime 250. 01 or. 02 V 04. 81 V 03. 82 Dx Code V 04. 81 V 03. 82 Code(s) Perform or Remind Provider NA Remind Provider Referral Perform Code(s) Perform Asthma Severity All patients with Asthma yearly 493. 00 Remind Provider Hypertension LDL Population All patients with Diabetes Frequency yearly Dx Code 401. 9 Pap F >30 -65, no hysterectomy V 76. 2 Surepap w/Rflex Surepap w/HPV 25 Code(s) 25 © Azara Healthcare Remind Provider 2015

What is a Visit Planning Report? Facilitates more efficient pre-visit planning sessions by allowing What is a Visit Planning Report? Facilitates more efficient pre-visit planning sessions by allowing care teams to review alerts for patients with upcoming appointments – Does the work MAs/ LPNs already do manually, using EHR data and electronic calculation of alerts – Displays only relevant and actionable items to help teams prepare for visits – Displays active diagnoses and relevant risk factors © Azara Healthcare 2015

Visit Planning Report Combines Registry & Preventative Care Alerts, by Provider, ordered by appointment, Visit Planning Report Combines Registry & Preventative Care Alerts, by Provider, ordered by appointment, in one report. 1: 25 PM l Friday, September 11, 2015 Gomez, Jose MRN: 780239 DOB: 11/23/2006 Age: 9 Diagnoses____________ Asthma Visit Reason: Well Child Visit Gender: M Risk Level: Moderate Alert _______ _ Nutritional Counseling Physical Activity Counseling BMI Percentile Asthma Severity Risk Factors___________ OBS Phone: 522 -113 -5837 Language: Spanish Message_____ Missing Overdue 3: 45 PM l Friday, September 11, 2015 Perkins, Sonja MRN: 5112866 Diagnoses____________ DM, HTN, DEP, COPD Risk Factors___________ SAD, SMIP m De ata o. D DOB: 3/18/1962 Age: 53 PCP: Cranston, Bill Most Recent Date _ __Most Recent Result 8/15/2014 90 Visit Reason: Headaches Gender: F Risk Level: High Phone: 522 -788 -5001 Language: English PCP: Gunther, Eric Alert _______ _ Message_____ Mammogram Missing Pap Smear Missing A 1 c Overdue BP Result out of Range 8/15/2014 Eye Exam Missing Flu Missing Tobacco Status Missing LDL Overdue 5/15/2013 90. 1 Most Recent Date _ __Most Recent Result 8/15/2014 150/95 10. 2 27 © Azara Healthcare 2016

The 3 buckets of Visit Planning Alerts: 1. MA performs: - BP BMI (weight The 3 buckets of Visit Planning Alerts: 1. MA performs: - BP BMI (weight and height) Monofilament Foot Exam FIT /FOBT (give pt. kit and instructions) A 1 c Point of Care (order and perform) Flu Immunization (order and give) PCV Immunization (order and give) Depression Screening Tobacco Assessment & Advice to Quit 3. MA reminds the provider: - Child/Adolescent Physical Activity and Nutritional Counseling Weight Counseling for Adults with BMI >24. 9 and <18. 5 Asthma Severity Assessment (open template for provider) A 1 c Lab LDL Nephropathy Screen Colonoscopy 2. MA creates an order/referral: - Pap - Mammogram - Eye Exam 28 © Azara Healthcare 2015

Huddle (limit to 5 -10 minutes) 1. Have a consistent time and stand for Huddle (limit to 5 -10 minutes) 1. Have a consistent time and stand for meeting. Any team member can initiate. 2. Must Discuss: a. Patients with special intervention needs b. Patients with risk factors DRVS Risk Factor Description Pregnancy Currently pregnant. OBS BMI indicates obesity. TOB Current tobacco user. SMIP Active Dx of Severe Mental Illness and/or Psychosis. SAD SOC Active Dx of Substance Abuse and/or Dependency Other Social Determinants c. Any scheduling bottlenecks anticipated, and plans to workaround 3. Organize for extra services if needed: a. Behavioral Health b. Care Coordination c. Diabetes, Asthma, Nutrition Education 29 © Azara Healthcare 2015

Rx for Data Usage in Your Practice Integrating data into the practice on a Rx for Data Usage in Your Practice Integrating data into the practice on a daily, monthly, quarterly, and yearly basis 30

