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      

Percen

t    

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  

Percen

t  

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