Quarter 1 2014 - Community Health Center

Quarter 1 2014 | Volume 9
Improving Quality In Everything We Do
Specialists have knowledge and skills that we in primary care do not. They have experience
treating rare and complex illnesses; they are skilled in various procedures that our patients
need; and they have years of additional training in a specific field that enables them to treat
and manage conditions that cannot be managed in primary care. Unfortunately the only
mechanism that we currently use to connect patients to specialists is a face-to-face consult.
CHCI providers know that obtaining a specialist consult is not without challenge. Limited access, long wait times, poor information transfer, no shows, and a variety of other barriers all
contribute to the fact that only approximately 60% of our patients who are referred have evidence in their chart that they saw a specialist.
Dr. Sanjeev Arora, founder of Project ECHO®, speaks of the “monopolization of knowledge”,
noting that the current system keeps specialty knowledge closely guarded in the hands of
specialists. In order to build a more sensible, patient-centered system of care, the current
paradigm for the primary care-specialty interface needs to be turned on its head and the
knowledge monopoly needs to be broken. There will always be a need for patients to see
specialists in person.
But how often could the patient’s needs be met by the primary care team with input from the
specialist provided through technology?
CHCI and WQI researchers just completed a randomized trial of eConsults that answered
that question: 70% of consults sent to the cardiologists via secure email message were resolved electronically with no need for a face-to-face visit. WQI also just completed a study of
Project ECHO®, evaluating the extent to which weekly video conferences between primary
care providers and teams of specialists empower primary care providers to manage specialty
conditions such as complex chronic pain, opioid addiction, Hepatitis C or HIV. Both of these
interventions are exploring new ways for specialists to share their knowledge, using technology to make the process more efficient and more effective.
by Daren Anderson, MD
CHCI, VP and CQO
We are excited that CHCI is taking a
leading role in rethinking how specialists and primary care providers
interact, and that CHCI providers
themselves are piloting and using
these new modalities to improve
care for their patients. In this issue of
Quality Focus we announced new
funding received by CHCI and WQI
to expand these initiatives to other
Above: A provider view of Project ECHO®.
health centers here at home and in
At right: A screen shot of a secure
surrounding states. It is a pleasant
email message for the eConsult
program.
irony that health center patients, usually the recipients of the short end of
the healthcare stick, are getting the highest technology, the most
patient-centered care, and that they are directly contributing to our
understanding of how to redesign the healthcare system to be more
effective, efficient, and elegant.
“Quality Is Everyone’s Responsibility”
—Edward Deming
Scan for more info
Under the Microscope
Take a closer look at how CHCI’s team approach is improving outcomes
and the quality of patient care
Care Coordination
by Amy Taylor, Associate Site Director and Stamford Microsystem Coach;
Lucy Golding, Nurse Manager, Stamford; Kathleen Thies, Project Manager,
Care Coordination
CHCI, in a joint partnership with Yale School of Public Health, has
launched an innovative and multi-faceted approach to care coordination to better manage patients with complex health care needs.
Because this new process requires major changes to existing work
flows and because all twelve of CHCI’s fixed primary care sites vary
in size and capacity, a uniform approach to care coordination is
unrealistic. Therefore, implementation of care coordination will be
incremental, one county at a time, and led by microsystem teams.
balance of the time required for care coordination and daily patient
care than a site with three nurses.
In comparison, the process of providing care coordination for people who are both medical and behavioral health patients will be fairly uniform for each site. The Norwalk microsystems team, with two
representatives from the behavioral health department, will study
and prepare this deliverable. When the team has defined a clear
mechanism for how care coordination will be provided for these patients, it will “spread” its approach to Stamford and Danbury, who
will “receive” the design and modify it as needed, but fundamentally keep it the same. In much the same way, the Danbury team will
be focusing on transition care management and the Stamford team
will work on dashboard utilization by MAs and PSAs and panel management by nurses and providers to support care coordination.
Throughout the entire process, each team will be committed not
only to care coordination itself, but also to the microsystems approach of change acceleration through documented PDSA cycles,
meeting rules, and continual self-reflection. As such, care coordination represents a powerful change in the way complex patients receive better care, as well as an evidence based approach to implementing change.