External Performance • Regulatory (UDS, MU, P 4 P) • PCMH • Grants, other External Performance • Regulatory (UDS, MU, P 4 P) • PCMH • Grants, other QI & Population Management • Registry & Exception Reporting • QI PDSAs & Trending Point of Care • Pre-Visit Planning • Huddle • Care Management Appetite for Data: CHCs who are the greatest consumers of their data have the best chance of success 31 on all levels of performance. © Azara Healthcare 2015

RX FOR INTEGRATING DATA INTO EVERY DAY PRACTICE • Report type- Visit Planning (VP), RX FOR INTEGRATING DATA INTO EVERY DAY PRACTICE • Report type- Visit Planning (VP), Registry, Measure Analyzer, Compliance, Scorecard/Dashboard? • What- specifically what report- Diabetes Labs and Services for X Providers, for what period- last month of patients. • Who- will be responsible for running it? • When- should they run it? Daily at 7: 45 am. • Why- what’s the goal? To identify needed care for today. • Where- will we use the data? Share results in huddle. • Responsible Administrator- who will ensure accountability for report being run consistently?

WHO SHOULD HAVE ACCESS TO REPORTING AND ANALYTICS DATA? • • • IT/Applications Staff WHO SHOULD HAVE ACCESS TO REPORTING AND ANALYTICS DATA? • • • IT/Applications Staff MA/LPN RN/RN Care Manager Provider Quality Director Health Home Director BH Consultant Pharmacist Operations Clinical Leadership Executive Director and Leadership • Establish an practice Administrator for Reporting and Analytics. • Make sure everyone is comfortable logging in to DRVS. It’s not enough to train once. • If there is concern about multiple users having access to the data, we can restrict access. • You cannot break DRVS- feel free to experiment. 33

GENERAL TIPS FOR SUCCESS • Create Your Own Accountability- Put an Outlook Reminder in GENERAL TIPS FOR SUCCESS • Create Your Own Accountability- Put an Outlook Reminder in your Calendar for running reports. • Share results – with your team by posting where everyone can see it (break room, etc. ), at regular times (monthly, etc. ). – with the practice on the Quality Board or other common space – Celebrate success at staff meetings consistently- make it a recurring agenda item. • Goal is for the whole practice to be aware of important measures and at any given point, how the practice is doing. 34

Pre-visit Planning/Huddle Preparation Report Name What Who • Potential Barriers • Solutions to Barriers Pre-visit Planning/Huddle Preparation Report Name What Who • Potential Barriers • Solutions to Barriers 35 When Why Where Person Responsible

Understanding the Value of a Common Reporting Platform How does EHR data end up Understanding the Value of a Common Reporting Platform How does EHR data end up in a data warehouse? How can we compare data from different EHRs? How do standard mapping practices support trust in data across centers and EHR platforms? 36 © Azara Healthcare 2015

Key Components of Centralized Data Reporting and Analytics Solutions for PCAs, Networks, and Community Key Components of Centralized Data Reporting and Analytics Solutions for PCAs, Networks, and Community Health Centers Dashboards Regulatory Comparison & Analytics Population Management Visit Planning © Azara Healthcare 2015

Managing Multi-Center Programs with Data • Manage and improve health outcomes: – training on Managing Multi-Center Programs with Data • Manage and improve health outcomes: – training on evidence-based clinical practice guidelines, technical assistance support on information technology and quality improvement projects, patient education materials • Quality improvement strategies: – problem assessment, identification, study, corrective action, monitoring, evaluation, and assessment • Health Information Technology: – to gather and analyze data, and to generate reports that can be used to track progress towards quality improvement goals – Needed a credible source of data across control and selected practices • 12 Measures: • • • A 1 c tested A 1 c <7 A 1 c 9 -7 A 1 c >9 or untested BP recorded BP <130/80 7. 8. 9. 10. 11. 12. Eye Exam BMI recorded BMI 18. 5 -24. 9 LDL tested LDL <100 Tobacco Users 38 © Azara Healthcare 2015

Data Warehouse Infrastructure and Extraction Security & De-Identification PRESENTATION LAYER Reporting & Analytics Application Data Warehouse Infrastructure and Extraction Security & De-Identification PRESENTATION LAYER Reporting & Analytics Application Data Warehouse CLEANSING & ORGANIZATION Data Normalization SOURCE DATA Meditab Epic All. Scripts Next. Gen Health Port Athena Vitera Compu Group Mc. Kesson Success EHS GE e. CW 39 © Azara Healthcare 2015

