Linking Health Across the Systems

In 2014, the Worcester Division of Public Health received a Prevention and Welllness Trust Fund (PWTF) grant from the Massachusetts Department of Public Health to improve care in regards to: senior falls, pediatric asthma and hypertension in 26 census tracts of city of Worcester. The primary objective of the Worcester PWTF project is to improve health outcomes by linking clinically prescribed activities to the home and community based resources through the engagement of community health workers

MA PCMH Eval Week: Ann Lawthers, Sai Cherala, and Judy Steinberg on How You Define Success Influences Your Findings

Blog post to AEA365, a blog sponsored by the American Evaluation Association (AEA) dedicated to highlighting Hot Tips, Cool Tricks, Rad Resources, and Lessons Learned for evaluators. The American Evaluation Association is an international professional association of evaluators devoted to the application and exploration of program evaluation, personnel evaluation, technology, and many other forms of evaluation. Evaluation involves assessing the strengths and weaknesses of programs, policies, personnel, products, and organizations to improve their effectiveness. This blog post was posted to AEA365 during a week of posts featuring the team at the University of Massachusetts Medical School that helped to evaluate the Massachusetts Patient-Centered Medical Home Initiative

How Can Care Management Improve Patient Outcomes? Focus on Risk Stratification

The poster helps practices recognized as PCMH identify and manage the care of the highest-risk, complex and costly patients. Clinical care management has helped patient-centered medical homes reduce costs and hospital admissions and stays, while increasing patient satisfaction. Presented at the Institute for Healthcare Improvement 2015 Conference

Diabetes Care Trends in the MA Patient Centered Medical Home Initiative (MA PCMHI) at Mid-Point

Background: The MA PCMHI is a multi-payer demonstration involving 45 primary care practices. Thirty-one (31) practices receive additional financial support; all receive technical assistance. Objectives: To assess data trends in diabetes quality measures from participating adult practices. Study Design: Quality improvement study utilizing practices’ self-reported data on clinical quality measures. Diabetes measures included blood pressure, LDL cholesterol and hemoglobin A1C control and depression screening. Methods: Monthly quality data from 38 practices reported June 2011 (baseline) through November 2012 were evaluated. Using a general linear mixed model Analysis of Variance (ANOVA), an overall comparison across time and pair-wise comparisons between times were made to identify periods with significant changes. The analysis also identified the effect of each practice’s performance on aggregate performance and practice performance in change over time for each measure, to determine high and low performers. Results: On aggregate, the change over time performance was statistically significant for two measures: hemoglobin A1C \u3e9% and depression screening. Some practices were either high or low performers on most measures. Some practices were high performers on some but low performers on other measures. Practices with and without financial support were equally represented in high and low performer categories. Conclusions: In the first 18 months of the MA PCMHI, participating practices have significantly improved diabetes care by reducing the percentage of patients with poorly controlled diabetes and by more consistently screening patients for depression. Certain sites are excelling – consistently or only in certain measures. Financial support does not appear to be a factor but practice payer mix, size and leadership engagement may be important factors. Analysis of the impact of these factors and a qualitative analysis of best practices implemented by high performing sites, are planned. Policy Impact: Findings will inform the technical assistance provided to practices undergoing transformation to PCMHs

Quality Improvement (QI) in Evaluation: Ask Why Again and Again and Again

Blog post to AEA365, a blog sponsored by the American Evaluation Association (AEA) dedicated to highlighting Hot Tips, Cool Tricks, Rad Resources, and Lessons Learned for evaluators. The American Evaluation Association is an international professional association of evaluators devoted to the application and exploration of program evaluation, personnel evaluation, technology, and many other forms of evaluation. Evaluation involves assessing the strengths and weaknesses of programs, policies, personnel, products, and organizations to improve their effectiveness

Implementing Integrated Clinical Care Management in the Patient-Centered Medical Home

Clinical Care Management (CCM) of the highest risk, most complex and costly patients is a key element of the Massachusetts Patient-Centered Medical Home Initiative (MA PCMHI), and is a new service for most primary care practices. There is much confusion about the role of the Care Manager (CM), and a lack of awareness of key foundational elements critical to successful implementation of CCM. This poster describes the shared approach to implementation of CCM in the MA PCMHI, use of care management and care coordination clinical quality measures to monitor implementation progress, and shared lessons learned in the implementation process

Innovations in Primary Care: Implementing Clinical Care Management in Primary Care Practices

The Massachusetts Patient Centered Medical Home Initiative (MA PCMHI) is a statewide, multi-payer demonstration that seeks to transform 46 primary care practices into PCMHs. Clinical care management of high-risk patients is a key element of the PCMH and a new service for most primary care practices. Training for practices in the MA PCMHI includes the clinical care manager (CCM) role, identification/tracking of highest-risk patients, care plan development/implementation, care coordination, and communications. Content is delivered through learning collaborative sessions, monthly webinars and practice-based transformation facilitation. Assessment of progress towards implementation is made through practice-based data on clinical care management measures and self-assessment of transformation. At year one of implementation, averages for measures such as percentage of patients who received timely follow-up after hospitalizations and ED visits range 37%-63% with 35-40 of 46 practices reporting. The challenges that have hampered implementation include lack of: (1) EMR/registry functionality, (2) hospital to practice notification systems, (3) clarity of the CCM role and workflow, (4) risk stratification criteria for high-risk patients, and (5) adequate resources to support this service. An important lesson learned is that engaged leadership is critical to successful clinical care management implementation. Next steps include refinement of the practice-based self-assessment that is used as a monitoring and QI tool, and a pilot to study the coordination of payer-based and practice-based clinical care management

Implementing Integrated, Interdisciplinary Clinical Care Management in the Patient-Centered Medical Home

Clinical care management (CCM) of the highest risk, most complex, and costly patients is an integral component of the patient-centered medical home (PCMH) but a new service for many primary care practices. The Massachusetts Patient-Centered Medical Home Initiative (MA PCMHI) is a 3-year, multi-payer demonstration with 45 participating practices. Support for CCM implementation is provided through learning collaboratives and practice facilitation. Techniques for shared learning include developing a CCM interdisciplinary team workflow utilizing process mapping and modeling care plan development. MA PCMHI practices have found these techniques valuable for clarifying what a care plan is and visualizing existing workflows, so others in the practice can more clearly understand the care manager role. Presenters will utilize these techniques with audience members to advance their knowledge and skill set in implementation of practice-based care management. Presented at the Conference on Practice Improvement Society for Teachers of Family Medicine

Developing the Medical Home Workforce

A pro-active multidisciplinary team-based care model was developed after identifying key skills and competencies needed for a patient-centered medical home workforce. The patient-centered medical home may solve many of the ills of our health care system; new health care payment methods support care team member roles and services in patient-centered medical homes; an enhanced skill set for the entire care team is needed for successful implementation; a redesign of training and education to support existing and incoming workforce is required; and a focus on inter-professional collaborative education is needed

Behavioral Health Screening in Primary Care Practices

The poster describes the importance of integrating behavioral health care in PCMH, and cites national studies that estimate 30 percent of adults suffer from one or more mental health problems in a one-year period. Presented at the Institute for Healthcare Improvement 2015 Conference