Pat Swim, Leslie Kelly (wearing her sociometric badge), Anandhi Baleswaren of Care Coordination
in Pod 1 in Groton.
Microsystems teams are often regarded as the crucibles of change
because they provide the forum within which front line players have
the opportunity to autonomously improve work flows and daily operations of their site. Less frequently, though, microsystems teams
play “catch ball,” a situation in which the team is given a new mandate from senior leadership and is tasked with figuring out the best
way to implement it at the site level.
The roll out of care coordination is unique in that it combines both
of these tactics.
Fairfield County, with sites in Norwalk, Stamford and Danbury, was
selected to receive the care coordination “ball” first. The three microsystems teams were given a playbook, which contains the framework, guiding principles of care coordination, and a list of “deliverables”. Some deliverables require each site to be the crucible of
change, while others will be molded and tossed from another site.
For example, each site will need to determine the most effective
way to allocate the time resources of the sites nurses, Patient Service Associates (PSAs) and Medical Assistants (MAs). This must be
done at the site level because each site varies in size and patient
volume. For example, a site with only one nurse will have a different
Seated, left to right: Brendan Green, Nurse, Norwalk; Lucy Golding, Nurse Manager, Danbury;
Myrna Velazquez, Nurse, Stamford. Standing, left to right: Joan Christison-Legay, self-management goal setting lecturer; Bozena Roberts, Nurse, Danbury; Michelle Kusnir, Nurse, Danbury;
Kathleen Thies, Care Coordination Project Manager, WQI.
Once the Fairfield County sites complete implementation, Hartford
county will “catch” the lessons learned from Fairfield County’s completed deliverables and modify and enhance as needed for each
site’s needs. This process will continue until all twelve primary care
sites have fully integrated care coordination into their delivery of
clinical care. The microsystems teams, with their ability to manage
change, make this all possible.
The Quality Focus Quarter 1 2014 | Volume 9 | Community Health Center, Inc. | www.chc1.com
CHCI Quality Improvement Department Scorecard
Area of Focus
Measurement
Diabetes
Quarter 1 Quarter 2
2013
2013
Quarter 3
2013
Quarter 4
2013
Quarter 1
2014
A1C>9 or not done*
Retinal Screening
(screened at CHCI)
27.0%
28.9%
24.6%
32.8%
23.7%
38.0%
23.5%
44.5%
30.0%
47.0%
Hypertension Control*
67.0%
69.0%
66.6%
64.1%
62.5%
Pain Management
Opioid Agreement
Urine Toxicology Screening
59.3%
70.1%
60.4%
69.9%
55.4%
70.4%
n/a
n/a
55.2%
75.3%
Cancer Screening
Colorectal* Cervical*
Breast
85.0%
88.7%
84.5%
89.7%
89.0%
50.0%
70.8%
75.6%
77.5%
76.0%
87.0%87.3%87.0%86.2%83.2%
CAD
Clinical
Aspirin use for Ischemic Vascular Disease*
Coronary Artery Disease
Lipid Therapy*
53.0%
57.4%
80.0%
87.4%
88.0%
85.0%
27.9%
83.0%
84.6%
87.0%
Obesity
Adult Weight Screen
and Follow Up*
Adolescent Weight Assessment and Counseling* 31.6%
26.4%
29.7%
37.2%
39.0%
50.2%
32.9%
49.0%
53.8%
54.0%
Smoking
Tobacco Use Assessment*
Tobacco Cessation Intervention*
99.6%
44.4%
99.8%
54.0%
99.7%
67.7%
100.0%
71.5%
100.0%
62.0%
Hypertension Control
Asthma
Asthma*
53.2%42.8% 89.0%92.0%91.0%
Immunizations
Childhood Immunization*
64.7%
71.2%
67.7%
82.0%
78.0%
Patient
Patients
Satisfaction
Overall Good/ Excellent
Overall Excellent
90.9% 55.6%
91.7%
57.9% 93.0%
59.5%
87.8%
52.1%
87.5%
54.4%
Recall
Unresolved Recalls
54.6%
49.3%
70.0%
41.6%
n/a
Patient Portal1
Patient Portal % Web Enabled
25.9%
23.4%
58.7%
63.8%
58.4%
Open Bubbles2
Operations
Telephone Encounters Labs
Documents
9,222
14,822
12,226
8,844
8,305
11,738
9,871
8,780
12,580
n/a
n/a
n/a
10,294
11,536
16,685
Panel Management
# of Providers3
# of Patients4
19
609
30
1,214
20
746
40
799
42
822
# of active RNCC Patients
60
256
298
316
317
Care Coordination
* HRSA Uniform Data Set (UDS) measures.