The Value of a Common Data Platform Extraction and Normalization: Data is extracted nightly The Value of a Common Data Platform Extraction and Normalization: Data is extracted nightly from practices and normalized so different A 1 c result names from EHRs can all be interpreted as A 1 c. e. Clinical. Works Health Center A Glucose Hb. A 1 c HA 1 c Health Center C Health Center B Glycohemogolobin A 1 c Epic Next. Gen Glycosylated Hb. A 1 c Glucose Hb. A 1 c GHb Health Center D Glycohemogolobin A 1 c Glucose Hb. A 1 c HA 1 c Glycosylated Hb. A 1 c HA 1 c Glycated hemoglobin Hb. A 1 c LOINC 17855 -8 Glycosylated Hemoglobin A 1 c Calc. Glycohemogolobin 1 2 3 4 DATA EXTRACTIONS Centralized Reporting Normalization Centralized Reporting A 1 C results 40 © Azara Healthcare 2015

The Value of a Common Data Platform Data Warehouse: After normalization, all result values The Value of a Common Data Platform Data Warehouse: After normalization, all result values are interpreted as A 1 c, and practice segregated data is used to calculate performance in the reporting layer. Central Reporting Data Warehouse Health Center B A 1 c Health Center A A 1 c Glycosylated Hb. A 1 c Glycohemogolobin Glycosylated Hemoglobin A 1 c Glycosylated Hb. A 1 c LOINC 17855 -8 Hb. A 1 c Glucose Hb. A 1 c HA 1 c GHb Glycated hemoglobin Health Center A Central Reporting Data Observations A 1 C Results Providers Patient MRN Encounters Diagnoses 41 © Azara Healthcare 2015

Peer Comparison, Data Validation by Drill Down, and Troubleshooting Drill Down with Providers, and Peer Comparison, Data Validation by Drill Down, and Troubleshooting Drill Down with Providers, and Common Data Pitfalls 42 © Azara Healthcare 2015

Troubleshooting and Validating Data When there are Questions about Data Validity or Performance Improvement Troubleshooting and Validating Data When there are Questions about Data Validity or Performance Improvement Plateaus…Investigate data and workflows. • Validate that what you think is true, is true. – Rogue workflows can develop quickly… – Get to the bottom of it: – Examine location and provider variation – Look for outliers- focus on providers whose results are outside of the pack – Use data to theorize, but you may have to ask and observe as well © Azara Healthcare 2015

Measure Analyzer- Cervical Cancer Screening Evaluate the layers of organizational performance with customizable scorecards. Measure Analyzer- Cervical Cancer Screening Evaluate the layers of organizational performance with customizable scorecards. • • • Monitor EHR adoption and training efficacy. Compare performance by center, and investigate down to the provider and patient level. Identify candidates for best practice sharing. Double-click on the measure to drill down. Or Click on Full Report to see details. © Azara Healthcare 2015

Center Trend and Performance Comparison Cervical Cancer Screening - TY July 2014 • Evaluate Center Trend and Performance Comparison Cervical Cancer Screening - TY July 2014 • Evaluate which centers are the best performers, and how your center compares to others. © Azara Healthcare 2015

All Center Comparative Analytics Cervical Cancer Screening - TY July 2014 • • Evaluate All Center Comparative Analytics Cervical Cancer Screening - TY July 2014 • • Evaluate which centers are the best performers to identify best practices. For lagging centers, drill down for more information. Double-click anywhere in the bar to drill down. © Azara Healthcare 2015

Your Center Comparative Analytics Cervical Cancer Screening – Month, Dec 2013 - March 2014 Your Center Comparative Analytics Cervical Cancer Screening – Month, Dec 2013 - March 2014 • Choose the appropriate time period- use shorter periods to evaluate PDSAs. 1 2 3 © Azara Healthcare 2015

Your Center Comparative Analytics Cervical Cancer Screening – Month, Dec 2013 - March 2014 Your Center Comparative Analytics Cervical Cancer Screening – Month, Dec 2013 - March 2014 • • • Evaluate performance across different locations Was one of these centers a PDSA pilot? Are there physical layout, equipment, staffing or other differences that make these locations significantly different? Double-click anywhere in the bar to drill down. © Azara Healthcare 2015

