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History

• HRSA Innovations Grant (2007-2010) – Health information exchange focused on reporting performance outcomes

– Established PIC

• RWJ P4P Research Grant (2009) – Focused on comparing incentivized clinic teams vs. non-incentivized teams (control

group)

– Three measures selected

• HRSA Enabling Services Grant (2010-2012) – Focused on incentivizing and reporting enabling service activities

– Formed an extension team PIC ES

• HRSA CHARN Research Grant (2010-2013) – Patient centered outcomes research focusing on diabetes

– Capacity expansion at the health center • Asian Health Services (AHS) in California

• Charles B. Wang Community Health Center (CBWCHC) in New York

• Waianae Coast Comprehensive Health Center (WCCHC) in Hawaii

• Island Innovation Fund (2011) – Online Disease Focused Patient Registry

• Will add Bay Clinic, Hilo Hawaii into the PIC HIE

Performance Indicators Measure Impact of Innovation

1. % by age 2 years, with 4 DTaP, 3 OPV/IPV, 1XMMR, 3XHepB, 3XHib (and Varicella) Effectiveness & Safety, Risk Management, & Quality

2a. % of patients with either Type 1 or Type 2 Diabetes whose HBA1c is > 9 Effectiveness & Efficiency

2b. % of diabetic patients with a behavioral health (mental health or substance) diagnosis whose HBA1c is > 9

Effectiveness

3a. % of pts < 7yo who had a primary care visit within the last 12 months Effectiveness & Timeliness

3b. % of pts > 6 yo who had a primary care visit within the last 24 months Effectiveness & Timeliness

3c. Third next available appt Effectiveness & Timeliness

4a. % of patients seen in ER with low complexity problems Effectiveness

4b. % of patients seen in ER who f/u with primary care. Effectiveness

5. % of pts with well child visits: a) In first 15 months; b) At 3-6 years; c) At 12-21 years

Effectiveness

6. % of patients on whom early notification of pregnancy was made to the Health Plan.

Timeliness & Efficiency

Enabling Services CODES Case Management – Assessment CM001

Case Management – Treatment and Facilitation CM002

Case Management – Referral CM003

Financial Counseling/ Eligibility Assistance FC001

Health Education/ Supportive Counseling HE001

Interpretation Services IN001

Outreach Services OR001

Transportation TR001

Other OT001

Table Structure

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Comparative Dashboards

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Detail Reports

Island Innovation Fund Project

Establish disease focused patient registries through data obtained from electronic medical records to improve

specific diabetes quality indicators and provide concise patient information to primary care providers

PIC Hawaii Patient Care Manager