1. % of patients that are web-enabled with an office visit in the last 12 months.
2. Actions to be addressed by providers.
3. Number of CHCI providers with >10 panel management TEs created in 2 months.
4. Total number of patients with TE labeled “panel management” in reason field.
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Weitzman Quality Institute Updates
Expanding High Quality Care and Innovation
$893,000 in Grants Awarded
to WQI in Q1 2014
—Delaware: The Delaware Medical Society started buprenorphine ECHO® in March and will meet more frequently than other ECHOists to ramp up support for PCPs
•$500,000 from the Jessie B. Cox Trust, one of the largest
grants in their history, for development and implementation
of the New England eConsult Network
• $393,075 from the Nicholson Foundation in New Jersey, for
the development and implementation of a Breakthrough Series Collaborative on quality improvement and Project ECHO®
for pain management and opioid dependence management
with Buprenorphine
Innovative Solutions to Connect
Primary Care Providers and Specialists
Along the East Coast
•New England eConsult Network (NEECN) is the first multistate eConsult in New England
—The NEECN will link multi-state specialist reviewers and
three primary care delivery systems: ProHealth Physicians of Connecticut, Penobscot Community Health
Care of Maine, and CHCI
Above, left: The new Buprenorphine ECHO® group from Delaware. Above, right: The
Delaware Buprenorphine ECHO® during their kickoff session on March 18, 2014.
—Maine: Providers from 8 PCMH-recognized primary care
practices will join pain ECHO® as one piece of an effort by
Main Quality Counts to improve quality and patient safety
related to the management of chronic pain. The WQI will
then evaluate the project for knowledge gained, improved
clinical quality measures, and patient outcomes
A Commitment to Quality
Improvement at Home
•Four CHCI staff join our other 11 Microsystem coaches after
starting their Clinical Microsystem Training with The Dartmouth Institute in March
—eConsults can help improve efficiency, health outcomes,
and quality for underserved patients by providing an avenue for increased access to and enhanced communication
with specialists
An eConsult is a clinical consultation between a primary
care provider (PCP) and a specialist conveyed electronically
via a secure message interface.
•Project ECHO® has seen tremendous growth adding 3 sites
along the east coast
—New Jersey: Debuting for the first time, a unique, WQI designed Breakthrough Series Collaborative will marry quality
improvement training and Project ECHO® for chronic pain
and buprenorphine
• With the aim of enhancing current procedures for managing pain and opioid dependence, PCPs will participate in a face-to-face quality improvement training session and will then join virtual pain and buprenorphine
ECHO® sessions until 2015
CHCI’s newest coaches, Katherine Kuzmeskas, Anna Rogers, Kerry Bamrick, and Grace
Capreol with Deb Ward, Senior Quality Improvement Specialist during the Dartmouth
Clinical Microsystem training in March 2014.
—Kerry Bamrick, Sr. Program Manager, is coaching the New
Britain Pediatrics team
—Grace Capreol, Analyst, EHR and Health Applications, is
coaching the Ryan White team
—Katherine Kuzmeskas, WQI Program Coordinator, is
coaching a team at our Middletown site
—Anna Rogers, Manager Community Wellness and AmeriCorps Program, is coaching a team at our Waterbury site
•WQI’s First Annual Clinical Microsystem Festival in June
2014 will showcase the progress and innovation done by our
microsystem teams. More information and invitations will be
sent soon.
The Quality Focus Quarter 1 2014 | Volume 9 | Community Health Center, Inc. | www.chc1.com

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