One Location in Your Center - Comparative Analytics Cervical Cancer Screening – Month, Dec One Location in Your Center - Comparative Analytics Cervical Cancer Screening – Month, Dec 2013 - March 2014 • Evaluate performance trend for one location. Double-click anywhere in the bar to drill down. © Azara Healthcare 2015

Provider Performance Variation- Chart view Cervical Cancer Screening – Month, Dec 2013 - March Provider Performance Variation- Chart view Cervical Cancer Screening – Month, Dec 2013 - March 2014 • Provider performance variation can be a factor of practice preference, staff differences, equipment, or other. Focus on the high performers with significant denominators to harvest best practices. Focus on the tail to identify rogue workflows and training issues. 50 © Azara Healthcare 2015

Provider Performance Variation- Table view Cervical Cancer Screening – Month, Dec 2013 - March Provider Performance Variation- Table view Cervical Cancer Screening – Month, Dec 2013 - March 2014 • • Sort by denominator (Qualifying Patients) to identify true high and low performers. Scroll bar on right allows you to view all providers. Click on the hyperlink to sort by denominator. Double-click on the name to drill down. © Azara Healthcare 2015

Single Provider Trend and Comparison Cervical Cancer Screening – Month, Dec 2013 - March Single Provider Trend and Comparison Cervical Cancer Screening – Month, Dec 2013 - March 2014 - Dr. Cheri Harlow Investigate trends. Look for focused training opportunities and low-hanging fruit. Drill down to the patient detail list for more information. 52 • • • © Azara Healthcare 2015

Patient Detail- Click Detail list on Menu for list of patients in the measure Patient Detail- Click Detail list on Menu for list of patients in the measure Cervical Cancer Screening – Month, Dec 2013 - March 2014 • • Sort by Numerator to identify out of compliance patients (N= Out of compliance for most measures). Export to PDF or Excel. Create an outreach list for staff to contact as appropriate. 1 2 © Azara Healthcare 2015

Results Quality Improvement Achieved, Grants and Other Funding Sources Awarded 54 © Azara Healthcare Results Quality Improvement Achieved, Grants and Other Funding Sources Awarded 54 © Azara Healthcare 2015

How can PCAs, Networks, and Consortia succeed with shared data infrastructure? Community Health Association How can PCAs, Networks, and Consortia succeed with shared data infrastructure? Community Health Association of NYS 1. 6 M Patients 4. 3 M Encounters, 58 CHC’s, 600 Sites Goals § Create statewide data repository and accompanying analytic tools to support the growth of primary care capacity, improve care quality and outcomes, and promote partnerships that strengthen care coordination and create a health home for every patient § Help members to succeed under delivery system and payment reform Results @ PCA/Network Level § 4 grant awards based on platform § 5 year, multi-million dollar CDC Cancer focused on improving cancer screening in CHC’s § HCCN Grant in 2012 for $2. 2 Million § RCHN grant to study cost of CHC care § NYDOH/IPRO for Healthy People 2020 § Half of NY’s 60 FQHC’s connected within 24 months § Platform provides backbone for multiple QI Programs © Azara Healthcare 2015

How do CHCs succeed with data initiatives? Bedford Stuyvesant Health Center Lutheran Family Health How do CHCs succeed with data initiatives? Bedford Stuyvesant Health Center Lutheran Family Health Center 13, 700 Patients, 38, 500 Encounters, 8 Sites 86, 000 Patients, 625, 000 Encounters, 37 Sites Goals for Data Usage § Improve Hypertension control (BP < 140/90) measured at 57% in October 2013 Results § Root Cause Analysis Performed – Corrective Action PSDA Put in Place § Hypertension control improved to 64% by Jan ’ 14 § Improve post-discharge follow up to reduce readmissions § Incorporate data driven decision making into PDSA Results § 150% Improvement in 48 hour follow up calls to high risk for Medicaid patients 32% to 82% § 200% improvement in follow up visits made by high risk patients within 48 hours of inpatient discharge § Diabetes foot exams increased from 30% to 46% © Azara Healthcare 2015

Pilot vs. Other Sites Results: Depression Screening and Follow-up Union City Pilot site 80% Pilot vs. Other Sites Results: Depression Screening and Follow-up Union City Pilot site 80% Hayward Site B San Leandro Site C Target 77% 70% 62% 60% 66% 49% 50% 40% 30% 20% 10% 0% 12% 10% 4% 11% 6% Aug Sept 15% 9% Oct 15% 10% Nov 21% 10% Dec Start VP Pilot © Azara Healthcare 2016

Missouri PCA Case Study Vision- Common Infrastructure • Missouri PCA invested in Azara DRVS Missouri PCA Case Study Vision- Common Infrastructure • Missouri PCA invested in Azara DRVS for all its CHCs Opportunity- Measure Performance with Common Infrastructure • Missouri Health. Net: Missouri’s Medicaid, as part of the Missouri Health Home initiative wanted to run a QI program to show impact of Health Homes on patient care and outcomes • MPCA was able to offer the DRVS tool, implemented for all health centers, as the data capture and analytics platform for the program – Normalized data, across sites, no reporting burden for centers Results- Paid for Performance with Minimal Reporting Effort • $60 PMPM (for each Health Home enrollee), plus encounter rate • Eligibility for cost-savings sharing if they a) save money and b) perform well on clinical measures • PCA- Enough $ to fund development, program management, and investment in future 60 © Azara Healthcare 2015

Health Center Controlled Network in MO • Focused on 4 measures – – Cervical Health Center Controlled Network in MO • Focused on 4 measures – – Cervical Cancer Screening Childhood Immunizations Hypertension Blood Pressure Control Diabetes A 1 c Control • Established a statewide quality improvement program called MOQu. IN to meet every other month to work on results using their centralized reporting and analytics tools to help the composite MO score, and share best practices to assist individual centers’ improvement. 61 © Azara Healthcare 2015

Missouri Workflow Mapping – Cervical Cancer Screening Electronic and Paper Results Patient Arrives for Missouri Workflow Mapping – Cervical Cancer Screening Electronic and Paper Results Patient Arrives for Visit Front Desk Checks in Patient. MA/LPN Rooms Patient MA/LPN performs vital signs and places order via standing orders. Care Coordinator arranges future visit. Pap Complete LPN reviews and adds result also to the OB GYN Hx tree in the visit note and fwd’s to provider only as needed. Results are forwarded to the Task Box LPN. Pap today? Yes MA/LPN preps for procedure. MA/LPN/Provider places order: Always order w/ HPV for women >=30). No Schedule future pap w/o copay, or refer to Show. Me Healthy Women for uninsured. Result returns electronically from Lab Received by Medical records, gets scanned and documented that it was received. Provider sees patient and performs pap. MA/LPN packages specimen to be sent to Lab performs diagnostics. Paper Pap Result Arrives 62 © Azara Healthcare 2015

Common PDSA Interventions Across Centers • Workflow Re-Design and Training – Process for retrieving Common PDSA Interventions Across Centers • Workflow Re-Design and Training – Process for retrieving from external organizations – Process for documenting in the EHR (which can be captured in DRVS) – Process for documenting exclusions (test not needed) • • Standing Orders for Pap Smears by support team members Add Pap to Pre-visit Planning activities Financial Vouchers to remove $$ barrier Patient education – Health Literacy – Cultural, ethnic, religious, fear barriers • Outreach to Patients – Proactive use of DRVS Adult Female Primary Care Registry to identify list – Send letters, make calls, distribute to teams, etc. • Data validation work and mapping – Identify missing Pap results that are unmapped © Azara Healthcare 2015

Missouri Cervical Cancer Screening- 22 Centers Year 3 Goal 65% 49% Year 2 Goal Missouri Cervical Cancer Screening- 22 Centers Year 3 Goal 65% 49% Year 2 Goal 50% Baseline- 29% Year 3 Goal - 65% © Azara Healthcare 2015

Connecting Quality Improvement to Cost Savings The Next Frontier 65 © Azara Healthcare 2015 Connecting Quality Improvement to Cost Savings The Next Frontier 65 © Azara Healthcare 2015

The Intersection of Cost and Quality Managing quality without cost or cost without quality, The Intersection of Cost and Quality Managing quality without cost or cost without quality, will not deliver the reform we need in healthcare delivery. Cost Quality The two must be evaluated together. 66 © Azara Healthcare 2015

Missouri PCA Case Study- Part II 438, 000 Patients, 1 M Encounters, 24 CHC’s, Missouri PCA Case Study- Part II 438, 000 Patients, 1 M Encounters, 24 CHC’s, 231 Sites Formation of an Independent Practice Association (IPA) • Missouri. Health+ will represent the participating health center members in negotiation with payers on their behalf • Better contracts due to volume of patients • Must meet quality measure standards to maintain membership Opportunity- Measure Performance with Common Infrastructure • Trust in common data collection and measure calculation across all participants • Proven track record on performance makes IPA more attractive to payer partners • Understanding their own performance (successes and areas for improvement) leads to informed negotiation around performance measures including which measures and performance targets 67 © Azara Healthcare 2015

Harnessing Data Beyond the CHC Health Info Exchange CHC Practice Data Hospital ADT Centralized Harnessing Data Beyond the CHC Health Info Exchange CHC Practice Data Hospital ADT Centralized Reporting and Analytics Imm. Registry Coordinate Risk, Cost & Quality Syndromic Surveillance Health Plans

EHR Clinical Data is Limited Understanding cost requires access to claims data – Medicaid EHR Clinical Data is Limited Understanding cost requires access to claims data – Medicaid (if significant portion of payer mix) – Medicare and Dual-Eligible – Commercial (target largest % of payer mix first) s im a a Cl at D R l EH ica in Cl ata D Central Reporting & Analytics Integrated Risk/Cost Analysis 69 © Azara Healthcare 2015

Match Members • Payers usually attribute a panel of patients to Providers/Practices – They Match Members • Payers usually attribute a panel of patients to Providers/Practices – They want you to deliver care to those patients • Critical Data Needs: – Match Your Own Patient MRNs to Payer Member Lists – Identify Patients Never Seen at the Practice • Action Steps: – Outreach to Patients to bring them in to be seen – Advocate with Payer to reassign patients who do not want to come to the practice 70 © Azara Healthcare 2015

Identify Total Costs and Basic Breakdown • Critical Data Needs: – Total Cost • Identify Total Costs and Basic Breakdown • Critical Data Needs: – Total Cost • • Primary Care Pharmacy Behavioral Health Specialty Inpatient Non-Maternity, ER Surgical Procedure By Chronic Disease • Action Steps: – Understand patient utilization and chronic disease patterns – Educate, design interventions, provide additional staff or services to meet needs. 71 © Azara Healthcare 2015

Integrate Risk Cost/Information into Daily Use • Critical Data Needs: – By Patient • Integrate Risk Cost/Information into Daily Use • Critical Data Needs: – By Patient • • Total Cost Annualized Cost Actuarial Risk Score Level High Cost Events (ER, Inpatient, Surgery) • Action Steps: – Identify highest cost patients, regardless of payer – Display risk, cost, high cost events on Visit Planning report with EHR data to help focus precious resources on highest cost patients 72 © Azara Healthcare 2015

Integrate Cost with Quality Measure Performance • Critical Data Needs: – By Patient • Integrate Cost with Quality Measure Performance • Critical Data Needs: – By Patient • Total Cost (Claims) • Chronic Diagnoses (Claims and EHR) • Quality Data (EHR) • Action Steps: $22, 500 In Control $95, 900 Not in Control – Understand the breakdown of costs of patients in the measure denominator and compare those in the numerator vs. those who are not. – Example: if it costs $13, 700 to care for a Diabetic patient whose A 1 c is not in control, but only $7, 500 to care for a patient whose A 1 c is in control, the savings opportunity of moving a patient into the numerator represents $6, 200. 73 © Azara Healthcare 2015

Recouping $$ Saved to the System • Health Centers will have to work together Recouping $$ Saved to the System • Health Centers will have to work together to use their collective leverage to negotiate with payers and other entities to recover the monetary savings • Currently savings accrue to the payers/CMS – Payers fund or partially fund reporting and analytics tools for practices to aid operations – Pay for Performance rewards for meeting QI goals – ACOs- savings created by participating entities are shared – Shared-risk programs - where payers and practices share savings – At risk programs -where practices take on risk but if they perform well could reap significant financial benefits 74 © Azara Healthcare 2015

Questions 75 © Azara Healthcare 2015 Questions 75 © Azara Healthcare 2015

Questions and Contact Information: HEATHER BUDD VP of Clinical Transformation, Azara Healthcare heather. budd@azarahealthcare. Questions and Contact Information: HEATHER BUDD VP of Clinical Transformation, Azara Healthcare heather. [email protected] com 76 © Azara Healthcare 2015